Research and analysis

Adult social care and immigration (accessible)

Published 27 April 2022

Executive Summary

Introduction

On 6 July 2021, the Minister for Future Borders and Immigration commissioned the Migration Advisory Committee (MAC) to

…undertake an independent review of adult social care, and the impact the ending freedom of movement has had on the sector.

The commission came from a commitment that the Government gave in the House of Lords as part of the Immigration and Social Security Co-ordination (EU Withdrawal) Act 2020, which ended Freedom of Movement (FoM) and introduced a new Points-Based immigration system for the UK.

The Government asked us to

…provide recommendations on how to address the issues which the sector is experiencing with the immigration system and to highlight, where they arise within the scope of the review, wider issues for the Government’s consideration, such as employee terms and conditions.

We were asked to report by the end of April 2022, and this report fulfils that commitment. On 15 December 2021, we published our Annual Report, which included an update on this commission and an interim recommendation to immediately make Care Workers and Home Carers eligible for the Health and Care Worker Visa and place the occupation on the Shortage Occupation List (SOL). The Government accepted this recommendation on 24 December 2021.

As with other commissions, we carried out an extensive programme of work to support our decision making. This included:

• wide ranging stakeholder engagement, including with representatives of the social care sector and Government in each nation, trade unions and people who draw on social care;

• analysis of relevant official statistics, job vacancy data and sector-led datasets to examine a range of issues such as the size, characteristics, and trends in pay in the social care workforce and migrants within it;

• primary research with employers and people who receive care and support across the UK, including in-depth interviews; and

• a 12-week Call for Evidence, which received 145 responses from a mix of individual care providers, representative organisations, and those responding in a personal capacity.

Throughout the commission we have worked closely with various bodies across the UK and have proactively engaged with as wide a range of voices as possible. It has been an incredibly busy and challenging period for the sector, so we are very grateful to all those we spoke to, or who contributed information to us.

We also appointed an expert advisory group with expertise of the social care sector to work with us during this commission. We are indebted to them for their guidance and help, but the recommendations and conclusions remain solely the responsibility of the MAC.

Over the course of this commission, we have heard powerful stories from people who receive care and support, who rely on high-quality care to provide dignity and protect their quality of life, as well as the pride that many social care workers and employers feel to be working in the sector. We also recognise the anger that many within the sector have felt at workers being viewed as ‘low-skilled’. We categorically disagree that care work is low-skilled; although some basic technical skills can be acquired through training, other skills are vital attributes in providing good quality care, such as emotional and physical resilience, communication, planning and organisation, problem solving skills as well as understanding individuals’ needs. We also recognise the further strain that the ongoing COVID-19 pandemic has caused the sector, with workers going above and beyond to continue providing a vital service in challenging conditions.

In previous MAC reports we have highlighted some of the many challenges that the care sector faces. These include increasing demand for care, high vacancy and turnover rates, low pay rates with little pay progression, and poor terms and conditions compared to competing occupations. These issues predate the end of FoM and have largely been compounded by the pandemic. As we have stated previously, the underlying cause of these workforce difficulties is due to the underfunding of the social care sector.

Whilst these problems are not unique to the UK, and are indeed similar in many other high-income countries, we maintain that properly funding social care to allow improvements in pay and conditions is ultimately the key to addressing these workforce difficulties. We do not believe that immigration policy is the cause of, or the solution to, all, or even most, of the workforce problems in social care, but that immigration could potentially help to alleviate some of the difficulties, at least in the short term.

Based on the terms of our commission and our areas of expertise, we have focussed on where we can add the most value in this commission. Our report therefore focuses on workforce issues and particularly immigration policy, and not issues of social care provision and funding.

Social care policy and workforce

Chapter 1 of this report sets out key facts on the size and nature of the social care workforce and details of how social care operates across each nation in the UK and the implications of this on issues like workforce strategies, funding, qualifications and registration, and data collection.

Social care is a devolved matter meaning that the Devolved Administrations (DAs) in Scotland, Wales and Northern Ireland have responsibility for their respective systems. This makes the intersection between immigration policy (which is a reserved matter, i.e., decisions are taken at a UK level and apply across the UK) and social care more complex. In each nation, local authorities (LAs) are responsible for care delivery, except in Northern Ireland where Health and Social Care Trusts play a comparable role.

Office for National Statistics (ONS) data shows that the social care workforce across the UK has grown steadily in the past decade, with a total of just over 1 million workers in 2019; other estimates suggest this workforce is larger. Care workers account for three-quarters of the social care employees in our scope, with the rest split between senior care workers, care managers and nurses. Given some of the difficulties we have had analysing data for this commission and inconsistencies between national datasets we recommend DHSC and the Devolved Administrations should consider adopting a common data collection framework and in addition where possible, social care and healthcare should be separated in ONS and other official data.

Directly employed care workers are likely to be underrepresented, or missing, from standard labour market surveys as their direct employment relationship with the person receiving care and support is often informal and may be transitory, and care activities in this area are unregulated. Skills for Care estimate (PDF, 995 KB) that there were 130,000 care workers employed by direct payments recipients in England as of 2021. Just over half of these were family or friends of the people who receive care and support. These estimates do not include workers employed via personal health budgets or through private funding. We recommend DHSC and the Devolved Administrations should work jointly on a review of the evidence available on directly employed care workers, including those paid for via direct payments, personal health budgets and private funding. The MAC has engaged with representatives of direct employers and has heard the difference this makes to people’s lives, particularly those with acute care needs.

We would expect, given demographic factors, that demand for social care will increase in future. Vacancy rates suggest that the social care sector already needs an additional 66,000 FTEs to fulfil demand today. Our projections, based on estimated future care need, suggest that the sector will need to recruit a further 236,000 FTEs to keep up with growing care need. Demand for labour in the sector is outpacing population growth: social care employs around 2% of the working-age population today and may need to employ 4% to fulfil demand by 2033.

Compared to the rest of the labour force, women are overrepresented, accounting for over four-fifths of the social care workforce. Part-time working is also more prevalent with 40% working part-time, and women are 3 times more likely to work part-time. Whilst most workers in the social care sector are British nationals, migrant workers form a considerable, and growing part of the sector, with significant variation by region – in particular, London is more diverse compared to the rest of the UK. In 2020, 1 in 4 social care workers were born outside the UK, most of whom were born outside the EEA.

We note though, that during the era of FoM the social care sector has not come to rely on EEA workers in the same way that some other sectors of the economy have. Indeed, for most employers in the sector, EEA workers are employed simply as a result of being part of the local labour market that they recruit from, rather than as a result of targeted recruitment across Europe. Over time, the ending of FoM will likely reduce the share of EEA workers in the labour market, and we expect this will feed through into their reduced employment in social care.

There is little standardisation of qualifications in the sector. Since 2003 the Scottish social care workforce has been subject to professional regulation, where workers are required to register with the SSSC and if they do not already possess a qualification, they must attain the specific qualification in line with their role within 5 years. Similarly, in Wales, in order to register with SCW, residential and domiciliary care workers must commit to complete a required qualification if they do not already possess one upon entry; this must be done within 3 years. Experienced care workers can have their competence certified by their manager. In NI registration is intended to demonstrate compliance with standards of conduct and practice, rather than qualifications. No such requirements exist in England. We recommend that the Government should consider what they might learn from the examples of good practice we have highlighted from across the UK. Additionally, we recommend that the Government embed a culture of regular consultation with the DAs and stakeholders from the Devolved Nations (DNs) to share knowledge and best practice.

As with any sector, formal qualifications are only part of the workforce development, and focus should also be given to learning on the job. Registration, qualifications, and skills frameworks are practical tools that can help ensure good quality care is delivered and is important for migrant and domestic workers alike. The social care sector would benefit from workers incentivised to invest in their career. We are supportive of providing such training to further upskill the workforce and increase the public perception of care work and formally recognise the skills which workers build over their time in their role. This type of formal training is valuable in maintaining a high standard of care and should be adequately funded throughout the UK to ensure that care workers can continue to learn whilst they work.

More generally, it is clear that a long term, coherent workforce strategy, that is fully implemented with adequate public funding, is vital to make social care an attractive, viable and sustainable career. We fully endorse the views expressed by the Health and Social Care Committee for DHSC to produce a

People Plan for social care in alignment with the NHS and would strongly recommend that DHSC, and the comparable bodies in the Devolved Administrations, develop a coherent workforce plan in consultation with the sector.

The social care labour market

Chapter 2 of this report provides details of the social care labour market. The social care sector has experienced high vacancy rates over the last decade, which have worsened as the economy has reopened after the third wave of the COVID-19 pandemic. Whilst high vacancy rates have been prevalent across the whole UK labour market as part of the post-pandemic economic recovery, the social care sector stands out in terms of faster rates of growth in vacancies. Where conventionally wages, and potentially the price of a service, would rise in response to high vacancy rates, the structure and shortfall in social care funding has limited the scope for such an adjustment; though it is important to note that this varies across care providers and their reliance on publicly funded care packages.

Social care also has high, and generally rising, rates of employee turnover. Some movement between employers can be healthy for the sector as organisations compete to attract workers, improving the job offer whilst retaining the same headcount across the sector; however, high levels can be disruptive for organisations and are often symptomatic of underlying issues.

Historically social care workers were paid a premium over occupations against which the sector competes today. However, this premium has narrowed in the past decade. This has been driven, in part, by the 2016 introduction of the National Living Wage (NLW) to sit above the National Minimum Wage (NMW) which has increased wages for the lowest paid whilst also compressing the distribution of pay, such that there is now little premium for relevant experience and the additional pay for working as a senior care worker, compared to a care worker, is often unlikely to be sufficient to persuade workers to take the extra responsibility that would come with promotion. In 2021, the Scottish Government introduced a minimum hourly wage of £9.50 per hour for care workers, which has risen to £10.50 per hour from April 2022. The Welsh Government has also set a new minimum wage for social care staff of £9.90 due to come into effect in April 2022, pegged to the Real Living Wage. We believe these changes, if fully funded, are desirable across the UK and will be key to improving recruitment and retention, but thought must also be given to maintaining differentials, to reward both experience and seniority, rather than just merely increasing minimums.

Even within the relatively low wages in social care there are some employment practices that may make effective pay even lower, and where we believe there is scope for further reform, for example:

• travel time between people receiving care and support and the extra time required to adhere to infection protocols (e.g., PPE, disinfecting surfaces etc) sometimes not being counted as working time, despite the requirement it should be; and

• social care may require care workers to stay overnight in case the person receiving care and support requires help during the night – referred to as ‘sleep-ins’. In 2021, the Supreme Court ruled that workers on sleep-in shifts were not entitled to the NMW while asleep. In this situation, when a worker is asleep but at work, the rate of pay is not regulated.

The Scottish Government have taken independent action and require care workers to be paid at least £10.50 per hour from April 2022 for time spent at work, including sleep-ins. This highlights an important point – statutory minima do not need to be where policymakers set the standard.

In commissioning this report, the Government were clear that we should feel free to highlight

…wider issues for the Government’s consideration, such as employee terms and conditions. This was in addition to recommendations on immigration policy. We are in no doubt that the single most important factor that underlies almost all the workforce problems in social care arise as a result of the persistent underfunding of the care sector by successive Governments. It is not for us to advise on either the appropriate level of funding for social care nor on the method of financing such funding. This is particularly so, as social care is a devolved matter and we were not commissioned by the DAs.

However, one cannot seriously address the workforce issues in social care unless pay is improved; this is essential to boosting recruitment and improving retention. There is no reason why the pay of care workers should rise only when the NLW rises; indeed, there are clear reasons why relying on NLW uplifts will not address the recruitment and retention difficulties. What is needed is a minimum pay rate for care workers that is fully funded by Government and is above the NLW. Both the Scottish and Welsh Governments have implemented a mandatory hourly wage for care workers above the statutory minimum. Higher pay across the rest of the UK is a prerequisite to attract and retain workers in social care. We therefore recommend that the Government introduces a fully funded minimum rate of pay for care workers in England that is above the NLW, where care is being provided through public funds. As a minimum starting point, we would recommend a level of £10.50 per hour to be implemented immediately. We would also strongly emphasise that an increase of this magnitude is not enough to address the issues presented by low pay in the sector and urge the Government to go significantly further as quickly as possible. In addition, differentials across the workforce must increase and the pay premium historically afforded to social care workers over other jobs must be reinstated to increase attractiveness and fairly reward employees for the unique nature of their work – increases to the NLW simply do not solve these issues.

Our remit comes from the UK Government, so we do not consider it appropriate for us to advise the DAs; however, if asked we would make the same recommendation to all the DAs. We would note of course that our recommended minimum starting point is the same as that adopted by the Scottish Government from April 2022. We also recommend that workers in social care should be paid for the hours while at work, whether this is time spent travelling or sleeping. Whilst these hours are not being properly compensated, low paid workers are being underpaid for their time spent at work. Where care is being provided through public funds, those funds should increase to fully reflect the additional costs involved.

Roles in the NHS often compete with the social care sector. This means heavily funded NHS recruitment campaigns can make it difficult for social care employers to hire enough workers. DHSC recruiting policies, driven by NHS demand, may also affect the quality or experience of the talent pool available to employers in the care sector, particularly in times of increased demand for care. The scale of the NHS, and the salaries and benefits it is able to offer, can make it difficult for the social care sector to compete.

With high vacancy rates also seen in the NHS, this dynamic is likely to continue. We recommend that DHSC and the Devolved Administrations work towards a joined-up approach when planning and executing recruitment campaigns for the health and social care workforces. This may include changes to the job offer, particularly in social care roles, to both attract a larger share of the total workforce and retain the current workforce.

Immigration policy for social care

Chapter 3 of this report looks at the previous and current immigration policy for social care, how the sector interacts with the immigration system, and sets out our recommendations for changes. Immigration cannot be viewed in isolation, nor as a sole solution to the issues faced by the social care sector. We believe that the Government needs to take a holistic view of immigration alongside the long-standing funding issues and unfavourable terms and conditions within the sector, which in turn are having serious impacts on the availability and quality of care for those who need it. These problems are the result of years of policy decisions not to fund the social care system properly. However, the end of FoM has contributed to shortages in the social care workforce.

Immigration policy may be able to help alleviate some of the workforce problems that the sector is facing, but it is not the best solution to these problems. The real solution lies well beyond our remit, in the design and funding of the system itself. It would also be highly damaging for the sector in the long term if the necessarily limited and short-term relief brought by immigration policy were used as an ‘excuse’ not to address the more fundamental problems the sector faces. Nonetheless, the MAC’s remit is to make recommendations on immigration policy. With this in mind, we have considered whether and how immigration should be used to alleviate the situation in the short-term and what options would work for this sector.

The Skilled Worker (SW) route – and the Health and Care Worker (H&CW) visa that implements the SW route for health and social care occupations – is now the principal employer sponsored immigration route for hiring migrant workers in social care. Following the MAC’s December 2021 recommendation to include care workers in the H&CW visa, all the major occupations in social care can now access this route. We reviewed the operation of this route in some detail to examine the extent to which changes could be made that would benefit the social care sector and not jeopardise the overall objectives of the SW route.

A new group of employers are now having to engage with the immigration system and they have not always found this straightforward, with concerns about both cost and complexity. However, we are seeing that use of the SW route is growing for senior care workers (since care workers did not qualify for the SW route until 15 February 2022, the data reveals little about the flow of migrants into the largest occupation within social care at the time of this report), suggesting that over time employers develop familiarity with the system and start to use it. The percentage of all new sponsorship applications that were made by employers from the Health and Social Care Sector increased from 18% between 1 January 2021 and 23 December 2021 to 30% from the 24 December 2021, when the Government agreed to include care workers on the route. We recommend that the Government either conduct or commission research to identify administrative burdens for employers and workers that could be eliminated across the SW route. This analysis should consider both the benefits to the integrity of the immigration route of specific requirements, and the burdens on those who must fulfil them.

Given the exceptional pressures on the care sector, we consider any tax on the recruitment of migrant workers which reduces the numbers who use the immigration route to be in opposition to the steps already taken to facilitate immigration into the care sector. We also recognise that the NHS is a large user of the H&CW route whilst care workers are often coming to fulfil LA commissioned care. It seems illogical to charge the Immigration Skills Charge (ISC) to public sector bodies or those meeting public sector needs and thus simply shifting funds across Government. We recommend the removal of the Immigration Skills Charge for all H&CW visas. More broadly, it would be useful to conduct a full review of the ISC across the entire SW route, which was introduced some years ago and there have been substantial changes in immigration policy and its objectives since that time.

In line with the rest of the SW route, the H&CW visa requires migrants to be paid the higher of their occupation’s going rate or an annual salary of at least £25,600. Occupations on the SOL receive a discount on these thresholds, so care worker and senior care workers must be paid an annual minimum of £20,480, equivalent to £10.10 per hour. Whilst we have clearly heard that some employers find this salary level to be problematic, reducing the pay threshold would also have disadvantages. It would mean explicitly allowing the immigration system to facilitate the already too widespread practice of paying care workers less than the value they provide, and less than the amount that is required for this labour market to function effectively. The Scottish example shows that it is possible to pay care workers more when the political will to do so is there – although it is also important to ensure that these increases are properly funded. On balance, we recommend maintaining the current salary threshold for the H&CW visa.

There are also significant costs associated with a migrant becoming settled in the UK. This problem is not specific to care workers, although their low salaries may make the fee less affordable in comparison to other work migrants. We want to encourage dedicated workers in Health and Social Care to remain in the UK. We recommend that workers who spend the full 5 years working in nursing or care roles on the H&CW visa should either receive a complete settlement fee waiver or pay a lower fee, that is no higher than the unit cost of processing. The cost of this recommendation should not be passed on to other visa fees.

In our 2021 Annual Report, in recognition of the fact that the wider issues facing the social care sector will need time to resolve, the MAC recommended the addition of Care Workers and Home Carers to the H&CW visa and SOL. This was accepted by the Government and implemented in February 2022. In light of the long-term and persistent nature of the challenge facing social care, the MAC recommends that the decision to make care workers eligible for the H&CW visa should be made permanent, i.e., should not have an automatic sunset date. This will give more certainty to employers in the sector.

Adding care workers on the SOL is separate from the decision to allow applications under the H&CW visa. The MAC would expect to review the position of care workers in the usual way when we next review the SOL. We would recommend that the Government keep care workers on the SOL until the next SOL review is completed, when we will make a further recommendation. While any future SOL review will examine the situation in the labour market at that time, realistically it is very unlikely that shortages in the social care sector will be resolved in such a short period. The MAC would likely only be minded to remove care workers from the SOL in the event of a very substantial change in the conditions facing social care employers.

Even if sponsorship duties are simplified and costs reduced, the SW model does not work for all care employers. A small, but highly impacted, proportion of people who receive care and support in the UK directly employ care workers, and stakeholders from this sector have told us how vital those care workers are to these people being able to function and live independent lives. They also told us about the difficulties in finding and recruiting suitable individuals to provide personal care, and the high harm to their lives when they could not find appropriate care.

Most of the people who receive care and support that we spoke to explained that finding qualified care workers who understood their specific needs was much harder following the ending of FoM, and although they were using agencies to help their search, this was hampered by the overall lack of care workers, including UK care workers, and a consequent rise in the daily rates charged.

Stakeholders in this position typically wanted a way to employ overseas care workers directly, as they had done in the past under FoM. Several recognised that the administrative burdens of the sponsorship process would be difficult to fulfil for many, even if individuals were allowed to become licensed sponsors under the immigration system. However, the sponsorship system prevents individuals from registering as a sponsor: this applies to all occupations, including in other activities where it is common for individuals to be employers, such as childcare. The sponsorship rules are designed to play a role in protecting sponsored migrant workers. There is already evidence that even when migrant workers are sponsored by organisations, they can be vulnerable to poor compliance with employment law. If workers are directly employed by individuals, through some form of sponsorship arrangement, these vulnerabilities are likely to increase because the absence of an external employer makes them more isolated. Whilst in theory migrant workers could find another sponsor, should sponsorship cease without a migrant having a new sponsor, they are required to leave the UK. This can create a power imbalance between the migrant and sponsor, especially where the migrant relies on the sponsor for their housing.

