(9 years, 5 months ago)
Lords ChamberRead Hansard Text Read Debate Ministerial Extracts
Baroness Kingsmill
To move that this House takes note of working conditions in the care sector.
Baroness Kingsmill (Lab)
My Lords, I am delighted to have the opportunity today to throw some light on this difficult and not very well publicised area of employment. Care workers are probably the most invisible members of the United Kingdom’s workforce. I have recently written a review of their working conditions and I was shocked. In the past, I was an employment lawyer for many years. I knew very little about the care sector and I am very grateful to those Members of the House here today who know an awful lot more about it than me.
Although I knew very little about the care sector, as a former employment lawyer I knew a lot about employment. This was my fourth report on employment conditions in various sectors of the economy. The previous one was on the fashion industry and the unhealthy terms and conditions of catwalk models. I have to tell the House that there are far fewer people working as models in the United Kingdom than there are care workers and yet you would not have thought so, given the amount of publicity that particular report received. It became known as the “skinny models” report and it was all over the press. This report, however, on the terms and conditions of care workers, passed almost unnoticed. When I sought some media attention for tonight’s debate, they said, “Give us the news element of this”. What they really meant was, “Tell us some ghastly story about some hideous happenings in a care home or about people who have been badly treated”. That is what creates the attention around this sector. I am, therefore, particularly grateful for the opportunity to throw a little more light on this area and for other noble Lords to add their experience to the debate.
We all know that care is not a glamorous occupation. It involves dealing with vulnerable people on a daily basis, entering the homes of elderly and disabled people in distant locations, providing intimate care and support and, often, prompting the taking of vital medication. Engaging with elderly people with dementia, Alzheimer’s and multiple conditions, in short bursts throughout the day, is a difficult occupation which none of us would find easy to do on a daily basis. These activities do not take place in high-tech hospitals with white-coated doctors and eager students. They do not take place in a colourful playroom with engaging staff and constant activities until the users are collected at the end of the day. They take place in people’s homes and care homes where there are multiple residents with multiple conditions.
Care plays a vital role in our society. Care workers deliver the support needed to people nearing the ends of their lives, to people who are disabled and to people with chronic illnesses, enabling them to live comfortably and in a dignified way. Yet it is the poorest people in our economy who are dealing with our most vulnerable people. The people in this sector are paid less than those in any other of our economy. They are looking after our most vulnerable citizens, in many cases in the most awful of circumstances, yet we value them the least and pay them the worst. Their conditions of work are among the worst.
Care workers are undervalued, underpaid, undertrained and underregulated. There are between 1.5 million and 1.8 million people working in the care sector and we do not know who they are at all. There is no register of care workers in this country. They come and they go, they ebb and they flow, we do not know who they are or where they come from. There is no system of regulation at all. I compare and contrast this with, for example, the care of children, where there are limits. Childminders have to be trained, are limited in the number of people they can care for, and have status. They are not particularly well paid either, but they have career progression and an opportunity to acquire qualifications and improve themselves.
Care workers do not have the status of childminders and they certainly do not have the status of nurses, although they often undertake in people’s homes many of the services that nurses provide in hospitals. They are subject to no regulation or registration. When I was looking into it, I often heard people saying, “I am just a care worker”. It sounded so unfair because there are, among them, some incredibly dedicated and committed people who love what they do and love the people they are taking care of.
However, their work is far more complicated than they give themselves credit for. They often have to deal with complex feeding methods. They have to learn how to use hoists for moving clients, but they are not taught this; they have to learn it on the job and many of them suffer injuries while doing so. They learn how to dress wounds, how to administer medication and, above all, how to provide vital emotional and domestic support for vulnerable people. It is certainly not a job for the faint-hearted and it is certainly not just a job. However, as I said, they are subject to some of the worst conditions of any workers in the United Kingdom. Their wages are almost universally either the national minimum wage or no more than 15% above that minimum. Frequently, even the national minimum wage is ignored, with employers refusing to pay domiciliary workers for the time it takes them to travel between clients.
Many care workers do not know what hours they will be working from week to week. Zero-hours contracts, which we have all read about, play a huge role in the sector and destabilise workers’ lives. Qualifications are patchy, the Care Quality Commission’s requirements have been reduced, and the provision of care has been increasingly focused on the independent sector. Training varies considerably, with no real common framework for care workers. The workforce tends to be older women or migrant workers. Many older women who have never really been in the workforce before but have been bringing up families and have been in so-called caring roles for most of their lives think that, when their children leave home or no longer have the dependence they once had, they can do something that they are good at. They feel as though they have no choice—that this is the only thing they can do—and often that is the case.
The same applies to migrant workers. Frequently, agencies bring in migrant workers from different countries. In many cases, they are subject to the most minimal checks on who they are and what their background is. In many cases, English is not their first language, and indeed often they do not speak very good English at all, yet they are looking after people who are anxious and vulnerable and who need support. That is not to say that brilliant care is not often given by these very same people, but it makes for a risky situation if people cannot communicate properly with those who are looking after them.
It would be very good if there were more young people in care work, but young people rarely enter this sector. There is no career progression and no status, and it is badly paid. It would be very good if we could get career progression going in this area, but at the moment younger people are not interested because it does not exist.
The truth of the matter is that care is in crisis. The exploitation of workers in the care industry has highlighted how badly they are treated, and it has highlighted the severity of the situation regarding their ability to deliver quality care to some of our most vulnerable citizens. Poor conditions for workers often lead to poor quality of service for clients, and this is particularly the case with the elderly and the disabled.
It has to be said that the pressure of austerity measures on local authorities has led to years of underfunding and to chronic conditions for care workers and service users alike. Throughout my work on the review that I have recently undertaken, the call from all sides and from all parties was for greater funding in the care sector. Underfunding the care sector is a false economy. If we truly valued care, there would be less need for vulnerable people to go to hospital, with both a benefit for the public purse and a benefit for the service users, who would avoid the trauma and uncertainty of a hospital visit.
Let us not forget that the care industry is big business. Research from Skills for Care estimates that it is worth about £43 billion to the UK economy, and it is growing as the population ages. Care for the elderly is a lucrative industry. Despite this, it is characterised by a plethora of small businesses dependent on diminishing local authority budgets. Even the largest provider, Four Seasons Health Care, has only a 5.2% market share.
It is a sector that has been beset by scandal. Companies such as Southern Cross Healthcare, which operated 750 care homes and employed 41,000 staff until it closed in 2012 with huge debts, have left the industry with a bad a reputation for poor financial management. Many smaller providers are also just hanging on by the skin of their teeth, threatened with closure. The sector is haunted by the spectre of abuse, such as the horrific case last year of the Orchid View care home. Given that it is likely that most of us will spend the last two years of our lives in receipt of some form of paid care, it is a sector that merits a brighter light being shone on it, and I am particularly grateful for the opportunity to do so this evening.
Baroness Gardner of Parkes (Con)
My Lords, I am very grateful to the noble Baroness, Lady Kingsmill, for bringing up this subject. It is something in which I have taken an interest for some time.
I am not a qualified solicitor, but I sat for many years as a lay member on industrial tribunals, which are now of course called employment tribunals. I was therefore fascinated when it was mentioned how badly paid these people were, with no pay for their travel time between jobs. A noble Lord who spoke earlier said that they should take their case to an employment tribunal, and that without doubt the employment tribunal would give them the right to be paid. That is all very well, except that all these people are working as individuals, usually for an agency, and the agency determines everything.
I have been trying to help a particular woman who has worked for many years caring for elderly people, usually for five, six, seven years. She has just finished seven years with someone who died in their 90s. When they died, the son came over from America and said, “We will not need you any more now she is dead”. He never offered to pay a penny of notice or said anything to her whatsoever. He just vanished, and she was left with nothing. I have spoken about this to various people in this House, such as the noble Lord, Lord Whitty. He said, “She must have had a contract of employment”. There was no contract of employment, as she was considered self-employed. The elderly lady had someone else to care for her five days a week and this carer’s responsibility was to go in on Friday night and stay through till Monday morning. I worked out that that was 48 hours or more. She was paid £100. It turned out that was around only £2 an hour—I had to use my calculator—for two full days in which she had to get up many times during the night to look after that woman. One talks about people being vulnerable, but a lot of old people also get very difficult. This was such a case. But this carer is such a caring person that she would say, “She does not mean to be difficult”. The carer really did her best for this woman.
