- Significant workforce issues around adult social care have gained greater prominence as the coronavirus (COVID-19) pandemic has unfolded. Even before the pandemic, workforce issues were identified as the single biggest challenge for the sector. As decisions about social care are driven as much by local authorities as by national policy, regional differences need to be accounted for by policymakers. This analysis focuses on the social care workforce in London, which differs in many respects from other regions in England.
- London has a significantly higher proportion of its social care workforce employed on zero-hours contracts (41%) than the England average (24%) and this gap has widened since 2012/13. The relatively high proportion of domiciliary care jobs in London (53%, compared to an England average of 42%) is a possible driver of this trend.
- Migrant workers play a key role in delivering social care services in the capital, with nearly two-fifths (38%) of London’s adult social care workforce estimated to be non-British nationals in 2018/19 (more than double the England average of 17%). Care in the capital risks being disproportionately affected by current proposals for the post-Brexit immigration system.
- Low and stagnant pay rates, both before and after adjusting for price inflation, also remain a concern for the social care workforce in London. The National Living Wage has helped prop up pay, particularly for the lowest paid independent sector care workers. However, if we use the cost of living adjusted ‘real’ living wage as a measure, the average earnings of independent sector care workers are further below the benchmark in London than in other regions.
The COVID-19 pandemic has raised awareness of a number of issues around adult social care in the UK. The government acknowledged the vital contribution of the sector during the pandemic in an action plan issued in April. Long before COVID-19 struck, however, the sector faced longstanding funding and workforce challenges, including poor pay, high staff turnover and vacancy rates and a relatively heavy reliance on zero-hours contracts. While central government has an important role to play in tackling these issues, recent Health Foundation research points to regional variations being highly relevant in developing a long-term coordinated approach to health and social care workforce planning.
Adult social care funding is driven as much by local authorities as by national policy, with care being provided by an estimated 18,200 private, charitable and state organisations employing 1.5 million people in England in 2019. The COVID-19 pandemic has been marked not only by variations in the regional spread of the pandemic in care homes, but also by regional policy implementation and impacts being different due to local contextual variation. Therefore, to deliver lasting solutions to long-running workforce issues, government policy must account for these regional differences.
This analysis focuses on the adult social care workforce in London. The capital is an important case study: it has almost nine million residents – one-sixth (16%) of England’s population – and its population density is more than 13 times the national average. London also has a more ethnically diverse population than the rest of the country with 2011 census data showing that just over 40% of London’s population was black and minority ethnic, compared to 14% for the England and Wales population.
In terms of the adult social care workforce (hereafter, the ‘care workforce’), London plays a significant role and accounted for around 14% (232,000) of adult social care jobs in England in 2018/19, a close second only to the South East region. The proportion of the London care workforce on zero-hours contracts in 2018/19 (41%) was much higher than for England (24%), which is indicative of a greater degree of work insecurity in the capital. Government policies on zero-hours contracts and working conditions have a crucial role to play in promoting job security.
London had a significantly more diverse care workforce than the rest of England in 2018/19 in terms of both ethnicity (67% being black and minority ethnic relative to the England average of 21%) and nationality (25% non-EU (non-British) and 14% EU, relative to the corresponding England averages of 10% and 8%).
There are also signs that social care demand patterns in the capital are distinctive for several reasons. Admission rates to nursing and residential homes are generally lower in London than in other regions. London has the lowest number of care home beds per 100,000 people aged 85 years and older. Further, London has the lowest proportion of people in care who are fully self-funded and the highest proportion who are fully funded by the local authority. COVID-19 brought London’s residential care sector to the fore, with the capital estimated to have had more deaths per care home bed than any other region. Another recent study found that care home resident infection rates in London during the COVID-19 pandemic were higher than all other regions in England, apart from the West Midlands, although care home staff in London had lower risks of infection relative to other regions in England (after controlling for relevant variables such as care home size, whether sick pay was offered, PPE usage and staff training levels).
In spite of these distinctive workforce and demand patterns, which imply that some national policies are likely to have a disproportionate effect on the capital, the London care workforce has received little focused attention in academic and wider literature. A 2015 report from London Councils highlighted the capital’s specific funding requirements in the medium term. Skills for Care have produced annual reports that provide a useful summary of key regional workforce characteristics and this analysis draws on their data for London. Otherwise, there is much scope for further research.
Skills for Care provides some useful definitions and explanations of key terms (such as direct care, residential care and domiciliary care) used in this analysis.
How does London’s social care workforce differ from other regions?