Direct employment raises particular challenges for the immigration system. One potential option to mitigate the problems faced by direct employers who previously relied on FoM would be to allow licensed umbrella bodies to sponsor workers who would then be placed with specific people who receive care and support. The model that allows agencies to sponsor staff exists elsewhere in the immigration system, for example in the Seasonal Agricultural Workers Scheme (SAWS). In theory, this can be an attractive option to improve oversight, as the licensed operators have an incentive to ensure compliance with programme rules in order to maintain their licenses. However, it does not remove risks of exploitation, as the recent evaluation of the Seasonal Workers scheme has identified.

The MAC has considered a similar agency sponsor model for social care. However, we believe that there may be better ways of achieving the same objectives through the existing SW route. The SW route already allows an agency to sponsor a migrant provided that they are delivering a service to a client (rather than simply providing workers). It should therefore be possible for organisations to use the H&CW visa to employ care workers, with individuals using personal budgets to purchase care and support services from those organisations. The important distinction is that the care worker must be formally employed by the agency rather than the person receiving care and support. Since care workers have only recently become eligible for the H&CW visa, it may take some time for this market to fully develop. However, LAs have a role in shaping social care markets and the MAC would encourage DHSC and the Devolved Administrations to work with local authorities to support the development of this market.

Even if this market were to be suitably developed, there is likely to be a small group of people who receive care and support who would not want to use an agency to contract care services in their home. They would prefer to have more involvement in the recruitment of the person they will rely on for their care and not be required to pay agency fees. Whilst using an agency would be the preferred model for many, if the Government is clear that allowing people who receive care and support to directly hire workers is a fundamental element of social care policy, the Government could consider the introduction of a pilot umbrella scheme. Under the scheme, an umbrella body would be appointed to sponsor care workers from overseas and people who can show their level of need requires live-in care would be able to directly recruit from the umbrella body. This would broadly match the approach used for SAWS but would require significant development and must have a robust evaluation plan in place before launch. We would be happy to be involved in the design and evaluation of such a pilot if the Government decided to pursue it. We would also strongly urge close involvement with the sector.

Introduction

Adult social care (hereafter referred to as ‘social care’) provides dignity, independence and a higher quality of life to hundreds of thousands of working-age and elderly people across the UK in a diverse range of settings. Work in social care can be vibrant and rewarding, with stakeholders consistently speaking of their pride in working in such a key area, the difference they make to the lives of those who draw on social care and their loved ones, and the relationships they form with people who receive care and support. However, stakeholders have also consistently told us of the problems within the sector. Chronic underfunding and staff shortages have posed critical and persistent challenges to the sector, which have been compounded by the COVID-19 pandemic. At the same time as the pandemic, the ending of Freedom of Movement on 31 December 2020 following the UK’s exit from the European Union (EU) may also have exacerbated the challenges.

On the 6 July 2021, the Minister for Future Borders and Immigration commissioned the Migration Advisory Committee (MAC) to

undertake an independent review of adult social care, and the impact the ending freedom of movement has had on the sector.

The commission came from a commitment that the Government gave in the House of Lords as part of the Immigration and Social Security Co-ordination (EU Withdrawal) Act 2020. The Act ended FoM and introduced a new points-based immigration system for the UK.

We were specifically asked to review the impact that the ending of FoM has had on:

• the adult social care workforce (such as skills shortages) covering the range of caring roles in adult social care including care workers, registered nurses and managerial roles;

• visa options for social care workers;

• long term consequences for workforce recruitment, training and employee terms and conditions; and

• any other relevant matters the independent chair deems appropriate which are relevant to the above three objectives.

The Government asked us to

…provide recommendations on how to address the problems that the sector is experiencing with the immigration system and to highlight, where they arise within the scope of the review, wider issues for the Government’s consideration, such as employee terms and conditions. It should be noted that whilst immigration is a reserved matter for the UK Government, social care is a devolved matter, with the administrations in Scotland, Wales and Northern Ireland overseeing their own respective systems.

We were asked to report by the end of April 2022. On 15 December 2021, we published our annual report, which included an update on this commission and an interim recommendation to immediately make Care Workers and Home Carers eligible for the Health and Care Worker Visa and place the occupation on the Shortage Occupation List (SOL). The Government accepted this recommendation on 24 December 2021. The interim recommendation reflected several key trends and problems in the workforce that our early analysis had highlighted and did not pre-empt our final recommendations, which are presented in this report.

What we did

As with other commissions, we carried out an extensive programme of work to support our decision making. This included:

• Stakeholder engagement – Stakeholder engagement played a key role in our understanding of some of the key problems affecting the social care sector. Members of the MAC met with people who receive care and support and representative bodies from all nations in the UK, some on multiple occasions. There were also meetings with Governments in each nation to understand the complexities being faced by those responsible for policy in the sector. Furthermore, we engaged with trade union representatives to obtain a clearer picture of the concerns facing workers in the sector.

• Data analysis – We undertook analysis of relevant datasets to examine a range of issues such as the size and characteristics of the workforce and migrants within it and trends in pay in the social care sector. These have been a combination of large-scale national surveys primarily conducted by the Office for National Statistics (ONS), such as the Annual Survey of Hours and Earnings (ASHE) and the Annual Population Survey (APS), Home Office administrative data such as the Certificate of Sponsorship (CoS) data, and data collected directly by bodies within the social care sector. We are grateful to the workforce bodies and regulators across the four nations for their help in identifying and accessing the data they collect.

• Primary research – A series of in-depth interviews and focus groups with employers and migrant social care workers within the adult social care sector were carried out by our independent research contractor, Revealing Reality^{[footnote 1]}. To ensure diversity, the sample frame covered a variety of characteristics, including geography (all four nations of the UK), care settings (residential, domiciliary, day and community), size of organisation, a mix of EEA (European Economic Area) and non-EEA nationalities, as well as a number of additional characteristics that were monitored throughout the project to ensure a range of viewpoints. This research was supplemented with an additional series of in-depth interviews, carried out internally, with direct employers.

• Call for Evidence – We ran a Call for Evidence (CfE) for approximately 12 weeks in Autumn 2021 and received 145 responses from a mix of individual care providers, representative organisations, and those responding in a personal capacity, including individual care workers and those in receipt of care and support. The questionnaire was focussed on a series of free text questions about the impact of the ending of FoM on the sector.

Evidence from these activities is interspersed throughout the report and informed our recommendations. As part of the analytical work we undertook, we looked at whether there were differences by protected characteristics as defined by the Equality Act 2010. It was not possible to collect data on all protected characteristics. This analysis was also viewed in the context of the distinctive demographics of the social care workforce, where women account for over 4 in 5 social care workers and where there are higher than average proportions of ethnic minority workers.

Due to the specialised nature of the commission, we appointed an expert advisory group to work with us for the duration of this commission. The group was set up to provide us with a diverse set of expertise drawn from different areas of social care to support all aspects of the commission. The group were appointed in an individual capacity, and they are not responsible for any of the recommendations and conclusions, which remain the responsibility of the MAC. We are extremely grateful for their guidance and help throughout this commission. The expert advisory group appointees were:

• Dr Franca van Hooren (University of Amsterdam)

• Dr Rhidian Hughes (Voluntary Organisations Disability Group)

• Professor Jill Manthorpe (King’s College London)

• Vic Rayner, OBE (National Care Forum)

Throughout the commission we have worked closely with bodies across the UK and have proactively engaged with as wide a range of voices as possible. It has been an incredibly busy and challenging period for the sector, so we are very thankful to all those we spoke to or who contributed information to us.

Wider context

In previous MAC reports we have highlighted some of the many challenges that the care sector faces. These include increasing demand, high vacancy and turnover rates, low pay rates with little pay progression, and poor terms and conditions compared to competing occupations. These problems predate the end of FoM and have largely been compounded by the pandemic. As we have stated previously, the underlying cause of these workforce difficulties is the underfunding of the adult social care sector.

Social care enables people to live full and independent lives and provides value far beyond the individuals who give and receive support. Shortfalls in social care provision have far-reaching consequences. Figure 1 contrasts the public funding of health care and social care over time. In the 10 years prior to the pandemic, healthcare spending per person rose by 16% in real terms, whilst public funding of social care fell by 7%. Social care provision is based on a combination of public and private spending, unlike the NHS. Estimating the proportion of self-funders is difficult due to the various ways they may interact with social care. Estimates from Skills for Care and Development suggest that England (PDF, 1 MB) has the highest share of self-funders (46%) with Wales (PDF, 1 MB) (32%) and Scotland (PDF, 601 KB) (25%) considerably lower. Northern Ireland (PDF, 1 MB) is estimated to have the lowest share at just 11%. It is worth noting the relationship between spending on health and social care: a strong social care system benefits the NHS, with fewer acute admissions and reduced delayed discharges. Ultimately, where there are shortfalls in social care provision, care needs must still be met, and the duty of care often falls to unpaid family members and friends.

Figure 1: Public per capita real spending (£ per head) on health and adult social care in the UK

Figure 1

Source: HMT Public Expenditure Analyses 2008-2020

Notes: Calculated using financial years with mid-year population estimates and 2020-21 GDP deflator from the ONS. Adult social care spending identified as spending on personal social services for old age, sickness and disability based on methodology used by the Nuffield Trust (PDF, 843 KB). Does not include spending by self-funders.

Throughout the CfE and primary research, the impact of this underfunding was raised repeatedly by employers, by people who receive care and support and by care workers. We were told that some agencies and employers were not only unable to deliver the quality of care that they wanted to, but in some cases were not able to deliver care at all – no longer supplying temporary social care workers, not taking on new work, and in some cases even handing back care packages to the local authority. We were also told of the resultant risk to people’s independence and safety.

Whilst the workforce problems in social care are not unique to the UK, and are similar in many high-income countries, we maintain that adequate public funding of social care to allow improvements in pay and conditions is ultimately the key to addressing these difficulties. We do not believe that immigration policy can solve all, or most, of the workforce problems in social care, but immigration can potentially help to alleviate the difficulties, at least in the short term.

Based on the terms of our commission and our areas of expertise, we have focussed on where we can add the most value in this commission. Our report therefore focusses on workforce issues and particularly immigration policy, and not on how social care should be funded or the structure of provision. Whilst this commission explicitly considers the range of caring occupations within adult social care, we have given particular focus to occupations less well-served within existing routes of the immigration system.

Over the course of this commission, we have heard powerful stories from people who receive care and support, who rely on high-quality care to provide dignity and protect their quality of life, as well as the pride which many social care workers and employers feel to be working in the sector. We also recognise the anger that many within the sector have felt at workers being viewed as ‘low-skilled’. We categorically disagree that care work is low-skilled. Unlike some low-pay sectors, social care is hugely relationship intensive and that, alongside practical caring skills, high quality care is reliant on soft skills qualities such as empathy and compassion. We also recognise the further strain that the COVID-19 pandemic has caused the sector, with workers going above and beyond to continue providing vital services.

Structure of this report

Chapter 1 describes the social care sector and workforce in the UK and the role migrants play in it.

Chapter 2 outlines issues relating to pay and terms and conditions in social care.

Chapter 3 covers immigration policy for the social care sector, the MAC’s interim recommendation in its annual report and further recommendations for the longer term.

Chapter 4 provides an overview of our recommendations.

Further to this main report, Annexes A, B, C and D provide additional background to our methodical approaches and a glossary of terms and abbreviations that we have used.

Chapter 1: The adult social care sector and workforce

Introduction

This chapter outlines the provision of adult social care in the UK and examines the size and structure of the workforce. This includes:

• How social care functions across the UK, including across the Devolved Nations (DNs);

• The size, structure and key characteristics of the social care workforce;

• Differences in the workforce across the nations;

• The role migrants play; and

• How the end of freedom of movement (FoM) has affected the social care workforce.

There is no universally recognised definition of the social care sector or workforce. We therefore focus on a subset of occupations (defined below) integral to the direct provision of care.

Adult social care in the UK

Social care is a term that generally describes the services that children, young people and adults who need extra support can draw on to enable them to lead fulfilling lives with dignity. Although it can include medical help, social care offers more practical support and personal care, and requires a high degree of resilience, empathy, and patience. Our commission is focused on adult social care for working-age and old-age adults, which we refer to throughout as social care. This section sets out, at a high level, how social care is provided across the UK.

Social care covers a wide range of activities and support designed to help people who are older, or adults living with disability, or physical or mental ill health, live with dignity, promote wellbeing and stay safe. The work involved can range from support maintaining a home, through to personal hygiene and overnight supervision. These services are usually provided in people’s homes, care homes, or elsewhere in the community. Social care services for adults include, but are not limited to:

• Domiciliary care – support and assistance in people’s own homes, including supported living;

• Residential care – care provided by care homes and nursing homes;

• Community and day care services – support with organising social or physical activities. This could involve meals, help with health problems or providing the opportunity to meet with others;

• Shared Lives Scheme – supporting adults with disabilities or other health problems that make it harder for them to live on their own. The scheme matches someone who needs care and support with an approved care worker who may live with them or visit regularly in the daytime or overnight. Also known as adult placements; and

• Live-in care – 24-hour care available to those wishing to stay in their own home. The care workers support individuals with their specific needs to keep them comfortable at home. This represents a small section of the social care sector workforce.

Social care is a devolved matter, so the DAs in Scotland, Wales, and Northern Ireland (NI) have responsibility for their respective systems. This makes the intersection between immigration policy, a matter reserved to the UK government, and social care more complex. In England and Wales, local authorities (LAs) are responsible for care delivery. In Scotland Integration Authorities direct how resources are used to deliver delegated care services, although ultimate responsibility lies with the LAs, whilst in NI Health and Social Care Trusts (HSCTs) play a comparable role in terms of responsibility.

LAs (or HSCTs in NI) commission the majority of social care services. In practice, at the point of service, a mixture of LAs, the NHS and independent (private and non-profit) providers deliver care. The proportions vary by nation, but generally the private sector provides the majority of social care. Despite this, public funding is integral to social care provision and is pivotal to wage setting. In general, care organisations accept both publicly and privately funded clients, with privately funded clients typically paying a premium. There is substantial variation between providers – a 2017 CMA report (PDF, 3.1 MB) noted that around a quarter of care homes in England have more than 75% of their clients funded publicly and that privately funded clients paid on average 41% higher fees.

In England, the Department of Health and Social Care (DHSC) has overall responsibility for social care. LAs organise and support care for those unable to fund it themselves and assist self-funders organising their own services, with funding from central government and local taxes. In Wales and Scotland, the DAs provide social care funding to LAs and revenue is also supplemented by NHS Wales and Scotland respectively. Unlike England and Wales, NI has a fully integrated health and social care system. Services are provided by five HSCTs which are funded by the NI Executive. In Scotland, there has also been some integration between the health and social care systems. Table 1.1 sets out the responsible bodies for social care across the four nations.

Table 1.1: Social care - responsible bodies

	England	Wales	Scotland	Northern Ireland
Responsible for care provisions	Local authorities	Local authorities	Local authorities	Health and Social Care Trusts (HSCT)
Social care providers regulator	Care Quality Commission (CQC)	Care Inspectorate Wales	Care Inspectorate	Regulation and Quality Improvement Authority (RQIA)
Eligibility criteria	Outlined in The Care Act 2014	Outlined in The Social Services and Wellbeing Act 2014	Outlined in The Social Care (Scotland) Act 2013	Set by HSCTs – NI Single assessment tool is used to ensure consistency

In recent years all four nations have stated that they are committed to reforming social care with similar objectives: better integration between health and social care, more care in the community and revised funding models. Recent publications have set out, amongst other things, proposals for the social care workforce. All four countries have begun implementing some of the recommendations made in the most recent reports. However, some of the ambitions outlined in these papers have not been fully implemented. Not all proposals have a structured strategy confirming that the necessary public funding and support is available to implement them. Table 1.2 sets out the key workforce publications by nation.

Table 1.2: Workforce publications

	England	Wales	Scotland	Northern Ireland
Publications	DHSC White Paper – People at the Heart of Care, Dec 2021	A Healthier Wales: Workforce strategy for Health and Social care, Oct 2020 White Paper –Rebalancing Care and Support, Jan 2021	Independent Review of Adult Social Care, Feb 2021 National Workforce Strategy for Health and Social Care, March 2022	DoH Workforce Strategy: Health and Social Care Workforce Strategy 2026, May 2018
Proposals	A ‘Knowledge and Skills Framework’ and career pathways, to be developed Funding for portable ‘Care Certificate’	Development of a national framework for commissioning services delivered by new department or NDPB Actions outlined to integrate health and social care	Formation of a Scottish National Care Service (NCS) with direct ministerial accountability	Focused on attracting, recruiting, and retaining the health and social care workforce Develop an effective Workforce Strategy

Across the UK, the social care sector faces additional challenges of growing demand and a restricted supply of care due to workforce shortages and budget constraints; problems exacerbated by the pandemic. In our Call for Evidence (CfE) the lack of a credible workforce strategy was raised often as an issue and there was general agreement from many respondents that without a credible strategy, backed by appropriate investment, the sector will continue to face significant challenges. Throughout the CfE and primary research, the combined impact of these problems, in terms of the quality and accessibility of care, was raised repeatedly by employers, people who receive care and support, and social care workers.

We were told that some agencies and employers were not only unable to deliver the quality of care that they wanted to, but in some cases were not able to deliver care at all – no longer supplying temporary social care workers, not taking on new work, and in some cases even handing back care packages to the LA. We were also told of the resultant risk to people’s independence and safety. Employers and individuals who draw on social care referred to people having to enter residential care rather than receive care in their own home; several also said that current staffing ratios were only being upheld with difficulty, and that if the staffing situation worsened there was a risk of safeguarding failures. The implications of not delivering care are clearly greatest for those with the highest needs and least alternative support.

We’re standing on the edge. Hoping it will get better. Three big care providers have just gone down. There’s a big risk for us. We have lots of demand from new clients but are having to turn clients down because we are struggling to recruit staff

Employer, Revealing Reality research interview, Scotland

Staff work additional shifts (if they can without losing benefits) and the residents get a lower standard of care which, if the staffing crisis gets any worse, will lead to safeguarding issues and breaches of the Care regulations. … There is only so much compensating that homes can do. When we get to the stage where residents are at risk then we will have to close the care homes and exit the market

Employer, CfE, England

Competition across low pay sectors is intensifying and when services are commissioned at minimum wage levels providers are unable to improve terms and conditions. Providers report that fees received from local authorities do not cover the direct costs of providing care and we have now reached the point where questions hang over the sustainability of services. Unlike other industries providers delivering state-funded care are unable to increase prices, and it is this inability that makes social care distinctive in comparison to other low pay industries and workforce supply planning

Voluntary Organisations Disability Group, response to CfE

The potential implications for the health sector were also highlighted:

Some care services are so short of staff that they are no longer able to accept residents from the NHS. If providers are unable to staff care services safely, providers may struggle to accept new residents which will not only destabilise the provider market, but equally have enormously adverse implications for the health sector; residents who need to be cared for would have to remain at home, on waiting lists, or in hospital

Care England, response to CfE

As well as differences across the four nations there are also differences within the nations. The differing experiences of care between urban and rural areas was consistently highlighted in our CfE. Whilst much of the UK is suburban and faces infrastructure challenges, rural and remote areas often experience these challenges more acutely. Poor public transport links, lower proportions of the population being of working age, long travel times and the pressure of time management between clients spread over often large geographical areas make the provision of care particularly difficult in rural settings.

