麻豆原创

Attract and retain

We must attract new people into social care and keep them. Evidence shows the two most immediate recruitment levers in adult social care are ensuring that adult social care is competitive in local labour markets (this includes by paying more and having good quality roles) and international recruitment. We can do both things - recruit from abroad and improve the quality of social care roles - but if we do neither then immediate workforce capacity issues are likely to continue.

However, we also need to guard against only pulling these short-term levers for attraction. We have to continue to focus on recruiting the domestic workforce¹ so that we have people in the areas we need them, and we need to do more to keep people. We know that pay and terms and conditions, including flexible employment policies, help to attract entrants into the workforce, but a mixture of factors helps people to stay and build a career in adult social care and we need to focus on these too.

• Pay and terms and conditions
• Pay modelling
• International recruitment
• Employee relations for non-regulated workforce
• Attraction
• Retention
• Inclusive work culture
• Wellbeing at work

Pay and terms and conditions

In this section we focus on pay and terms and conditions of the unregulated adult social care workforce. It is important to state that regulated professionals working in social care should receive at least the same pay, terms and conditions as their colleagues in equivalent and comparable organisations for example, registered nurses and nursing associates and NHS Agenda for Change roles.

Research from the University of Kent and The London School of Economics and Political Science has demonstrated, using Adult Social Care Workforce Dataset (ASC-WDS) data, that: increasing wages in the adult social care sector can increase employment, with a 5% increase in real wages in the sector (and keeping everything else constant) likely to increase employment by 9 to 11%.³

Social care suffers from low base pay and low differentials between roles within social care and with similar sectors.

80% of jobs in England pay more than the median rate of pay for independent sector care workers in adult social care, and 41% of care workers earn below the Real Living Wage (as at December 2023). A healthcare assistant role pays 78p an hour more than a new healthcare assistant within two years, and £1.45 more than a care worker. This impacts on the ability of adult social care roles to compete with others in the labour market.

The chart below shows the difference between the median independent sector hourly care worker pay in adult social care and selected jobs with low pay across whole economy.

Source: 麻豆原创 estimates and ONS Annual Survey of Hours and Earning NHS Agenda for Change pay data.

High turnover is impacted by low pay, so not only do we find it harder to attract people but when we do attract them it is harder to keep them. Turnover is significantly higher for those independent sector care workers on the National Living Wage (37.2% for those on £8.91 between March 2022 and March 2023, compared to those earning more 31.6% for those earning £10 an hour or more).

National Living Wage increases have squeezed pay differentials which does not encourage experienced workers to stay, meaning that there is a 6p/hour difference between new and experienced workers. This differential was 33p in March 2016.

Unstable work conditions (22% of all roles on zero-hours contracts in 2022-23 and 32% of care workers compared to 3.4% of the general labour market) exacerbate the issue. This points to a systemic issue: providers struggle to offer better pay and benefits (sick pay, pensions) due to challenges in funding and commissioning. Notably, homecare has an even higher zero-hour contract rate (43% across all job roles and 51% for care workers). Care workers on zero-hours contracts are more likely to leave (38.2%) compared to a care worker with full time hours (30.1%) which suggests these contracts are not primarily driven by workers' preference for flexibility. 

There are many examples of providers not relying on zero-hours contracts, paying more than statutory sick pay and more than the minimum pension contribution while providing publicly funded care where fee rates are adequate. 

The chart below shows the effect of employment benefits on turnover rates. 

Source: ASC-WDS unweighted data, March 2023.

Pay modelling

Social care worker pay is low, impacting recruitment and retention. Solutions depend on the specific issue (ethics, competition with the NHS and other sectors, attraction and retention). We modelled pay increases for care workers (the largest part of the workforce) but implementation would need to include personal assistants and consider sector-wide impact and the need for differential pay.

We have explored cost-benefit estimates, impacts on recruitment, turnover, savings to the NHS and improved wellbeing. There may be additional savings from reduced training costs and reduced agency staff costs, which are difficult to include in the modelling. It is also important to note that we have not included the financial benefits of people rejoining the wider workforce as a result of extra care capacity, including unpaid carers. More information can be found in the Economic analysis of policy recommendations.

Actual costs and benefits depend on implementation details including funding, who realises the benefits and enforcement. We assume full funding from central government with consideration as part of Fair Cost of Care exercises – but, without it, social care provision might decrease, and the market is likely to be made more unstable.

