This policy primer discusses the challenge of the growing demand for social care for older people and the role of migrant care workers. It considers the tensions between social care and immigration policies in tackling this challenge.
- The issue: Are migrant workers needed to address labour shortages in social care?
- The growing demand for social care services
- The state of the debate in the UK: social care providers demand better access to migrant labour
- The growing reliance on migrant care workers
- What is driving demand for migrant workers in social care?
- Staffing pressures impact on the quality of care
- Addressing the challenge: the tensions between immigration and social care policies
The ageing of the population in the UK and in other western countries presents major challenges for public policy. Social care for older people – including care in nursing and residential homes and home care services – faces increasing demand. The implications for the reform of the social care system have been the focus of ongoing policy debate in the UK (Wanless 2006, HM Government 2009, Department of Health 2010). A fundamental concern for meeting the needs of older people, now and in the future, is the workforce required to deliver social care services.
“Chronic difficulties” in the recruitment and retention of social care workers have been identified, which impact both on the capacity of the sector to deliver services and on the quality of care support (Commission for Social Care Inspection 2005: 178). Social care, which includes a range of care-related occupations, e.g. care assistants in residential care homes and in home care services, is one of the lowest paid sectors of the labour market (Low Pay Commission 2010). The sector has historically been reliant on women, who have combined low paid part-time work in social care with unpaid caring responsibilities for families (Moriarty 2010). Although the introduction of the National Minimum Wage in 1999 brought about an increase in average pay levels for social care workers, particularly in care homes, most pay has since stayed on or near the National Minimum Wage (Hussein 2010).
Increasingly, migrant workers are being employed to care for older people. This trend is taking place in other European countries, such as Austria (Österle and Hammer 2007), Ireland (Walsh and O’Shea 2009) and Italy (Bettio et al. 2006), and in North America (Bourgeault et al. 2010). In the UK, social care providers have turned to recruitment within and outside the European Union as a means of filling their vacancies for care workers (Cangiano et al. 2009, Hussein et al. 2010). Likewise, migrants in the UK have entered social care work because of high levels of demand for workers in this sector of the labour market (Cangiano et al. 2009).
These developments point to the following key issues for public policy:
- What should be done to tackle the workforce challenges facing the social care sector?
- Are migrant workers a solution to those challenges?
In the second half of the twentieth century, demographic ageing reached unprecedented levels in the UK as well as in other western countries. This trend is expected to continue for the foreseeable future. According to population estimates and projections, the number of people aged 65 and over in England will increase by 65% from 8.2 million to 13.4 million between 2007 and 2032. There is likely to be an even greater increase of 136% among those aged 85 and over (Wittenberg et al. 2010: 15). This growth in the number of older people, which includes people with disabilities or long-term health conditions, has major implications for demand for social care services.
The provision of care for older people relies on both the unpaid care of families and other carers alongside publicly and privately funded social care services. Social care services are mainly arranged by local authorities, through funding from central government supplemented by revenue from council tax, other local sources and by charges that older people are asked to pay for services (Forder and Fernández 2010). The majority of services are delivered by private and voluntary sector organisations contracted by local authorities. There has, however, been increasing emphasis in policy on the use of personal budgets and direct payments, which give care users the option of arranging their own provision, including directly employing their care workers.
Older people’s access to publicly funded provision is assessed by local authorities on the basis of an individual’s care-related needs as well as their income (i.e. ability to pay). Local authorities set their own criteria regarding needs. Increasingly, eligibility has been restricted to older people with higher levels of assessed needs (CSCI 2008a).
Projections of future demand for care estimate that, under current care patterns, expenditure on social care would have to nearly double from 1.4% of GDP in 2007 to 2.7% by 2032 to meet increased demand for social care and rising real unit costs of care. The model also projects that the social care workforce caring for older people would need to increase by 79% (Wittenburg et al. 2010: 15).
