Consultation outcome

Statement of impact – The Health and Social Care Act 2008 (Regulated Activities) (Amendment) (Coronavirus) Regulations 2021

Updated 9 November 2021

The following impact statement sets out the analysis which has been conducted on the requirement for all those working in a care home registered by the Care Quality Commission (CQC) to be vaccinated, covering estimates of the potential size of the workforce who may not have met the requirement by the end of the grace period, the potential scale of exemptions, and assumptions made around the cost of replacing workers. This will form the basis of a more detailed impact assessment which will be submitted to the Regulatory Policy Committee (RPC) for their scrutiny and published in due course.

While the analysis in this document covers those areas set out in the paragraph above, we expect the policy to have some additional costs and benefits which we have been unable to quantify. These are described at the end of this document.

The main impact is the displacement of workers not fulfilling the condition of deployment (having received both doses of the vaccine by the end of the 16-week grace period). There is a significant degree of uncertainty resulting from the unknown impact of behaviour change as a result of this policy’s introduction as well as other potential wider freedoms granted to those who are double vaccinated.

We have therefore produced 3 estimates (an upper and lower estimate, and a further sensitivity analysis) of the potential proportion of the workforce who will not have met the condition of the deployment in order to illustrate this uncertainty. We have also arrived at a central estimate, considering the most likely position between our upper and lower estimates. The upper and lower estimates for the proportion of the workforce who may be unvaccinated by the end of the grace period are 12% and 3% (having accounted for exemptions), with a central estimate of 7% which equates to roughly 40,000 workers out of around 570,000 working in CQC-registered care homes. This is in the context of an annual turnover of care home staff of 33% in 2019 to 2020.

Upper estimate

The first of these estimates, representing the upper-bound, uses the number of staff from both older adult care homes and younger adult care homes who have received their first dose of the vaccine, as reported weekly by care providers on the Capacity Tracker Tool – a regular mechanism for providers to provide requested information to the Department of Health and Social Care (DHSC) to aid the design of sector support and which serves as the basis for relevant NHS and DHSC statistical publications. This uptake is then projected forwards in time using a logarithmic trendline-of-best-fit. We think that this is appropriate given that such a trendline is often used when change begins quickly before slowing gradually and approaching a limit, which is a similar pattern to that we have observed in vaccine uptake among care home workers.

Using weekly data from 14 March to 4 July 2021 to project England-level uptake of the first vaccination 8 weeks into a grace period starting in the week commencing 18 July (so as to allow a further 8 weeks for a second dose within the grace period, per current guidance), our projection suggests that around 87% of the workforce would have had both doses and therefore around 13% of the workforce will not have met the requirement by the end of the grace period, without factoring in exemptions which are covered below in the document.

We have used the data on the number of workers who have had their first dose (rather than those with both doses) as it provides a more robust forward projection given that a longer time series is available, as well as enabling additional sensitivity analysis on our projections described below (as it leads second dose uptake by around 8 weeks). As a result, since we require the estimate of those who have had both doses by the end of the grace period, and current guidance states that 8 weeks is required between doses, we use a cut-off date of 8 weeks into the grace period to measure the number of staff who have had their first dose (covering both those who have already had their first dose and allowing 8 weeks for those who haven’t had either to get their first dose) – this then assumes that all those with the first dose will then receive their second dose 8 weeks on from this date, per the current guidance.

Medical exemptions

There is limited data to determine the number of workers who would qualify for exemption in line with ministerial decisions on exemption eligibility, and this uncertainty extends to the number of workers who may need to be replaced. Though unknown, we expect there to be very small numbers of staff who will have medical reasons not to be vaccinated and therefore will be exempt. Only a small proportion of staff will have relevant allergies to a specific vaccine ingredient, for example, as these are very rare in the overall population. Similarly, only small proportion of pregnant staff are likely to experience the kind of complications which would mean that vaccination is not advised, and exemption is to be determined on a clinical, case-by-case basis. Taking these factors together, we have arrived at an estimate that 1% of the overall workforce may be exempt. This estimate is supported by a Driving Uptake Project survey (also detailed below), and though that survey sample is not representative of all care homes, we would expect the share falling within this category to be broadly consistent across all homes.

Applying this figure to our projection above, we estimate that at most 12% of the workforce might no longer be deployable as a result of the policy.