Respondents to our CfE indicated that providers in urban areas struggled to retain workers due to high housing costs with workers relocating to areas where accommodation is more affordable, along with greater competition for workers from other sectors such as retail or hospitality. In addition, urban areas also experience higher volumes of clients. Several of these challenges were summarised in the following response to our CfE:

Generally, for social care, the issue is that the care settings (either community settings or residential settings) will be based where the need is and not necessarily in the areas where staff can be easily recruited from. This is a particular problem in rural areas and areas with high housing and other living costs. Existing staff and the wider labour market feeding into these settings are unlikely to be local. This means staff have to travel

National Care Forum, response to CfE

The social care sector is diverse and through engagement with the sector stakeholders have shared the numerous ways that they are attempting to bolster recruitment efforts and promote careers within the sector. It is evident that a long term, coherent workforce strategy, that is fully implemented with adequate public funding, is vital across the UK to make social care an attractive, viable and sustainable career. Last year, the Health and Social Care Committee called for DHSC to produce a ‘People Plan’ for social care in alignment with the NHS People Plan, having already called for a 10-year plan for the sector. It noted the absence of this

serves only to widen the disparity in recognition and support for the social care components of health and social care (p.47), but also that its delivery requires adequate resourcing.

We fully endorse the views expressed by the Health and Social Care Committee and would strongly recommend that DHSC, and the comparable bodies in the DAs, develop a coherent workforce plan in consultation with the sector.

Throughout this report, we signpost the different approaches that the DAs have taken in response to the problems faced in the sector, particularly pay and qualifications, most notably in Scotland and Wales. However, having assessed the arguments made by the DAs alongside the evidence from all four nations, we are of the view that the sector faces broadly similar challenges across the UK.

The Government should consider what they might learn from the examples of good practice we have highlighted from across the UK. Additionally, we recommend that the Government embed a culture of regular consultation with the DAs and stakeholders from the DNs to share knowledge and best practice

How the social care workforce is organised

This section establishes how responsibility for the social care workforce is organised across the UK, including worker registration, qualifications, and data collection. In Scotland, Wales, and NI there are non-departmental public bodies which have responsibility for regulating the social care workforce. This is not the case in England, where the workforce development and planning body is a charitable organisation working as a delivery partner for DHSC, with whom registration is not required. Table 1.3 sets out the respective workforce bodies across the UK. England is the only UK nation to have no regulatory body mandated by and accountable to government which may have hindered the development of a strong professional identity, underpinned by standards and qualifications.

Table 1.3: Social care workforce bodies

	England	Wales	Scotland	Northern Ireland
Organisation	Skills for Care (SfC)	Social Care Wales (SCW)	Scottish Social Services Council (SSSC)	Northern Ireland Social Care Council (NISCC)
Public body	no	yes	yes	yes
Registration required	no	Yes*	yes	yes
Requirement to obtain specified qualifications	no	yes	yes	no
Responsibilities	Strategic workforce development and planning body	Strategic workforce development and service improvement	Strategic workforce development and ensuring fitness to practise	Setting standards of conduct and practice, investigating fitness to practise concerns, and supporting the learning and development of the workforce

Source: Skills for Care, Social Care Wales, Scottish Social Services Council, Northern Ireland Social Care Council

*Registration is mandatory for social care managers and domiciliary care workers currently. Mandatory registration for care home workers will be implemented in October 2022.

There is little standardisation of qualifications in the sector. The Scottish social care workforce has been subject to professional regulation since 2003. Social care workers are required to register with the SSSC in order to work in the sector. If they do not already possess a qualification, they must attain the specific qualification in line with their role within 5 years of registration. Similarly, in Wales, in order to register with SCW, residential and domiciliary care workers must commit to complete a required qualification if they do not already possess one upon entry. This must be done within 3 years of registration. Experienced care workers can have their competence certified by their manager; this is known as ‘confirmed competence’.

In NI registration is intended to demonstrate compliance with standards of conduct and practice, rather than qualifications. The NISCC have developed guidance (PDF, 941 KB) detailing desirable qualifications for a range of job roles. Employers are encouraged to use this guidance to inform learning and development plans for staff although it confirms employers across all sectors and services can set their own specific qualification and training requirements based on service needs. Essential qualifications and required experience are set for social care managers under the Department of Health’s published minimum standards.

As with any sector, formal qualifications are only part of the workforce development, and focus should also be given to learning on the job. Research carried out for Community Integrated Care, and cited within a response to our CfE, challenges the perception that social care work is ‘low-skilled’. They acknowledged that, although some basic technical skills can be acquired through training, other skills are vital attributes in providing good quality care such as emotional and physical resilience, communication, planning and organisation, problem solving skills as well as understanding individuals’ needs. This was a point reiterated by many in both the CfE and in the primary research interviews across the social care sector. Those providing or receiving live-in care (many of whom train their own staff) also highlighted the importance of the skills needed to live with another person successfully for extended periods. Our engagement with stakeholders, CfE and primary research also highlighted other skills those in the social care sector possess and the importance and the difficulty of recognising or quantifying these in formal qualifications. This was emphasised in relation to roles across the UK and at all levels.

The sector relies on empathic, skilled workers to provide support to some of the most vulnerable people in our society, the lack of recognition for the skills and value these workers bring in the new system is both dismissive of their social and economic contributions and operationally damaging

Employer, CfE, Scotland

Not just anybody can do it. You know, it doesn’t matter if you’ve got training, qualifications coming out of your ears. If you don’t have the right personality and mindset and commitment, you can’t do it

Direct employer, research interview, England

Registration, qualifications, and skills frameworks are practical tools that can help ensure good quality care is delivered and are important for migrant and domestic workers alike. Respondents to the CfE also highlighted the importance of training to those who were already working in the social care sector, providing evidence of staff having left for employment in other sectors with better training and development offers. The social care sector would benefit from increased professionalisation, with workers incentivised to invest in their career. We are supportive of providing such training to further upskill the workforce and increase the perceived professionalism of care work as an occupation and formally recognise the skills which workers build over their time in their role. This type of formal training is valuable in maintaining a high standard of care and should receive adequate public funding throughout the UK to ensure that social care workers can continue to learn whilst they work.

We have been in contact with all the social care workforce bodies during this commission. They have played a vital role in providing information and data on the social care sector as well as recruitment of research participants for our primary research – further detail on the sample breakdown is available in Annex B.

Social care data collection

In this report we have used a wide range of data sources to provide a UK-wide picture, but this was not always possible, and all data sources have some limitations. Our approach to social care workforce data is set out in Annex C. The workforce bodies in each nation have been enormously helpful in providing data not included in ONS datasets. However, each defines the social care sector in particular ways and utilises varying methodologies, making comparisons between the four nations difficult. A common, UK-wide, framework on social care data collection across these organisations would make national comparisons easier and provide a better picture of social care across the UK.

We recommend that DHSC and the DAs should consider adopting a common data collection framework.

Data from the ONS and other government agencies relating to social care are often grouped together with health care. These two categories should be separated so that social care specific analyses are more feasible.

We recommend that, where possible, social care and healthcare should be separated in ONS and other official data.

Work in social care

Work in social care is diverse and varies by occupation, care setting, location, and employer. The way these factors intersect means that individuals can be in the same occupation but carry out very different duties. We focus on social care and not social work and the direct provision of care (and not supporting activities such as cleaning and cooking in residential care facilities, although the importance of these activities was stressed in the CfE) in any care setting, based on the most prevalent occupations specific to the social care sector.

We focus in particular on the occupations detailed in Table 1.4. Work done across and within these occupations can vary greatly depending on the needs of people who receive care and support. For example, care workers and senior care workers may support individuals in their daily lives (e.g. to attend appointments, eat and drink at mealtimes and carry out household chores), provide personal care (e.g. getting washed and dressed) and provide basic clinical support (e.g. help with medication, monitoring temperature or weight).

Table 1.4: Social care occupations

Occupation	Description
Care worker	Supporting individuals who need additional help to live independently in their own home or a residential home with all aspects of their day to day lives.
Senior care worker	There is no formal boundary or clearly defined distinctive job roles between a senior care worker and care worker. Generally, a senior care worker will undertake similar duties as a care worker and may manage or monitor care workers.
Nurse	Undertaking of a variety of clinical and healthcare tasks to people in nursing homes or in the community.
Care manager	Planning, organising, and coordinating the resources necessary in the provision and running of residential and day care establishments and domiciliary care services to ensure high quality care is provided.
Directly employed care workers	Supporting individuals with various aspects of their daily lives both at home and in the community. They are employed directly by the individual they support. This role may include supporting individuals with social activities, personal care and helping with practical tasks around the home. Also referred to as personal assistants.

The nature of work in social care is influenced by a broad range of factors. Providing care in a set, regulated residential or nursing setting differs considerably from travelling between clients’ homes to provide domiciliary care. Domiciliary care in turn is influenced by location: care provision in rural areas may be characterised by long distances between home visits and high travel costs, whilst the same care in urban areas may instead be heavily reliant on public transport or the availability of parking.

Similarly, the nature of the employer can also influence the work done. A care worker employed by a residential care home may expect to work in the same place, with the same people every day, while an agency care worker may work between multiple, changing sites. Care workers may also be directly employed by the person for whom they provide care and support, even living with them. We refer to this subset of workers as directly employed care workers; elsewhere they are also referred to as personal assistants (PAs). The direct employer of a care worker will decide exactly what tasks they need help with, depending on the individual’s care needs, social life, and employment.

The social care workforce over time

This section explores the size of the social care workforce and how it has evolved. Annex C explains how we define the social care sector for this analysis.

Office for National Statistics (ONS) data shows that the social care workforce across the UK has grown steadily in the past decade, with a total of just under 1 million workers in 2019 (Figure 1.5). This likely constitutes a lower bound for the size of the workforce – Skills for Care, using their own sampling and weighting methodology, estimate that there are a similar number of workers in England alone. We have deliberately reported ONS data up to the end of 2019 only. The pandemic has caused significant difficulty in producing reliable survey-based estimates, particularly when examining specific occupations, sectors, and migrants in the workforce. Care workers account for between three-quarters to four-fifths of the social care workers in our scope, with the remainder split between senior care workers, care managers and nurses. This occupational split is similar across the four nations.

Figure 1.5: Size of the UK social care workforce, 2012 to 2019

Figure 1.5

Source: ONS APS 2012 – 2019, individuals by main or second job.

Skills for Care estimate that the workforce in England continued to rise in 2020, but there is some evidence that the number of people working in social care has declined during 2021. Skills for Care report that since March 2021 vacancy rates have risen dramatically and there were nearly 5% fewer filled posts by March 2022. We discuss current workforce pressures in more detail in Chapter 2.

Directly employed care workers are likely to be underrepresented, or missing, from official data for several reasons. Their direct employment relationship with the person receiving care and support is often informal and may be transitory, and care activities in this area are unregulated. Skills for Care estimate (PDF, 995 KB) that there were 130,000 care workers employed by direct payment recipients in England as of 2021. Just over half of these were family or friends of the people who receive care and support. These estimates do not include workers employed via personal health budgets or through private funding. The MAC has engaged with representatives of direct employers and has heard the difference this makes to people’s lives, particularly those with acute care needs.

The importance of PAs for people like me means I can live in my own home [and work]. Currently, I’m not costing the government, you know. It is not as much money as if I was dependent and placed in a home or even with an agency that’s more expensive. So you know we want to… be as little burden as possible and we want to contribute to society as much as possible and PAs enable us to do that

Direct employer, research interview, England

There is an evidence gap about the labour market for directly employed care workers, despite the fact that public funds contribute to the employment of a significant number of these workers. Given the interface between local authorities and direct payments recipients, and the NHS and personal health budget users, this information should be collected.

DHSC and the DAs should work jointly on a review of the evidence available on directly employed care workers, including those paid for via direct payments, personal health budgets and private funding.

These estimates cover the number of people working in the social care sector. This is not the same as the number of people needed to adequately provide social care services, which continues to grow with demographic pressures. Table 1.6 provides an illustrative projection of the full-time equivalent (FTE) social care workers that may be needed over the next decade. This is based on research commissioned by DHSC carried out by the Care Policy Evaluation Centre (PDF, 185 KB) to estimate the likely number of people who receive care and support in the future. From this we derive the ratio of social care FTEs, plus vacancies, to people who receive care and support today. The technical details behind this projection are in Annex D.

Table 1.6: Projected demand for social care occupations (FTEs)

Occupation	2023	2028	2033
Care workers	644,000	714,000	807,000
Senior care workers	77,000	85,000	96,000
Nurses	41,000	45,000	51,000
Care managers	66,000	73,000	83,000
Total FTEs needed	881,000	976,000	1,100,000

Source: MAC analysis

Vacancy rates suggest that the social care sector already needs an additional 66,000 FTEs to fulfil demand today. Our projections, based on estimated future care need, suggest that the sector will need to recruit a further 236,000 FTEs over the next 11 years to keep up with growing care need. Demand for labour in the sector is outpacing population growth: social care employs around 2% of the working-age population today and may need to employ 4% to fulfil demand by 2033.

The projection above is highly indicative and does not account for policy changes or the capacity of the system to operate amidst persistent labour shortages. It should not be interpreted as a definitive forecast of future workforce needs. In comparison, the Health Foundation found that the sector would need to employ 627,000 extra FTEs by 2031 under scenarios in which access to care improves, while Skills for Care (PDF, 995 KB) estimate that 490,000 new jobs will be required to care for the old-age population in England alone. It is unfortunate that DHSC and the DAs do not routinely produce detailed projections, which would inform workforce planning. Our earlier recommendation that DHSC should develop a coherent workforce plan would address this for England. We note that, in its National Workforce Strategy for Health and Social Care, the Scottish Government has stated that Health Boards and Health and Social Care partnerships will be required to publish three-year LA-level workforce plans from summer 2022.

Key features of the social care workforce

Social care is a mixed market split between private, public, and non-profit organisations and agencies. Most of the social care workforce is employed by the private sector, which employs 73% of workers. Charities and other voluntary organisations employ 9% of the workforce and local authorities employ 10%.

By care setting, residential and domiciliary care make up the vast majority of employment, though the respective shares of each differ by nation. Table 1.7 documents the shares for each nation, though the numbers are not directly comparable. Residential and domiciliary care employ similar numbers in England, while residential care employs more in Wales and fewer in Scotland. Data for NI should be treated with caution, as this is only based on those on the social care register who provided information about the care setting in which they work.

Table 1.7: Employment in adult social care by type of care

Care Service	England	Scotland	Wales	Northern Ireland
Residential	49%	38%	43%	48%
Domiciliary	46%	54%	31%	44%
Day	2%	5%	13%	7%
Other	3%	2%	12%	N/A

Source: England - Skills for Care Workforce Dataset 2020, Scotland - Scottish Social Service Sector: Report on 2020 Workforce Data, Wales - SCWDP reports 2019, NI Social Care register 2020.

Notes: Data does not include directly employed care workers. NI data has not been filtered for adult social care or the occupations specified in scope; ‘Other’ includes community care, nursing agencies and supported living.

Table 1.8 sets out the distinctive characteristics of social care workers. Compared to the rest of the labour force, women are overrepresented, accounting for over 4 in 5 social care workers. Part-time working is also more prevalent, driven by the high share of women. However, the share of women working part-time is similar in both social care and the rest of the economy at approximately 42%. This working pattern often affords significant flexibility to workers with additional caring responsibilities. Whilst the share of over 50s was similar for social care and the rest of the economy in 2012, the social care workforce has aged more rapidly compared to the wider labour market, and by 2019 there are 6 percentage points more workers over 50 in social care since 2012. The share of younger workers is very similar to the rest of the economy.

Table 1.8: Key characteristics of social care and all other workers in the UK in 2012 and 2019

-	Social care 2012	All other workers 2012	Social care 2019	All other workers 2019
Female	83%	46%	83%	46%
Part-time	40%	27%	38%	26%
Age – Share: Under 30	24%	22%	24%	22%
Age – Share: Over 50	28%	27%	34%	30%
Ethnic minority	15%	10%	20%	12%
Qualification at NVQ3, A-level equivalent or above	53%	57%	53%	62%
Non-UK born	19%	14%	23%	18%

Source: ONS APS 2012, 2019

Ethnic minority workers are also overrepresented in social care, with their share growing more rapidly compared to the rest of the economy. Around half of workers possess a qualification at NVQ3, A-level equivalent or above, with a growing gap compared to the rest of the economy – though this measure is imperfect in capturing equivalent foreign qualifications. In our analysis we have examined demographic characteristics to understand whether there may be disproportionate impact on certain groups from our recommendations. This is discussed at relevant points in the following chapters.

Migrants in the social care workforce

This section explores the role of migrants within the social care workforce. Whilst most workers in social care are British nationals, migrant workers form a considerable part of the sector. Employers were keen to emphasise the importance of migrant workers within the sector and the positive qualities that they bring, including the ability to deliver care to a diverse population. Whilst employers valued the contributions of their British staff, they also felt that migrant labour was vital to ensure sufficient coverage without compromising quality. Employers also expressed perceptions that migrant workers tended to be able to work more flexible hours than those settled in the UK because of their life stage or lifestyle, and that some migrants (particularly from the EEA) had brought qualifications from their home countries.

EU workers have proven to have the qualities we need to employ care workers and are dedicated and flexible workers. We need to encourage and provide a volume of workers currently not available to fill the vacant positions

Employer, CfE, England

It is important to note that migrant workers contribute more to the social care sector than just substituting for domestic labour. The UK comprises diverse communities who are ageing, and in the future, to deliver personalised care this may require staff who can speak multiple languages and who share a cultural understanding. There is also evidence to suggest that migrant workers have brought much-needed flexibility and experience to their teams

Nuffield Trust, response to CfE

Figure 1.9 compares the share of EEA and non-EEA migrants, by nationality and country of birth, in social care and in the rest of the economy. Non-EEA migrants are overrepresented by both nationality and country of birth, making up 7% of the workforce by nationality and 17% by country of birth in 2019. The large difference between these two measures reflects the fact that many non-EEA born migrants have subsequently acquired UK citizenship. In contrast, migrants from the EEA, by nationality are slightly less likely to work in social care compared to in the rest of the economy. The share of migrants, in both social care and other sectors, has generally grown moderately over time. Whilst most workers are UK born, the share of migrants tends to be highest amongst nurses and care workers. 38% of nurses were migrants, with 12% from EEA countries. Similarly, 24% of care workers were migrants born outside the UK.

Figure 1.9: Share of migrant workers in social care in the UK

Figure 1.9

Source: ONS Annual Population Survey, Jan 2012 to Dec 2019

Note: The ONS asks individuals to provide one nationality, so the possibility of dual nationality cannot be excluded.

The picture for directly employed care workers is less clear. Skills for Care (PDF, 995 KB) report that only 6% of such workers are non-British, with 4% having EU nationality. Much of this is due to the fact that just over half of such workers are family or friends of the employer. For direct employers reliant on care workers they did not previously know, especially where care needs are more acute or in a live-in setting, there may be much greater reliance on non-UK and particularly EEA migrants. Data provided to us by PA Pool, a platform providing a matching service that introduces personal assistants to care recipients, suggests that around 45% of PAs on the platform are from outside the UK, with a quarter from the EEA. The working patterns involved in live-in care (often a few weeks on, then a few weeks off) may be more suited to commuting EEA workers, many of whom were ineligible for the EU Settlement Scheme (EUSS) and would be ineligible for the Skilled Worker route under this employment arrangement. We return to this in Chapter 3.

The pool of potential directly employed care workers is now limited to those who already have EUSS or an alternative right to work in the UK, and British workers. However, respondents told us that the on-and-off nature of the work often made it less appealing to those with more permanent status within the UK.

Pre-Brexit… there was never any sort of considerations around is this person going to be legal to work. So I didn’t have to think about that aspect of it, but primarily [there was] just that big pool of people who offer this particular type of care that I need, and the type of commitment and the way it works, which is quite obviously different to live-out care. And it always just seemed to suit them better because for financial reasons for them, and also sometimes for… how they wanted to live and work

Direct employer, research interview, England

Figure 1.10: Difference in migrant employment share between social care and the rest of the workforce

Figure 1.10

Source: ONS APS 2019

Note: Figures are estimated percentage point differences in migrant employment shares between social care and the rest of the labour market.