None of these options are mutually exclusive. A sector-specific minimum wage would make social care more attractive in the labour market, helping to attract more people. A pay scale to recognise development and experience would help to retain people.

It is important to note that the policies proposed are not fully scoped. Therefore, the aim of this work was to provide high-level estimates of likely costs. Where possible, we used assumptions from existing work to estimate the financial costs of introducing the policy recommendations as well as benefits, including wider societal benefits.

Modelling question one: increasing compliance with the National Living Wage and paying for travel time

The problem we are trying to solve

The Low Pay Commission (2020)⁵ suggests that approximately 15% of low-paid social care workers were earning below the National Living Wage (NLW) in 2020 due to non-compliance and enforcement challenges. They state: “A further problem, specific to social care, is that employers are not required to separate out travel time and can therefore potentially mask underpayment. For homecare workers, travel time is usually a significant element of their working time, and the pressure to get from one appointment to another is one of the main ways in which non-compliance can arise.” However, HMRC investigates fewer than 1% of care providers each year.⁶

Modelling

The cost to enforce a minimum wage in adult social care depends on the number of underpaid workers. We estimated this by:

1. Assuming 15% of staff in ASC-WDS were low-paid care workers (care workers, support staff, personal assistants and others) and underpaid.
2. Using Resolution Foundation data (2023)⁷ suggesting underpaid workers earn 3% below minimum wage (accounting for travel time).

We applied this to homecare staff which provided a starting point for calculating enforcement cost based on the estimated number of underpaid workers and the under-payment amount (considering travel time).

Costs

Our analysis suggests that enforcing the 2023 NLW for adult social care workers would cost approximately £42m per year, of which £30m would be paid by the state and £12m by self-funders.

Benefits

Increase in adult social care workforce size: one of the potential benefits is an increase in the supply of adult social care workforce, including both recruitment and retention. There is no consensus in the literature on the size of the elasticity for the adult social care sector (such as how many additional people would become adult social care workers for a 1% increase in wages). Previous research estimates a wage elasticity between 1.6% and 4%.⁸ We present results using a conservative assumption of wage elasticity at 1.6%. Removing the number of people retained, described below, from this figure gives the total number of people recruited.

Wellbeing of people receiving care: as a result of additional adult social care workers recruited, more adults are likely to receive care. Apart from the savings to the NHS, receiving care also improves the wellbeing of adults. In particular, metric '1B: Quality of life of people who use services' included in the Adult Social Care Outcomes Framework measures the impact of social care on the quality of life of people who receive these services. To monetise this wellbeing impact, we used evidence by Stevens et al. (2018) showing that the information in metric 1B can be monetised by applying the monetary value of a Quality-Adjusted Life Year (QALY).

Savings to NHS: due to an increase in the number of people receiving social care services. As a result, a proportion of people receiving care from the NHS (in the absence of the recommendation) can now be accommodated by adult social care services at a reduced cost. We assume that this proportion is equal to the proportion of adults in nursing care compared to all adults in care, as the nursing care population has more intensive needs and would need to receive support in either case. We also calculated a reduction in costs due to avoided injuries. In particular, fewer people would receive social care without the new care social workers recruited, some of which would experience injuries that would be treated by the NHS. To calculate the reduced cost due to avoided injuries, we use evidence from the Health Foundation and Nuffield Trust (2015) showing that 8.2% of all hospital admissions in England come from care home residents. We then apply the average unit cost of hospital admissions, using unit costs for elective and non-elective inpatients from the NHS England National Cost Collection.

Reduced turnover: according to estimates produced by Vadean, F. & Saloniki, E.C. (2023), a 26% increase in pay would reduce turnover by 27% in residential care settings. Similarly, a 23% increase in pay in domiciliary care settings would reduce turnover by 22%. We estimate savings due to reduced turnover based on the cost of recruiting new care workers (as calculated in the Economic analysis of policy recommendations; Care England, 2024).

Value of benefits

• Increase in the adult social care workforce: 7,200 additional people recruited and 650 retained in the workforce over 15 years.
• Improved wellbeing: An increase in the size of workforce will create new care placements leading to £111m in benefits in wellbeing for people in care per year.
• NHS savings: save the NHS £15m per year.
• Savings due to avoided recruitment costs: 650 extra workers would be retained over 15 years will save £0.4m per year in recruitment costs.

How would we do it?