Sensitivity analysis – potential impact of government efforts to improve uptake

Care homes in London have recently seen an uptick in the number of staff coming forward, due at least in part to additional measures put in place by Integrated Care Systems and other local partners to address low vaccination rates. Additional measures first introduced in London have since been shared as good practice across other regions. This policy effect cannot be fully captured in an England-level projection estimated over a longer time period. We have therefore conducted a sensitivity analysis which assumes that the recent progress in London can be replicated in other regions as good practice is implemented.

By applying the rate of ‘acceleration’ seen in London from 1 June to 6 July (in the latest Capacity Tracker data received by DHSC) to each other region’s own rate of uptake for the following 6 weeks, we can arrive at an alternative projection over the same timeframe. Using this approach, we find that, having aggregated the regions to national level, by the end of the grace period up to 92% of the England workforce in care homes would be vaccinated and so 8% unvaccinated. Applying our estimate of medical exemptions within the workforce, we estimate that under this scenario, 7% of the workforce might no longer be deployable as a result of the policy.

Lower estimate

Our second estimate, representing a lower bound on uptake, uses a range of survey data to estimate the proportion of the workforce who may choose to remain unvaccinated. Using Office for National Statistics (ONS) survey data on the proportion of the entire adult population of Great Britain who indicate vaccine hesitancy^{[footnote 1]} broken down by key demographics and adjusting those figures to match the demographics of the adult social care workforce (principally age and gender) through a weighted average, we estimate that 5% of the care home workforce could be vaccine hesitant.

Vaccine hesitancy as measured in this survey has been declining over time, as more people have been offered and chosen to accept a vaccine. A significant share of those who are ‘vaccine hesitant’ and aged under 30 told the ONS that they have not made up their minds or prefer not to say – in part because many in this cohort have been offered access to the vaccine more recently than others. If these positive trends were to continue – for example, if hesitancy amongst women aged 16 to 29 were to fall to the level amongst women aged 30 to 49 – the proportion of the care home workforce who might choose to remain unvaccinated could fall to 2 to 4%.

This impact could vary between care homes. The Driving Uptake Project (part of the government’s programme of work to encourage vaccine uptake) surveyed the managers of care homes who were reporting that only 25% to 50% of staff had had the first dose of the vaccine. On average, this found that 8% of all staff in such homes were considered unlikely to ever accept the vaccine. While this survey deliberately focused on care homes with low vaccination rates, and so is not representative of the wider care home workforce,^{[footnote 2]} it provides information on the potential effect of the policy in the most-impacted individual care homes.

Moreover, analysis using 2011 Census and Skills for Care demographical data to estimate the proportion of the workforce who may be pregnant at any one point (one of the primary reasons given for hesitancy by respondents to the ONS and a further NHSEI survey of care home managers), found this to be around 4%. Since many of those who are currently pregnant will choose to take up the vaccine, an estimate of 2 to 3% is again plausible. Taking this survey evidence together, there are a range of estimates for those who may decide not to take up the vaccine. While the Driving Uptake survey provides a useful upper estimate at care home level, the ONS data provides a more reasonable estimate for the likely vaccine hesitancy amongst the workforce. We therefore conclude that the most reasonable lower estimate would be 3%, including those who are medically exempt from the regulation.

Central estimate

Based on estimates of between 12% and 3% as detailed above, combined with our sensitivity analysis using regional data, we judge that a midpoint of 7% represents our best possible single estimate. This midpoint is also broadly in line with the sensitivity analysis resulting from government efforts to improve uptake. This implies 40,000 current members of the workforce (out of around 570,000 working in CQC-registered care homes) may choose not to take up the vaccine before the end of the grace period.^{[footnote 3]} However, the range between our upper and lower estimates implies that this could fall between 17,000 and 70,000 as a consequence of the uncertainties detailed above.

Cost implications for care home providers

Since the condition of deployment will require all staff working in a CQC-registered care home to be vaccinated, we have included an estimate of the full possible cost of replacing those workers who do not meet this condition. We estimate this cost as £2,500 per worker derived from the stated costs of recruitment by a small adult social care provider reported by Skills for Care (given the uncertainty around the relative productivity of a new worker compared to an experienced worker – and the lost output or increased wage costs which result – we have reduced our estimate compared to that reported by Skills for Care by 50% of the productivity estimate).^{[footnote 4]} The costs from this source are based on a single small adult social care provider that employs 20 full time equivalent care workers and recruits 6 over the course of 12 months, so are used with caution (although the size and turnover of this provider are fairly typical within the sector, there may be opportunities for larger providers especially to achieve economies of scale). The total calculated cost of recruitment from this source combines the costs of temporarily covering the hours of exiting staff, preparing a job description and the application process, advertisement and promotions, shortlisting, conducting interviews, doing checks and contracting, completing induction and training, having initial supervision support and the lower productivity caused by a reduced capacity. Combining our 2 central estimates indicates a one-off cost to care home providers of £100 million.