Having lost that last person, the carer decided she would join a system that the councils use, whereby they are associated with a particular employment agency. I did a lot of phoning to various employment agencies to see which would be a good one to go to. The differences that came up were quite interesting. The important thing was that the workers had to have had training. The noble Baroness mentioned that there is no such thing as a national standard of training. There is none. When you ask the agencies, “What do you mean by training?”, they tell you, “You have got to pay for it,” and the carers pay from £25 to £40 for this. When the workers get the training, it is simply a bit of paper that applies to that particular agency. They cannot use it to go to any other agency. If they want to go to another agency, they have got to do that agency’s training. Someone here who does a lot to help people into employment said to me, “That is the way they lock them into that agency. If they have got to pay for new training, they are not going to leave their place of work, because that is the one that approves them”.
When I asked the agencies what things they trained their workers in, I was told they wanted to be sure a carer knows how to get a patient in and out of the bath, or how to cook a little meal—all the things that are practical. They only ask you in a written question what you would do in an emergency if, say, a person is unconscious on the floor. It seemed very unsatisfactory to me, to say the least.
They asked her to sign on with the company and I asked her to show me a copy of the paper. “They do not give you a copy”, was her reply. I told her to ask for a copy. How would she know what the conditions of work are otherwise? I then asked about travelling between jobs. The answer was that you are sent to client A for an hour and then you are sent to client B, but they might be an hour apart in travel terms. There is no pay at all for the travelling time. I have spoken to local authorities about this in a meeting in one of the Committee Rooms. They said that they should not really be using these agencies unless they know that they are paying proper wages.
Time is running out because I have only six minutes in which to speak, unlike the wonderful speech we have just heard. I come to the most important thing, and it is worth spending the last minute on it. We need a nationally recognised standard of training. The training should not be too complicated or difficult for people to achieve, but it should cover the essentials. Someone with the qualification should be able to go anywhere in the country, and it should be accepted. That would be a great help.
There is a great deal to this subject. I am a retired dentist. No one can just help out in a dentist’s surgery any more. The staff all have to be fully and extensively trained. Every field in care or health requires training that is recognised nationally, and that is what we need in this sector. When we have that, it will mean that we would be able to help the very large number of people who are going to need care in the future.
Lord McKenzie of Luton (Lab)
My Lords, we should thank my noble friend Lady Kingsmill for initiating this debate, but more importantly for her work and that of her team in producing a significant review of working conditions in the care sector. The review was commissioned by Ed Miliband to see what could be done to tackle exploitative working practices in the sector and so improve the quality of care within the existing care budget. The review seeks to do this as well as produce a vision for the longer term that does not have this funding constraint. Like, I suspect, a number of noble Lords in this debate, I have an elderly relative in receipt of domiciliary care, and the messages and analysis in this report ring very true.
Care work is in crisis and care workers need to be treated fairly and to be valued if they in turn are to deliver quality services to their clients. As my noble friend has stressed, care workers are undervalued, underpaid, undertrained and underregulated. This leads to high rates of staff turnover, and for clients, constant changes in carers, erratic timings of visits, missed appointments and no continuity of client engagement. The review has been produced at a time when much else is going on in the world of caring. We are in the era of dramatic cuts to funding for local authorities; demographic change, which the LGA say has run at about 3% of the service budget for the past four years; implementation of the Care Act and the Better Care Fund; the consequences of the Supreme Court judgment that changed the definition of “deprivation of liberty”; and changes in technology that are enabling people to live more safely at home.
The spending pressures on local authorities are having a profound adverse effect on the sector. A National Audit Office report issued just last week sets out the stark facts. Real-terms reductions in government funding to local authorities for the period 2010-11 to 2015-16 amount to 37%. If council tax is included, the reduction is 25%. Moreover, local authorities with the highest levels of deprivation have seen the greatest reductions in their spending power. The NAO report shows that local authorities’ main response to reductions in government funding has been to reduce spending: in the four years to 2013-14, on employees by 15%, and on running costs by 6.7%, although they have tried to protect spending on statutory services for vulnerable people. Notwithstanding this, over the period of this Government, adult social care expenditure is estimated to fall by 8.7%. But those authorities that have been suffering the biggest reductions in spending power—the most deprived—have seen budgeted spend on adult services fall by nearly 13%. Those at the other end of the spectrum have seen a fall of just 1.2%. This is an ugly inequality, which must be addressed.
The Local Government Association’s Adult Social Care Funding: 2014 State of the Nation Report concludes that adult social care funding has been kept under some control through a combination of budget savings, the NHS transfer and at least £0.9 billion of savings by other departments. It considers the medium term to be particularly challenging, with an estimated funding gap over the period to 2020 of £4.3 billion. It also says that the Better Care Fund, to help develop better integration with health, will not provide an immediate solution. These budget pressures are undoubtedly being visited on those who need adult services as well as those who are working in the sector. In 2013-14 there was a 5% decrease in the total number of people receiving services and an increase in the number of authorities tightening eligibility criteria. Delayed discharges from hospitals are at their highest rate ever.
In terms of service levels, as my noble friend’s review highlights, there is increasing use of 15-minute visits, a practice that drives poor-quality care and exploitative working practices. The review stresses that such a limited time means that carers are simply unable to give the human interaction that service users need. We agree with this, and given the opportunity, will work with councils and care providers to bring this practice to an end.
The review also confronts us with the shocking statistic that between 160,000 and 220,000 care workers are paid less than the minimum wage. This is often due to failure to pay workers for time spent travelling between care visits; this can be made worse by incompetent management who are not always familiar with an area and arrange schedules that zig-zag across the town. Equally to be deprecated is the growth in compulsory zero-hours contracts, which create financial instability for carers and an environment in which bad employer practices are likely to be unchallenged.
We have already set out our plans to ban the use of exploitative zero-hours contracts and to improve enforcement of the minimum wage. Fines for non-payment of the minimum wage should be increased to £50,000 and we will champion the living wage through “make work pay” contracts. We have also signed up to the CQC being given an inspection role in the commissioning of care. There are other recommendations in this splendid review which we still have under consideration.
On funding, my noble friend has already shown how there is room to improve workforce planning and commissioning to generate savings. Obviously, the big challenge for the future is to raise standards and save money by the better integration of health and social care. We are committed to a £2.5 billion transformation fund that will cover both the NHS and social care and includes money to pay for 5,000 home care workers.
My noble friend Lady Kingsmill has given us a glimpse of the future and a vision of the professionalisation of care work—a cause towards which we should be proud to work.
Baroness Brinton (LD)
My Lords, I congratulate the noble Baroness, Lady Kingsmill, on securing this important debate. I want my focus to be slightly more positive by picking some of the good examples in the sector, particularly in training and skills, to show that there is a way out of some the problems that the sector faces at the moment. However, I start by reiterating the point made by other speakers: the care sector has some of the most dedicated staff in the UK workforce, who have the incredibly responsible job of helping to look after the most vulnerable adults in our society.
The vast majority of the 1.5 million staff do it very well, but sadly the small handful who abuse their clients and our trust are the ones who capture the headlines. My mother had domiciliary care for a decade until she moved into residential care about 18 months ago. I have seen, at first hand, carers and their managers at work. During that time, nurturing relationships have been created and sustained and her carers have travelled with her on her difficult journey. In other visits and meetings outside the family, I have seen some less good practice but also some unusual places—I will come on to the healthcare assistants in geriatric wards and prisons later.
In the main, those services that are excellent are often unseen; problems, many of which seem to be appearing more frequently, are the result—I believe—of pressure from above which comes from two sources. The first is the still very small pool of people prepared to work in the sector, and the second is the funding packages for social care that cause organisations to take short cuts. Some local authorities now offer ridiculous hourly rates to organisations that do not cover travel time, annual leave and training in particular. I am afraid to say that the tri-borough in London is one of those and Bradford is another, so it is not just a London problem. I ask my noble friend the Minister: what can the Government do to ensure that the living wage and the overheads that healthcare organisations ought to be paying should be included in a contract from local government?