Figure 1.10 shows the difference between the share of migrants working in social care compared to the rest of the workforce across areas of the UK. The geographical variation in EEA and non-EEA born workers in social care broadly matches that for the labour market as a whole, with a few exceptions. Non-EEA born workers are overrepresented in social care in London by 30 percentage points, whilst EEA born workers are underrepresented. Outside of London, the share of EEA-born workers in social care closely matches the share of such workers in the local labour market, with a tendency towards non-EEA born workers being overrepresented.

Migrants in social care come from a diverse range of countries. Nigeria, the Philippines, India, and Poland have consistently been among the top origin countries over the last decade. Romania has also become more prominent in recent years. EEA and non-EEA born workers in social care report similar reasons for initially coming to the UK as in other sectors. Half of EEA born workers in social care reported employment (not necessarily in social care) as their reason for coming to the UK, while half of non-EEA born workers in social care reported coming to the UK as a dependant of someone in the UK. These differences are likely to reflect historic migration routes and Freedom of Movement (FoM) for EEA nationals.

Figure 1.11: Reasons given by migrants currently in social care for coming to the UK

Figure 1.11

Source: ONS APS 2019

Our primary research indicated that many care workers who had come to the UK for employment had done so because of pay differentials between the UK and their home countries. Interviews with care workers themselves showed that, whilst some had sought out their jobs because they had a vocation and a desire to work in the sector (or were already studying in a related field), others had initially gravitated towards social care because they wanted to work in the UK, and knew that social care was in demand, and was a comparatively easy sector for migrant workers to move into. This is not to suggest that these workers did not also enjoy their jobs or were not good at them, as the quotes below indicate. The flexibility of social care jobs was also a factor in this choice, for example for those who were studying or had other commitments.

I thought that it’s the ‘done thing’ for students to get a job while studying. I did some voluntary care work in Nigeria. I like meeting people and listening to their stories

Social care worker, Revealing Reality research interview, England

There is always going to be a job for you as a care practitioner

Social care worker, Revealing Reality research interview, Scotland

Care work for an agency gave me the opportunity to go out and about and meet people and understand UK culture more. Plus, it aligned with my public health course

Social care worker, Revealing Reality research interview, Northern Ireland

Figure 1.12: Year of arrival in the UK for migrant workers

Figure 1.12

Source: ONS APS March 2019

Of the migrants working in social care in 2019, over half had been living in the UK for at least 15 years while only 8% had arrived within the previous 5 years (Figure 1.12). This emphasises that the vast majority of migrant workers in social care are not recent recruits that have come to work in social care from abroad, but rather are long-term residents in the UK who just happen to work in social care. More recent arrivals are more likely to report employment as their main reasons for coming to the UK, whereas earlier arrivals from before 2001 are more likely to have come as a dependant. Over the last few years, on average around 170,000 workers have started a new job in social care (defined as having a tenure of less than twelve months) each year. Only 3,500 (2%) of these were migrant workers that had also just arrived in the UK, with only a thousand from EEA countries. This highlights the key fact that historically there has been very little direct international recruitment of migrant workers into social care. Most migrant workers, including those from the EEA, who start a job in social care were already in the UK.

The ending of FoM will prevent some new EEA workers from entering both the social care sector but also some other sectors. Social care is not heavily reliant on EEA workers, but the sector faces increased competition from other sectors such as retail and hospitality, which will seek to replace EEA workers as they leave. This may also encourage non-EEA and UK born workers to move into other sectors, applying indirect pressure to the social care workforce. This was expressed in our primary research, and by research carried out for the Low Pay Commission (PDF, 2.3 MB).

We’ve known about impending care staff shortages for years and nothing has been done. Falling numbers have been compounded by Brexit and COVID, by better opportunities in other sectors… We generally hadn’t relied on people from the EU in our care organisations – but ending of freedom of movement has meant that people have left from other sectors which has left spots available for care workers to move into. And in NI, there is a limited pool of people to draw from, so we’re running out of options

Employer, Revealing Reality focus group, Northern Ireland

We have not seen evidence of large-scale exits of EEA workers from the social care sector since the ending of FoM and the onset of the pandemic, though sampling issues in the ONS Annual Population Survey has made the overall picture unclear. Experimental statistics on payrolled employment from HMRC suggest that the number of EU workers employed in health and social work has been largely unchanged since the start of 2020, while non-EU employment has increased significantly. It is not possible to separate social care from healthcare within these statistics, but it is likely that this broadly reflects the picture for social care. On the other hand, accommodation, food services and arts, entertainment and recreation have experienced large falls in the employment of EU nationals. Some employers said that they had seen far fewer new applications coming from the EU – unsurprisingly this meant that those who had relied more on short-term workers felt that they had been hit particularly hard.

Finally, it should be noted that the UK is not alone in having a high share of migrants in its social care workforce, and for this share to broadly reflect the overall share of migrants in the total workforce. Figure 1.13 details the share of foreign-born workers in social care in a range of countries part of the Organization for Economic Cooperation and Development (OECD), based on analysis by Fernández-Reino and Vargas-Silva (2020) and OECD (2020). Although these figures are not strictly comparable, they suggest that the UK sits in the middle of OECD countries – far from the shares of foreign-born social care workers in Israel and Italy, but greater than the shares in France and Norway. In general, foreign-born workers make up at least 10% of the social care workforce across the OECD, and as such the UK ultimately competes against these countries for the global pool of potential migrant social care workers.

Figure 1.13: Share of foreign-born workers in social care and the total workforce in OECD countries

Figure 1.13

Sources: UK analysis based on ONS APS 2018; analysis of European countries excluding Norway from Fernández-Reino and Vargas-Silva (2020) based on EU Labour Force Survey 2018, analysis of all other countries from OECD Who Cares (2020) based on official national data circa 2015. Some observations may be based on low sample size and total workforce observations from Israel, Australia, New Zealand were unavailable.

Conclusion

The ending of FoM has undoubtedly restricted access to a pool of European workers who could previously move to the UK with no immigration restrictions. However, during the era of free movement, the social care sector has not come to rely on EEA workers in the way that some other sectors of the economy have. Whilst this aggregate picture hides some areas of much greater exposure – notably for nurses – for most employers in the sector EEA workers are employed simply as a result of being part of the local labour market that they recruit from, rather than as a result of targeted recruitment across Europe. Over time, the ending of FoM will likely reduce the share of EEA workers in the labour market, and this will feed through into reduced employment in social care. The end of FoM has therefore made care provision somewhat more difficult, but the challenges in the sector predate it. And of course, for those who struggle to find the social care workers they need, the consequences can be far more severe than for labour shortages elsewhere as it impacts on the quality of lives for people who draw on social care.

Chapter 2: The social care labour market

Introduction

In this chapter we examine the social care labour market, the recruitment and retention difficulties faced by the sector, and the reasons for these, including pay, progression and the terms and conditions of employment.

These are all longstanding problems within the social care sector which evidence suggests have worsened over recent years. Respondents to our Call for Evidence (CfE) described a ‘fragile ecosystem’ which the ending of Freedom of Movement (FoM) and COVID-19 have intensified rather than caused.

Vacancies and turnover

The social care sector has experienced high, and growing, vacancy rates over the last decade. Skills for Care (SfC) data for England shows that the vacancy rate for care workers rose from 5.2% in 2012/13 to 8.2% in 2019/20. For nurses the increase was more substantial, from 4.9% to 12.3%. Vacancies have surged as the economy has reopened following the third wave of the pandemic, as in several other sectors.

Figure 2.1 compares the index of online job postings on Burning Glass through the pandemic for care workers and competing occupations. Competing occupations are those that make up more than 3% of worker flows into or out of a care worker job, and are discussed in more detail in Annex C. These include other public service roles, hospitality roles, administrative roles, retail roles, and cleaning and domestic roles.

Figure 2.1: Vacancies for care workers and competing occupations, 2019 to 2022

Figure 2.1

Source: Labour Insight Burning Glass, January 2019 to February 2022.

Notes: January 2019=100. Competing occupations are defined in Annex C.

Figure 2.2: Clicks per posting on Indeed, 2016 to 2022

Figure 2.2

Source: Indeed, January 2016 to February 2022

Notes: Clicks per posting are relative to the average seen across all jobs on Indeed.

Whilst vacancies fell elsewhere during the height of the pandemic they continued to grow in social care. Vacancies for care worker roles increased by 124% from January 2019 to February 2022, compared to a rise of 90% for competing occupations.

ONS report that the vacancy rates in the health and social care sector are higher than all but two other sectors: information and communication and accommodation and food services. This is consistent with a higher level of unmet demand in this sector compared to the wider labour market, against a backdrop of record overall vacancy rates.

Compounding this, Figure 2.2 shows that the interest from job seekers for online social care job adverts is lower than the average on the Indeed website. Most other low paid sectors, such as hospitality and retail, see interest above the average. The social care sector has been in the lower half of all sectors since at least 2016 and in the bottom 10 almost continuously since June 2019.

Analysis of online job postings suggests that, compared to competing occupations, care worker roles are less likely to offer part-time work, less likely to require A-level or equivalent qualifications and less likely to ask for prior experience where explicitly listed. Most online care worker and competing occupation adverts do not specify any academic or experience requirement. Since 2016 this proportion has been increasing for care worker roles, suggesting employers are having to become more flexible over these requirements in order to recruit staff.

Demographic pressures have increased the demand for social care services, and these will continue to build, as discussed in Chapter 1. Conventionally we might expect the price of a service, and therefore wages, to rise in response to high vacancy rates, attracting more workers as the job offer improves. However, the structure and shortfall in social care funding has limited the scope for such an adjustment, though it is important to note that this varies across care providers and their reliance on publicly funded care packages.

We have seen evidence in our interviews with people who receive care and support and providers in the live-in care sector that wages are rising in those parts of the sector less constrained by government funding limitations. Respondents to the MAC’s CfE documented the extent of their recruitment difficulties. They highlighted that:

Recruitment into the care sector has been becoming progressively more difficult over the last ten years, and many providers report things are at breaking point

South East Social Care Alliance, response to CfE

This pattern is unlikely to change soon, with a representative body in the East of England stating that in a survey they conducted:

Everyone polled noted that they have tried every avenue available to them to attract staff to social care, including using agencies and sponsorships of overseas staff and have still been unable to fill these positions

Norfolk Care Association, response to CfE

Alongside difficulties in recruiting workers, the social care sector also has high staff turnover. Responding to the CfE, the trade union Unison emphasised that:

[A] high rate of turnover is contributing to a decline in standards in the sector. The poor terms and conditions experienced by care workers are the main drivers of the shortages

Unison, response to CfE

A case study from primary research carried out for us by Revealing Reality further illustrates the pressures on social care workers forcing them to leave their roles, sometimes for other ones in the care sector:

Case study: push factors in social care

Yasmini*, who is in her late 20s, moved to the UK to complete her master’s degree in nursing. She works part time as a care assistant in a residential home.

The low wages, strenuous work and lack of progression are difficult and unappealing. She noted that they are always understaffed, and she has to work extra hours, which is difficult because she can only work 20 hours per week on her student visa. She is planning on leaving her job and getting work through one of the big social care agencies who pay more.

*Yasmini is a pseudonym; this case study is based on a research interview conducted by Revealing Reality

Figure 2.3 shows SfC’s estimated staff turnover rates for care workers, senior care workers and nurses in social care over the last decade. Turnover rates for care workers and nurses have routinely exceeded 30%.

Figure 2.3: Turnover rates for selected social care occupations, 2012 to 2021

Figure 2.3

Source: SfC, April 2012 – March 2021.

Notes: Years run from April to March, i.e., 2012 represents April 2012 to March 2013. Rates are for local authority sector and independent sector only. SfC do not provide monthly tracking for turnover.

It is important to distinguish between staff turnover at the organisation level and the sector level. Employee moves between social care organisations can be driven by differences in pay and conditions. Some level of organisational turnover indicates healthy competition between employers, but a high level can disrupt care provision. SfC estimate that only 1 in 3 of those leaving a social care role in England in 2019/20 exited the sector entirely, with younger and less experienced workers, those on zero-hours contracts and those travelling long distances the most likely to leave.

In the early stages of the pandemic, many employers said that their retention levels improved, though this was not experienced universally. Reasons cited by employers included the vocational nature of the work, with workers feeling duty bound to stay in their post, and the lack of alternative job opportunities due to the effective closure of many other sectors, as reasons for this. Some employers responding to our CfE and interviewed in the primary research said that this reduction in competition had somewhat cushioned them from the full impact of the ending of FoM initially.

As the economy has emerged from pandemic restrictions, this picture has changed. SfC data suggests that the social care workforce in England contracted in 2021. Surging vacancies in sectors previously more reliant on EEA labour and against which social care employers compete, such as hospitality and retail, have driven intense competition in the labour market. Early data indicates that employers may have responded by raising pay in these competing occupations, although more analysis is required to understand other factors that could be driving changing pay across different sectors. Figure 2.4 shows changes in advertised pay on the Indeed website, grouping jobs by the proportion of EU workers that were employed before the ending of FoM. Those occupations with the highest share of EU workers have seen the largest increases in wages, with wage growth more than double that seen by low share occupations.

Figure 2.4: Advertised pay growth for online adverts by share of employed EU migrants, 2019 to 2021

Figure 2.4

Source: Indeed, ONS, January 2019 to December 2021

Notes: Low, medium, and high EU worker shares occur when 0-5%, 5-10% or 10%+ of the workforce are EU nationals. Wage growth is adjusted for shifts in the mix of job titles over time.

Occupations with the greatest reliance on EU labour were also found to be mainly lower paid occupations, such as construction, cleaning, and hospitality by Indeed. These are broadly similar to the competing occupations that we are examining in this chapter. These occupations have been significantly affected by the ending of FoM.

Though social care has been less reliant on EEA labour (as discussed in Chapter 1), the structure and scarcity of public funding in the sector does not allow employers to compete effectively with these other occupations. This was stated by some employers and employees we spoke to in the care sector, with employees increasingly leaving for roles where there was higher pay and less stress, even if they deemed these roles to be less interesting or meaningful. Some employers also mentioned losing staff to the NHS, which they said tended to offer better pay and benefits.

I wanted to leave my organisation. I read reviews of other care organisations and they all sounded terrible. I didn’t want to go out of the frying pan and into the fire… I ended up taking a job in a factory. It pays £11.50 an hour for the night shift. It’s boring, not fulfilling but it’s less stressful

Social care worker, Revealing Reality research interview, Northern Ireland

I see the social care sector collapsing unless there is huge investment into the sector so that we can attract people by offering similar pay and conditions to those working in the NHS. While there is no parity between the pay and conditions in the NHS and social care we will struggle to recruit from anywhere other than from abroad

Employer, CfE, England

Recruiting and retaining suitable individuals in social care is vital to the provision of high-quality care. This was highlighted in our CfE, where some direct employers explained the importance of having the right ‘fit’ of care worker, who they trust and can live with compatibly, in a situation where many would live in or spend significant periods of time within the employer’s own home, carrying out intimate tasks. For many, this also meant having a choice of social care workers so that they could choose the person who was the best fit.

Respondents also described the considerable time they spent training care workers to meet their unique personal requirements, and the negative impact on their independence and quality of life if these were not met. Some direct employers told us of the increasing difficulty in recruiting care workers, which they said meant that they increasingly struggle to find care when needed, especially for short-term placements. Unfortunately, difficulties in recruiting and retaining care workers will influence care outcomes.

It’s not uncommon to sort of have doubts about somebody, but I have to take them on because you kind of need someone really. Right now, rather than in two months’ time… I need someone, you know? If it was trying to arrange a gardener, I’d just leave the garden for two months until I find someone, but because it’s care I need every day, it can’t be put off. Yes, I do take on people who I consider are not ideal. But it’s a case of needs must

Direct employer, research interview, England

Roles in the NHS often compete with the social care sector. This means heavily funded NHS recruitment campaigns can make it difficult for social care employers to hire enough workers. DHSC recruiting policies, driven by NHS demand, may also affect the quality or experience of the talent pool available to employers in the care sector, particularly in times of increased demand for care. Such policy-driven recruitment is not yet seen in the wider social care sector. The scale of the NHS, and the salaries and benefits it is able to offer, can make it difficult for the social care sector to compete. Employers spoke about the impact of this on social care recruitment during interviews conducted on our behalf:

I go through all this rigour, and then the NHS can pay more. It’s the elephant against the mouse. We can’t change that

Employer, Revealing Reality research interview, Scotland

I can’t blame anyone for [leaving]. It’s better pay on the NHS

Employer, Revealing Reality research interview, England

Findings from our recent research on the international recruitment of nurses suggests the better pay, terms and conditions offered by the NHS continue to create a ‘gravitational pull’ on staff in social care, and this includes nurses recruited from abroad. We also heard some had been falsely led to believe by recruitment agencies that they were signing contracts to work in the NHS but actually were bound by their contracts to work for social care employers, sometimes for a fixed number of years

Nuffield Trust, response to CfE

With high vacancy rates also seen in the NHS, this dynamic is likely to continue. We recommend that DHSC and the Devolved Administrations work towards a joined-up approach when planning and executing recruitment campaigns for the health and social care workforces. This may include changes to the job offer, particularly in social care roles, to both attract a larger share of the total workforce and retain the current workforce.

Pay, progression and conditions

This section will discuss the key factors in the attractiveness of social care work, focusing on pay, pay progression and terms and conditions of employment. We focus largely on care workers, who make up the largest share of the social care workforce. We present our recommendations at the end of the chapter after reviewing the evidence.

Pay

Historically care workers were paid a premium over occupations against which social care employers compete today. Figure 2.5 shows how this premium has narrowed over the last decade, partly driven by the introduction of the National Living Wage (NLW) to sit above the National Minimum Wage (NMW) in 2016. In 2011, care workers’ hourly pay was over 5% more than those working in competing occupations at the median; this premium has fallen to just 1% in 2021. Similarly, the NLW has risen at a much faster rate than care worker pay. The NLW is now worth 87% of median hourly care worker pay, whereas the NMW in 2011 was worth 77%.

Evidence from the Low Pay Commission (LPC) (PDF, 3.7 MB) shows that as the minimum wage rises relative to median earnings, there tends to be wage compression within low-paying occupations. Workers paid at the previous minimum experience the largest wage rise as the minimum rises, and workers higher up the distribution tend to see lower increases as firms squeeze the distribution to cover the cost of minimum wage increases and try to maintain profit margins. This effect can be seen for care workers over the last decade. Pay at the 10th percentile has risen by 48%, compared to 30% at the median and just 25% at the 90th percentile.

The minimum wage has also risen faster than the median pay for care workers. For workers paid at the NLW, nominal hourly pay has increased by 47% from £6.08 per hour in October 2011 to £8.91 per hour as of April 2021. The NLW rose further to £9.50 per hour in April 2022 and the Government has announced a target of reaching two-thirds of median earnings by 2024, which the LPC predict (PDF, 426 KB) will require a NLW of £10.95 per hour.

Figure 2.5: Median hourly pay as a percentage of care worker pay

Figure 2.5

Source: ASHE 2011 and ASHE 2021

Notes: Competing Occupations are defined in Annex C. Competing occupations have been reweighted to reflect the age and gender distribution of care workers. NMW was £5.93 per hour until October 2011 when it rose to £6.08.

Care worker roles in England and Northern Ireland do not currently have to conform to any minimum rate of pay other than the NLW/NMW. As of April 2022, the Welsh Government has provided funding to ensure that adult social care staff delivering direct care are paid a new minimum wage pegged to the Real Living Wage (RLW). This is currently £9.90 per hour and will automatically increase when the RLW is uprated in October. The Scottish Government has had a similar policy since 2016 and has recently gone further; they have funded increases above the RLW, raising minimum pay to £10.02 in December 2021 and to £10.50 per hour in April 2022. In Scotland, these minimum hourly rates apply to publicly funded care services. In addition, registered residential and domiciliary care workers in Wales received lump-sum payments of £500 in 2020 and £735 in 2021, and are due to receive £1,498 in 2022 – all in recognition of their efforts during the COVID-19 pandemic. Similarly in November 2020, the Scottish Government announced a £500 ‘thank you’ payment to social care staff for their efforts during the first lockdown of the COVID-19 pandemic.

