‘We shouldn’t have had to find our own way in’: the homecare workers calling out changes needed in adult social care
- 1 day ago
- 11 min read
By Rachel Kelso, founder of Homecare Voices
Our grassroots network of homecare workers is pushing for genuinely fair pay and a secure income as essential ingredients to tackle substandard care.
As three women downed hot drinks across the street from Big Ben, the question of “how did we get here?” buzzed like a current through the cold November air. We are Rachel, 30 (me), Julie, 54 and Hannah, 40. This is the first time all three of us have met in person, though we have been in touch almost every day this year. Linking us together despite our different generations and hometowns is our choice of occupation: we are all domiciliary care workers. The ones that visit your neighbour, parking up in our own car and pulling on blue gloves as we step across the threshold. Over the past 2 years, more than 650 of us have managed to make contact, cutting across the lines drawn by over 15,000 competing employers.
We are in London to submit evidence to the Independent Commission on Adult Social Care, aka the Casey Commission. As expected, we will be the only direct care workers present at this 20-strong roundtable of sector representatives. Making the short walk to the Cabinet Office where today’s meeting is to take place, I reflect on all the other women who would ideally be with us and who have been keeping us focused all week with their messages of support. Monika, Elaine, Kyly, Amaka, Ann, Temmie, Dawn, Josephine, more. These ladies have seen me through so many meetings attended on my own as ‘founder’ of Homecare Voices over previous months, fuelling the intensive work necessary to build our organisation’s credibility in a relatively short space of time. To attend an event like today alongside Julie and Hannah is what it's all been for.
When the invitation arrived for Homecare Voices to submit evidence to the Independent Commission on Adult Social Care, our first question was: “how many of us can come?”. On learning only one other member could attend, we arranged a subsequent online session with the Commission exclusively for members of Homecare Voices, and launched a survey to gather insights from as many people as we could. In under a month, over 500 current and former homecare workers had completed a 30-point questionnaire, with no incentive beyond the chance to be heard. By the time the roundtable convened in London, five of us had secured a presence in the room, one way or another. Julie and I were there in person. Two other members had their stories printed in the pack of case studies circulated for discussion. Hannah received an eleventh-hour invite via another organisation.
A grand room - the old Chancellor’s office, we are told - is split into four small discussion groups. Julie wasted no time in establishing that we are here not only to self-advocate, but to sound the alarm loud and clear on behalf of the people we support. She tells our group about the elderly lady who has been visited by over a hundred different homecare workers to date, and the trauma inflicted by having so many strangers assisting you to shower in what should be the comfort of your own home.
We speak about how the interests of the people we support constantly end up pitted against our own. One homecare worker we know spent a full 10 months staying an extra fifteen minutes per day unpaid before the visit in question was finally extended; no such thing as back-pay. In these all-too-common scenarios, an impossible choice sits on our shoulders: we either leave the client without the care they need and get to the next person on time, or we stay unpaid and arrive late to the next visit. A client once told me plainly that if we were paid for our gaps between visits, the cost of his wife’s care would surely rise and they couldn’t afford to pay any more than they already are. This is how the fallout of an underfunded system, haemorrhaged by profit-making companies, lands in the lap of the worker and the person being supported. Two groups who should be able to trust each other without money hovering like a referee in the room.
For context, on paper many of us earn what sounds like a half-respectable wage. In reality, we are often paid for “contact time” only. The gaps between visits - despite being legally part of our working time - go unpaid. The result: an average contracted rate of £13.23 falls to an average true rate of £9.74 once unpaid gaps are factored in. It drops even lower for those who walk rather than drive, though walkers at least avoid the fuel, insurance and maintenance costs silently subsidised by those of us who use our cars for work. When we met the Minister for Employment Rights earlier this year, we were advised that we had enough evidence to report our employers individually to HMRC for potential underpayment of the National Minimum Wage. But on a zero-hours contract, or a high-stakes Certificate of Sponsorship, there aren’t many of us prepared to take that risk.
Respect, too, is rationed. After I spent 45 minutes with a non-verbal gentleman in the advanced stages of dementia - hoisting, supporting, encouraging, operating heavy moving-and-handling equipment - his wife looked at me and asked, “So when are you going to get a proper job?”. Another client’s family removed the toilet seat in the ensuite so that we could not use the bathroom while we were there. Humiliation is not listed in our job descriptions. It simply arrives, unannounced. It would seem that if this job is so bad and yet we’re still doing it, people assume it must be because we’re not good enough to get anything else. Even among our own families, stigma lingers. I panicked about how I would explain to certain people that I intended to keep doing care work after completing my degree, albeit part-time.