I want to reflect briefly on the social care workforce demographics for 2012, which I think is the most recent year for which we have figures, and Skills for Care’s report, The Size and Structure of the Adult Social Care Sector and Workforce in England, because some interesting points come out of them. I suppose it is no surprise that over 80% of the workforce are women but it is worth highlighting that for managers it is still 80% women, which is encouraging and shows that there is not a glass ceiling there. However, that is not reflected in the black and minority ethnic data, which show that 18% of the workers are BME but for carer staff the figure rises to 29%, while for managers it drops quite considerably. Will my noble friend the Minister say what support is being offered to junior BME staff by employers or Skills for Care to help them progress their careers and get through that glass ceiling?
Interestingly, the data also show that 82% of staff are British, 4.5% are from the EU and 13% are from non-EU areas. Given the debate that your Lordships’ House has just had, if UKIP wanted to repatriate non-British workers, we would have an urgent and immediate shortfall of 17.5%, which rises to nearly 20% among front-line carers.
There has been considerable focus on the qualifications of the care workforce over the past 10 years, much of it introduced by the previous Government and continued by the present one, and with some considerable success. There has been the development of the national vocational qualifications—NVQs—at levels 2 and 3, as well as the national occupational standards, where each standard is a unit of care that demonstrates that the worker can effectively look after that particular thing; it might be bathing an elderly patient or working with them to try to bring back some memories. At the higher level there is certainly work on dementia care as well.
One difficulty was that the focus of the previous Government was on NVQ level 3, the equivalent to an A-level, rather than level 2, which left many in the sector concerned about those staff with no qualifications at all. The data show that almost half the workforce are now qualified to level 2, which is great news, and over 15% to level 3, both of which are improvements. But 37% of the workforce have no qualifications at all. We want anyone in a caring role, or who is managing carers, to have the national occupational standard—NOS—qualifications to at least level 2 to guarantee a minimum level of understanding about the care that is being given, and for the safety of the clients and patients. Inevitably, the majority of people without qualifications are direct carers. I ask my noble friend the Minister: what incentives can the Government provide for small businesses particularly to help train their staff, especially those who have no qualifications at all, given that there is an excellent national framework and many employers offer these qualifications?
This raises a further point. The future workforce projections to 2025 show that the workforce will need to grow by 800,000 in the next 11 years. If we do not have training and recruitment plans in hand, we will not be able to provide the skilled workforce we need as our ageing society needs more and more assistance.
To end on a positive note, I mentioned earlier the geriatric ward in a prison, the number of which is increasing. One healthcare assistant I met was just beginning training to qualify as a nurse because her employer realised the benefit of a proper progression pathway. That is the way this business should be going in the future.
Lord Lipsey (Lab)
I, too, thank the noble Baroness, Lady Kingsmill, for initiating this debate and for her excellent report. There is another vote of thanks that I want to give, which on my part is even more heartfelt: I want to thank the 700,000 people working in the residential sector in particular for what they do for our elderly people.
Of course I know that there are a few bad apples in the barrel. The most profoundly frightening statistic that I have come across in some time is one that says that 54% of people fear going into a residential home because they think that they will get poor or even cruel care—that is the newspapers for you. Then I think of St Luke’s Hospital in Oxford, where my 92 year-old mother is. It is a special place. It is not a special place because it is a special building; to call it workaday would be generous. Nor is it in a special place: it is in a suburb of Oxford. It is special because of the people who work there. There is a highly educated and absolutely delightful couple from Botswana; the Nepalese Gurkhas, with whom the home has a connection; the Filipinos; and the eastern Europeans—a staff of people dedicated to care.
The number of care workers in residential homes is going to have to increase by about a third by 2025 to cope with the demands. Where are they going to come from? I understand why our politics is turning the way that it is on immigration—of course I do. However, weight has to be given to the fact that not only are we providing a home for people from abroad but they are providing services that we as a society desperately need—services that there is not, at present pay rates, a huge queue of British people dying to perform.
My point is that in most areas of public life there is quite a lot of controversy about what needs to be done—sometimes partisan and sometimes not. However, the Kingsmill report has to be taken with Camilla Cavendish’s wonderful report, with bits of the Burstow report on the residential sector and the earlier reports that have been mentioned today. They nearly all say essentially the same thing: the pay is too low. The too-low pay may have even come below the minimum wage and does not approach the living wage. Care workers are forced, often illegally, to pay for their uniform and for training and to spend time on duty even if they are not actually working at the time. Training is inadequate and career prospects are poor. It is hard for a care worker to graduate to becoming a nurse. To me, it is quite wonderful, despite all this, that we have a workforce at all, let alone one that is as conscientious as the great majority of it is.
There is total consensus on what is needed. Why does it not happen? The reason is money. I will give three examples. There is a huge shortfall in the amount paid in fees by local authorities for people in residential care—it is way below what would be an economic rate. Laing and Buisson calculated that for 2008-09 the total sum involved was £540 million. Unfortunately, it will not even give a Member of the House of Lords the current figure that it has calculated for use in this debate; I suppose that it makes its money by selling it. The figure is not likely, however, to be any smaller than that, so the fees are already inadequate. There is going to be an additional problem because, when the Dilnot report takes effect, those who are paying for themselves are going to find out what the council is paying for its own residents and they will say, “Why should I pay more than them?”. That will put more downward pressure on the fees, so the homes will not have the money to pay their staff properly.
Secondly, there are huge demographic pressures, with the number of 85-plus year-olds in 2030 likely to be more than twice what it was in 2011. We live longer, which is great for us, but somebody has to pay. Thirdly—and this annoys me, so I will not labour it—it is very distressing that the Government prefer to cut council budgets, even when those council budgets are the only thing that keeps care going, rather than cut their own budgets, because they feel that they would get the blame for that. No money, no improvement for care workers. Indeed, it will get worse. In addition to the cost of all this, we have the cost of Dilnot, which I on the whole support, although it is a much lower priority to pay better-off people a share towards their care than to provide the basic care that the poorest in our community need.
At the end of the day, there has to be more money for care. When that money is forthcoming, there has to be better treatment for the workforce as a key priority. I hope that this debate and the unanimity that I expect to diffuse it will persuade the Government that eventually, however reluctantly, they and particularly the Treasury will have to face up to this unpalatable fact.
Lord Birt (CB)
My Lords, we are all grateful to the noble Baroness, Lady Kingsmill, for, in her words, shining a brighter light on this critical set of interlocking issues. I declare an interest as a business adviser to a fund that invests in care homes as well as in many other sectors.
The care of the elderly is an issue about which we all have strong feelings. Those have been expressed many times already. I shall not easily forget, just a small number of years ago, my own father’s last chaotic and distressing months tumbling from hospital to home, to care home, back to hospital, back again home and, finally, to a hospice. It was a journey for the most part marked by high standards of care but absent any trusted guide whatever. He was but a baton passed clumsily from hand to hand.
A fortnight ago, I spent a morning in a care home and was inspired—others have spoken of this—by the utter dedication and kindliness of the staff there, who meet the whole gamut of human and bodily needs over 24 hours a day, seven days a week. It truly is a challenging set of tasks. Some help patients who have severe dementia, while other patients are,
“sans teeth, sans eyes, sans taste, sans everything”.
Almost all those staff were immigrants to the UK. To echo the noble Baroness, Lady Brinton, and the noble Lord, Lord Lipsey, without these immigrants, whatever would we do? The care and nursing sectors in the UK face severe skill shortages. Major businesses are forced to recruit in huge numbers in the Philippines, Romania, India and other countries for the skills that the UK labour market is simply not supplying. Why cannot we manage our education and skills sector so that it produces skills—they are skills—on the scale that we need?
We would all agree that we want the highest standards in the care sector for our loved ones and finally, no doubt, ourselves. Yet we know from excellent investigative journalism—I am sure that we have all seen it and it is very painful—that standards are not always high. The CQC, quite rightly, is increasingly vigorous and rigorous and it is raising the bar. As a result, staff numbers are increasing and costs are rising. Were the Labour Party to assume office and raise the minimum wage, costs would rise higher still in the sector. Yet around two-thirds of those in care homes are funded by local authorities. Local authorities, as we have heard many times in this short debate, are themselves straitened and have been reducing not raising fees by some 5% in real terms over the past three years.