Low pay for care workers is not unique to the UK. Across EU member states, those working in residential long-term care were paid 79% of average earnings79% of mean national earnings, whilst the UK lagged behind at just 71%. This was lower than that paid in countries such as France (79%) and Germany (82%). Non-residential care workers fare worse, being paid only 67% of average earnings in the UK compared to 80% paid in EU member states. With the commitment to increase the NLW to two-thirds of median pay by 2024, it is likely that this proportion will rise somewhat over time, but the UK will continue to lag behind without more positive action on pay.

We did not find compelling evidence of migrant care workers being paid differently to UK born care workers. However, pay in social care differs significantly by region due to the local commissioning context and the structure of the labour market. In general, social care workers employed by local authorities are paid more than those employed by private and charitable organisations (though the work done may not be completely comparable). SfC data for England suggests that hourly care worker pay is around 16% higher in local authority employers compared to the independent sector, and that, in general, social care workers in residential care are paid less than those in domiciliary care. As mentioned previously, pay in social care may also be contingent on the capacity of an organisation to adjust its prices and wages, i.e., its reliance on privately versus publicly funded care packages. Analysis based on Knight Frank’s most recent trading performance review (PDF, 4 MB) states that a care worker in a privately-funded care home earns a mean hourly wage of £9.38, 2.6% more than the £9.14 per hour that their peers working in local authority-funded care homes receive.

Responses in the CfE suggest that this leads to several changes as employees look for better pay and conditions, with private sector roles being used as a stepping-stone to public sector roles, with more attractive pay and conditions, and moves into self-employment and agency work. Several of the current employees interviewed as part of the research said that poor pay was a driver that meant that they were considering leaving full-time work in care organisations and moving into agency work, and others were doing extra agency work alongside work in their main organisation to supplement their pay.

Work in social care is undervalued for several reasons, but chiefly it is a direct result of insufficient public funding. In addition, many of the non-market benefits of care work to wider society are difficult to measure in comparison to sectors traditionally deemed to make greater economic contributions, adding to this undervaluation. Evidence (PDF 648 KB) also indicates that there is a gender dimension to undervaluation. Occupations traditionally dominated by women – as social care occupations are – are generally lower paid than comparable occupations dominated by men, with gendered values, norms and preferences shaping motivations around women providing care leading to lower pay for their labour.

Analysis conducted for Community Integrated Care suggests that a comparable care employee in the NHS would be paid at the Agenda for Change (AfC) Band 3, equivalent to an emergency care assistant or occupational therapy worker. All workers paid on the AfC bands are also entitled to a supplement worth between 5% and 20% of their salary if they work near to, or within, London. Table 2.6 shows the difference in median contracted pay for care workers compared to these bands. This highlights the attractiveness of working in the NHS, especially if the worker is more experienced and will receive more pay for an arguably similar role.

Table 2.6: Comparison of contracted hourly pay for AfC Band 3 and care workers

	Hourly pay
NHS AfC Band 3: 0 to 2 years’ experience	£10.43 per hour
NHS AfC Band 3: 2+ years’ experience	£11.17 per hour
Care worker (Median)	£9.38 per hour

Table 2.7: Comparison of contracted annual pay for NHS nurses and nurses in social care

	Salary range
Nurse (Band 5)	£25,655 - £31,534
Senior Nurse (Band 6)	£32,306 - £39,027
Nurse in social care (Median)	£37,736

Source: ASHE 2021 and NHS Health Careers

Note: Pay data for care workers and nurses in social care in these tables is based on measures of ‘stated’ pay for more direct comparison with the Agenda for Change. Pay data based on measures of actual pay is preferred elsewhere in this report. See Annex C for more details.

A more direct choice between working in social care or the NHS is available to registered nurses. Table 2.7 demonstrates the wage differential between NHS nurses paid on AfC Bands 5 and 6 compared to median pay for those working in social care. This shows the salary is comparable to that of a senior nurse in the NHS. Whilst the median estimate given by ASHE is £37,736, this is based on a relatively small sample size, and SfC estimate that the mean full-time annual salary of a registered nurse in social care is far lower at £33,600, suggesting experienced senior nurses in the NHS are paid more.

Against a backdrop of living costs rising at the fastest rate since 1990, it is important to highlight that social care is different to other low pay sectors as employers are much more constrained in their ability to raise wages, due to their heavy reliance on Government funding arrangements. Respondents to the CfE suggested that whilst efforts had been made to increase pay for care workers, employers in other sectors may find it easier to adjust their pay because they are not bound by the same restraints. They said that in some cases, employers in other sectors can offer substantial ‘golden-handshakes’ or bonuses, which are not usually features of care worker pay.

There is evidence that in some settings care costs can be more easily adjusted, and in these cases wages may have risen. Direct employers spoke of the spiralling rates being charged by care workers, particularly those who were being sought on a short-term basis. These employers said that consequently, in some cases, they were having to accept care workers who were untrained or inexperienced.

Case study: The rising cost of live-in care

George* lives in England and employs a team of two live-in PAs, who have been with him for several years and who rotate on two-week shifts. They are from different European countries and both have settlement: one lives locally with her husband, but plans to retire to her home country eventually; the other lives in her home country and flies in for each shift. He says he is “really lucky to have kept both PAs” and that “a lot of my friends are struggling for care”. Although in general his care workers liaise with each other to cover holidays, occasionally he has to find temporary short-term cover.

Since the ending of Freedom of Movement in particular, George has found that the prices he pays for short-term care have increased dramatically. His care workers currently receive £150 per day for a ten-hour day plus an overnight stay. Two or three years ago he found it very easy to employ short-term care workers on this rate. However, he now finds that the prices charged by care workers are nearer to £240 per day (the figure of £240 was also given to us by two other employers as a daily rate that is commonly charged).

George puts the rise in prices down to the lack of available workers, and says that “in their industry, which is in crisis… they’ve had the opportunity to work for that kind of money. They know that if they say no to me someone else will contact them next week”. While he does not blame care workers for increasing their fees, the amount George receives from the local authority to cover his care needs has not increased, and he therefore finds it very difficult to obtain short-term care.

*George is a pseudonym; this case study is based on a research interview conducted by the MAC secretariat

Pay and career progression

Pay progression in the social care sector stands out as being poor compared to other sectors. SfC report (PDF, 2.8 MB) that the gap in pay between care workers with less than one year of experience and those with 5 years’ experience has narrowed from 5% in 2013 to 1% in 2021. Similarly, Figure 2.8 shows that those who have been working with the same employer for between 5-10 years as a care worker can expect to earn only 3% more than those who have had less than a year tenure with employer - in competing occupations this differential is 7%.

Figure 2.8: Indexed returns to tenure in role for care workers and competing occupations

Figure 2.8

Source: ASHE, 2021.

Notes: Competing occupations are defined in Annex C. These have been reweighted to reflect the age and gender distribution of care workers.

Whilst recent increases in the NLW have compressed the pay distribution in low-pay sectors, including social care, competing occupations are rewarding their employees for experience with increases in pay larger than those seen for care workers. Given the nature of the job, the stresses it entails, and the impact of COVID-19, workers may not feel appropriately remunerated for the work that they do, which may increase the incentive to either leave the profession and seek employment in another sector or avoid joining the sector altogether.

Care workers experience little pay progression staying in the same role, and this is little changed upon promotion to a senior care worker role. As of 2021, the median senior care worker earned 74p more per hour than the median care worker, despite the additional responsibilities including potentially leading a team of care workers. Poor pay progression within and between roles in social care not only drives high turnover at an organisational level but may also disincentivise individuals from pursuing a career in the sector.

There’s no career progression. I see some people who have been in the same role for 10 years. I’m applying for jobs in public health for when I graduate

Social care worker, Revealing Reality research interview, Northern Ireland

In contrast, the NHS offers a comprehensive and well-defined career and pay path, exemplified by Agenda for Change. Respondents to the CfE argued that whilst they had made efforts to improve wages within the sector, a lack of investment and a lack of parity with NHS pay and conditions meant other sectors were often more attractive to potential workers. The interaction, and comparison, between the NHS and the social care sector is important. Nurses may work in either sector and social care will compete against the NHS to both recruit and retain them, while prospective care workers may consider several factors in choosing between a career in health or social care. We set out further advantages of working in the NHS in the next section.

Conditions

Alongside pay, working conditions are an important factor for recruitment and retention. There is a general perception, highlighted in the literature, the CfE, and qualitative research that working conditions in the social care sector compare unfavourably with other sectors.

Social care needs a fundamental overhaul of its funding, staffing, wages and training. This needs to go hand in hand with a cultural change around how we view social care and the value we place on the staff who deliver it

Unison, response to CfE

Research carried out by the Work Foundation (PDF, 5.2 MB) in 2021 highlighted some of the reasons respondents were reluctant to enter social care. These included low pay, unpredictable hours, not feeling valued by their employer, or simply not enjoying the work. It also highlighted misconceptions about the entry requirements for social care. This may suggest a proportion of the workforce do not believe that they would be eligible to apply. However, not all the responses were negative: almost 1 in 3 jobseekers said that they would consider roles within the social care sector as they felt they could make a difference, have job satisfaction, and feel pride in their work. Conversely, the view expressed by employees working in the care sector was that other jobs might be more attractive even if they were less fulfilling – staffing difficulties were a key factor in this.

If you are offered the same amount of money working for the store on the corner or for (a supermarket), why would you ever come and work for us?

Employer, Revealing Reality research interview, Wales

The rota-ing is rubbish. I rarely get two days off in a row. And it’s all so disorganised. They know they are going to be short-staffed but don’t organise agency staff quick enough

Social care worker, Revealing Reality research interview, Northern Ireland

Figure 2.9: Terms and conditions for care workers compared to competing occupations

Figure 2.9

Source: LFS, April to July 2020

Notes: Competing occupations are defined in Annex C. These have been reweighted to reflect the age and gender distribution of care workers.

Figure 2.9 sets out how terms and conditions in social care compare to those in competing occupations. Zero-hours contracts, shift work and night working are more prevalent among care workers than in other low-paid occupations. These contracts can create uncertainty about hours but to some they offer flexibility, particularly to those who may have other responsibilities or wish to keep working hours below the threshold for Universal Credit eligibility. In as much as care workers can self-select into these contract features, this flexibility is likely to be beneficial rather than a restraint on hours and pay.

I can choose my hours and cancel, with some notice, if I discover that there is any clash with my schoolwork

Social care worker, Revealing Reality research interview, Scotland

Night working is fundamental to the provision of social care. However, the Trades Union Congress (TUC) has noted health and safety issues for night workers, with depression and cardiovascular disease being particular risks and harassment and attacks, especially for women, during journeys to and from their place of work.

Providing care for individuals is a huge responsibility, as the health, comfort and safety of a patient may rest entirely on a care worker, as well as the physical and emotional demands of providing support and companionship even when the person’s needs make this challenging.

There’s nothing they don’t say. They tell you they will call the council, call the police to do this and you become threatened even at your own job, trying to save them

Social care worker, Revealing Reality research interview, England

People’s physical and mental health, independence and quality of life are greatly affected by the standards of care they receive. Staffing shortages and high workloads may make it difficult to deliver a high standard of care. This pressure may make working in social care unattractive in comparison to other competing occupations.

Benefits offered as part of employment contracts to care workers are often inferior to those offered in the NHS and in other competing occupations. Table 2.10 shows that care workers often receive inferior pensions with low employer pension contribution (the minimum employer contribution for those automatically enrolled is 3%) and fewer days of annual leave entitlement. These conditions are important factors for workers who want to ensure that their future is secure with an adequate retirement fund, so the lack of competitiveness in the typical care worker offer can be a negative factor when a worker is seeking employment.

Table 2.10: Comparison of pension and annual leave conditions

	Care Worker	NHS equivalent	Competing Occupations
Paying into any pension scheme	72%	91%	61%
Paying into a Defined Benefit scheme	17%	82%	23%
Median employer pension contribution	3%	14%	6%
Median annual leave entitlement (Full time)	25	27	25

Source: ASHE 2019 Revised and 2020 provisional.

Notes: ‘NHS equivalent’ is defined as working in the Human Health SIC code, in the public sector and earning less than £11.56 per hour. This is the minimum for band 4 in AfC, so represents equivalents to Care Worker (Band 3 and below). Competing occupations are defined in Annex C.

Other contractual features of care work are less well-defined. We have received evidence from stakeholders regarding the opacity in the way in which some domiciliary care workers’ hours are calculated, with the travel time between clients and the extra time required to adhere to infection protocols (e.g., PPE, disinfecting surfaces) sometimes not being counted as working time.

The LPC has repeatedly highlighted how the treatment of travel time in payslips leads to underpayment of the NLW in social care. “Each year we hear accounts of non-compliant practices … including the non-payment of care workers for travel time” (2021, 2020 (PDF, 476 KB)). Travelling between work assignments is considered as working time for minimum wage purposes, and therefore should be paid at least at this level.

Further to this, domiciliary and agency care workers are usually required to provide their own transport to reach people’s homes. This may present an additional barrier for those without a car and as the cost of fuel has risen quickly in recent months but the allowance payable has remained fixed at 45 pence per mile, this has resulted in an increased burden on workers.

Whilst this is not unique to social care, increased unpaid travel costs and the lack of public transport may be further barriers. These problems are amplified in rural settings as highlighted in a response to the CfE:

Even when we supply transport and pay mileage, it is still not an incentive

Suffolk Association of Independent Care Providers, response to CfE

I only pick shifts that are nearby and at decent times because I don’t drive and the public transport stops at a certain time of night

Social care worker, Revealing Reality research interview, Northern Ireland

Rural settings mean that the staff pool who are able to fulfil the role is limited, needing those who have access to their own vehicles and ability to travel to a wide spread of locations. This also has an impact on available local services, such as day centres, respite care, etc. With these services finding it difficult to find staff local to the region as well as difficulty in continuing services within these localities due to poor attendance

Norfolk Care Association, response to CfE

In addition, workers may be required to stay overnight to be on hand should the person require help during the night – referred to as ‘sleep-ins’. In 2021, the Supreme Court ruled in Royal Mencap Society vs Tomlinson-Blake that workers on sleep-in shifts were not entitled to the national minimum wage while asleep. In this situation, when a worker is asleep but at work, the rate of pay is not regulated.

Whilst this decision was based on a 1998 report by the LPC, the LPC themselves have highlighted (PDF, 3.7 MB) that the sector has changed since 1998, due to a tightening funding situation in social care resulting in deteriorating working conditions and employment practices.

The overall trend is likely to be that workers on sleep-ins are not paid the NMW, and that it is harder to attract workers to these shifts. This will be to the detriment of people who need overnight care and could mean a move towards unstaffed systems, reliant on alarms or cameras

Low Pay Commission

The LPC has called for consensus and clarity on the issue of sleep-ins, and for a sustainable funding settlement for the sector. This issue, like others prevalent in social care such as the lack of payment for travel time presents the potential for employees to be exploited and underpaid. Whilst our primary research with workers did not directly uncover examples of employers pushing the boundaries around pay and conditions, other stakeholders cited examples they were aware of in relation to those working in the care sector.

Across these areas, the Scottish Government have taken independent action and provided public funding for care workers to be paid at least the minimum rate for all hours worked including sleep-ins. Pay for overnight support services has increased in line with the minimum rates for adult social care workers set by the Scottish Government as outlined above. This highlights an important fact – statutory minima do not need to be where policymakers set the standard. Stakeholder feedback on the policy for sleep-ins in Scotland suggested that this was welcomed by the sector. However, there have been some unintended consequences, mainly relating to funding. These include difficulties maintaining pay differentials and organisations with higher workforce costs than the national weighting experiencing a lower level of public funding.

Another important working condition is the provision of sick pay. There are limited data available on the level of sick pay across the social care sector and competing occupations. However, we are aware that sickness absence in the social care sector is generally higher than that seen across the rest of the economy. In 2020, 118.6 million working days were lost because of sickness or injury in the UK, equating to 3.6 days lost per worker. The ONS highlighted that generally while COVID-19 may have increased sickness absence, the measures such as furlough and increased homeworking appear to have helped reduce other causes of absence when focusing on sickness absence across the economy as a whole.

However, COVID-19 exacerbated some existing difficulties in the social care sector. There was a sustained rise in sickness levels due to COVID-19 and quarantine regulations. This was heightened in the initial wave when some care workers had limited access to personal protective equipment (PPE) outside of the NHS. SfC’s 2021 report shows that in England an average of 5.1 days per year were lost due to sickness in 2019/20, which rose to 9.5 days in 2020/21 and remains higher than pre-pandemic levels in the most recent data.

Measures introduced during the pandemic indicate that sickness pay may not have been at an adequate level across the social care sector. At the end of 2021 the UK Government announced an extra £60 million for adult social care in January to support the sector. This additional funding was for, amongst other things, paying for COVID-19 sickness and self-isolation pay for workers. In addition the Welsh Government introduced an enhancement to statutory sick pay for those working in the social care sector. This was introduced to provide financial support to care workers when they need to take time off work due to COVID-19, given the lack of occupational sick pay in the sector.

The pandemic had a large impact on conditions within the social care sector. There were increased requirements on workers such as wearing PPE, regular testing and other infection prevention controls which were not necessarily required in competing sectors. Some care workers may have taken on additional responsibilities, such as verification of death and applying catheters, which could increase the pressure of the role. A further condition, which has recently been removed, was mandatory COVID-19 vaccinations for those working in CQC-registered care homes in England. This added an additional challenge for recruitment and retention for workers in social care, and even with the recent removal of this policy it is likely that some workers will have already left the sector and will not choose to return.

Overall, the increased pressure on the remaining workforce may have created a risk of burnout amongst staff working in social care.

Given the choice of working in social care or retail, many people choose to not work in social care due to the challenges of the role, despite its many emotional rewards. The hospitality sector has increased what they are willing to pay both prospective and current employees. Care sector employees operate under more restrictive and demanding employment conditions than other sectors; employees are still subject to Personal Protective Equipment (PPE) requirements, testing regimes, mandatory vaccination policies etc. This has only heightened the likelihood of staff burnout and has made retention increasingly challenging for employers

Care England, response to CfE

Skills for Care data indicates sickness levels doubled over the pandemic to an average of 9.5 days per worker, with many staff needing to step away from frontline care to self-isolate. Our NIHR-funded research (forthcoming) suggests this has put pressure on existing teams and increased the likelihood of burnout among frontline staff

Nuffield Trust, response to CfE

Work in social care can be intrinsically rewarding. Care work is a relationship-intensive occupation, and those working in the sector often speak highly about the pride they feel doing their work. Within the CfE, respondents expressed pride at working in social care and appreciated the positive impact that they could make on people’s lives. However, this was tempered with the belief that social care is undervalued within society with employees feeling underpaid for their work, and the strain under which COVID-19 had put the workforce. Respondents stated that many workers were now suffering from burnout due to the pandemic which had led to increased workloads for employees, as well as the emotional toll of working in the sector during this period.

Recommendations

In commissioning this report, the Government were clear that we should feel free to highlight “wider issues for the Government’s consideration, such as employee terms and conditions”. This was in addition to recommendations on immigration policy that we turn to in the next chapter.

We are in no doubt that the single most important factor that underlies almost all the workforce problems in social care is the persistent underfunding of the care sector by successive governments. It is not for us to advise on either the appropriate level of funding for social care or on the method of financing such funding. This is particularly as social care is a devolved matter and we were not commissioned by the Devolved Administrations (DAs). So, our recommendations in this chapter will focus on terms and conditions of employment, leaving the question of how to pay for our recommendations to the Government and DAs.

