Let’s start with the good news, such as it is. The immigration white paper published on Monday re-affirms the government’s commitment to a “fair pay agreement” to improve the terrible pay and conditions faced by care workers. This cannot come soon enough, but whether it will be sufficient, alongside withdrawal of the social care visa, to avoid a social care staffing crisis is another question.
London is at the sharp end, as the Skills for Care dashboard shows. The capital has the highest care worker vacancy rates in England: 11 per cent compared to an average of eight per cent across the country, with vacancies highest in the “independent” sector (that is, not directly employed by the NHS or local authorities), which accounts for four fifths of the city’s 250,000 adult social care workers.
These include workers in care homes, nursing homes and ‘domiciliary’ carers who visit mainly elderly clients (precise numbers are hard to come by, but around 60-70 per cent of adult social care clients are over 65) in their own homes to help them with food, getting dressed, washing and personal care.
London’s care workforce is older than elsewhere and includes more foreign nationals: 54 per cent are British, compared to 73 per cent across all England and 80 per cent-plus in the north. Workers directly employed by London local authorities are paid an average of £15.52 per hour, but these are only a small minority.
Those in the independent sector receive an average of £11.54 – little more than their counterparts outside London and substantially less than the London Living Wage of £13.85. Lastly, and these factors may all be connected, London’s care workers are far more likely to be employed through an agency and on zero hours contracts.
So, if a staffing crisis hits, London will be in the front line. A fair pay agreement may help over time, but if there are vacancies across the country during a transition period, London’s care workers may vote with their feet, seeking better pay and conditions beyond the M25.
But – and I don’t think this point is made enough – it’s not just about pay. The best care workers I have met are those who feel a genuine sense of vocation. As well as the patience, gentleness, and physical and emotional strength to deal with frail bodies and failing minds, these carers genuinely love the work they do, looking past the difficulties to take pride in looking after other humans. We shouldn’t exploit their calling with poor wages. But I’m not sure a pay boost, together with some general gesticulating towards economically inactive people, is enough either.
Setting that to one side, how would a 20 per cent pay rise (based on raising the average to London Living wage) for London’s care workers be funded? Though local authorities only employ a minority of care workers, they generally pay care costs for anyone with assets of less than £14,250 and a proportion of costs for those with up to £23,250. (Hammersmith & Fulham Council is one of the few local authorities not to apply a means test for domiciliary care and day care).
In London around 70 per cent of people in care homes and 85 per cent of those receiving care at home are local authority-funded – some of the highest proportions in the country, reflecting the relative poverty of London’s older people. Given growing demand from an aging population, national insurance rises and adult social care overspends mounting up every year, boroughs would struggle to pay an extra 20 per cent on care home and care agency fees. And it doesn’t look as if the government is inclined to pay them more.
For those paying fees themselves, an increase in costs might mean quicker draining of capital reserves (and recourse to local authority support), or attempts to cut back on spending. But cutting back on care provision could be a false economy. Battling on, as many older people are inclined to do, can raise the risk of accidents at home and send more older people into hospital. Finding enough carers to provide short-term “re-ablement” support for them when they leave hospital is already a challenge. Shortages of care staff will likely mean longer hospital stays for “medically fit” older people – adding to pressure on beds, and often resulting in worse health when they do leave.
Alternatively, family members could be asked to do more, as Conservative ministers have occasionally suggested. But is it right or economically sensible to ask people (generally women) to leave careers at a time of peak earnings to become full-time carers? Families need to be involved in care but abandoning other plans to become a live-in carer for elderly parents, as many women of my mother’s generation did, is not going to work for everyone.
The whole thing is a mess, and is going to become messier as the population ages. Yes, we need to improve pay, conditions and esteem. And yes, we probably should enable some continued immigration for the care sector. But the whole system needs a rethink. It’s not new to say this. There have been plenty of reviews (the Casey Review announced earlier this month is the latest in a long line), and more or less sensible ideas for caps on care costs, for compulsory insurance policies and for levies on estates. But all have been shot down or proved electorally toxic.
The problem is, as the Financial Times’s Stephen Bush observed this week, “at any given time, most people are not experiencing the care crisis”. And when we stop experiencing it, we don’t want to think about it any more. I don’t really want to think and write about it. My parents no longer receive care and I hope it’s a few years before I need to. But we need to find a better way. What we have now simply isn’t good enough, and I fear it’s about to get worse.
OnLondon.co.uk provides unique, no-advertising and no-paywall coverage of the capital’s politics, development and culture. Support the website and its writers for just £5 a month or £50 a year and get things that other people won’t. Details HERE. Follow Richard Brown on Bluesky.