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Speech to local Integrated Care Board, June 2023

Below is the opening speech made at a meeting of the Nottingham and Nottinghamshire Integrated Care Board (ICB) on 8th June 2023.

Each ICB in the country exists as part of the Integrated Care System, which seeks to bridge the gap between health and social care to ensure services are considered from an integrated perspective (NHS England, 2023). I had the opportunity to speak at the meeting as a result of involvement with Nottingham Citizens, my local branch of Citizens UK, which is campaigning to secure a real Living Wage for all care workers.

The meeting was held as part of ongoing talks about securing real Living Wage accreditation for the organisations the ICB represents. Those organisations include the local NHS Trust, city council and county council. If an organisation becomes accredited with the real Living Wage foundation, all of its employees must be paid at least the real Living Wage, which is a higher, more realistic hourly rate in terms of the true cost-of-living than the National Living Wage (Living Wage Foundation, 2023).

I wished to draw attention to the fact that the vast majority of care workers in the region are not actually employed by these public-sector organisations, but by the private sector care providers they contract out to, meaning the impact of real Living Wage accreditation for any of these organisations would be limited as far as care workers as concerned.


"Hi, I'm Rachel. Since 2018, I have worked as a home care worker. In that time, I have worked for three independent sector home care agencies, two of which source part-or fully-funded clients via their local authority, whilst the other only accepts self-funding clients.

April’s Agenda for Change announcement is good news for care workers who are employed directly by the NHS. However, those employees only account for seven percent of all direct care workers in the East Midlands, according to the latest Adult Social Care Workforce Data Set published by Skills For Care (Skills For Care, 2022). A further five percent of care workers are directly employed by local authorities, but the vast majority, 88%, work for care agencies in the independent sector, like those I have worked for (Skills For Care, 2022). To be clear, the promise of a National Living Wage as part of the NHS' Agenda for Change does not apply to 93% of an estimated 118,000 direct care workers in the East Midlands (Skills For Care, 2022).

Before the COVID-19 pandemic, adult social care was facing a serious recruitment and retention crisis. Since COVID-19, the situation has become far worse. Meanwhile: “the number of older users of local authority funded home care services…is projected to rise by 87% between 2015 and 2040”, thanks to an ageing population, rapidly increasing rates of conditions like dementia and a declining supply of informal care (Wittenberg, Hu and Hancock, 2018, p.7). From the simple perspective of ensuring basic staffing levels to meet current and future demand, pay for care workers must be adequate, so as not to lose care workers to other sectors. I could go to Aldi and earn more than I do as a care worker, according to the pay rates at many home care agencies.

More fundamentally, the nature of the work itself warrants decent pay. Not only do care workers meet the practical care needs of countless clients day in, day out, we also tend to their emotional needs: there to reassure them about what the next GP appointment is for, to think of creative ways for people to find fulfilment in everyday life, and explain what the district nurse or OT meant when they last visited. We are always there joining the dots in between visits from other, more highly regarded professionals. We often manage aggressive behaviour from clients with advanced dementia and do so with patience and compassion. More so, we are personally liable for the correct administration of all manner of medications, despite having no clinical or medical qualifications. All of these bases are usually covered in back to back 30-45 minute visits, which in a full day start at 7am and do not finish until 10pm, with some unsociable, unpaid gaps in the middle.

A real living wage for all care workers should therefore be the bare minimum, offering a basic level of dignity and recognition for the kind of work most people do not even like to think about, except for when they are clapping in a pandemic, and would represent a major breakthrough in securing parity of esteem with NHS colleagues. Direct care work is highly-skilled, highly-rewarding and in such high demand that it should be paid well enough for young people to view it as a genuine career option, rather than just a dead-end job or a work experience opportunity. This is the only way the social care workforce will grow.

We cannot have a conversation about hourly rates of pay for home care workers without addressing the matter of unpaid travel time. Travel time refers to the minutes home care workers spend travelling from one client to the next, which is typically unpaid, despite the fact said workers are unquestionably ‘at work’ during this time. In a full time week of home care, I would typically make around 60 visits to clients, with unpaid gaps of five or ten minutes between each visit. This amounted to a loss of earnings equivalent to around 12 hours' work per month. If I wanted to be paid for 40 hours' work, I’d have to do a 45 hour week. I am sure you can appreciate the implications here for an already difficult work-life balance. Unpaid travel time undermines the hourly rates of pay advertised for home care work and must be considered before announcing that any set of home care workers will now receive a real living wage. For lack of a reform to the contact-time only pay model, a 2023 report by the Resolution Foundation recommends "a sector-wide minimum wage which is £2 higher per hour than the national minimum” for home care workers (Cominetti, 2023, p.5).