Growing demand for care and the cost implications raise considerable concerns. Evidence suggests that there is already a shortfall in social care provision for older people. The former Commission for Social Care Inspection estimated that the number of households receiving home care support in England declined between 1997 and 2006 (from 479,000 to 358,000) as a result of local authorities tightening their criteria for assessing eligibility for public provision (CSCI 2008a: 188). There is also evidence of significant difficulties in the recruitment and retention of social care workers (Care Quality Commission 2010). Vacancy rates in England in social care work are estimated to be double the average for all types of industrial, commercial and public employment (Eborall and Griffiths 2008; Eborall et al. 2010). Vacancies for occupations that fall under the SOC 2000 classification ‘care assistants and home carers’ have more than doubled over the past five years (July 2005 to December 2009), indicating that the social care workforce is expanding (Eborall et al. 2010: 99). Turnover in social care jobs is also higher than in most other occupations but varies across the social care sector. Data for 2009 show that in England it is higher for care workers in the private sector (24.2%) compared with the voluntary sector (17.6%) (Eborall et al. 2010: 102).
The workforce implications of growing demand for social care and the need to address recruitment and retention difficulties was acknowledged in the previous Labour government’s strategy for the adult social care workforce in England, Working to Put People First (Department of Health 2009). The current Conservative-Liberal Democrat government’s Vision for Adult Social Care, published in November 2010, similarly acknowledges the need for “renewed work with employers to improve recruitment and retention within the sector” (Department of Health 2010: 35).
Over recent years, the former Commission for Social Care Inspection, now the Care Quality Commission, has emphasised the impact of poor pay and conditions on these staffing problems in the sector (CSCI 2005). Social care providers – predominantly private and voluntary sector organisations contracted by local authorities – have argued that low levels of pay reflect the underfunding of social care and the low levels of fees paid to contracted providers by local authorities. The Low Pay Commission has continued to underline the importance of ensuring that the commissioning of services by local authorities reflects the actual costs of care, including the National Minimum Wage (Low Pay Commission 2010). At the same time, the future impact of major cuts in local authority budgets raises considerable concerns regarding the funding of the sector and its capacity to increase pay levels (Audit Commission 2010, Low Pay Commission 2010).
Faced with difficulties in attracting UK-born workers to the sector at current pay rates, social care providers have argued that they are reliant on migrant workers, including workers from the ‘A8’ (the Central and Eastern European countries that joined the European Union in 2004) and those from outside the EU (UK Home Care Association 2008). Prior to the introduction of the points-based system in 2008, work permits could be obtained for ‘senior care workers’ from outside the EU and for other types of health and social care workers (e.g. nurses in nursing care homes). The former Working Holiday Maker Scheme also provided a means of recruiting non-EU workers. Other groups of migrants, e.g. those holding domestic worker or student visas, could also be legally recruited from within the UK in care work, according to the terms of those visas.
The points-based system has limited the recruitment of non-EU workers in the UK labour market to those categorised as ‘skilled’ workers. There is no means for recruitment for social care occupations categorised as ‘low-skilled’ (e.g. care assistants in residential care homes). Senior care workers are identified on the Shortage Occupation List under Tier 2 of the system and can apply to work in the UK for employers who are licensed ‘sponsors’. However, the introduction of an interim cap on non-EU workers, as part of the government’s plans to reduce the number of non-EU workers entering the UK, has restricted recruitment (see the policy primer on ‘Responding to Employers: Labour Shortages and Immigration Policy’). The social care sector has argued that this cap has resulted in sponsorship licenses being removed from social care providers, limiting the ability of the sector to recruit senior care workers from outside the EU and leaving the sector “struggling with staff shortages” (Clews, 2010). The English Community Care Association, which represents providers in England, initiated a judicial review of this policy. More recently, the Migration Advisory Committee recommended that senior care workers be removed from the list of shortage occupations.
In addition to a cap on non-EU workers entering the UK, the government intends to reduce the number of other non-EU migrants entering the UK, including students, which may also have implications for the recruitment of other groups of migrants to the social care sector.