In the home that I visited—the noble Lord, Lord Lipsey, just made the same point—the local authority was paying fees significantly below the actual cost of providing the very services that it and we would expect. This simply cannot continue. It is not viable or sustainable as a policy. The great majority of care homes are privately owned. The returns for those investing in the sector are dangerously low. The whole system is in extreme financial tension and we lack sufficient incentives to ensure that provision will increase, as the noble Lord, Lord Lipsey, has just said, as need grows, which it will. There appears to be a policy vacuum. Whoever forms the next Government simply must provide a holistic policy and financial overview of the care challenge. That must involve the NHS. Everyone can see that unnecessarily filling a hospital bed is vastly more expensive than providing a place in an appropriate care home.
We need an overview from the Government of how best to provide effective, civilised, seamless care to those in the final stages of their lives, whether at home, in care or in hospital. We need appropriate structures—we do not have them—processes and incentives, a single point of responsibility at local level and the right governance in place to ensure that the system is working as it should and as we would all wish. Finally, we need not only to determine the proper balance between state and private funding but to be clear that, where the state accepts financial responsibility and rightly requires high standards, then in turn it must also will the means as well as the ends.
Baroness Howells of St Davids (Lab)
My Lords, I, too, congratulate the noble Baroness, Lady Kingsmill, on raising this debate and giving a very thorough insight into her report on what is happening in the care field. I have a particular interest in carers because so many immigrants from the early 1950s and 1960s from the Caribbean, when they were invited to come to support the mother country, found work in the caring sectors and were happy to do so. It is no secret that I have been a tireless campaigner for better services for black communities, but today I speak for all citizens of the United Kingdom.
I was very struck in October by a Statement read out in this Chamber by the Parliamentary Under-Secretary of State in the Department of Health. It was entitled Five Year Forward View. This Statement brought to our attention how the proposed plan would make the service better and fit for purpose. The Government claimed to have recognised the challenges facing care and declared that continuing with a comprehensive tax-funded NHS was intrinsically doable and that there were viable options for sustaining and improving the NHS over the next five years.
The Statement also claimed that the challenges of an ageing population can be met by a combination of increased real-terms funding efficiencies and changes to the models of how care is delivered. Much was said of the value of greater integration, of releasing hospital beds by combining primary community and specialist tertiary sectors alongside national urgent and emergency networks. The Statement went on to say that this would give older people in particular the personal care we would all want for our own parents.
That is very laudable, but what has been done? What has happened? When the Statement talked about reducing variations in quality in the wake of the tragedy of Mid Staffs, they were all very grand words. Can the Minister tell the House what has gone wrong? We are told that the economy is doing well, so cash should not be a problem. Did the Government really mean to downgrade the workers who carry out some of the most important work; the sort of work that is meant to have a real impact on those receiving care?
The trade union Unison cites that there are a number of appalling examples of exploitation. Employment rights are not properly observed and bogus self-employment presents a big problem. Employers operate with relative impunity in an unregulated sector. This is not care; it is an abuse in this century not only of those needing care but of those giving the care. They need to be cared for so they can offer good care.
Those who are engaged in caring know what a difficult task it is. They do it because they care. To them, the patient is first but needs time. The report highlights that the sick, elderly and disabled people who rely on care services are increasingly facing a 15-minute visit from carers. What can you do in 15 minutes? If the person is well and healthy you might do something, but if they are not, 15 minutes can never be enough to bathe, dress and feed a patient. Some people may need 15 minutes, but others need a lot more.
I recently met carers who have had nervous breakdowns because of the strain of getting to places on time. Caring is natural, but we need to help. We need not only to train carers but to be aware of their circumstances and to give them more. I urge the Minister to put his weight behind the recommendations of the Kingsmill report. Most of those needing care are those who have paid into the health service. It is not a charity. Those who advocate 15 minutes per patient are those who live inside the radar of the healthy, the employed and the respectable. They have no idea of what it is like to be in the other camp.
Unless you have been a carer you have no idea of what is happening. I cared for my husband for seven years, and I assure noble Lords that the man I married was not the man I was caring for. Being unhealthy, unemployed and treated as not respectable so that any old thing will do is not good enough for citizens of the United Kingdom. Care workers should be treated fairly, and I trust the Minister will revisit the five-year plan because patients and carers deserve better.
This country can do better and must take heed of the report and implement the recommendations as soon as possible. As lawmakers, we are guilty of failing the most vulnerable, those most in need. I say this not because I want to make noble Lords feel bad but because I have seen carers, some of whom have retired from nursing, who have had to take breaks because of the strain of caring. Those who are caring and those who are dependent on them need our help. If not, we are very guilty as lawmakers.
Baroness Chisholm of Owlpen (Con)
My Lords, I thank the noble Baroness, Lady Kingsmill, for initiating this debate and the noble Baroness, Lady Howells of St Davids, for the thought-provoking words we have just heard. This is such an important issue. Our ageing population is growing, which is going to lead to an increase in demand for residential and home care, day centres and meals—but care workers look after people of all ages.
As a former nurse, I know only too well the invaluable service that care workers perform in our communities throughout the country. They carry out some of the most important work in society, caring for those who are elderly, frail, disabled both mentally and physically, and in some cases suffering from addiction problems. Their work is physically and emotionally demanding, often undertaken in unsocial hours. As a nurse, I know that looking after someone can be and is a rewarding experience, but it can also be a deeply emotional, draining and lonely one.
I would like to turn briefly to those carers who perform this vital role unpaid, and how important paid care workers are to this group. As the noble Baroness, Lady Kingsmill, pointed out, across the UK there are more than 1 million paid care workers. But they are in the minority compared to those who do this work for no pay. It is estimated there are 6.5 million unpaid carers; three in five people will take on this role at some point in their lives. These selfless people are estimated to be saving the state £119 billion a year, and they can be anyone of any age who provides unpaid care to family or friends who could not manage without this help. But these carers need care themselves to be able to continue in this role. They are twice as likely to be permanently sick or disabled from their demanding work. Many face depression. There is a clear moral and economic case for supporting carers, and this support usually comes from paid care workers.
Voluntary carers are the first line of prevention. It has been well documented that they experience disproportionately high levels of ill health, but increasing support for them improves their health and well-being, as well as the health outcomes of the recipients. I am proud to be part of a Government who have initiated the Better Care Fund, which is integrating health and social care across health sectors; but we must have a joined-up approach for our voluntary carers and paid care workers. Research shows that providing good-quality support for voluntary carers prevents an escalation of demand on statutory services. Local authorities can reduce spending on care by more than £1 billion per year by spending on breaks, information and support for carers. When support is required, voluntary carers depend on high-quality care for recipients with care needs. They will forego assistance from care workers unless they feel the care received is of the high standard expected.
Anecdotally, I was told about care workers who went from appointment to appointment by bus. They had no access to a car and were frequently up to two hours late, causing distress to the person they were looking after, and, where present, distress to relatives. So it is imperative that paid care workers have the right attitude, are well trained and supported, and given the right tools for their job; that they know the needs of the person they are caring for, and are paid appropriately for their time and not the cheapest rate possible.
Under a new scheme that came into effect from October 2013, it is now simpler to name and shame employers who break national minimum wage law. But cases from the care sector can take longer to investigate than comparable cases from other sectors because of issues around travelling time and on-call pay. I am pleased to see that the Department of Health is clear that social care employers should pay home care workers for travel time between clients. The department is looking to ensure that the statutory guidance that accompanies the Care Act states that local authorities must have evidence that conditions and fee levels are appropriate.
The challenges faced today to give high-quality care are enormous. The care certificate for new healthcare assistants and social care workers is being introduced from 1 April 2015. This surely will go some way in developing the required behaviours, competences and skills, to enable them to provide high-quality, compassionate care.
We all want the most vulnerable in our communities to receive the best possible care, and this will be possible only if the authorities are committed to making sure that the care workers they employ are of the highest standard. For this to be the case they must value them by the training they are given, the information given on the recipient of their care, and the financial reward they receive for their work.
Baroness Andrews (Lab)
My Lords, it is a real privilege to take part in this debate. Like so many other noble Lords, I am extremely grateful to my noble friend for creating the opportunity for us to have this debate but even more so, obviously, for the force and clarity with which she presented the evidence and the recommendations of the report. She said that while writing the report she was shocked. I was certainly shocked when reading it.