One cannot seriously address the workforce difficulties in social care unless pay is improved. Improving pay is essential to boosting recruitment and improving retention. There is no reason why the pay of care workers should rise only when the National Living Wage rises. Indeed, there are clear reasons why relying on NLW uplifts will not address the recruitment and retention difficulties, as we have documented in this chapter. First, since all sectors must pay at least the NLW, such uplifts will not make care work more financially attractive compared to competing occupations. Second, the evidence shows that such uplifts tend to squeeze the wage distribution and the social care sector already fails to reward experience adequately. Third, there is no direct link between NLW uplifts and government funding, so there is a clear risk that even the NLW uplifts cannot be adequately resourced by the sector.

What is needed is a minimum pay rate for care workers that is fully funded by Government and is above the NLW. We believe that this can be done if there is enough political will to implement it. Both the Scottish and Welsh Governments have implemented an hourly wage for care workers above the statutory minimum. Higher pay across the rest of the UK is a prerequisite to attract and retain workers in social care, while similar pay for the same work across the UK would also avoid inefficient competition across the four nations.

However, it is important to note the complexities when implementing such a pay rise. When making any decision about raising minimum rates of pay, the funding mechanism must be well thought out. Our discussions with stakeholders revealed that the implementation of the increased pay rate in Scotland has been slow and difficult, with one reporting that the increase in funding simply does not cover the cost of uplifting pay. It was also highlighted that there has been a further squeeze on the differential between care worker and senior care worker pay in Scotland as a result of the rise – with some workers feeling that the extra responsibility of the senior care worker role is not worth the increasingly small gain in pay it comes with. It is important to maintain these differentials especially where additional qualifications and responsibilities are required for roles, so that there is a motivation for progress and a defined career path.

We therefore recommend that the Government introduces a fully funded minimum rate of pay for care workers in England that is above the NLW, where care is being provided through public funds. As a minimum starting point, we would recommend a level of £10.50 per hour to be implemented immediately.

Our remit comes from the UK Government, so we do not consider it appropriate to formally advise the Devolved Administrations. However, if asked, we would make the same recommendation to all the DAs. We would note of course that this minimum starting point is the same as that adopted by the Scottish Government from April 2022.

We would also strongly emphasise that an increase of this magnitude will not be enough to address the difficulties presented by low pay in the sector and urge the government to go significantly further as quickly as possible. In addition, differentials across the workforce must increase and the pay premium historically afforded to care workers over other jobs must be reinstated to increase attractiveness and fairly reward employees for the unique nature of their work. Again, and to be crystal clear, increases to the NLW simply do not solve the problems.

We have indicatively estimated the additional wage bill cost implied by a rise in minimum hourly pay, in three scenarios, shown in Table 2.11. These provide an indication of the level of spending required to better compensate care workers, with full details in Annex D. It is for the Government to consider detailed costings and to work out the fiscal impact, which will not be the same as the wage bill cost. The three scenarios we present are, firstly, a wage of £10.50 per hour (this would fall within AfC Band 3); secondly, aligning care worker pay with the NHS AfC Band 4 minimum which is £11.53 per hour; and, finally, a 39% increase on the NLW in 2022/23, based on analysis done for Community Integrated Care (PDF, 3.9 MB). We do not take a view on the ultimate level of care worker pay as this will partly be determined by how the supply of labour to social care responds as wages rise, and to judgments on the value of social care which are outside both our remit and our expertise.

Table 2.11: Proposed hourly wage rates and their respective estimated wage bill increases

Hourly wage	Pay floor	Whole distribution
£10.50	£0.7bn	£2.1bn
£11.53	£2.1bn	£4.2bn
£13.21	£4.9bn	£7.7bn

Source: Internal MAC calculations based on ASHE 2016 – 2021 and APS October 2020 – September 2021.

Note: Includes pay, pension costs and national insurance contributions. The £13.21 wage rate is derived from applying a 39% uplift to the NLW. Assumes no spill over from higher service costs through private spending caps to public spending.

The ‘pay floor’ cost assumes pay rises entailed by the minimum level taper up the pay distribution, narrowing differentials. The ‘whole distribution’ cost fully preserves existing pay differentials. As such, we estimate that raising pay in social care could cost between £0.7 and £7.7 billion per year, depending on the extent of both the increase and the protection of differentials.

As discussed above, there are unique features of working in the social care sector. Workers may be required to travel between locations and sleep-in as part of their role. Whilst time spent travelling for work assignments is regulated for by the NMW, there is less certainty surrounding payment for hours spent during sleep-ins. The current regulations in place for these hours worked may result in workers being underpaid for the hours worked. This may heighten recruitment difficulties for the sector.

We therefore recommend that workers in social care should be paid for the hours while at work, whether this is time spent travelling or sleeping. Whilst these hours are not being properly compensated, low paid workers are being underpaid for their time spent at work. Where care is being provided through public funds, those funds should increase to fully reflect the additional costs involved.

Again, as our remit comes from the UK Government, we do not consider it appropriate to formally advise the Devolved Administrations. However, if asked we would make the same recommendation to all the DAs. Again, we would note that this policy has already been adopted in Scotland.

Chapter 3: Immigration policy for social care

Introduction

This chapter explores previous and current immigration policy for social care, examines how the sector interacts with the immigration system, and provides recommendations for reform.

In our 2021 Annual Report, we recommended that the Government make Care Workers and Home Carers (SOC code 6145) immediately eligible for the Health and Care Worker (H&CW) visa and place the occupation on the Shortage Occupation List (SOL) due to the extreme pressures faced by the sector. The Home Office accepted this recommendation in their 24 December response, which came into effect on 15 February 2022. We review this recommendation later in the chapter.

Current immigration policy for social care workers

It is important to note at the outset that work-based immigration routes, which comprise the majority of discussion in this chapter, are and continue to be one of a number of ways through which migrants can obtain employment in social care. Historically, social care employers have broadly employed those able and willing to work in the sector, who already had work authorisation in the UK – most were not sponsored on work visas. In this section, we set out the main work route through which migrants can work in the social care sector, alongside other immigration routes.

Under Freedom of Movement (FoM), UK immigration rules distinguished between EEA and non-EEA born migrant workers. Prospective migrants from the EEA could seek work directly in social care without restriction, whilst prospective migrants from outside the EEA could not come to the UK with the express purpose of working in occupations that were not eligible for the Tier 2 visa. Between 2012 and 2020 this ruled out care and senior care workers, but not nursing as this was an eligible occupation. In contrast, significant volumes of EEA migrants have obtained employment in social care in the UK via FoM, albeit in about the same proportion as in the wider economy (see Chapter 1).

The Tier 2 route was replaced by the Skilled Worker (SW) route in December 2020 as the transition period of the UK leaving the EU ended. This aligned EEA and Swiss immigration routes with all other routes into the UK. At the same time, the occupational skill requirement was reduced, making all RQF 3+ (at or above A-level, NVQ3 or equivalent) occupations eligible. This included all social care occupations apart from care workers (SOC 6145). Following the MAC’s 2021 Annual Report recommendation, care workers were also made eligible.

In other words, since the end of FoM the immigration system has become more restrictive for EEA workers, who no longer have unrestricted access to jobs in the sector; but it has become more liberal for non-EEA workers, who can now work in a wider range of social care roles. The end of FoM has thus had different impacts for different groups of migrants moving under the main categories facilitating work:

• For migrants from the EEA, there is no change for those who qualify for settled or pre-settled status. The EU Settlement Scheme (EUSS) has also ensured a continued pool of labour from which the social care sector can recruit. Moving forward, migrants from the EEA without status under the EUSS must have a sponsoring employer and a job offer that meets the criteria of the SW route to work in the social care sector. These conditions are therefore more stringent than what was previously possible under free movement.

• For migrants from outside the EEA, the SW route is open to a broader range of occupations – including several in social care – compared to the previous Tier 2 (General) visa, has lower salary thresholds and no Resident Labour Market Test requirement. This is therefore a relative relaxation of the rules.

The Skilled Worker route

For migrants who want to move to the UK for work purposes, the SW route – called the H&CW visa for the subset of occupations in health and social care – is the most direct route into the social care workforce. Applicants to the SW route must be sponsored by an eligible employer, speak English to a required level, and work in a job that is categorised to be skilled to at least RQF level 3 (NVQ3, A-level or equivalent). The annual salary threshold is £25,600, unless the ‘going rate’ for the occupation is higher. The ‘going rate’ is defined as the 25th percentile of earnings within the occupation. Table 3.1 details how occupations in social care relate to the SW route.

Table 3.1: Social care occupations’ pay and the Skilled Worker route

Occupation	25th percentile annual full-time gross pay	50th percentile annual full-time gross pay	Salary threshold for route if on the SOL	Currently on the SOL
Care workers*	£17,261	£20,789	£20,480	Yes
Senior care workers	£18,620	£22,417	£20,480	Yes
Nursing auxiliaries	£17,361	£20,180	Set by pay scale	Yes
Nurses	£33,209	£39,634	Set by pay scale	Yes
Care managers	£28,295	£37,297	£21,360	Yes

Source: ONS, Annual Survey of Hours & Earnings (ASHE) 2021

*Not eligible for SOL prior to the MAC recommendation which came into force on 15/02/2022.

Occupations on the Shortage Occupation List (SOL) generally benefit from reduced salary thresholds. For care workers and senior care workers this means they must be paid a minimum of £20,480 per year (and £10.10 per hour) having been designated as a shortage occupation. Care managers must be paid a minimum of £21,360 per year (and £10.54 per hour). This threshold is largely inconsequential for care managers but equates to the 37th percentile of annual pay for full-time senior care workers and the 47th percentile of annual pay for full-time care workers.

Nurses and nursing auxiliaries are subject to pay scales in the NHS but not in social care. The nursing auxiliary SOC code is prevalent in ONS data for the social care workforce but is not widely recognised by the sector; in principle it provides another option for social care employers to sponsor migrants directly involved in care provision. Immigration rules require migrant nurses and nursing auxiliaries to match or better the corresponding NHS pay band, irrespective of whether the NHS is their employer. They therefore have different thresholds dependent on their salary band. This means migrants wanting to work in these occupations must be paid at least within the pay bands.

There are significant regional differences in care worker pay that make these thresholds less onerous in London, the South-East of England and Scotland. Figure 3.2 illustrates these regional differences in hourly pay for care workers across the UK.

Figure 3.2: Care worker hourly pay by region

Figure 3.2

Source: ONS, Annual Survey of Hours & Earnings (ASHE) 2021

The H&CW visa allows people sponsored for eligible health and social care occupations to have their applications fast-tracked under the SW route, with reduced application fees and an exemption from the Immigration Health Surcharge (IHS). There was a transition period where the IHS was paid on application and refunded, but this is no longer the case. This lowers the cost of a 3-year visa by £2,104 and a 5-year visa by £3,584, which is likely to make the route more attractive for migrants and employers. The application fee for a migrant care worker earning £20,480 on a visa for more than three years equates to 2.3% of gross annual pay, with the percentage doubling if accompanied by a partner or dependant. Assuming the employer already holds a sponsor licence, the Certificate of Sponsorship (CoS) and the Immigration Skills Charge (ISC) can cost as much as 5.9% of gross pay per annum. Underlying all these costs is the expertise, time and potentially legal costs of navigating the immigration system.

It is perceived that employers may be discouraged from sponsoring migrant workers and potential candidates may be discouraged from applying for posts in the UK due to concerns about navigating a costly and bureaucratic immigration system

Convention of Scottish Local Authorities (COSLA), response to CfE

Table 3.3 breaks down the official fees associated with the H&CW visa.

Table 3.3: Health and Care Worker visa fees

Fee	Cost
Sponsor licence	Small/charitable employer pays £536, renewed every 4 years Medium/large employer pays £1,476, renewed every 4 years
Certificate of Sponsorship	Employer pays £199 per worker
Immigration Skills Charge	Small/charitable employer pays £364 for first 12 months, £182 for each additional 6 months Medium/large employer pays £1,000 for first 12 months, £500 for each additional 6 months
Application fee	Migrant pays £247 upfront for a visa less than 3 years, plus £247 extra for each partner/dependant Migrant pays £479 upfront for a visa more than 3 years, plus £479 extra for each partner/dependant
Healthcare Surcharge	Migrants on this visa are exempt
English language test	If required, migrant or employer pay on average ~£180

Sources: gov.uk; information about the English Language test from MAC 2021 Annual Report (PDF, 1.2 MB).

Notes: Employers are classed as small if at least 2 of the following apply: annual turnover is £10.2 million or less; total assets are worth £5.1 million or less; 50 employees or fewer. If fewer than 2 of these conditions apply, the employer is medium/large.

Other routes into social care

Free movement and the SW route (formerly Tier 2 General) are not the only routes for migrants to enter the social care workforce. Prior to the ending of FoM, there were a number of other routes that allowed migrants to work in social care, and these continue to operate in the post-Brexit immigration system.

As discussed in Chapter 1, partners and dependants of UK citizens and other migrants are an important source of labour for the social care sector. There were, and are, substantial numbers of non-EEA migrants working in social care, despite there being no route through which they could enter the UK to work in most social care roles as the main applicant until recently. A migrant arriving as a dependant of another migrant on certain work visas or on a partner visa is free to work in any sector within the UK. A partner visa can be obtained by foreign-born spouses of people with indefinite leave to remain or who have been given refugee status in the UK, as well as foreign-born partners of British citizens

Given the key features of the workforce – often female and aged over 35 – family and dependant visas are likely to remain an important route for the sector. Partners and dependants of EEA migrants now require a visa (if not eligible for the EU Settlement Scheme), which was not the case under FoM. This is offset by the liberalisation of the SW route to a greater number of occupations and a substantial expansion in the number of dependants of student visa holders, which may enable more partners and dependants of non-EEA migrants to come to the UK and seek work in social care. How these two changes will balance out remains unclear. Students provide a further, albeit less significant source of labour. International students are free to work part-time during term time or full-time during holidays in certain sectors. This is likely to contribute a small pool of migrants into the social care sector. The Graduate route allows graduates and postgraduates to work after their studies for a maximum period of 2 years, or 3 years respectively. There is no restriction on the kind of work a graduate can do on this visa, but we would expect graduates to look for RQF 6+ roles in the long term.

A range of unsponsored schemes also provide migrant labour to the sector – notably the Youth Mobility Scheme (YMS), which is available to those from eligible countries aged 18 to 30 who want to live and work in the UK for up to 2 years, without needing a job offer. Social care may offer casual and flexible work for individuals on this route but will compete with other occupations such as hospitality or retail. Alongside this, those with an Ancestry visa can work in any job role, as can the subset of EU citizens who hold Frontier Worker Permits who previously but no longer live in the UK. In addition, asylum applicants who have waited 12 months or more for a decision are able to work in an occupation on the SOL, while migrants who have been granted refugee status are free to work in any sector.

Box 1: International comparison of occupation-specific immigration routes for social care workers

In 2021, the MAC commissioned an international review (PDF, 944 KB) of immigration routes for social care workers. The review identified a diverse mix of immigration policy approaches to the social care sector, including the embedding of social care roles in generic work migration routes, regional migration schemes, reliance on Freedom of Movement, and family and humanitarian migrants.

The differences in the approaches taken by the handful of countries with sector-specific routes, which reflect their individual migration management strategies and whether the route is intended to address the care needs of individuals, or the recruitment needs of care service providers, are informative for the UK context.

Under Canada’s Home Support Worker Pilot (HSWP), foreign workers who receive a full-time job-offer from a qualifying employer for a role in a home-care occupation are eligible to apply for a work permit. Applicants must also have at least one year of post-secondary education and intermediate English or French language skills. Any resident can qualify as a sponsor, provided the job meets the requirements and that the wage offered meets the prevailing wage for the occupation in the region. To aid accessibility for individual employers, sponsors do not have to carry out Canada’s Labour Market Impact Assessment and HSWP application fees are payable by the migrant. These conditions help counterbalance the risk to the sponsor of migrant workers switching employers, as the HSWP ties the migrant’s work permit to the occupation, not the sponsoring employer. There is also no requirement that the role is for a live-in care worker. When applying for their work permit, prospective migrants can include their dependants and must also apply for permanent residency, which is then automatically granted following 24 months working as a full-time domiciliary care worker. The unrestricted labour mobility attached to permanent residency means that foreign social care workers may move out of the sector once they receive permanent status.

Israel’s Temporary Migrant Worker (TMW) route has a specific category for live-in care workers and takes a contrasting approach to the recruitment of foreign social care workers into domiciliary care roles. Individuals and families looking to recruit a foreign domiciliary care worker must apply for a permit from Israel’s Population and Immigration Authority (PIBA), and then recruit through a licensed recruitment agency. Prospective migrants generally require no work experience and there is no salary threshold or labour market test. Labour legislation concerning wages and working hours also do not apply for domiciliary care. Migrants receive a one-year occupation-restricted permit for live-in care work, which is renewable for up to 63 months, and they can change employers, as long as they work as live-in care workers for PIBA-authorised employers in the authorised region. However, in practice, TMW permits are tied to the employer the longer the foreign care worker is in the country, as repeated renewals beyond the 63-month limit are allowed for those serving the same elderly or disabled person. This employer dependency may leave migrant care workers more vulnerable to abuse.

Unlike the Israeli route, prospective migrants under Japan’s Care Work visa route are subject to significant human capital requirements. To qualify, foreign workers must hold Japan’s National Care Worker Certification and understand everyday Japanese, although a higher level of proficiency may be required to pass the Care Worker Certification exam. The national certification requirement is also applicable to domestic workers in Japan’s Long-Term Care Insurance System and reflects the country’s overall approach to standards in adult social care. To be eligible for the route migrant care workers must hold a job offer from a Japanese residential care facility for a role that consists of providing support for elderly or disabled residents. However, the human capital requirements mean that the route is most used by those already in Japan undertaking care work training who switch onto the route because the visa can be renewed indefinitely and thus provides a de facto route to permanent residency. Like Canada’s HSWP, the route allows workers to change employers from the outset, although the role must be in residential care rather than domiciliary care.

Use of the Skilled Worker route

There is no universal dataset that links migrants’ immigration status with their employment, and as we have seen migrants working in social care enter the sector through a diverse range of routes. Home Office Management Information contains details relating to the occupation, salary and characteristics of migrant workers entering the UK via the SW route. It is important to note that this is real time administrative data, which is not quality assured to the same degree as official labour market surveys. These data give an insight into how the social care sector is interacting with the new immigration system; but they do not tell us about other parts of the system – for example how migrants on partner visas come to work in the sector.

As care workers did not qualify for the SW route until 15 February 2022, the data reveals little about the flow of migrants into the largest occupation within social care at the time of this report. However, we can examine applications from employers looking to become sponsors to give an indication of the early impact of the MAC’s recommendation that care workers become eligible for the H&CW visa and be added to the SOL. It has also proved difficult to separate nurses in social care from those working in health care within the Home Office data. Inflows of migrant care managers and nursing auxiliaries into social care are negligible.

Senior care workers

Figure 3.4 shows the volume of visa applications for senior care workers and their share of all RQF 3-5 visa applications since December 2020. As the figure shows, the number of senior care workers arriving in the UK via the SW route rose steadily during 2021. By the end of February 2022, a total of nearly 9,000 senior care workers had been sponsored. It seems probable that at least some of those entering the UK as senior care workers are effectively doing care worker roles, although they must still be paid at or above the threshold. We have received evidence from employers and other stakeholders supporting this:

They have the same salary threshold at £10.10 an hour for carers as well as senior carers. So why would we not recruit more senior people instead of junior people if the pay is the same?

Employer, Revealing Reality research interview, England

There is also no widely agreed distinction between care workers and senior care workers in the sector, despite the immigration system distinguishing between the two occupations. If taken as a percentage of the total care worker and senior care worker workforce, the number of senior care workers who have arrived via the SW route since its introduction equates to around 1% of the comparable existing workforce. Figure 3.4 also shows that senior care workers have made up an increasing share of the visa applications among all RQF 3-5 occupations on the SW route, accounting for over 40% of all RQF 3-5 visa applications by the end of February 2022.