‘Migrant’ workers are identified using different data sources as foreign-born workers, foreign-nationals and according to their length of stay in the UK (see the briefing on ‘Who Counts as a Migrant: Definitions and their Consequences‘).
Evidence indicates that foreign-born workers make up a growing proportion of the social care workforce (Cangiano et al. 2009). Labour Force Survey (LFS) data on care workers employed in occupations classified under ‘care assistants and home carers’, presented in figure 1, show that between 2001 and 2009 the proportion of foreign-born care workers more than doubled – from about 7% in 2001 to 18% in 2009 (Cangiano and Shutes 2010). The proportion of foreign-born workers in employment in the UK overall increased from 8.4% to 12.9% during the same period. Of the current stock of foreign-born care workers, the majority entered the UK over the past decade (during or since 1998). This growth of the foreign-born share of care workers occurred as a result of a rapid expansion of foreign-born care workers – from about 40 thousand in 2001 to just under 130 thousand workers in 2009 – and despite the increase in the number of UK-born care workers over the same period (Cangiano and Shutes 2010).
Figure 1. Numbers of UK-born and foreign-born care workers in the UK and percentages of foreign-born care workers, 2001-2009
However, within the UK there is considerable regional variation, with foreign-born workers comprising around 60% of care workers in London compared with less than 10% in the North East of England, Scotland and Wales (Cangiano et al. 2009: 72).
As is the case for the social care workforce overall, the majority of foreign-born care workers are women (76% compared with 87% of UK-born care workers, according to LFS estimates) (Cangiano et al. 2009: 67). The main countries of origin of foreign-born care workers include Poland, the Philippines, Zimbabwe, India and Nigeria, which partly reflects the post-colonial relations and migration policies of the UK and these countries, and the enlargement of the EU to Central and Eastern Europe in 2004.
Data on the nationality and length of stay of foreign-born care workers provide a more detailed picture of the ‘migrant’ social care workforce. LFS estimates suggest that 28% of foreign-born care workers are UK citizens and 20% are nationals of other EU countries, who have unrestricted rights to work in the UK (Cangiano et al. 2009). Therefore, just over half of foreign-born care workers are non-EU nationals. According to the LFS data, around four in ten foreign-born care workers (38%) are non-EU nationals who have been in the UK for four or fewer years. The National Minimum Data Set for Social Care is currently collecting data on the social care workforce, which will provide more detailed information on foreign-born care workers according to the nationality of workers.
As regards EU nationals from the A8 countries, the data in figure 1 suggest that they contributed to the increase in the foreign-born care workforce that can be observed post EU enlargement (since 2004). However, data from the Worker Registration Scheme (under which workers from the A8 countries are required to register) show that registrations of care assistants are in decline from a peak of just under two thousand registrations in the third quarter of 2005 to just above 500 registrations in the first quarter of 2009 (Cangiano et al. 2009: 61).
Although data on the immigration status of non-EU nationals is not available, administrative data on work permits for senior care workers indicate that 23,300 were issued between 2001 and 2007 (Cangiano et al. 2009: 66). Data obtained through research carried out by COMPAS on the employment of migrant care workers (see Cangiano et al. 2009) – which included a survey of social care providers, interviews with migrant care workers and focus groups with care users – indicate that, in addition to work permit holders, non-EU nationals include students, domestic workers, working holiday makers, asylum seekers and refugees. The data were collected between June 2007 and June 2008 (before the points-based system had been fully implemented).
The above data indicate that the majority of foreign-born care workers are non-EU nationals – though the introduction of the points-based system and the cap on applicants under Tier 2 may be affecting the number of non-EU nationals working in social care.