The idea that care could be a vocation - something chosen rather than fallen into - no longer fits the narratives my generation was raised on: compete, maximise income, keep climbing. Care work sits outside that ladder entirely. Part of this is the historic hangover of gendered labour. Homecare roles grew out of unpaid domestic work performed by women, and so a logic persists that if such work has been unpaid all this time, why should a formalised version be rewarded anything but the bare minimum? Aside from protesting the glaring undervaluation of unpaid domestic labour in any such assessment, the public rarely sees how our roles have mutated since the 1990s days of the ‘home help’, into a quasi-medical role. Did you know that we are entrusted to directly administer all manner of medication to our clients despite having no medical qualifications and within the constraints of highly limited timeframes, entirely unpredictable working environments (aka private homes) for in some cases less than the minimum wage, assuming personal legal liability should anything go wrong?
Against this backdrop, there is a risk that the sector at large may be barking up the wrong tree in its intentions to “professionalise” the direct care workforce. Yes, we need better and infinitely more consistent training in areas of high-responsibility. Yes, we need induction standards worthy of the responsibility placed on our shoulders. But the belief that introducing mandatory qualifications will resolve adult social care’s recruitment, retention and quality issues may be misguided. Such an approach risks pushing out some of the most naturally gifted workers who possess crucial ‘soft’ skills that do not translate well into measurable units of economic value - intuition, patience, and emotional intelligence - and erecting new barriers to entry. It also reinforces the idea that quality problems stem from deficiencies in individual workers, when in truth they are born of poverty pay, untenable time pressures and unpredictable working hours. You can train someone to complete a Level 3 diploma; you cannot train them out of the 15-minute visit that is all they are commissioned for. Finally, there is legitimate concern on the part of people who rely on visits from care workers that to ‘professionalise’ the workforce would alter the interpersonal dynamic at the heart of caring relationships, placing the worker in a position of authority over the individual they are there to support in such as way as to erode autonomy over their daily routines and choices. If we look at nursing and its professionalisation, how is that going in terms of recruitment, retention and outcomes?
The solution - as we suggest before the Casey Commission - is likely far more basic: income security. Guaranteed hours. Payment for all working time. The Employment Rights Bill, soon to become the Employment Rights Act, promises to introduce guaranteed hours contracts as standard and initiate the UK’s first Fair Pay Agreement for adult social care. On paper, this is monumental and we encourage as many direct care workers as possible to express what they wish to see from a Fair Pay Agreement by completing the government’s online survey. But careful oversight will be essential in the current homecare setup, to navigate the risk that guaranteed hours morph into a new kind of trap: homecare workers pressured to remain “available” from dawn until dusk to satisfy rostering systems designed for zero-hours flexibility. The proposed creation of a Fair Work Agency is welcome, but only if resourced sufficiently to challenge non-compliance in an extensive privatised market.
In time, a shift away from zero-hours will almost certainly force many homecare providers to close. This is uncomfortable to admit, but a necessary transition that now appears to be accepted even by those membership bodies representing care providers. Fragmentation has produced inefficiency at scale. 46% of over 500 homecare workers we asked said they did not feel confident that when rotas are published they will get the hours they need, despite a supposed shortage of workers and sky-rocketing demand for services. Consolidation - whether through fewer providers in each area or local authority provision - would finally allow workers to receive consistent hours and lay the foundations for social care as a legitimate career choice. The fear is that, during a turbulent period of change, workers may be persuaded by their employers to protest the reforms ultimately intended to improve matters for themselves and the people they support. People receiving care will understandably fear losing contact with the workers they trust. There will be upheaval. But the alternative is the slow collapse already happening in real time. If homecare were allocated to a limited number of providers per area - or brought fully back in-house to local authorities - things could improve rapidly. Instead of slicing the pie into dozens of slivers, care packages could be coordinated intelligently. Workers could be paid by the shift, not the minute and be given their own autonomy to make additional social visits to clients during gaps, where appropriate. Travel distances could be reduced by keeping runs local. Local authorities could conduct proper due diligence. CQC inspections would be simpler and more meaningful. The whole system would breathe for the first time in years.