Figure 3.4: Cumulative senior care worker visa applications and share of all RQF 3-5 visa applications

Figure 3.4

Source: Home Office Management Information, Certificates of Sponsorship (CoS) December 2020 – February 2022

Note: 1) Used Certificates of Sponsorship (CoS). CoS is assigned to a migrant by their sponsoring employer and the migrant can then use the certificate number to make a visa application. 2) Figures include both in-country and out-of-country visa applications. 3) Both volume of visa applications and share of all RQF 3-5 visa applications are shown cumulatively.

Large social care organisations have been most likely to use the SW route to recruit senior care workers, with roughly 24% of such organisations using the route (Figure 3.5). This compares with around 14% of small and medium organisations and a negligible share of micro-organisations. However, this appears to reflect the difficulties faced by all micro-organisations when using the immigration system, rather than a specific issue for social care organisations. In fact, smaller organisations in social care are more likely to use the immigration system than similar sized organisations in other sectors.

Figure 3.5: Share of employers sponsoring Skilled Worker visa applications by organisation size

Figure 3.5

Source: Home Office Management Information, Certificates of Sponsorhip (CoS) data, December 2020 – February 2022;

Inter-Departmental Business Register (IDBR), 12 March 2021

Notes: 1) Used CoS. CoS is assigned to a migrant by their sponsoring employer and the migrant can then use the certificate number to make a visa application. 2) Figures include both in-country and out-of-country visa applications. 3) Micro Organisations – (0-9 Employees); Small Organisations – (10-50); Medium Organisations – (51-250); Large Organisations (251+).

As we highlighted in Chapter 4 of our 2021 Annual Report, smaller firms face a number of challenges when using the current sponsorship system, including high administrative costs per migrant worker hired and a lack of capacity or specialised knowledge to make use of the system. Respondents to the CfE also echoed the sentiment that the sponsorship system can be particularly difficult to use for smaller providers, who may have less capacity to deal with the responsibilities of sponsorship:

Skilled Worker Visas are being used by care providers, particularly those offering nursing care. However, the current system places a considerable administrative burden on registered sponsor organisations and this is often unfeasible for smaller providers

Representative body, response to CfE, England

Figure 3.6: Senior care worker visa applications as a percentage of total care workers and senior care workers by region

Figure 3.6

Source: Home Office Management Information, Certificates of Sponsorhip (CoS) data December 2020 - February 2022; ONS, Annual Population Survey 2019

Note: Used CoS. CoS is assigned to a migrant by their sponsoring employer and the migrant can then use the certificate number to make a visa application.

Whilst social care employers in all nations and regions of the UK have begun to use the SW route to recruit senior care workers, usage has tended to be higher in London and the South East – which has historically employed a higher share of migrant workers in the care sector (Figure 3.6).

Nurses

It is difficult to separate nurses in social care from nurses in health care within the visa application data. As the sector of the employer for whom the migrant will be working is not recorded, our best estimate of the number of nurses arriving in the UK via the SW route to work in adult social care relies upon filtering for nurses who are marked as being employed by nursing homes or care homes. This means that our estimate does not include nurses working in non-residential care or for organisations that provide a mix of health and social care and is thus likely to be an underestimate. We estimate that the number of social care nurses entering the UK via the SW route was a little over 1,100 in 2021.

Care workers

Since the Home Office announced it was accepting the MAC’s 2021 recommendation on care workers, the sector has shown interest in utilising the SW route to recruit care workers. To utilise the route, employers must obtain a sponsor licence that allows them to issue CoS to prospective migrant workers. Home Office data on new applications from employers looking to acquire a sponsor licence offers an encouraging sign that social care employers are willing and able to use the SW route (Figure 3.7). The percentage of all new sponsorship applications that were made by employers from the Health and Social Care Sector increased from 18% between 1 January 2021 and 23 December 2021 to 30% from the 24 December 2021, when the Government agreed to include care workers on the route. This increase has been wide-ranging across the sector, with little evidence of differences by organisation size. Home Office data also indicates that there has been an increase in all regions of the UK. Although these figures cover applications to become sponsors made by employers in the health sector as well as social care, the increase observed is likely to be at least somewhat driven by the announcement. Home Office data also shows that 100 visa applications were made by care workers in February, after the recommendation came into effect on February 15.

Figure 3.7: Percentage of all new sponsor applications and visa applications made by the health and social care sector

Figure 3.7

Source: Home Office Management Information, New sponsor applications (01/01/2021 – 02/03/2022).

Notes: Micro Organisations – (0-9 Employees); Small Organisations – (10-50); Medium Organisations – (51-250); Large Organisations (251+).

Future immigration policy for social care workers

Immigration cannot be viewed in isolation nor as a sole solution to the issues faced by the social care sector. We believe that the Government needs to take a holistic view of immigration alongside the long-standing funding issues and unfavourable terms and conditions within the sector, as discussed in other chapters of this report.

The social care sector is facing a workforce crisis. As stakeholders and our own evidence has highlighted, recruitment and retention of workers has become increasingly difficult for the sector, and this is having serious impacts on the availability and quality of care to those who need it. These problems are not driven by the end of free movement but are the result of years of policy decisions not to fund the social care system properly. However, the end of FoM has contributed to shortages in the social care workforce.

When thinking about the appropriate role of immigration policy, the MAC therefore faces a difficult task. Whilst on one hand, immigration policy may be able to help alleviate some of the workforce problems the sector is facing, it may not always be the best solution to these problems. Some of the potential immigration policy options also bring risks, most notably the risk that migrant workers in low paid positions may be exploited. We were told by a consortium of labour market exploitation experts that their forthcoming research highlights examples of risks that already exist within the immigration system, with examples such as workers being brought to live and work in care settings on Tier 5 volunteer visas on unknown rates of pay. It would also be highly damaging for the sector in the long term if the necessarily limited and short-term relief brought by immigration policy were used as an ‘excuse’ not to address the more fundamental problems the sector faces.

Nonetheless, the MAC’s remit is to make recommendations on immigration policy. With these qualifications in mind, in this section we consider whether and how immigration should be used to enable the employment of workers to the social care sector. In this section we discuss three options:

• an employer-sponsored route;

• alternative sponsorship routes; and

• an unsponsored route.

Employer-sponsored route

Sponsored routes bring workers to perform specific jobs that meet a given set of eligibility criteria. These routes usually require those employing migrants to engage with the Home Office sponsorship system. Sponsorship is designed to ensure compliance with the immigration rules. For example, it provides an opportunity for the Home Office to ensure that the person is working in an eligible occupation, and enables it to regulate the terms and conditions on which migrants can come to the UK, such as requiring pay rates above the minimum wage. Any visa issued under this system requires continued sponsorship if the worker is to remain in the UK.

This section takes as a starting point the SW route, considering whether the different requirements it involves are appropriate for the social care sector. Some of our recommendations relate broadly to the SW route, whilst others are focused more narrowly on the H&CW visa, which applies to only a subset of the SW route.

Costs

The current costs of sponsorship were reviewed in the MAC’s 2021 Annual Report (PDF, 1.2 MB). The MAC’s analysis showed that immigration costs were not proportionate to wages and make up a larger share of total labour costs for firms employing lower-wage workers. Sponsors who hire fewer workers also spend more per worker to recruit. The MAC concluded that, whilst there may be benefits, the UK immigration system is (relative to international comparators) expensive and time consuming. Smaller firms in particular may struggle to sponsor employees, due to the high initial direct and indirect fixed costs. However, the employers interviewed as part of the qualitative research carried out for this commission did not necessarily see the sponsorship costs as an insurmountable barrier, especially if they were employing agency staff to fill their staffing gaps.

“£536 [for a licence] is peanuts in the scheme of things compared to what we spend on agency staff. It’s not prohibitive”

Employer, Revealing Reality research interview, Scotland

We pay agency staff £19 per hour on weekdays and £22 per hour on weekends. Getting staff from abroad would be cheaper in the long run. And also it’s about consistency of service and care. Even if it cost us, we would go this route

Employer, Revealing Reality research interview, Scotland

The government charges for sponsorship on the H&CW visa are set out in Table 3.3 above. As part of the licence, the Home Office expects the sponsor to fulfil their responsibilities to ensure that the migrant is qualified for their visa and that they comply with the conditions of their visa. A sponsor licence requires renewal every 4 years.

A notably large element of the costs is the Immigration Skills Charge (ISC). This is £364 per year per migrant for small and charitable firms, and £1,000 for medium and large firms. Revenue generated from the ISC is not ring-fenced or linked directly to any fund for training to reduce the reliance on migrant workers and is simply a tax on the use of migrant labour which goes to the Treasury.

Given the exceptional pressures on the care sector, we consider a tax on the recruitment of migrant workers which could deter potential migrants to be in opposition to the steps already taken to facilitate immigration into the care sector. We also recognise that the NHS is a large user of the H&CW route whilst care workers often fulfil local-authority commissioned care. It seems illogical to charge the ISC to public sector bodies or those meeting public sector needs and thus simply shifting funds across Government. We therefore recommend the removal of the Immigration Skills Charge for all H&CW visas.

More broadly, it would be useful to separately conduct a full review of the ISC across the entire SW route, which was introduced some years ago and there have been substantial changes in immigration policy and its objectives since that time.

Administration

The Home Office has held oversubscribed information stakeholder events, in partnership with DHSC, before the H&CW route opened to care workers. The Home Office has also told us that work is already underway to further streamline and improve the sponsorship system. Whilst this will undoubtedly be welcome, we would encourage the Home Office to ensure a wide variety of stakeholders are directly involved in the process.

Stakeholders have consistently highlighted that small businesses within the social care sector have had little interaction with the immigration system prior to the ending of FoM and that many small businesses may not have a dedicated HR lead that can ensure their sponsorship responsibilities are met. Whilst we heard from medium-sized businesses that these difficulties are not specific to small employers in the social care sector, they may slow, and ultimately limit, the uptake of care workers on the H&CW visa.

The time delays in obtaining the necessary licences as well as assigning the appropriate Certificates of Sponsorship adds such a burden of responsibility on to the employer that navigating the Sponsor Management System is almost an impossibility for many SME employers who simply don’t have the knowledge, time or financial resources to engage as well as be totally compliant. At best it is confusing and costly and at worst, it is impossible to navigate without expert professional assistance

Employer, CfE, England

In our stakeholder engagement and the qualitative research conducted for this commission, stakeholders commonly identified the administrative burdens of sponsorship as a problem. Some pointed to factors such as the need for regular and detailed reporting on their staff, whilst others were primarily concerned about the risks of penalties if they accidentally did something wrong and losing the money that they had invested in the sponsorship process.

We applied for a licence in June 2021 and had huge problems logging in and seeing if we had done our application form correctly. We heard in September that we had done it wrong and then had to engage a solicitor to help

Employer, Revealing Reality research interview, Northern Ireland

“There’s a lot we have to do. I read it in the guidance from the Home Office. We have to report the hours, if they stop working, if they leave before 2 years…it’s feasible but it would take a lot, on top of all the paperwork we have to do anyway”

Employer, Revealing Reality research interview, Scotland

The principal concern is around all your existing paperwork and the inspection process because we’ve not done it before. So it’s whether we keep our records or have the appropriate wording in contracts and documents and stuff like that. That’s the bit where you need proper advice, which we need to get ourselves

Employer, Revealing Reality research interview, England

The sponsorship requirements have a policy function, such as ensuring that employers and workers are complying with the immigration rules. There is a balance to be struck between the benefits of oversight and the costs of the administrative burdens for employers. We did not receive sufficient specific evidence as part of our research or stakeholder engagement to recommend particular changes that could be made to the administrative processes involved in acquiring and maintaining sponsor status. As the policy change has only been recently implemented many employers were still getting to grips with the process, about which they expressed some feelings of uncertainty and confusion. We note that when designing the EU Settlement Scheme, the government carefully engaged with users to understand what aspects of the application they found difficult and how the system could be improved. We recommend that the Government either conduct or commission research to identify administrative burdens for employers and workers that could be eliminated across the SW route. This analysis should consider both the benefits of specific requirements, and the burdens on users.

Salary threshold

In line with the rest of the SW route, the H&CW visa requires migrants to be paid the higher of their occupation’s going rate or an annual salary of at least £25,600. Occupations on the SOL receive a discount on these thresholds, so care worker and senior care workers must be paid an annual minimum of £20,480, equivalent to £10.10 per hour. Nurses must be paid according to the Agenda for Change pay scales.

Given the Government’s commitment to raising the National Living Wage (NLW) to two-thirds of median earnings by 2024, the minimum hourly wage for a care worker will inevitably increase in the next few years. Figure 3.8 compares the LPC’s projected path for the NLW to the potential path of the SW route threshold for care workers (assuming they remain on the SOL) – first uprated for 2021 data and then increasing in line with LPC assumptions. This suggests that the NLW could exceed the current £10.10 minimum threshold in 2023, if the £10.10 threshold were itself not uprated. Uprating the SW route thresholds annually, in line with the most recent data on UK earnings as we have consistently recommended, would maintain a gap between the minimum hourly rate for care workers on the SOL and the NLW over time. The gap would however narrow somewhat as the NLW is likely to increase at a faster rate than the SW route thresholds.

Figure 3.8: National Living Wage and updated SOL hourly wage threshold projections

Figure 3.8

Source: National Living Wage rates and projections from the Low Pay Commission (PDF, 426 KB). 2021 updated SOL minimum hourly rate uses 2021 ASHE data and subsequent years are based on 2022 LPC assumptions on wage growth. Years on the x-axis are financial years.

Data from ASHE show that around 48% of care workers currently employed in the UK do not receive £10.10 per hour or more (although data from Skills for Care for England suggests this percentage is considerably higher), and some stakeholders have stated that they will struggle to meet the salary requirements of the H&CW visa for care workers. Whereas many of the employers interviewed in relation to this commission thought that the annual salary threshold of £20,480 would be achievable for them to pay, in several cases they expected that this would be on the basis of working longer hours at a lower hourly rate, and so expressed more concern about the hourly rate of £10.10 per hour, as this was more than they currently paid. Some also expressed concerns that the minimum hourly rate of £10.10 per hour would mean a dual system may develop where UK workers are paid less than migrant workers.

There was a strong consensus across the stakeholder engagement, CfE and qualitative research that increasing wages and providing sufficient public funding to allow this was the most appropriate response to shortages in the care sector, and we have been clear on our view in the previous chapter. Stakeholders’ views differed on whether the H&CW salary threshold should be reduced to reflect the current reality of low pay in the sector. Some, particularly employers, felt that reducing pay would be a helpful step to alleviate the problems caused by the lack of public funding. Others, including experts in the social care sector, felt that maintaining the hourly threshold of around £10.10 per hour would create upward pressure on wages at least in some parts of the sector.

Data from advertised job postings suggests that the annual threshold of £20,480 is achievable for many employers. Figure 3.9 shows the pro-rated mean and median annual salary advertised online for entry-level care workers. Whilst the mean salary has been above the £20,480 SOL threshold since 2019, the median also went above this level in 2021.

Figure 3.9: Median and mean advertised pay (pro-rated) for care workers, 2018 - 2022

Figure 3.9

Source: Labour Market Insights, Burning Glass

Notes: 2022 data are from January to March.

If the current wage requirements are maintained and the Government continues to fail to fund the sector at the levels required, some employers may not be able to use the H&CW visa to sponsor migrant workers, but the evidence suggests that many would. For example, Scottish care employers would benefit from the route more than English employers, due to the increases in social care pay in Scotland to £10.50 per hour from April 2022 onwards.

An alternative approach would be to reduce the pay requirements on the route for care workers so that a greater share is eligible for visas. This would make the H&CW visa a more realistic option for the care sector and would provide relief to the sector particularly in the short term.

However, reducing the pay threshold would also have disadvantages. First, it would mean explicitly allowing the immigration system to facilitate the already too widespread practice of paying care workers less than the value they provide, and less than the amount that is required for this labour market to function effectively. It is also possible that it would reduce pressure on the Government to increase its funding for the sector. The Scottish example shows that it is possible to pay care workers more when the political will to do so is there –although it is also important to ensure that these increases are properly funded.

Second, it is also a concern that migrants entering on the H&CW visa have no recourse to public funds including Universal Credit (UC), which British workers can use to supplement their net earnings. Table 3.10 illustrates the monthly UC entitlement of a British worker earning the NLW or £10.10 an hour. Entitlement to UC is largely dependent upon the local housing allowance rate and varies considerably by region. To account for this, the ‘Median Housing’ columns in the table assume that the worker is subject to the median UK housing allowance rate. The table shows, a British care worker, working full-time for the minimum wage, with 2 children and a partner who is not working, is potentially eligible to receive £16,620 a year in Universal Credit and Child Benefit. This award could be around £3,500 lower if they live in an area with low housing costs like County Durham or around £10,000 a year higher in a high housing cost area like London. An equivalent migrant care worker is not entitled to these additional funds so any reduction in the salary thresholds could push them well below levels required to live in the UK.

Table 3.10: Indicative monthly Universal Credit and Child Benefit award of British workers

Working Pattern - Hourly Wage	Single, No Children, No Housing	Single, No Children,Median Housing	Lone Parent,1 Child,Median Housing	Couple, 2 Children, Median Housing
Full Time: £10.10	£0	£28	£725	£1,348
Part Time: £10.10	£0	£353	£1,049	£1,673
Full Time: £9.50	£0	£66	£762	£1,385
Part Time: £9.50	£0	£378	£1,074	£1,697

Source: Department for Work & Pensions analysis
Notes: The housing component of Universal Credit (UC) is dependent upon the Local Housing Allowance rate, which differs across the UK. The ‘No Housing’ option above excludes any entitlement to the housing component of UC, while the ‘Median Housing’ option assumes the median Local Housing Allowance rate. Full-time defined as a 39-hour week (equivalent to the number of hours required to meet the SOL salary threshold at the minimum hourly rate of £10.10); part-time as a 20-hour week. In the couple scenario, only one member of the couple is in work. These figures do not account for the increase in the National Insurance threshold announced in the 2022 Spring Statement.

Third, if low pay in social care is not addressed, it will be difficult for employers to retain migrant workers once the immigration system no longer ties them to the sector, i.e., once they receive permanent status.

The arguments are finely balanced. We recognise that if the Government fails to act on social care funding, some employers will not be able to recruit either from within the UK or from overseas, and that this is likely to exacerbate existing shortages in the social care workforce. On the other hand, early indications suggest that many employers are beginning to sponsor care workers at the current thresholds and thus that the salary thresholds are in reach at least for some.

On balance, we recommend maintaining the current salary threshold for the H&CW visa. It is important to understand that this judgment is based on the current minimum threshold of £10.10 per hour. If this threshold was uprated to reflect average earnings growth since it was set in 2019, the minimum threshold would now be £10.34 per hour. We may well wish to reconsider the balance of the arguments if the threshold were uprated and no appreciable action was taken by Government to raise wages in the care sector.

Required hours

There is no requirement in the SW route rules for a migrant to be on a full-time contract. However, practically speaking, were a migrant to be on part-time hours, their hourly rate would need to be far higher than the level a social care provider would pay to meet the annual salary threshold. Where migrants are working part-time hours in the social care sector, they will typically have entered the UK on a non-work route, for example as a family member.

Social care has a number of different contract features, including sleep-ins and unpaid travel time that were discussed in Chapter 2. The various types of contract can create large amounts of unpaid work within a care worker’s day. This additional unpaid work is clearly an issue for recruitment and retention in the sector that we have made recommendations on in the previous chapter. Stakeholders also advised that whilst some in the social care sector are happy with part-time or zero-hour contracts, migrants coming to the UK for work are more likely to be seeking a full-time position.

The MAC has previously considered the issue of part-time work in its 2020 report: A Points-Based System and Salary Thresholds for Immigration (PDF, 3.5 MB). Though the MAC recommended that the Home Office take account of migrants’ change of circumstances once they are in the UK, we did not recommend that the annual salary thresholds should be pro-rated to allow for part-time work. Taking the concerns set out in that report, along with the considerations above, we maintain that recommendation for migrants on the H&CW visa. In practice this means that only full-time care workers will be able to obtain entry under the H&CW visa.