I no longer do full-time care work and, as things currently stand, I hopefully never will, because as much as I love the work itself and my clients, the way the work is organised takes too much of a toll on my physical and emotional health for it to be a sustainable full-time occupation. It does not feel right that I should be managing chronic lower back pain in my 20s, which is thanks to the amount of time I have spent crouching and kneeling whilst supporting clients. The owner of the first home care agency I worked for told me that everyone who goes full time burns out within a matter of months. How we can expect to grow the workforce based on current working conditions is beyond me.

In 2020, I welcomed a team of care workers into my family home to care for my mum in her final weeks of life. My nan also had home care throughout her last couple of years. This is profoundly important work. When you place your trust in people to look after your loved ones, you hope that those people are going to be experienced and dedicated to their work. I have met many admirable and inspiring colleagues, but if a care worker is fed up with their employment conditions, in some cases that frustration is bound to be expressed in the quality of care they provide. Every time a good care worker leaves the sector, or reduces their hours for obvious reasons, the overall standard of care available to people drops a little more.

To be clear, I know that there are no bad actors in any of this, except perhaps those who see social care purely as an investment opportunity. Yet, it seems that everyone else is stuck between a rock and a hard place. Care agencies would love to pay their employees a real living wage, but they can't, because local authority contracts do not pay enough per hour of care to make this commercially viable. Local authorities cannot pay more per hour because there isn't room in their budget. Those budgets are not going to get any bigger all the while political parties are afraid to propose tax increases for fear of losing voters. Yet as long as this paralysis continues, as it has done for years now, the situation for care workers and for recipients of care - which could and probably will at some point, include ourselves or our loved ones - gets worse, and worse, and worse.

Care workers, unlike other professions linked to the public sector, have not gone on strike this year. That is because its workers are not unionised (Cominetti, 2023). Care workers who do belong to a union are in a minority and are usually employed directly by a local authority. The lack of representation for the social care workforce is why this gathering of individuals from organisations which may be able to influence how care work is organised, whilst not employing us directly, matters so much.

Some of the issues I've talked about today likely extend beyond the remit of what can be expected to be achieved at a local level. That said, I would urge you to engage with this issue as an individual, rather than as someone doing their job, as part of a system. If we only act according to the letter of our job descriptions, things will carry on as they are. This coming together of partner organisations is cause for genuine optimism. In order that we do not sit here and have the same conversation again in three months time, and in six months time, and in a year's time, on behalf of all care workers in the region, I urge you to leverage your networks and think outside the box about how Nottinghamshire can lead the way in addressing these issues. Thank you"


Conversations that followed focused on what is possible within the commissioning process: that is, the way that local authorities engage with care providers whose employees deliver social care. As part of the commissioning process, a contract is signed between the local authority and a given care provider. There was discussion about so-called "values-based commissioning" which aims to ensure care providers employ their care workers on decent terms by writing certain conditions into said contract. Would it be possible, for example, for local authorities to insist that care providers pay staff a living wage? This goes to the heart of the relationship between local authorities and care workers: whilst care workers are not directly employed by the local authority, it has major influence over the conditions of their employment:

“When the Equality and Human Rights Commission (EHRC) undertook an investigation into the extent of disregard for human rights in the provision of homecare it noted that service delivery contracts between commissioning local authorities and care providers very rarely include any reference to terms and conditions of employment, even though local authorities are aware that low pay impacts on the quality of care services (EHRC, 2011, pp. 73–4). In over 90 per cent of local authority areas, the hourly rate at which homecare services are commissioned falls below the rate the industry claims is necessary to fund its compliance with minimum labour standards (UKHCA, 2014). Given the poor quality of employment on offer, it is perhaps unsurprising that the homecare industry suffers from a higher annual turnover of labour than any other sector in the UK economy. Over one-third of workers leave their jobs each year and about half of all new recruits move on to a new job within less than 12 months” (Hayes, 2017, p.6)

Following on from this, the point was raised that once a contract has been signed between a local authority and a care provider, there is usually very little in the way of follow up on the part of the local authority to check that the care provider is employing staff as per the conditions of the contract. So, even if payment of a living wage was written into the contract, it would be easy for a care provider to get away with non-compliance. This makes me think of the Ethical Care Charter, a voluntary code which has been signed by numerous local authorities. One of its many conditions is that local authorities who sign up must pledge to ensure care workers are paid for their travel time. I know through personal experience that, despite my local authorities signing the Ethical Care Charter, travel time is still not being paid to care workers in my region, as standard.

It was agreed that at the next meeting there should be more representatives from local authority finance departments present, so that they could be involved in conversations about how pay for care workers is influenced by hourly rates paid by local authorities to care providers. It was also noted that nobody representing home care providers were present at the meeting and that it would be good to get input from this key stakeholder at future meetings.

No tangible actions have been taken as a result of the above meeting and a date for a follow-up meeting is still yet to be agreed, stalling any momentum that was achieved in June. This is disappointing, but alongside Pete Rogers at Nottingham Citizens, we will do what we can to stay on the case.


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