Skills for Care estimates that London had about 232,000 adult social care jobs in 2018/19, with 213,000 people working in the sector. The London care workforce largely mirrors national averages, in terms of three-quarters of roles being in direct care and the dominance of the independent sector (77% of jobs in London relative to 78% across England). Skills for Care data indicate that women account for 81% of the care workforce in London, which is very similar to the corresponding figure for England (83%).
Local authorities account for only 5% of social care jobs in London (compared to 7% across England). NHS staff and staff who are directly paid by individuals receiving care account for the remainder (17%) of London’s care workforce (15% across England), but relatively little is known about this segment of the workforce. Here, we focus on only adult social care staff employed by local authorities and the independent sector in London.
Despite the general workforce similarities to national averages, there are several defining factors that make London’s care workforce quite different to other regions in England.
The share of adult social care jobs on temporary contracts is higher in London (7%) than in other regions (the figure for England is 3%). This also applies to bank or pool and agency staff (8% of London’s care workforce, as opposed to 5% for England), which points to a greater degree of staffing shortfalls in London relative to elsewhere.
Alongside its relatively high reliance on temporary contracts, bank or pool and agency staff, London’s care workforce stands out for having a significantly higher share of zero-hours contract jobs (41% in 2018/19) than any other region in England (where the average was 24%, with no other region exceeding 26%).
Figure 1a shows how the zero-hours contracts share has increased in London since 2012/13, even as most other regions have registered lower or largely unchanged shares of zero-hours contract jobs. This does not reflect a generally higher prevalence of zero-hours contracts in the economy. ONS data indicate that only 2.5% (2.6% across England) of all people employed in London in 2018/19 were on zero-hours contracts (Figure 1b).
Employers are not required to offer minimum working hours to staff on zero-hours contracts. As a result, zero-hours contracts can sometimes provide flexibility to providers facing volatile service demands, increased staff turnover, staff shortages or to employees who wish to work around family and other commitments. However, zero-hours contracts can also result in insecure work and reduced certainty regarding work hours and earnings from an employee perspective. Further research is needed into the factors underlying London’s increasing zero-hours adult social care contracts trend.
The relatively high proportion of domiciliary care jobs in London is a possible structural driver of the rising zero-hours contracts trend. Domiciliary care providers account for around 53% of adult social care jobs in London as opposed to 42% across England (Figure 2). This anomaly may be partly rooted in home care being less expensive to provide, and therefore more widely available, in urban areas (such as London) due to lower transport costs.
In theory, at least, domiciliary care providers are likely to find zero-hours contracts more appealing. One study has linked zero-hours contracts to higher stress levels for domiciliary care workers in the West Midlands, due to workers feeling they have less bargaining power over their pay and working conditions in relation to their employer. Two-thirds (67%) of domiciliary care roles in London (relative to 50% in England) were on zero-hours contracts in 2018/19.
These figures have implications for policy. For example, the Welsh government moved to curb zero-hours contracts in domiciliary care in Wales in 2018, after research suggested that well over 50% of workers in the sector were on such contracts. Stakeholder input suggested that there had been an increase in the use of these contracts in Wales when local authorities had outsourced home care services, with competitive tendering driving reductions in the prices paid for outsourced home care.
Staff vacancies and turnover
London had the highest regional adult social care vacancy rate of 9.3% in 2018/19 (relative to 7.8% across England). This was particularly visible for regulated professional roles (a vacancy rate of 11.6% in London and 9.4% across England) and direct care roles (a vacancy rate of 10.2% in London and 8.5% across England). More recently, London was the only region to record an increased vacancy rate in England in the COVID-19 period (over February 2020 – June 2020), with every other region registering lower vacancy rates. Research indicates that increased vacancy rates are associated with poorer standards of care.
Although London’s adult social care staff turnover rate was lower than the other regions in England in 2018/19 (27.5% relative to 36.0% in England), a higher proportion of adult social care job leavers in the capital left the sector relative to other regions. In particular, the NHS is likely to be a stronger ‘magnet’ for adult social care job leavers in London than in other regions, with 20% moving to the health sector in London (as opposed to 14% in England as a whole).
Both vacancy and staff turnover rates in London’s domiciliary adult social care sector were above average in 2018/19 (the vacancy rate being 12% and staff turnover rate 30%). This hints at the higher prevalence of zero-hours contracts in the sector being more a marker of insecure work rather than labour market flexibility, although further research on this is required.