Social care work remains one of the lowest paid sectors of the labour market (Low Pay Commission 2010). According to recent data obtained by the National Minimum Data Set for Social Care, the median hourly pay rate for care workers during 2009 was £6.45 (Hussein 2010: 6). The National Minimum Wage for adult workers (October 2009) was £5.80. Pay levels in social care work are lower in the private sector compared with local authorities and the voluntary sector. Being paid at or below the National Minimum wage is more prevalent in the private sector in social care (Hussein 2010), which is true for the private sector overall in the UK (Low Pay Commission 2010). Low levels of pay are associated with the gendered status of care work: in 2009 women made up around 80% of social care workers and between 85 and 95% of workers in direct care and support providing jobs (Eborall et al. 2010: 10). Despite the importance of social care work to meeting the care needs of older people, low levels of pay, the low status and gendered assumptions about the nature of the work, unfavourable employment conditions such as shift work and lack of career opportunities have made it unattractive to a range of groups of potential workers in the UK (Moriarty 2010).
These factors underlie the recruitment difficulties in the social care sector that have driven demand for migrant workers among providers. In the COMPAS survey of providers – nursing and residential care homes and home care providers (82% of which were private sector, 15% voluntary sector and 3% local authority providers) – just under half of the providers reported difficulties in recruiting UK-born care workers and 58% reported difficulties recruiting nurses. (Cangiano et al. 2009: 91). Providers identified low pay as the main reason for these difficulties. Eighty seven per cent agreed that UK-born workers can earn more in other jobs and 74% that UK-born workers demand higher wages than those paid in social care (Cangiano et al. 2009: 92). In follow-up interviews with providers, low levels of pay were attributed to the low levels of fees paid to providers contracted by local authorities to deliver social care. Other difficulties in employing UK-born workers identified by at least two-thirds of providers were: the unwillingness among UK-born workers to do shift work; the likelihood that UK-born workers will leave the job; and the lack of the right work experience.
The role of migrant labour in filling low-waged jobs in social care is reflected in the pay levels of migrant workers. Foreign-born workers appear to be concentrated in the lowest paid care jobs, within a sector marked by low levels of pay overall. The LFS data suggest that foreign-born care workers (who entered the UK since 1998) are over-represented at the lower end of the pay scale compared with their UK-born counterparts: 42% earn less than £6 per hour (before taxes) compared with 31% of UK-born care workers (Cangiano et al. 2009: 82). They are also more strongly concentrated in the private sector where, as noted earlier, pay levels are lower compared with local authorities and the voluntary sector: 79% are employed by a private sector organisation compared with just above half of UK-born care workers (Cangiano et al. 2009: 74).
While employers sometimes refer to migrant workers as the only pool of workers applying for their vacancies, they may also consider there to be advantages to employing migrant care workers. Among social care providers, these advantages include migrant workers’ willingness to work all shifts, to learn new skills, and their ‘good work ethic’ (Cangiano et al. 2009). Some of the perceived advantages of employing migrant care workers indicated by providers are reflected in working patterns. Over 30% of foreign-born care workers work more than 40 hours a week, compared with 18% of UK-born care workers. Slightly higher proportions of foreign-born care workers do shift-work (74%) compared with UK-born care workers (60%) (Cangiano et al. 2009: 81). Indeed, migrant care workers interviewed in the COMPAS research indicated that their managers relied on them to work overtime and to work less favourable shifts compared with UK-born workers in order to address staffing gaps. There is also evidence of some migrant workers being employed in social care occupations that do not reflect their level of qualifications and experience, e.g. those with nursing backgrounds working as care assistants, providing a source of skilled labour at commensurably lower levels of pay.
These advantages may be partly associated with the restricted rights of non-EU workers. For example, the ‘good work ethic’ of work permit holders may be influenced by the fact that they are dependent on their employer for their work permit and, therefore, their right to work and remain in the UK. Likewise, migrant workers who do not have family members with them in the UK may be more ‘willing’ to work longer hours and to work all shifts. Restrictions on entry to particular occupations, e.g. nursing, may also facilitate the retention of workers in lower grade and lower paid positions.