Counterfactual context, risk and mitigation

Making vaccination a condition of deployment in a care home is likely to have a significant impact on staffing in the short- to medium-term for at least some providers, with those who do not fulfil the requirements needing to be replaced by providers who can no longer deploy them. This could present a risk to staffing levels, given existing capacity and recruitment issues reported by the sector. However, we believe it is likely that any exits will occur throughout the 16-week grace period and not all at once, therefore representing increased turnover rather than a very sudden reduction in staff. These impacts occur in the context of a sector which experiences a relatively high annual workforce turnover rate of around 33%,^{[footnote 5]} where recruitment forms a regular part of operations. Given that high level of turnover, it is also plausible to think that at least some of any affected staff members would have left the sector anyway over the course of the 16-week grace period.

It is worth noting that the extent of the challenge posed by increased turnover will also depend on the local labour market conditions. Some of these risks could be somewhat mitigated at the local level through levers which are set out below. For example, we can expect local authorities to proactively manage these risks given their knowledge of local provider and labour markets and the ongoing work taking place regarding vaccine uptake. We can expect them to have contingency plans in place to deal with workforce shortages as set out in the Care Act. The DHSC regional team will be working with local authorities over the coming weeks to offer support in relation to this. Examples of actions that can be taken are redeploying staff from their own or other services or relocating residents in the event of service closures. We are working with Skills for Care to ensure that resources such as guidance and best practice are available to support providers and local authorities with capacity and workforce planning, recruitment and well-being.

While we are assuming that a potentially large number of replacement workers may be needed to help address the vacancies that may arise as a result of the policy, there are plausible reasons to suggest why we think this may be possible. These include the approaching end of the furlough scheme, introduced to help deal with the pandemic, which may result in a possible sudden increase in the size of the adult social care (ASC) workforce entrant pool, helped further by the limited level of requirements necessary for those entering the sector. The policy may also incentivise some people to enter this labour market, given their increased level of protection against the spread of the virus at the workplace relative to other labour markets. There could additionally be workers who may not respond in time to the requirements initially and so will temporarily need to exit the workforce, but once having received both doses would be able to re-enter into the workforce.

Unquantified impacts of the policy

The potential unquantified costs may include a temporary loss of job for those who may leave the workforce due to the policy. This may place a temporary increased strain on those workers already vaccinated, until replacement workers are recruited. There is also an unquantified risk that some care homes who have higher levels of vaccine hesitancy amongst staff will find it more difficult or costly to replace workers. This risk may be focused in certain areas or regions, as the uptake of vaccinations in the local labour market will vary and partly determine the available supply of and demand for new workers.

On the other hand, we expect there to be unquantified benefits which we believe are fairly substantial and long lasting. These include the benefits to workers and residents from reduced illness. This will avoid loss productivity due to absences caused by COVID-19 among staff and maximise protection for those most clinically vulnerable. Care users will also benefit from a reduction in the currently unequal level of risk across care homes which will help to ensure that care users are not unequally impacted by the threat of the virus or the impact of staff absences.

The wider community will also benefit from this policy, as it will increase the number of people vaccinated within the population which will help to reduce the spread of the virus. Our analysis focuses on estimates of the potential size of the workforce who will not have met the requirement, the potential scale of exemptions, and assumptions made around the cost of replacing workers.

1. Coronavirus and vaccine hesitancy, Great Britain. The ONS define “vaccine hesitancy” as the proportion of respondents who: have been offered a vaccine but declined the offer; are very or fairly unlikely to have the vaccine if offered; are neither likely nor unlikely to have the vaccine if offered; don’t know; or preferred not to say. ↩

2. Alongside this caveat, it is worth noting that: a sizeable proportion (23%) of staff reported as unvaccinated in the care homes undertaking the survey were missing from the call agent team data, so it is not known if managers estimated them as likely or unlikely to take the vaccine; the survey was undertaken before the government had announced its intention to introduce legislation to require vaccinations as a condition of deployment, but the consultation had launched before this. ↩

3. Based on aggregated workforce estimates for older adult and younger adult care homes as per Capacity Tracker on 6 July. ↩

4. Skills for Care, Calculating the cost of recruitment. ↩

5. ASC-WDS 2019 to 2020 ↩