This is a report that sets out a long-term and sustainable future for care workers and deals with the historical failures and the immediate challenges. In summary, it graphically describes a largely poor, privatised workforce marked by low status and low wages, who work in intensely personal and stressful conditions, in uncertainty and insecurity, with poor and unco-ordinated training, few national standards, a weak and fragmented regulatory environment, irresponsible procurement and poor workforce planning and management skills. That summary of working conditions could have been written as an account of early industrial Britain, where rights and effective regulation were won, but largely by men and for men. The difference is that we are not dealing with history but very much with the present and with a workforce that is largely female, highly fragmented and comprises a high proportion—70%—of immigrant workers. They are not dealing with machinery or factory processes. As many noble Lords have said, they are dealing with the most frail and elderly and the consistently lonely in our society, many of whom have chronic and complex conditions which require highly skilled under -standing as well as compassion. Many of them are confused and lonely and the visit by the care worker is often the highlight of their day because it is about emotional as well as physical support. When one considers that the visit can be rationed to 15 minutes, it diminishes the carer just as much as the client and is a recipe for bullying conditions as well as for neglect.
Andrew Smith said in a recent debate in the other place that luck and money were only too likely to decide people’s quality of care. My family were very lucky. My mother was looked after by a wonderful collective of Welsh aunties in her residential care home—Cartref Aneurin Bevan—who were not only affectionate but highly skilled and gave all the time that they could to these wonderful elderly ladies and gentlemen. They were typical of the kindness and selflessness that we have always relied on and which, unfortunately, we have always exploited. This report shows that this is no longer sustainable. It has never been sustainable but we have neglected to challenge it. Changing this is not just about finding the money because the crucial failure is the failure to value the sector, to promote and articulate the workers’ skills and to understand that this is the front line of healthcare, not just community care.
This is a notoriously low-paid sector, as the Low Pay Unit recently documented. As we have heard, wages have been driven down by the failure of providers to pay more than 200,000 of these workers the minimum wage, the refusal to pay travel costs and by the fact that a fifth of workers are on zero-hours contracts and there is very little career progression or incentive. What makes the failure to enforce the minimum wage more intolerable—which makes me angry—is that there are mechanisms in place to limit the exploitation of care workers that are simply not being used.
Astonishingly, HMRC, having revealed the extent of the breach of the minimum wage regulations, has stopped carrying out proactive investigations of compliance in home care. One in five councils responding to an ADSS survey did not even know whether their providers paid the minimum wage. The only recourse care workers have is to ring up HMRC’s pay and rights helpline. I am fairly sure that that does not go down well with their employers. So can the Minister tell me exactly what he and his department are doing to galvanise HMRC into doing its simple duty of rooting out this total failure? Will he agree to meet HMRC and BIS to take the concerns in the report forward? Does he agree with me and other noble Lords that we should aim for a living wage and not a minimum wage? All this means that this is a sector that sets records for vacancy and turnover rates. A culture of uncertainty means that thousands of care workers do not know where their next paid work will come from and where clients face a stream of strangers in their houses. The Minister in the other place said that it would not survive without migrant workers, who account for about 17% of the workforce. Perhaps the Minister can say whether he endorses that opinion, which was so clearly expressed.
As my noble friend Lord McKenzie has shown, all the problems have been exacerbated by cruel cuts in funding. Without acknowledging that reality, it is difficult to see how the Care Act, with all its good intentions, and the guidance will bring about the changes that we want to see. In contracts that in reality are bound to be driven by price, how will the guidance be able to enforce the intention that local authorities’ contract terms, conditions and fee levels will not compromise the ability of care providers to pay at least minimum wages? Does the Minister agree that the guidance would be much more effective if it simply said that councils “must” act to end illegal practices rather than “should”? There have been some very good changes—I count the care certificate among them—but without the implementation of the recommendations in this report we will not see the scale of changes that we need to see.
Baroness Wheeler (Lab)
My Lords, I, too, congratulate my noble friend Lady Kingsmill on her excellent report and on securing this debate. At a time when your Lordships’ House will shortly begin focusing on the regulations that will underpin the implementation of the Care Act from next April, discussing now the key role of the social care workforce in bringing about the changes that we want to see in health and social care in the future is both crucial and timely.
My noble friend’s report paints a grim picture of the low pay and working conditions of the 220,000 home care workers in England who are illegally paid below the national minimum wage, and those of residential care staff, day care and community-based staff, who together make up more than 1.3 million of the total social care workforce. This is in the context of the latest data from the Office for National Statistics, which show that in 2014 British workers overall have suffered the sixth straight year of falling real pay, taking earnings back to levels seen in the early 2000s.
My noble friend and other noble Lords have ably covered the key issues raised in the report—low pay, the terrible impact of zero-hours contracts, the impact of staff shortages and high turnover on the quality of care, and the vital importance of improving training and career pathways for social care workers. Like the noble Baroness, Lady Chisholm, I want to highlight the impact that this situation has on carers because, above all, carers need to know that their parent, child or partner are in the good hands of caring, motivated and competent care staff.
We know that, as our society ages and people live longer with complex health needs, the pressure on families to provide care and support will continue to grow. If families are able to take on these caring responsibilities, and often juggle them alongside paid work that is vital to the family budget and other family commitments, then sufficient, reliable, affordable and good-quality care services will be the linchpin that helps them hold it together. Care workers are at the heart of these services in both home and respite care. The skills, suitability, empathy and reliability of staff are at the core of good-quality care. If care is poor because care workers are undervalued, not properly trained, unreliable or stretched too far by their employers, then carers have to step in, often at the expense of their own health, their career, their relationships and their ability to cope.
If you are a carer for people with dementia, autism or mental health issues, for example, high staff turnover is a particular problem because the person you are caring for can become distressed by change or by being looked after by people they do not know. It also takes time for families to build trust with someone new. One respondent to the recent Carers UK survey reported having 22 different care workers in 12 months. As she put it, “They all have to be trained by us to care for our daughter, and it takes hours”.
As noble Lords have said, there is good-quality care out there despite the pressures, low pay and low status. I am myself a carer for a disabled adult with a long-term health condition, and our experience of domiciliary agency care is that it is of a very high standard. We know the majority of the care worker team that comes in for the week, providing essential personal care for my partner, who is paralysed down his left side following a stroke. Our experience is of having a caring service from care workers who seem to have exactly the sort of attitude, empathy and approach to clients, to disability and to me, as a carer, that we so often call for to be the norm across health and social care. Most of our care workers are women in their mid-to-late 20s—mostly a migrant workforce—and they do a great job in difficult circumstances. We have to remember that personal care—washing, dressing, safe care and dealing with continence care—is intimate care and needs respect and understanding on the part of the care worker. That is what is delivered in our case.
However, the flip-side of this, of course, is the long hours and low pay for care workers that have been highlighted today, involving conditions such as non-payment if a call is cancelled—which seems to be one of the most unfair practices since cancellation is not the care worker’s fault—and pressure to carry on from early morning to late at night if there is staff sickness or shortages and nobody else to cover. Keeping consistent staff so that carers know them, providing better training, giving staff more time to carry out tasks and paying staff more are the four most important things that carers highlight in their responses to the Carers UK survey. As one of the respondents commented:
“Employ people you’d want to look after your family and pay them for the important job it is”.
UNISON’s Time to Care report shows the staff’s frustration at not having the time to do the job they want to do, and many are providing unpaid care just to get the job done. As one contributor said:
“I’d always stay and be late for my next client or, if it was my last call, I would still stay and not get paid for it, as I could not leave someone that needed me”.
Good care that meets the needs of the person they look after can improve carers’ ability to work, spend time with their family members, look after their own health and have a life of their own outside the caring role. It means dignity, respect and a better life for the person they care for.
Lord Curry of Kirkharle (CB)
My Lords, I will be brief. Other Peers have spoken eloquently and very adequately covered this subject. I, too, am grateful to the noble Baroness, Lady Kingsmill, for leading this debate. My wife and I have a personal interest in this subject. Our daughter had a severe learning disability; she had to be fed, dressed and toileted. She could not speak and latterly had two full-time carers. Hoists were required to lift her out of bed, et cetera. Sadly, she died last year, aged 42.