Employers that are reliant on migrant workers as a source of low-waged labour may adopt other tactics to contain their labour costs. In social care, there is evidence of unlawful conditions of employment experienced by some migrant care workers, though it is not possible to determine the extent of these practices (Anderson and Rogaly 2005, Cangiano et al. 2009, Gordolan and Lalani 2009, Wilkinson et al. 2010). These experiences include wages being withheld by employers, including care homes, home care agencies and individuals and their families who are directly employing migrant care workers. Care workers without permission to work in the UK are particularly vulnerable to exploitation due to fear and insecurity surrounding their immigration status. However, care workers who are legally entitled to work in the UK, e.g. those holding work permits or domestic worker visas, are also highly dependent on their employers through the terms and conditions of their immigration status. Migrant care workers employed directly by individuals and their families in private households face particular issues regarding the lack of regulation of their employment.
The recruitment of migrant workers also presents challenges for social care providers. In the COMPAS research, limited English language proficiency was most frequently identified by providers (by 66%) regarding the challenges of employing migrant care workers. In addition, race discrimination towards migrant care workers by care users (as well as by employers and co-workers) poses tensions between demand for low-waged migrant labour and the preferences of individual users regarding who delivers their care.
Labour shortages in social care are not simply an issue of concern to employers. Staffing pressures in social care directly impact on the quality of care provided to older people (CSCI 2005). A number of studies have identified the impact of staff shortages, workload demands and time pressures facing care workers on poor standards of care (CSCI 2008b). These constraints are also experienced by migrant care workers. Staff shortages in care homes, insufficient time allocated to home care visits and related workload pressures were found to limit the time available to migrant care workers to interact and talk with care users, a crucial aspect of the quality of care (Cangiano and Shutes 2010). It also affected other minimum standards, e.g. concerning the inadequate personal care of residents in care homes, the responsibilities of nurses for medication being delegated to care assistants, and staff handovers not being carried out.
The long-standing issue of the underfunding of social care, despite increased funding over recent years, is at the heart of the challenge of meeting the care needs of an ageing population. Current cuts in public spending in the UK are likely to further constrain the allocation by local authorities of adequate levels of funding to social care (Audit Commission 2010). Ongoing constraints on funding and growing demand for social care may lead to increasing pressures to ration older people’s access to publicly funded care. Given the direction of social care policy towards the use of personal budgets and direct payments, those pressures for cost containment will also be transferred to users who directly purchase their care and employ their care workers. Older people may have to rely increasingly on privately funding their care as well as on so-called informal, unpaid support. The type of public provision – the provision of services or the provision of cash transfers to older people – alongside the contribution of private funding, will affect the future structure of the social care market. Pressures for cost containment within that market have implications for any improvements in pay and conditions for care workers in the future and, therefore, for the potential expansion of the social care workforce.
The question that remains is who will contribute to that workforce? As regards UK-born workers, the rise in the level of unemployment in the UK may, in the short term, be expected to expand the potential pool of workers available to the social care sector. However, the number of UK-born workers entering social care will have to expand considerably to match the growth in the number of older people over the long term. This raises issues not only regarding pay levels, training and recruitment but the gendered low status of caring for older people and the ability of the sector to attract a broader range of potential workers, including men. In the absence of any step-change in the recruitment of UK-born workers in social care, the social care sector will potentially continue to rely on migrant workers. Whether this is a viable or equitable option in tackling the workforce challenges facing social care in the short and long term is highly debatable. As regards EU workers, the evidence suggests that the number of EU nationals entering care work in the UK (based on Worker Registration Scheme registrations) may currently be in decline. As regards non-EU workers, immigration policy in the UK aims to restrict the entry of non-EU migrant workers to the UK, targeting skilled occupations, and to restrict the entry of other categories of migrants, e.g. students. This will place limits on the extent to which social care providers can draw upon non-EU workers as a source of labour to carry out so-called ‘low-skilled’ work in caring for older people. In the long-term, these restrictions may increase efforts to recruit other workers within the UK. However, if the social care workforce is to nearly double in size to meet the needs of a growing older population, policy will need to rapidly address the factors that underlie recruitment and retention difficulties in social care.
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Financial Times (26 May 2016)
Public services experts blame strains on austerity, not an influx of migrants
- Financial Times (26 May 2016)