Minimum wage regulations are in place, but enforcement needs improvement. The Kingsmill Review⁹ recommended making commissioners liable with providers for under-payment. The Resolution Foundation lay out the experience of social care workers and the enforcement of employment rights in their 2023 'Who Cares?' report.¹⁰

Modelling question two: a sector minimum wage

The problem we are trying to solve

Evidence shows that, if we want to attract more people into the workforce, we need to differentiate ourselves from the labour market. It shows that, where we pay more than the NLW, we see more people attracted and retained.

Modelling

We modelled the costs and benefits of raising pay to different targets (Real Living Wage, NLW plus £1, NLW plus £2) by multiplying the difference in pay between the target and the current pay. We adjusted for possible under-payment mentioned above, especially for domiciliary care workers. We also factored in maintaining wage differentials for senior staff. We assumed that social care workers with more than three years’ experience would receive an additional £2 per hour.

Costs

We have calculated the total annual cost and benefits and the costs to public finances if we exclude self-payers.

Benefits (15 years)

The benefits are calculated on the full costs above (as opposed to purely costs for the public finances if we exclude self-payers) and modelled over 15 years. It should be noted that the additional people recruited and retained figure does not account for other sectors responding to changes to pay in the adult social care sector. For example, other competing sectors may also increase wages to remain competitive with adult social care wages. Therefore, in practice, the impact on recruitment and retention is likely to be lower than figures presented in this section.

Modelling question three: pay differentials

The problem we are trying to solve

Pay differentials are important in social care:

• Internal differentials: Reward experience and skills within social care to retain staff (for example, senior worker turnover is 15% compared to a new worker 35+%)
• Inter-sector differentials: There is often a call to make social care salaries competitive with other sectors (for example, NHS Agenda for Change) to attract and retain a strong workforce. The Health Foundation has suggested that, when people leave adult social care, they are most likely to move into health roles.¹¹
   

We know that pay differentials within social care have been squeezed. Research by Community Integrated Care (2024) suggests care workers are paid significantly less than their counterparts in the NHS.¹² We have chosen some options to model below but there are different choices and implications for each. Community Integrated Care for example, in their Unfair to Care report, arrived at three different comparisons of a care worker’s pay with their equivalent role in the NHS. They are advocating that the pay rise needed by care and support workers to achieve take-home pay parity with their NHS counterparts is 35.6%.

Modelling

To explore potential solutions, the modelling considers two options for raising the minimum wage in social care, referencing the NHS band three structure (Community Integrated Care, 2024) and recognising pay differentials based on experience:

• Matching NHS band three (under two years): this aligns social care pay with the starting salary of band three NHS workers.
• Matching NHS band three (two-plus years): this aligns social care pay with the higher salary of band three NHS workers with more experience.

The costs associated with each option will be calculated using the previously described methodology.

Costs 

Benefits (15 years)

Social care funding uniquely impacts the labour market. Unlike retail or hospitality, national government, local authorities, employers, and unions all have a role to play in pay policy for adult social care.

International recruitment

The adult social care sector has become increasingly reliant on international recruitment to meet workforce supply challenges. In 2020-21, there were 10,000 new international recruits in social care, but by 2023-24 this had grown to approximately 105,000. One in three new starters in the independent sector were recruited internationally. Most of these were care workers and senior care workers.¹³

International workers are crucial for social care, but visa changes and global competition threaten future recruitment. Alongside pay, international recruitment remains a key short-term lever to boost workforce supply.

This means the sector must improve domestic recruitment and retention to become less reliant on overseas workers. This will take time, as currently international recruitment is significantly bolstering capacity and there is not the immediate domestic supply to replace such significant numbers. In 2023-24, we still had 131,000 vacancies despite welcoming 105,000 international recruits.

Internationally trained staff are vital, but vulnerable to exploitation. We need to support employers with tools and resources to prevent this, which requires the right infrastructure and funding. For deliberate abuse, strong measures are needed to identify and stop it.

Employee relations for non-regulated workforce

The dispersed nature of adult social care with 18,000 providers is a very different structure to its closest and most significant partner, the NHS. This is one of the factors that makes the day-to-day discussions and delivery of good employment practice with some degree of consistency difficult to achieve. Nevertheless, in any sector, a culture of listening to the workforce and seeking to ensure that common concerns and employment practices are considered is one of the ingredients that creates a supported and motivated workforce.

