Care Sector

Lord McKenzie of Luton Excerpts

Tuesday 25th November 2014 Lords Chamber

[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.

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[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?