Diversity of the workforce
London’s care workforce is also considerably more diverse than the rest of the country in terms of ethnicity and nationality. Skills for Care statistics for 2018/19 suggest that London had a much higher share of black and minority ethnic group workers in adult social care jobs. These groups accounted for as many as two-thirds (67%) of adult social care jobs in London, much more than other regions in England (the England average being 21%) – even accounting for differences in the black and minority ethnic share of the overall population (40% in London relative to 14% across England). In particular, ethnic minority groups accounted for nearly three-quarters (72%) of direct care roles in the capital, with the West Midlands being a distant second at 23%.
Migrant workers play an important role in delivering adults social care services in the capital, with nearly two-fifths (38%) of London’s care workforce estimated to be non-British nationals in 2018/19, compared to an average of 17% across England. In every other region, migrant workers accounted for less than 20% of adult social care jobs. Among all migrant workers, workers reporting non-EU (non-British) nationalities held a higher share of London’s adult social care jobs (25%, Figure 3) than those of EU nationality in 2018/19 (14%). However, while EU workers have accounted for a rising share of adult social care jobs in London since 2012/13, the share of roles carried out by non-EU (non-British) workers in London declined from 35% in 2012/13 to 25% in 2018/19 (Figure 3). These trends are in line with their national counterparts, although the gap between the non-EU (non-British) and EU worker shares is considerably higher in London than in other regions.
As at 20 August 2020, the Immigration and Social Security Co-ordination (EU Withdrawal) Bill 2019-21 had been approved by the House of Commons and was under consideration by the House of Lords. The Bill poses a challenge to the supply of workers from the EU, as it seeks to end the current system of freedom of movement between the UK and the EU. In place of this, a new points-based immigration system for people moving to the UK from both EU and non-EU countries will be put in place in January 2021. At the time of writing, care workers and home carers from both EU and non-EU countries are also not eligible for work visas under this proposed new immigration regime. In light of the capital’s relatively heavy reliance on migrant social care workers, this looms as a particularly concerning issue for care services in London.
What about pay?
Adult social care has long been a poorly remunerated occupation in England. While staff costs have been estimated to account for over half of overall costs for homecare, residential and nursing care providers alike, low pay rates remain a major concern relative to comparable sectors. Evidence points towards care workers’ pay having risen more slowly relative to other low-paying roles (such as sales and retail assistants, cleaners and domestic help) since 2012/13.
The National Living Wage (NLW) is a relevant benchmark to consider for hourly pay rates, as it is government mandated for all employees aged 25 years and over in the UK (apart from a very small number in their first year of apprenticeship) and 94% of London’s care workforce is aged 25 and over (relative to 91% across England). Prior to the introduction of the National Living Wage in 2016, the same National Minimum Wage (NMW) rate applied to all UK employees aged 21 years and over.
An alternative benchmark for hourly pay is the voluntary ‘real’ living wage proposed by the Living Wage Foundation, which is an independent measure of minimum pay that aims to account for basic living costs. In 2018/19, this ‘real’ living wage was set at £10.55 per hour for London and £9.00 per hour for the rest of the UK (the differential rate being because of higher living costs in the capital).
Figure 4 shows how median hourly adult social care pay rates in both London and England as a whole have increased very slowly since 2012/13 both in nominal or current price terms (not accounting for inflation), just managing to stay above the national living wage and national minimum wage rates (which are also set in current prices). Skills for Care provide data on nominal and real term median hourly pay rates in adult social care. The nominal rates capture median pay levels in current prices (that is, at the time of data collection), while the real term rates account for inflation as measured by the Consumer Prices Index.
In 2018/19, median nominal hourly pay for care workers in London’s independent sector was £8.52, just 69 pence more than the National Living Wage of £7.83 per hour in that year (Figure 4). If we ignore inflation and living costs, the London median hourly rate of £8.52 for independent sector care workers in 2018/19 was the highest in England, and London and the South East region registered the highest regional shares (82%) of care workers being paid above the National Living Wage.
The Low Pay Commission (LPC) estimates that the proportion of workers across all sectors covered by the national living wage in London in 2019 (4.1%) was lower than for other regions (UK average 6.6%). Notwithstanding these relatively low National Living Wage coverage rates in London, research by Vadean and Allan (2017) and Datta et al (2018) suggests that the introduction of the National Living Wage in 2016 was associated with an increased prevalence of zero-hours contracts in social (particularly domiciliary) care. This may help to explain the increased use of zero-hours contracts in London over the past few years, as discussed earlier.