In 1990, we formed a business with charitable status in the north-east of England to provide care and support for people with learning disabilities, which I chaired until three years ago. At that time, we merged with a larger organisation, Prospects. It is a Christian organisation and I am currently vice-chair of that company. We employ more than 600 wonderful people to care for people with learning disabilities across the United Kingdom. We provide residential care, domiciliary care with personal budgets, and a range of other services for local authorities.
Our biggest challenge by far is recruiting, retaining and adequately rewarding our staff—our carers. The tragedy is that we compete in a market with the stacking of supermarket shelves. The responsibilities bear no comparison. Having to recruit staff on low wages to care for vulnerable people is an unacceptable model. We want to pay the living wage and fully intend to do so, but not only is the relentless economic pressure on this sector driving providers out of business but it is proving difficult to maintain the high standards we want to provide.
The tendering process adds to that economic pressure. Some of our contracts pay £12 an hour. This is to cover not only salaries, management and overhead costs but food, living expenses and training. The sums just do not add up. In some companies in our sector, staff turnover is 20%. Training costs are huge and recruitment costs are high. Dependency on agencies when staff leave adds to the economic pressure because of the high charges we have to pay for agency staff.
I am not making a political point when I say this: this Government and the next have no alternative but to bear down on public expenditure, but every year longevity and costs increase. We need a different model. I hope that the Minister will give this matter his serious attention. We are stretching the loyalty of some of the most amazing people in our society to the absolute limit.
Lord Kennedy of Southwark (Lab)
My Lords, like other noble Lords who have spoken in this debate, I congratulate my noble friend Lady Kingsmill on securing this important debate today and on the review that she undertook into the working conditions in the care sector, which certainly deserves more attention in the media. The review is an important marker that highlights some of the most pressing issues surrounding working conditions in the care sector and how unacceptable these conditions are. It is for government to take action to deal with the worst excesses. The noble Baroness, Lady Gardner of Parkes, highlighted some of those in her contribution. My right honorable friend in the other place, Mr Andrew Smith, highlighted some of these issues in the Westminster Hall debate held on 14 November—as my noble friend Lady Andrews mentioned.
In my remarks this evening I want to talk about the working poor, the problems that they face and the fact that the care industry has lots of people working in it who can be described as working poor. Maybe some years ago it would have been suggested that poor people are those who are unemployed and have no job. We have also talked about and identified pensioners who are in poverty, but this concept of working poor and the fact that this is growing should be a matter of much regret and shame. My right honourable friend Andrew Smith quoted Winston Churchill, who spoke in the other place in 1909. He said:
“It is a serious national evil that any class of His Majesty’s subjects should receive less than a living wage in return for their utmost exertions … where you have what we call sweated trades, you have no organisation, no parity of bargaining, the good employer is undercut by the bad and the bad by the worst; the worker, whose whole livelihood depends upon the industry, is undersold by the worker who only takes up the trade as a second string … where these conditions prevail you have not a condition of progress, but a condition of progressive degeneration”.—[Official Report, 28/4/1909; Commons; col. 388.]
Things have without doubt improved since 1909, but there are unfortunately numerous examples such as those referred to in this debate where bad practice exploits workers and people are treated very badly, and it is the duty of government to protect workers from this exploitation. I would say that the Government will have to be a little more proactive in this area to convince me that this is something they are truly committed to delivering on.
Returning to the point I made about the working poor, this sector employs the vast majority of people in the private sector or in the voluntary sector, amounting to about 76% of the total workforce of approximately 1.15 million, with nearly two-thirds working in private establishments. It is a matter of much regret that the sector has high levels of non-compliance with the national minimum wage, to which my noble friend Lady Andrews referred, and I hope that the noble Earl will tell us what will be done to make good this terrible wrong.
The growth in zero hours contracts in this sector, to which my noble friend Lord McKenzie of Luton referred, is generally encouraging exploitation of workers and making life difficult and unstable. Some people may like the ability to fix their employment hours week by week or day by day but I contend that it is a significant minority. According to the latest report by the Joseph Rowntree Foundation, insecure, low-paid jobs are leaving record numbers of working families in poverty, with two-thirds of people who found work in the past year taking jobs for less than the living wage—and a large number of those jobs will be in this sector.
The living wage is calculated at £7.85 an hour nationally and £9.15 in London, which is much higher than the legally enforceable but still breached minimum wage of £6.50 per hour. While not all these issues are in the noble Earl’s area of responsibility, I hope that he can see the perfect storm of people working in a sector where the majority of staff are on low wages, the problems that that can bring in not being able to provide an income to be able to look after yourself and your family, and the reliance on the benefits system. We should add to that the housing crisis, where we have low-paid workers who are not able to get a foothold on the property ladder and are unable to get into social housing, so they are forced into the private rented sector. Then we have banks refusing to lend to people, so access to affordable forms of credit is more difficult or not available at all. People are pushed into more expensive and unsuitable forms of credit and, as I said earlier, we have the perfect storm, because these things come together: they are not in isolation.
The care worker being exploited by an unscrupulous employer and not paid even the minimum wage will be the same person who is struggling to make ends meet. They will be the same person who goes to the bank and is unlikely to get the financial products they want at an affordable price. They may also, through desperation, purchase financial products that are totally unsuitable: payday loans, logbook loans and other unsatisfactory rip-off products. They are also more likely to live in an area that does not have an abundance of free cash machines—they will pay to get their own money out—and are more likely to live in poor accommodation.
As I said, not all of those things are in the noble Earl’s immediate area of responsibility, but as a member of Her Majesty’s Government I am sure he will agree these are serious matters that a joined-up and collective approach by government needs to address. In conclusion, I look forward to the noble Earl’s response, and that of my noble friend Lord Hunt of Kings Heath.
Lord Hunt of Kings Heath (Lab)
My Lords, I, too, pay tribute to my noble friend Lady Kingsmill for her speech and for her report, which were both profound in their analysis of the crisis in care work and of what needs to be done. As she said, we know that people who receive care are very vulnerable. The fact is that the current situation means that in many cases they are not being treated with the care and attention that they deserve. All too often, their only source of support, care workers, are, as my noble friend said in her report,
“exhausted, unable to plan their own lives through insecure contracts, and unable to spend enough quality time with the person in receipt of care”.
As she says, they are invisible,
“under-valued, under-paid and under-trained. They don’t have the status of Nurses. They don’t have the status of Child-Minders. The sector is subject to weak regulation”.
The noble Baroness also said:
“The low status of Care Work and poor treatment of workers has led to a vicious downward spiral into one of the most difficult sectors for workers, with widespread exploitation”.
It is clear that the demographics that we face mean that the challenges in the care sector are going to grow. Our population is projected to continue ageing. The number of people aged 80 and over in the UK is projected to more than double to 6 million by mid-2037. As the noble Baroness, Lady Brinton, said, we will need 800,000 more people in the workforce to attempt to cope with the extra demand that is bound to be placed on the care sector. She, my noble friend Lord Lipsey and the noble Lord, Lord Birt, made the telling point about our absolute reliance on people from other countries to provide many of the care workers whom we need. That reliance will clearly continue, but we could do more to grow our own workforce. However, we will not do that without tackling the fundamentals identified by my noble friend.
I very much agree with my noble friend Lady Howells. She said that recommendations made by my noble friend Lady Kingsmill are eminently sensible and doable, including introducing a licence to practise for care managers—indeed, for all care workers. How many times have we called for the regulation of care workers in your Lordships’ House? Surely the noble Earl, Lord Howe, will be able to tell us that the Government now recognise that this is something that has to be done.
We need to enforce the national minimum wage and encourage the living wage. My noble friend Lady Andrews asked the Minister about HMRC’s weakness in monitoring and investigating cases where workers are paid less than the minimum wage. We look forward to a response. However, the point that I put to the Minister is that it is not just that workers in this industry do not receive what is due by law, but, because HMRC is not being proactive, we are essentially penalising the good companies—such as that of the noble Lord, Lord Curry—for doing the right thing. That is why it is important that HMRC must have a much more aggressive role.