Such essential improvements to the mainstream infrastructure of adult social care must not be used as an opportunity to quash more personalised approaches to care and support. It is right that people in need of social care should be able to design their own packages of support should they wish to, especially since moves to improve income security for homecare workers may inadvertently reduce the level of choice available via the mainstream system. Some of the best quality, outcomes-focused adult social care is currently identifiable in the relationships between directly-engaged Personal Assistants and the people they support. This is of course in part because of the sorry state that mainstream services are in. Yet 58% of homecare workers we asked said that if they had help to find clients and access to ongoing training, support and advice, they would consider becoming a Personal Assistant for people in their neighbourhood. Meanwhile, Homecare Voices has been approached numerous times by parties seeking to bring ‘client-carer matching platforms’ to market. This style of relationship must therefore be taken seriously as a probable future trend, to avoid Uber-esque infringements of employment rights. There are also risks to client safety in such setups. These could be navigated either by prohibiting certain high-responsibility tasks like medication administration by Personal Assistants, or else by requiring Personal Assistants join a register at local authority level, with ongoing training in high-risk areas. We say this in full appreciation that the suggestion of regulation in any form is unpalatable to many of those pushing for personalised care as the only way forward.
Yet different people have different preferences, expectations and priorities when it comes to accessing adult social care. When my Nan began having falls more regularly but otherwise continued to live well in a warden-assisted complex, bringing someone in via a homecare agency to check she was up and about each morning was a straightforward and entirely suitable choice made in collaboration with my mum, aunt and uncle. When my mum was in her final days, she needed to get home from hospital as quickly as possible; a care package arranged for us was the way to go, all things considered. Despite searing tensions within ‘the sector’ around this question of ‘regulated’ versus ‘personalised’ support, it does not have to be one or the other.
The significance of three direct homecare workers taking seats at this particular table cannot be overstated. But we wonder: where were our counterparts from care homes, nursing homes and supported living? Where were the Personal Assistants and Shared Lives Plus carers? All those who make up the other 50% of the direct care ‘workforce’? The truth is, the only reason we got into that room is because we have taken it upon ourselves, off our own backs and against the odds, to come together on our own terms and get ourselves through the door. We shouldn’t have had to find our own way in. Nor should our colleagues from other parts of the ‘system’ need to. For years, well-resourced bodies in the sector should have been inviting every kind of direct care worker along to decision-making spaces, rather than attending in our place and speaking ‘for us’. At the close of the session, a representative from the Trade Union Congress (TUC) used the word “complicit” to describe the role of sector leaders in the years-old injustices suffered by direct care workers. When I think of how those fronting the sector knew full well that migrant homecare workers with all those unpaid gaps would need to work exploitative hours to meet their minimum salary threshold, and yet supported the Health & Care Worker Visa nonetheless - the word “complicit” feels entirely appropriate.
So what for the future?
In the days leading up to our trip to the Cabinet Office, I spent evenings watching The Hack on ITV Player. It recounts in extraordinary detail the protracted, painstaking and highly-personal journey undertaken by those courageous enough to attempt to bring to widespread public attention the practice of phone-hacking by tabloid media. At its conclusion, The Hack offers a cautionary tale for adult social care. Arguably the biggest ‘win’ for those who sacrificed so much of themselves for that particular cause was the then-government’s decision to launch the Leveson Inquiry. To be undertaken in two parts, the inquiry’s objective was to reset relationships between the media, politicians and the police in line with basic ethics, as is firmly in the public interest. Yet the recommendations of the first part of the Leveson Inquiry were never implemented and the promised second part was scrapped altogether once a new political party took office.
The fear for adult social care is that, even if the Casey Commission produces a set of recommendations that all key stakeholders can get behind, there is no guarantee these will see the light of day. We’ve been here so many times before: The Royal Commission on Long Term Care 1999, The Dilnot Commission 2011, The Cavendish Review 2013, the Kingsmill Review 2014, The Burstow Commission 2014 to name just a few. With the final phase of the Casey Commission only due to report once we are palpably close to the next General Election, it is no surprise that those of us keeping tabs on adult social care collectively groaned when the commission was announced at the start of the year. We will of course engage earnestly with the process. We have no choice but to do so. Then when the Commission’s work is passed back to elected politicians, it will be in the hands of whoever is running the show at the Department of Health & Social Care and the Department for Housing, Communities and Local Government to drive through the necessary changes, navigate key barriers to funding reform and make a compelling case to the Treasury. To ensure support at the ballot box when the time comes, members of the public must be informed now and by any means necessary about the true state of affairs facing adult social care, including the promise of how much better things could be and must become.
Work with us
If your work could benefit from ground-level insights about care in the community, members of Homecare Voices are ready to talk.
Watch our clip about our trip to see the Casey Commission:
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