Slow growth in care workers’ pay is more starkly visible when we examine pay increases net of inflation (price increases) or living costs. This matters because price levels on average tend to be higher in London than in other regions. In 2016, for example, ONS data suggested that London consumer prices were on average 7% higher than the UK average, and this held across nearly all ten categories in a representative basket of consumer goods and services.
After accounting for inflation (by using the official Consumer Prices Index measure), Skills for Care estimate that the median care worker in London’s independent sector earned only 65 pence more per hour in 2018/19 than in 2012/13 (Figure 5). The inflation-adjusted median hourly care worker pay rate in London in 2018/19 (Figure 5) was nearly 20% less than the voluntary ‘real’ London living wage rate of £10.55 per hour, while the corresponding gap for other regions was on average significantly less at 12%. In other words, if we use the ‘real’ living wage as a measure, the average earnings of independent sector care workers are further below the benchmark in London than in other regions. With approximately 90% of care workers across England estimated to be earning below the voluntary ‘real’ living wage in 2018/19, this is a cause for concern.
Underpayment relative to the National Living Wage also remains an issue for social care. Research undertaken by the LPC has highlighted that among 101,000 social care workers covered by the National Living Wage in 2019, 15,000 (15%) were underpaid (paid below the National Living Wage rate). While this fraction is less than the estimate for the economy as a whole (22%), a more serious issue was that among low-paying occupations, social care had one of the highest shares (40%) of underpaid workers paid even beneath the previous year’s National Living Wage. This indicates a relatively high likelihood that underpaying employers are disregarding the National Living Wage requirement (as opposed to making minor calculation errors or responding to national living wage increases after a small delay).
The LPC recommended that while the Social Care Compliance Scheme, which closed on 31 December 2018, had helped a number of underpaid workers receive pay arrears, the government should take more responsibility to deliver higher National Living Wage targets in sectors such as social care, where it accounts for a lion’s share of funding.
This research highlights the relevance of regional differences in employment and pay patterns in adult social care in England. The case study of London underlines the need for a coordinated national workforce strategy in health and social care, which accounts for regional and local variation.
London’s social care workforce is distinct on a number of fronts, most visibly by its high share of zero-hours contracts, domiciliary care jobs and migrant workers, compared to other regions. The rising prevalence of zero-hours contracts is a major concern as it points to providers and councils in the capital passing on the pressures engendered by sustained funding squeezes to a poorly paid workforce.
London also has the highest social care vacancy rate and the highest social care migrant worker share in England. But without a sector-specific visa route enabling international recruitment into social care, the proposed post-Brexit immigration system will make it much harder to recruit people from the EU to work in social care in the UK. The government’s new Health and Care Visa does not cover the majority of the social care workforce (with care workers and home carers excluded from the list of qualifying health and social care occupations). Care in the capital is at risk of being disproportionately affected.
While there is room for more research, this analysis presents a concerning picture for the social care workforce and, more generally, for the delivery of care services in London. The government needs to deliver through more thoughtful regional workforce policy and planning in both health and social care. As the LPC has recommended, it also needs to consider carefully the mechanisms through which it can increase the likelihood of well-intentioned ambitious increases in the National Living Wage reaching the pockets of a care workforce that has long been undervalued and underpaid.
The author gratefully acknowledges input provided by Omar Idriss, Elaine Kelly, Anita Charlesworth, Claudia Barclay, Lucinda Allen, Sean Agass, Pete Stilwell, Joshua Kraindler and Ben Gershlick.
This research is based largely on the Health Foundation’s analysis of data obtained from Skills for Care, who compile data and report on the adult social care sector and workforce in England each year. The Skills for Care data are collected online at the provider and worker level, with individual providers responding to an online survey. Our analysis uses 2012/13–2018/19 data from Skills for Care’s Adult Social Care Workforce Data Set, which was known as the National Minimum Data Set for Social Care until 2019.
The data cover all local authorities in England as direct employers, in addition to around 55% of Care Quality Commission-regulated social care establishments in England (42% in London). Around half of the adult social care workforce in England is covered (40% in London), with Skills for Care using weights to derive estimates that are nationally representative. Complementary data sources include ONS data and in particular the Labour Force Survey.
Health Foundation @HealthFdn
What can be done to improve NHS Test and Trace? @ADMBriggs discusses the role of local contact tracing in a new… https://t.co/sIS2Wg8qKvFollow us on Twitter
Work with us
We look for talented and passionate individuals as everyone at the Health Foundation has an important role to play.View current vacancies
The Q community
Q is an initiative connecting people with improvement expertise across the UK.Find out more