My noble friend Lady Kingsmill says that we should ban exploitative zero-hours contracts and the 15-minute care slots, introduce a care charter, improve training standards and progression and, overall, improve the oversight and regulation of working conditions. All those things are surely right. We should also listen to my noble friend Lady Wheeler and the noble Baroness, Lady Gardner of Parkes, who focused on the role of social care personal assistants who are directly employed by service users. We would all recognise that personal budgets have a lot going for them, in giving people who are being cared for more control over their own lives. Many of them do the right thing, but Unison has shown, on a number of occasions, evidence of personal assistants being exploited by the people who have the budgets. We need to see some action in that regard.
We cannot talk about the plight of care workers without talking about funding. Many noble Lords referred to funding issues in local government and they are surely right to do so. My noble friend Lord McKenzie pointed out that local authorities are not just hugely challenged financially but are seeing their statutory responsibilities grow. Those of us who debated the Care Bill for many hours will understand that it is in this very sector that local authorities are going to see statutory responsibilities grow considerably, starting in the next few months. It is particularly worrying that the local authorities that are under the greatest pressure face the greatest reduction in spending power, due to the changes in formula that the Government have introduced.
My noble friend Lord Lipsey has challenged us to go beyond simply talking about local authority funding to thinking about the whole situation of the future funding of care. The noble Lord, Lord Curry, also drew attention to that. As we are shortly to debate many statutory instruments relating to the implementation of the Care Act, we are bound to come back to some of the fundamentals of funding long-term care in the future.
The noble Earl has never really responded to the point raised by my noble friend. It is a matter of a year or so until self-funders discover that they are subsidising people funded in homes by local authorities. We have yet to hear an answer from the Government about how the system will cope when people realise that they are paying much more than what a local authority pays for a similar service. As the cap operates, it will soon become apparent to them that the cap is not £72,000 at all but much larger. The cap will be based on what the local authority pays, but the self-funder will have to pay much more than that to reach the £72,000 cap. We are in for some interesting debates on that over the next few weeks. There is no doubt that the issue of funding will have to be tackled. There is also no doubt that part of the answer has to lie in a much more integrated approach between health and social care and the integration of budgets, which this side of the House is very much committed to.
It is not just a question of funding, however. My noble friend was right to say in her report that, if you look at the evidence of a weak and fragmented regulatory environment, irresponsible procurement practices by local authorities and poor workforce planning and management skills within care providers, there is still much that can be done that is not a question of resources. Through its leader, Ed Miliband, my own party has recently said that a Labour Government will legislate to give employees the legal right to a regular contract if they are working regular hours; to refuse demands that they must be available over and above their contracted hours; and to compensation when shifts are cancelled at short notice. We are also pledged to make CQC inspect the commissioning of care. I think that that answers the point raised by the noble Baroness, Lady Chisholm, about ensuring that local authorities check up on employment practices relating to care workers.
As my noble friend Lord Kennedy said, my noble friend Lady Kingsmill has done a noble service in shining a light on a hugely important question. We owe a huge debt to those working in the care sector—those paid to work there and those who volunteer. Despite the lousy conditions, every day many of them go the extra mile, as many noble Lords have mentioned. Surely the better we appreciate and support the contribution of the care workforce, the better the care will be. My noble friend has done a signal service to this nation with the report that she has produced and I hope very much that the Government will respond positively to it tonight.
The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con)
My Lords, I begin by congratulating the noble Baroness, Lady Kingsmill, on securing debating time for this Motion and on her opening speech. I thank all noble Lords for their excellent and thoughtful contributions.
I say immediately that working conditions in the care sector are very important for the well-being of our nation. We know that there are issues of concern and the Government are taking action. The White Paper, Caring for our Future: Reforming Care and Support, and the Care Act set out clearly what care and support system we want to achieve. Everything we want to achieve will depend on the competence, commitment and sensitivity of care workers. The positive relationships that are formed with people needing care are essential to providing good care.
The Department of Health is committed to ensuring that there are the right numbers of people with the right skills, knowledge and behaviours to deliver the quality, compassionate care that people need. We know that the recruitment and retention of care workers is fundamental to this. In that connection, I listened with great care to the noble Lord, Lord Curry. We published the recruitment and retention strategy in May 2011 in conjunction with Skills for Care, which worked to address the issue of how we attract and retain more people in social care. A refreshed recruitment and retention strategy was launched in September this year. Skills for Care leads the DH recruitment and retention working group, which will progress the implementation of the recommendations in the new strategy.
We have done three things straightaway. We have doubled the number of social care apprenticeships starts; we have launched a new care ambassadors service; and we have launched and piloted a values-based recruitment toolkit for the sector. Our aim is to continue this important work by supporting employers.
Registered managers, referred to in the noble Baroness’s report, have a vital front-line responsibility, and it is imperative that they are supported and do not feel isolated. We have worked closely with the National Skills Academy for Social Care to launch a national programme of support for registered managers.
The noble Baroness, Lady Kingsmill, proposed that we should introduce a licence to practise. I am afraid I need to make it clear to her that we do not think that a licence to practise is necessary or desirable. The idea of compulsory statutory regulation can seem an attractive means of ensuring patient safety, but our view is that regulation is no substitute for a culture of compassion, safe delegation and effective supervision. Putting people on a centrally held register does not guarantee public protection. Instead, the key is for employers, commissioners and providers to make sure that they have the right processes in place to ensure that they have the right staff with the right skills to deliver the right care.
Systems and processes are already in place to provide public assurance, including Care Quality Commission registration requirements and the Disclosure and Barring Service, which are being enhanced with the new chief inspectors. Under the leadership of the Chief Inspector of Adult Social Care, the CQC has put in place specialist inspection teams that subject care providers to more effective scrutiny and result in a rating that celebrates outstanding care as well as identifying where there are problems. Therefore, I cannot agree with the noble Baroness’s contention that the CQC’s requirements are somehow weaker than they were.
Better skills and training are an important part of raising standards overall. Camilla Cavendish told us that social care support workers and healthcare assistants do not have consistent training and do not have a clear status or standard job titles. I can tell my noble friend Lady Gardner that we are on track to introduce a care certificate for new healthcare assistants and social care support workers from 1 April 2015. This means that there will be specific standards for the training of new care workers.
My noble friend Lady Gardner expressed concern that employers and agencies train only for their own organisations and my noble friend Lady Brinton asked about the support that exists to enable staff to build their qualifications. Skills for Care has produced a range of training materials that are recognised across the sector. I mentioned the care certificate that we are introducing. In general, I would say that we are committed to working with employers to ensure that this part of the workforce receives high-quality and consistent training to enable them to deliver the best standards of support and care to patients and service users.
My noble friend Lady Brinton asked specifically about BME staff. The department has worked with the National Skills Academy for Social Care to produce training and development support for BME staff to enable them to progress to higher levels within the sector. As regards incentives for small businesses to train staff, which my noble friend also asked me about, small social care businesses are able to apply to Skills for Care for funding to help train their staff. The department provides £12 million to Skills for Care for this very purpose. However, it is incumbent on small businesses to ensure, like bigger enterprises, that their staff are appropriately trained and competent to carry out their role.
The noble Baroness, Lady Kingsmill, called for a care contract to be held between local authorities and care providers setting out working conditions and employment law. The statutory guidance to the Care Act which we launched recently is clear that when local authorities commission services they should make sure that care providers comply with national minimum wage legislation. The statutory guidance is also clear that, in most circumstances, very short home care visits are not appropriate to deliver intimate care needs. In addition, new fundamental standards will come into force next year. These new standards cover staffing and will allow the CQC to prosecute those providers that are responsible for the most serious failings in care. The CQC has an enormously challenging task in transforming its approach to the regulation and inspection of providers of social care.
We are also asking employers and employees working in care to sign up to the social care commitment, pledging to improve the quality of the workforce. My noble friend Lady Brinton once again asked what can be done to improve rates of pay in the sector, a concern also raised by the noble Lords, Lord Lipsey and Lord Kennedy. Under the Care Act, local authorities will be required to shape their whole local markets to ensure that they are sustainable, diverse and offer high-quality care and support for people in their local area. The Act is clear that a local authority’s own commissioning is a key driver in shaping the market. Ultimately, local authorities, not the Government, are responsible for the commissioning of services. However, when commissioning, a local authority must ensure that it promotes a sustainable market that delivers high-quality services for all local people. The department has developed statutory guidance to support local authorities to meet these new duties when commissioning and we are working with the Association of Directors of Adult Social Services, the Local Government Association and other partners to develop a set of commissioning standards which will, again, help local authorities to improve in this area.