We are concerned that the prevalence of unpaid hours, in particular between shifts in domiciliary care, may mean that employers will require migrant workers on full-time contracts to work very long hours in order to meet the full number of paid hours required. However, it is difficult to address this problem through the immigration system itself. For example, requiring employers to pay sponsored migrants for hours that other workers would not be paid for would add to the risks of different contracts for workers of different nationalities. As a result, we think that the problem of unpaid hours, as discussed in Chapter 2, is best addressed for all workers and not via the immigration system alone.

English language requirement

Migrants entering the UK on a H&CW visa are required to demonstrate knowledge of English to a minimum of level B1, which needs to be evidenced through passing a Secure English Language Test, an appropriate qualification obtained at a UK School or a degree-level qualification that was taught in English. The MAC have previously set out the benefit for a migrant having a reasonable level of English to allow them to integrate and have better outcomes in both the labour market and society more generally.

Care employers and people who draw on social care were clear on the need to speak English in order to carry out the role and deliver care effectively. We therefore do not recommend any changes to English language requirements for migrants on the H&CW route.

I feel, I’ve got two levels of responsibility. My clients, who are elderly and vulnerable, and my staff. But the first responsibility is the welfare of the clients. … And so I think being understood or being able to have a conversation, we’re not just emptying a tin of beans from the can and leaving. They have to be able to have a relationship of some sort with the person coming to the door… They only have them for one hour. It needs to have been an experience that leaves them more comfortable and better off than when that person arrived. … People have to be able to communicate well and that is usually verbal

Employer, research interview, England

Settlement requirements

Migrants who have entered the UK on the H&CW visa will be eligible for settlement, known as Indefinite Leave to Remain (ILR), after a 5-year period. The cost of the application is £2,389 per person. Dependants also pay the same fee, so a person with dependants also applying for ILR may have to pay a large share of their annual post-tax salary in fees.

This represents a significant cost for a migrant given the low wages paid in the social care sector. The cost of a settlement application is very high compared to the unit cost of processing the application, which the Home Office reported as £243 in 2021/22. In fact, the discrepancy between the fee charged and the unit cost for settlement is among the highest in the immigration system.

The reason that fees exceed the cost of processing is that the Home Office funding settlement relies heavily on fee revenue to cross-subsidise other parts of the immigration system. However, this approach has drawbacks, including imposing very large fees on settlement applicants who effectively have no other choice than to pay it if they are to remain in the country.

A 2022 study on migrant economic integration shows that selective regimes, like the SW route, can increase wages and labour market incorporation of migrants in the long run, but only when combined with easier paths towards settlement and high security of rights upon arrival. This can deliver economic returns for the destination country, outperforming both open borders and more restrictive types of policy.

The problem of high settlement costs is not specific to care workers, although compared to many other migrants on work visas their lower salaries make the fee even less affordable. Some other applicants for settlement, such as certain family migrants, may also struggle to pay the settlement fee. However, these individuals are beyond the scope of the current report. As a society, we surely want to encourage dedicated workers in health and social care to remain in the UK. We recommend that workers who spend the full five years working in nursing or care roles on the H&CW visa should either receive a complete settlement fee waiver or pay a lower fee, that is no higher than the unit cost of processing. The cost of this recommendation should not be passed on to other visa fees.

More generally, while we recognise the value of enabling visa operations to be self-funding at least to some extent, we struggle to see a justification for such a large premium being imposed on settlement applicants, especially where the purpose is to cross-subsidize parts of the immigration system from which they do not particularly benefit. We are also aware that reducing the settlement fee for some or all applicants may create pressure to increase fees elsewhere, and this would have negative impacts on individuals in other visa categories. We recommend that there should be a review of all visa application fees more broadly to ensure that fees are affordable for people on middle and low incomes.

The interim recommendation to add care workers to the H&CW visa and SOL

In our 2021 Annual Report, in recognition of the fact that the wider issues facing the social care sector will need time to resolve, the MAC recommended the addition of Care Workers and Home Carers (SOC 6145) to the H&CW visa and SOL. This was accepted by the Government and implemented in February 2022, though the Government independently imposed the qualification that the route would be initially open to applications for a period of 12 months (although the length of the work authorisation issued is up to 5 years as with the rest of the H&CW route). The Government have announced that they intend to internally review the decision during 2022.

In light of the long-term and persistent nature of the challenge facing social care, the MAC recommends that the decision to make care workers eligible for the H&CW visa should be made permanent, i.e., should not have an automatic sunset date. This will give more certainty to employers in the sector to plan for the long term.

The placing of care workers on the SOL is separate from the decision to allow applications under the H&CW visa. The MAC would expect to review the position of care workers in the usual way when we next review the SOL. We would recommend that the Government keep care workers on the SOL until the next SOL review is completed, when we will make a further recommendation. While any future SOL review will examine the situation in the labour market at that time, realistically it is very unlikely that shortages in the social care sector will be resolved in such a short period. The MAC would likely only be minded to remove care workers from the SOL in the event of a very substantial change in the conditions facing social care employers.

Alternative sponsorship routes

Direct employment

Even if sponsorship duties are simplified and costs reduced, the SW route model does not work for all care employers. Some very small employers were reluctant to take on sponsorship duties and individuals who directly employ care workers are not permitted to become sponsors under the immigration rules.

A small, but highly impacted, proportion of people in the UK directly employ care workers and stakeholders from this sector have told us how vital those care workers are to the people who receive care and support for being able to function and live independent lives. They also told us about the difficulties in finding and recruiting suitable individuals to provide personal care, and the high harm to their lives when they could not find appropriate care. Some direct employers live with care workers in their homes, while others employ workers who work shifts but do not live in. Many of those responding to the CfE in a personal capacity or interviewed explained that finding qualified care workers who understood their specific needs was much harder following the end of FoM, and although they were using agencies to help their search, this was made more difficult by the overall lack of care workers, including UK care workers, and a consequent rise in the daily rates charged by many directly employed care workers. Research undertaken by the NIHR Policy Research Unit in Health & Social Care Workforce at King’s College London has highlighted the challenges faced by individuals understanding their rights and responsibilities as employers.

Stakeholders in this position typically wanted a way to employ overseas care workers directly, as they had done in the past under FoM. It was recognised that the administrative burdens of the sponsorship process would be difficult to fulfil for many. The direct employers we spoke to included people who paid their care workers directly and were registered with HMRC to do so.

However, the sponsorship system prevents individuals from registering as a sponsor, as set out in the guidance for sponsors. This applies to all sectors – with no individual being able to sponsor a worker for any reason, including in other activities where it is common for individuals to be employers, such as childcare. Rules requiring sponsors to be organisations that meet requirements, such as sufficient HR capacity to comply with immigration and employment regulations, play a role in protecting sponsored migrant workers. There is already evidence that even when migrant workers are sponsored by organisations, they can be vulnerable to poor compliance with employment law. If workers are directly employed by individuals through some form of sponsorship arrangement, these vulnerabilities are likely to increase because the absence of an external employer makes them more isolated. Whilst in theory migrant workers could find another sponsor, should sponsorship cease without a migrant having a new sponsor, they are required to leave the UK. Research on senior care workers conducted in the mid-2000s suggested that workers felt tied to their employer despite the ability on paper to switch jobs, because they were worried that a gap in sponsorship would lead them to lose their residence rights or pathway to permanent status. This can create a power imbalance between the migrant and sponsor, especially where the migrant relies on the sponsor for their housing.

Direct employment thus raises particular challenges for the immigration system. One potential option to mitigate the problems faced by direct employers who previously relied on FoM would be to allow licensed umbrella bodies to sponsor workers who would then be placed with specific people. Stakeholders, including those who receive care and support from live-in care workers, frequently spoke of the reliance on agencies to source staff. It was noted that agencies have been struggling to provide care workers and some of the examples given predate the ending of FoM but as with other issues, the ending of FoM and COVID-19 are likely to have exacerbated these shortages.

The model that allows umbrella bodies to sponsor staff exists elsewhere in the immigration system, for example in the Seasonal Agricultural Workers Scheme (SAWS). In this scheme, four licensed ‘operators’ manage the programme and sponsor workers who are then provided to farm employers. In theory, this can be an attractive option to improve oversight, as the licensed operators have an incentive to ensure compliance with programme rules in order to maintain their licenses. However, it does not remove risks of exploitation, as the recent evaluation of the scheme has identified. The ‘end user’ employers are also still subject to significant paperwork and compliance requirements that individual direct employers of care workers would potentially struggle to meet.

We have considered an umbrella sponsor model, similar to the SAWS model, for social care. However, we believe that there may be better ways of achieving the same objectives through the existing SW route. As described above, the SW route already allows an agency to sponsor a migrant to the UK provided they are delivering a service to a client (rather than simply providing workers). It should therefore be possible for organisations to use the H&CW visa to employ care workers, with individuals using personal budgets to purchase care and support services from those organisations. The important distinction is that the care worker must be formally employed by the agency rather than the person receiving care and support. The Government created direct payments to allow individuals to manage their own care either by choosing their preferred provider or by employing care workers directly. The ending of FoM does not change the first option. The second option of direct employment may now be harder for some direct payment recipients because they may in the past have used EU workers – particularly for live-in care. This is now generally not feasible and so if they cannot directly employ resident workers, they will have to use the first option instead.

The existing sponsorship arrangements do not preclude individuals from identifying specific care workers that they would like to employ, and then working with a care agency who could sponsor that worker and then provide care to them under a service contract. Since care workers’ have only recently become eligible for the H&CW visa it may take some time for this market to fully develop. Local authorities have an important role in shaping social care markets and the MAC would encourage DHSC and the Devolved Administrations to work with local authorities to support the development of this market.

Even were this market to be suitably developed, there is likely to be a small group of people who would not want to use an agency to contract care services in their home. They would prefer to have more involvement in the recruitment of the person they will rely on for their care and not be required to pay agency fees. Whilst using an agency would be the preferred model for many, if the Government is clear that allowing individuals to directly hire workers is a fundamental element of social care policy, the Government could consider the introduction of a pilot umbrella scheme. Under the scheme, an umbrella body would be appointed to sponsor care workers from overseas and people who can show their level of need requires live-in care would be able to directly recruit from the umbrella body. This would broadly match the approach used for SAWS but would require significant development and must have a robust evaluation plan in place before launch. We would be happy to be involved in the design and evaluation of such a pilot if the Government decided to pursue it. We would also strongly urge close involvement with the sector.

Unsponsored routes

Unsponsored routes do not tie workers to a specific job but allow them to take any position, so any unsponsored route would be wider than social care. Whether a particular route is sensible is a much wider question than just the impact on the social care sector, which will often be relatively minor. FoM was the largest unsponsored route for the UK and many social care employers used it. More generally, the large majority of EEA and non-EEA migrant workers in social care will have come to the UK through routes that were not sponsored by employers, whether this was FoM or non-work routes such as partner visas. Many stakeholders and employers we heard from in both the consultation and primary research have said that they have consistently recruited from their local area, and the migrants they employed were in the locality already.

The main unsponsored work route in the current immigration system is the Youth Mobility Scheme (YMS), where migrants from a restricted number of countries, who are aged 18 to 30, can apply to come to the UK for up to 2 years with very few restrictions on what work they can do. The Government has said that it would like to expand the YMS to cover EU countries (by agreeing reciprocal deals with those countries) but has not yet done so. Whilst migrants on the YMS scheme have full access to the labour market, the numbers allowed under this route are capped and subject to reciprocal arrangements which can take a long time to agree. Whilst stakeholders stated that some migrants on a YMS visa could work in social care, many felt that they would not have the experience needed by the age of 30.

Unsponsored routes have both advantages and disadvantages as a mechanism for addressing recruitment difficulties in social care.

Benefits of unsponsored routes

Where a migrant is not reliant on sponsorship from a specific employer, migrants can work for multiple employers. For example, they can combine more than one part-time role, or combine a role in social care whilst also working in another sector. This enhances the flexibility of the worker.

An unsponsored route imposes a much lower administrative burden on employers because the person already has work authorisation and can simply start working as soon as they are recruited without any additional paperwork.

For the migrant, it also means they are not reliant on sponsorship from a specific employer. This freedom to move between jobs reduces their vulnerability and increases their bargaining power.

Drawbacks of unsponsored routes for addressing social care recruitment difficulties

It is not clear to what extent a new unsponsored route or an expansion of an existing one such as the YMS would lead to more migrants working in the social care sector. The same issues that make the social care sector less attractive to the resident population are also likely to mean that migrants are less willing to work in these roles. Nonetheless, it is clear that many EU workers under FoM worked in social care, despite having the option to work in other sectors. The vast majority of migrant workers in social care, EU or non-EU, will have entered the country through routes that do not tie them to this sector.

Unsponsored routes cannot realistically be explicitly targeted at specific sectors. It would be very difficult to enforce any requirement for people in an unsponsored route only to work in social care, as there would be few mechanisms to prevent people from working across sectors. Experience overseas with unsponsored routes requiring people to work in particular sectors, such as the Australian Working Holidaymakers’ Visa, suggests this model is vulnerable to exploitative practices.

Since unsponsored routes cannot be targeted at specific sectors and because it is likely that a minority of unsponsored workers would actually work in social care, it is important that such routes should be beneficial in their own right and not just because of the potential benefits to social care. As a result, we do not recommend any changes to unsponsored routes in the context of this commission. We have however in the past highlighted the benefits of the Youth Mobility Scheme and would continue to urge the Government to expand the scheme to cover some or all EU countries. Undoubtedly some additional entrants on YMS would work in social care, whilst others would take roles in sectors that often compete with social care which would marginally alleviate recruitment difficulties. Several stakeholders, particularly direct employers of care workers and live-in care workers, felt that an expansion of the YMS would alleviate some recruiting pressures.

Conclusion

Immigration policy cannot solve the workforce crisis in social care, though it can mitigate some of the damage that the shortage of care workers is creating. Using the immigration system to address shortages in social care also has costs. These include the risk of exploitation of potentially vulnerable workers, especially when workers are isolated within the home; as well as the risk that the immigration system will be used to paper over problems that urgently need to be addressed.

Our recommendations on the role of the immigration system in the social care workforce aim to find an appropriate balance between these concerns. In particular, we believe that the SW route is the most suitable route for admitting care workers, and that they should be made indefinitely eligible. On the most difficult question – the issue of required pay – we have set out our recommendation in Chapter 2 of a minimum starting point of £10.50 an hour. We believe that this strikes a balance between the need to make the immigration route accessible to social care employers facing pressing recruitment difficulties, and the need to maintain pressure across Government including DHSC, Local Authorities and the Devolved Administrations to address the core problems the sector faces. Recruitment of senior care workers on the H&CW visa increased over the course of 2021, and there are early indications employers will make use of the new rule expanding eligibility to all care workers.

The social care sector is not heavily reliant on EEA workers, but the ending of FoM shut off one source of workers at a critical time for recruitment and retention. One group that did make significant use of EEA workers were those who require live-in care workers. We have spoken with a number of stakeholders in this group and do not underestimate the severe impact that not being able to source an appropriately skilled care worker for this type of role has. Using immigration policy to address the impacts of the ending of FoM on this particular group is very difficult. We believe that there is a role for care agencies to sponsor staff for this kind of role, as is currently permitted through the SW route. This will not enable direct employers of care workers to replicate the arrangements that were previously available under free movement but should nonetheless help to mitigate some of the negative impacts that they have faced.

Chapter 4: Recommendations

In this report we have assessed the impact of the ending of Freedom of Movement (FoM) on the adult social care sector. Our main recommendations are summarised below, by chapter.

Workforce strategy and data

A long-term, coherent workforce strategy, that is fully implemented with adequate public funding, is vital to make social care an attractive, viable and sustainable career. A common, UK-wide, social care data collection framework would provide a better picture of the sector. There is a serious evidence gap about the labour market for directly employed care workers, despite the role of public funds in employing many of them.

Recommendations:

1. We fully endorse the views expressed by the Health and Social Care Committee and would strongly recommend that the Department of Health and Social Care (DHSC), and the comparable bodies in the Devolved Administrations (DAs), develop a coherent workforce plan in consultation with the sector.

2. The Government should consider what they might learn from the examples of good practice we have highlighted from across the UK. Additionally, we recommend that the Government embed a culture of regular consultation with the DAs and stakeholders from the Devolved Nations (DNs) to share knowledge and best practice.

3. DHSC and the DAs should consider adopting a common data collection framework.

4. Where possible, social care and healthcare should be separated in Office for National Statistics (ONS) and other official data.

5. DHSC and the DAs should work jointly on a review of the evidence available on directly employed care workers, including those paid for via direct payments, personal health budgets and private funding.

Chapter 1

Labour market

Persistent underfunding of the care sector by successive Governments underlies almost all the workforce problems in social care. It is not for the MAC to advise on the appropriate level or method of social care funding. Higher pay is a prerequisite to attract and retain social care workers and they should be paid for the hours while at work. We would make the same recommendation to the DAs, if asked.

Recommendations:

6. We recommend that DHSC and the DAs work towards a joined-up approach when planning and executing recruitment campaigns for the health and social care workforces.

7. We recommend that the Government introduces a fully funded minimum rate of pay for care workers in England that is above the National Living Wage, where care is being provided through public funds. As a minimum starting point, we would recommend a level of £10.50 per hour to be implemented immediately.

8. We recommend that workers in social care should be paid for the hours while at work, whether this is time spent travelling or sleeping. Whilst these hours are not being properly compensated, low paid workers are being underpaid for their time spent at work. Where care is being provided through public funds, those funds should increase to fully reflect the additional costs involved.

Chapter 2

Immigration policy

Immigration cannot be viewed in isolation nor as a sole solution to the issues faced by social care. The MAC would likely only be minded to remove care workers from the Shortage Occupation List (SOL) in the event of a substantial change in the conditions facing employers. Some visa costs are not logical or affordable for low-paid, publicly funded social care workers, while other aspects of current policy are, on balance, appropriate.

Recommendations:

9. We recommend the removal of the Immigration Skills Charge (ISC) for all Health and Care Worker (H&CW) visas. More broadly, it would be useful to separately conduct a full review of the ISC across the entire Skilled Worker (SW) route, which was introduced some years ago and there have been substantial changes in immigration policy and its objectives since that time.

10. We recommend that the Government either conduct or commission research to identify administrative burdens for employers and workers that could be eliminated across the SW route.

11. On balance, we recommend maintaining the current salary threshold for the H&CW visa.

12. Taking the concerns set out in the MAC’s 2020 report: A Points-Based System and Salary Thresholds for Immigration (PDF, 3.5 MB), we maintain the recommendation that annual salary thresholds should not be pro-rated to allow for part-time work for migrants on the H&CW visa.

13. We do not recommend any changes to English language requirements for migrants on the H&CW route.

14. We recommend that workers who spend the full five years working in nursing or care roles on the H&CW visa should either receive a complete settlement fee waiver or pay a lower fee, that is no higher than the unit cost of processing. The cost of this recommendation should not be passed on to other visa fees.

15. We recommend that there should be a review of all visa application fees more broadly to ensure that fees are affordable for people on middle and low incomes.

16. The MAC recommends that the decision to make care workers eligible for the H&CW visa should be made permanent, i.e., should not have an automatic sunset date.

17. We recommend that the Government keep care workers on the SOL until the next SOL review is completed, when we will make a further recommendation.

18. The MAC would encourage DHSC and the DAs to work with local authorities to support the development of the market for individuals to work with a care agency to sponsor a specific care worker.

19. The Government could consider the introduction of a pilot umbrella scheme. Under the scheme, an umbrella body would be appointed to sponsor care workers from overseas and people who can show their level of need requires live-in care would be able to directly recruit from the umbrella body.

Chapter 3

1. Revealing Reality (forthcoming) Recruitment and retention in the Adult Social Care Sector: A qualitative study. ↩