UNISON estimates union membership in adult social care to be around 200,000 people. It is one of the fastest growing sectors for union membership. UNISON and GMB have some national and local recognition agreements with social care employers where they seek to improve the working conditions for care sector staff. Both unions have played a role in advocating for a national Fair Pay Agreement for social care and see themselves as having an important role in this mechanism, should it be implemented. 

UNISON argues that it has a role in shining a light on some of the poorer practice in the sector, including practice that does not meet legal requirements such as adherence to the requirements of national minimum or living wage. It cites examples of highlighting and advocating for best practice as well as representing the views of the workforce. It argues that a developing relationship between commissioners, employers, unions and the Government is essential to provide as a basis for creating the best possible employee relations environment. This currently involves a relatively new Social Care Partnership Forum comprising of the Local Government Association, representative employer organisations and UNISON/GMB. Any future Government may wish to consider whether and how it engages with this forum and facilitate improved partnership working between employers and unions.

Attraction

The social care workforce faces challenges with high personal assistant vacancies, under-representation of men and younger people, a need for new tech skills and a need to harness the benefits of its ethnic diversity. To address this, a multi-partnered, long-term approach is needed to attract personal assistants, under-represented demographics and highlight the workforce’s diversity to become the most inclusive in England. 

Retention

We can keep recruiting more people into social care but, with so many people leaving, we have a leaky bucket. High turnover (28.3% in 2022-23) in social care, especially for care workers (35.6%), nurses (32.6%), and social workers (16.1%), increases costs, disrupts the continuity of people’s support so it is harder to build relationships, and lowers morale.

Five key retention factors are: higher pay, non-zero-hours contracts, full-time work, training access, and relevant qualifications.¹⁴ When all these factors are present, turnover is reduced by half. Combining this with 麻豆原创 research Secrets of Success, the top three retention factors are role quality, learning and development, and organisational culture and leadership.

Turnover is particularly high in the first three months of people starting their role, which makes a focus on improving inductions particularly important (the new national entry-level induction for all health and social care staff was launched in 2024 as a recommendation from the Messenger Review).¹⁵

The NHS has a similar issue with turnover, and it has seen impact with their retention pilots.¹⁶ These initially supported 23 organisations, including providing a People Promise Manager and access to evidence-based interventions such as the Workforce Race Equality Standard, induction for internationally trained colleagues, compassionate leadership and support with terms and conditions reviews. They started with a baseline exercise and then an individual retention improvement plan funded for two years. This successful approach is being scaled in the NHS.

We would expect retention to be affected by other recommendations elsewhere in this Strategy, including pay and training.

Inclusive work culture

We should want diversity in our workforce so that we represent our population, creating the most inclusive workforce in England, attracting and retaining talent through equal access to career development.

Social care is diverse but lacks inclusivity, especially in management where people from ethnic minorities are underrepresented and face discrimination and limited development.¹⁷ The Social Care Workforce Race Equality Standard (SC-WRES) helps local authorities address race inequality by collecting data on key indicators and developing action plans for improvement, promoting race equity, fairness, transparency, morale, care quality and workforce capacity. Its data shows significant racial inequalities - compared to white staff, staff with a minority ethnic background were:

• half as likely to be appointed from a shortlist

• half as likely to be promoted

• 1.5 times more likely to be in disciplinary processes

• more likely to experience bullying and abuse (from colleagues, managers, clients).¹⁸
  

Wellbeing at work

The wellbeing of social care workers is crucial to reduce stress, burnout and improve care quality. Poor wellbeing leads to high vacancies, lower care quality and increased sickness absence (8.1 million days lost in 2022-23)¹⁹, and impacts on the NHS. Equipping the workforce with the right skills and addressing harassment and violence at work can improve wellbeing and safety, aligning with NICE guidance which advocates for organisations to take a strategic, top-down approach to mental wellbeing.²⁰

We have some idea about the wellbeing of parts of our workforce, for example the Local Government Association (LGA) holds the annual employer standards survey for registered social workers and occupational therapists intended to better understand a number of critical questions about the experiences of the social care workforce in England. But we do not regularly survey the broader workforce to understand how they are feeling so there are gaps in our understanding.  

Free NHS health checks are available for everyone aged 40-74 and, if they were taken up more by social care staff, we would expect to see returns due to the demographic make-up of the workforce. Analysis shows a £1.90 socio-economic benefit for every £1 invested in promoting these checks.