The noble Lord, Lord Lipsey, asked specifically what we are doing to make sure that local authorities pay fair fees, while the noble Lord, Lord Birt, drew attention to the disparity in some instances between the actual costs of care and the fees paid by local authorities. We are clear that local authorities should have regard to the cost of care when setting prices. The Care Act sets out a duty on local authorities to have regard to the importance of sustaining the market as a whole, as I mentioned earlier, to meet the needs of local people. That will include where the local authority commissions services itself, considering the impact of how it contracts with individual providers, including the price it pays in fees. Contracting is of course a local matter, with fees paid to providers best left, in our view, to local negotiations in an open market that reflects local conditions.
My noble friend Lady Chisholm spoke powerfully and knowledgeably about the role of unpaid carers. I would say to her that the Government fully recognise the role of unpaid carers, who do an invaluable job in providing care for their loved ones. My department agrees that unpaid carers need support in the form of breaks. There are examples being provided by local authorities and charities, but as my noble friend knows, the Care Act is ushering in a significant new set of rights, effectively putting—for the first time—their needs on an equal footing with those of the individuals they look after.
We agree with the noble Baroness, Lady Kingsmill, that low pay can be a concern for some working in this sector. It was a concern also raised with particular emphasis by the noble Lords, Lord McKenzie and Lord Curry. The Government do not directly employ care workers, but let me be clear: non-compliance with the national minimum wage is not acceptable. That is why we are working across government on enforcement activity. I can tell the noble Baroness, Lady Andrews, that HMRC is responsible for ensuring that staff receive the minimum wage and it takes that role seriously. It has set out the action it has taken in the care sector in a report published last November. While the CQC does not itself enforce national minimum wage legislation, where its inspections uncover evidence that suggests the employer may not be paying the minimum wage, we would expect the commission to pass that intelligence to HMRC for its consideration. HMRC is continuing to carry out enforcement action in the social care sector. It will investigate all complaints made by care workers that their employer is not paying them the national minimum wage. Between April 2011 and March 2013, HMRC undertook a targeted enforcement exercise in the care sector. The work investigated complaints relating to 224 employers. Evidence of non-compliance was found in nearly half the cases and resulted in payments of more than £1 million in arrears to care workers.
I can tell the noble Lord, Lord McKenzie, and the noble Baroness, Lady Andrews, in particular that we are taking a tough approach to naming and shaming any providers who do not comply with our national minimum wage laws, with a more robust scheme now in place for cases opened after October 2013. Cases involving care workers often take longer to investigate than comparable cases in other sectors for a number of reasons, but we anticipate that the first examples of care providers to be named under the new scheme will appear in the next few months. Social care providers who have not paid the national minimum wage previously will be required to pay workers the money owed to them, to pay a penalty for failing to meet their legal obligations, and to change their practices to ensure future compliance.
The terms and conditions of employment for social care workers are essentially a matter for local employers within the existing requirements of employment legislation. However, it is important that the Department of Health continues to work with local authorities to ensure that the providers they commission services from have a high-quality workforce with fair terms and conditions. That brings me to zero-hours contracts. These contracts, when used responsibly, may be appropriate in some circumstances and can offer flexibility and opportunities to both the employer and the individual. The Government are committed to ensuring that zero-hours contracts are used fairly and have included provisions in the Small Business, Enterprise and Employment Bill banning exclusivity clauses in employment contracts that do not guarantee any hours. The Bill was introduced into Parliament on 23 June. Following feedback from stakeholders on the ban on exclusivity clauses, the Department for Business, Innovation and Skills is consulting further on how to prevent unscrupulous employers evading the exclusivity ban.
The noble Lord, Lord McKenzie, spoke powerfully about 15-minute visits. Short care visits are not normally adequate for the needs of service users. We know that care workers find 15-minute appointments demotivating because they are unable to complete their tasks within the time and develop meaningful relationships. We will continue to learn from the best employers and commissioners about how this situation can be improved. A focused peer challenge that will use elements of the commissioning standards will be piloted with two reviews by ADASS and the LGA in the coming months. We agree that in most cases very short visits are incompatible with high-quality care and the Care Act sends a clear message: commissioning services without properly considering the impact on people’s well-being is unacceptable.
However, it would be inappropriate to introduce a blanket ban on 15-minute home care visits since they may be appropriate in certain circumstances; for instance, when checking medication has been taken. A more fundamental culture shift towards a focus on outcomes through guidance and support is, we think, the way forward. Ultimately, local authorities are responsible for the commissioning of services, as I have indicated, but we agree, as does ADASS, that inappropriately short home care visits should be discouraged.
My noble friend Lady Brinton asked about the repatriation of foreign workers. I will need to write to her about that. Turning to a point raised by the noble Baroness, Lady Kingsmill, in relation to Southern Cross, the new Care Act establishes the CQC as the financial regulator for the largest social care providers. It will look at the finances of these providers and, where financial failure is likely, it will warn the affected local authorities to ensure that there is no gap in care services. The regime will not prop up failing providers but ensure continuity of care services for those affected, which surely is the most important consideration.
In response to some of the remarks made by the noble Lord, Lord Birt, with which I agree for the most part, it is worth reflecting that an effective market has been operating in social care for the best part of 20 years. Increasingly, private providers and third-sector organisations have provided services. They have done so effectively but, as in any market, some providers leave and others join. Exits can happen for any number of reasons but what we do not want to see is the kind of disruption to the market that the Southern Cross debacle could have led to had it not been managed successfully.
Delivering high-quality care is dependent upon a range of factors and uppermost is having a workforce that has the right attitudes, values, skills and qualifications. I hope that noble Lords will accept from my remarks that we have a programme of work in hand that is aimed at improving working conditions. We are working across government to tackle non-compliance with the national minimum wage. We are also making it clear that commissioners of services should ensure fair pay, terms and conditions and compliance with the national minimum wage when commissioning services, and we are ensuring set standards of training are introduced. These are surely the key pillars on which to ensure an attractive and fulfilling career can be built for this vital sector of the workforce.
Lord McKenzie of Luton
I apologise for interrupting the Minister. Is it the Government’s view that in determining whether or not the national minimum wage has been paid, the time spent travelling between client visits should be included?
Earl Howe
It is certainly our view that the time spent travelling between assignments should be paid-for time. But that, as I have indicated, is a matter for the local commissioners to ensure is borne out in contracts; it is not something that we as a Government can enforce. However, it is something that will be looked at very carefully in the ways that I have described.
Baroness Kingsmill
My Lords, I am delighted by the response to this debate. I did not expect that there would be as many speakers as there were, and I am very grateful to those who have stayed late and made such valuable contributions. I have had a number of tweets; I happen to know that people are watching this debate and many of them are going to be very pleased by the universal support, encouragement and appreciation that have been given to social workers.
Although every speaker has spoken warmly of the contributions that those care workers have made, the fact is that we are exploiting their dedication and commitment. We are looking at a group of workers who through their commitment and dedication have invited their own exploitation. We all know what needs to be done. My noble friend Lord Lipsey pointed out that there have been many reports prior to my own that have said more or less exactly the same thing in different words. We know what needs to be done. We know how to fix it.
I tried extremely hard in my report to make recommendations that were not going to have serious financial impacts, because we are all very much aware of the limitations on government spending, both for this Government and probably the next. But the fact remains that there is a case for priorities and we are not making a priority of these most vulnerable people. I am very grateful to other noble Lords who pointed this out.
Truthfully, this is a dysfunctional market. It was interesting to hear the noble Earl talk about the functioning of the market, but the fact is that it has all the characteristics of a dysfunctional market. I sympathise hugely with the noble Lord, Lord Curry, whose efforts to create a proper working environment for the care workers in his employ are being increasingly frustrated by his inability to recruit and retain proper staff.
Although, as I say, I tried to keep my recommendations to those that would cost little money, the fact is that we need more money. We need more money and the only source of that money is the Government, so we must find a way of finding that.