A public policy blind spot? The possible futures of the social care workforce

Long read: With last week’s Migration Advisory Committee report offering recommendations ahead of an immigration white paper, Nina Hemmings takes a closer look at what it all might mean for social care – drawing on key lessons from overseas.

Blog post

Published: 04/02/2020

Within 11 months from now, if pledges are kept, the government will have rewritten the terms on which workers from both European Economic Area (EEA) and non-EEA countries come to the UK. But the implications for the care workforce are as yet unknown.

Prime Minister Boris Johnson has suggested his government will publish an immigration white paper in March, setting out an ‘Australian-style’ points-based system that will come into effect in 2021. The Migration Advisory Committee (MAC) was tasked with investigating how this new system might work. Their report, published last week, offers recommendations and insights into what we might expect in the white paper.

A tiered debate

The UK already has a points-based system for non-EEA workers, which has been in place since 2008. But the MAC says this is points-based in name only – the Tier 2 visa is our general work visa and assesses ‘high-skilled’ workers (meaning jobs that require an undergraduate degree or higher). It works as more of a checklist of criteria, so, rather than being able to accrue points through different combinations of qualities, as in other countries, non-EEA workers must tick all the boxes to be allowed in: holding a job offer, having an occupation that generally requires a degree, a salary of £30,000 per year, and English language knowledge.

The MAC’s key recommendations are for the current Tier 2 visa to remain in place, but with a lower salary threshold of £25,600 that also covers “medium-skilled” jobs (requiring A-level equivalent qualifications and higher). If adopted, this checklist would be extended to EEA workers who hold a job offer. This isn’t necessarily the huge change that the government has claimed; it’s broadly similar to the system that we have now for ‘high-skilled’ workers from non-EEA countries. The Committee also recommends separate pilot visas with lower salary thresholds to attract workers to ‘remote’ areas of the UK, and active monitoring and evaluation of the new system.

But the MAC wasn’t asked to investigate a route for so-called ‘lower-skilled’ workers, and as academics have pointed out, this leaves a lot of unanswered questions for the social care workforce.

Left in the lurch?

As a sector grappling with significant workforce shortages and worryingly high turnover, it’s vital that any changes to immigration policy do not make matters worse. Social care is highly reliant on migrant labour: in total, an estimated 98,710 migrant workers joined the formal care workforce between 2009 and 2019. And the UK’s reliance is particularly high in regions like London, where two in five care worker jobs are filled by non-British workers. It’s important to note that migrants have contributed more to the sector than just substituting for British labour and plugging workforce gaps; many have brought much-needed flexibility and experience to their teams.

While a £25,600 salary threshold is lower than the £30,000 proposed by Theresa May’s government, the proposals are a serious cause for concern for the sector. The new Tier 2 visa could help with the recruitment of a select handful of social care workers currently in shortage, like nurses, managers and some senior care workers, if these jobs require the right qualifications and earn enough. But the majority of care staff fall within the so-called ‘lower-skilled’ bracket, outside the MAC’s investigative brief, and would fall foul of these requirements. Many care workers have few or no qualifications and limited training, and, with average pay of £16,200 per year, would come nowhere close to the lower salary threshold.

This means there is now a looming gap in immigration policy. How might the UK recruit much-needed migrant care workers?

MAC to the drawing board?

The Committee suggests that this gap could be filled by British workers if a sustainable funding model is found first, to improve pay. The sector is already facing an estimated £3.5 billion funding gap by the end of this Parliament, and increases in pay will likely widen that financial shortfall further. Nigel Edwards has commented on how rising wage bills will also have far-reaching implications for the overall costs of delivering services, which providers may pass on to people self-funding their care, many of whom are already struggling with catastrophic costs.

With no plan for comprehensive reform to the system in evidence and with the Conservative manifesto only pledging £1 billion per year to 2024/25, it is unlikely that sufficient funds to enable tangible pay rises will materialise in the short term. British workers alone are unlikely to fill projected gaps, so we are still likely to need international recruitment. The MAC suggests the government could address this need for ‘lower-skilled’ workers “through another route” such as the temporary route proposed in Theresa May’s immigration white paper, or via a sector-based scheme.

Other countries with long histories of immigration and experience using points-based systems such as Australia, New Zealand and Canada are heavily reliant on migrants to deliver long-term care, and have had to devise similar parallel routes to remedy workforce shortages. These countries have not fully solved their care workforce issues, but our government would be wise to learn from their experiences – both positive and negative – in considering its next steps. Failure to get this right could be the last straw for social care, and will impact on NHS capacity too.

Lessons from abroad

There are many reasons why the temporary route proposed in Theresa May’s immigration white paper could make problems in social care worse. Experience from other countries suggests the following:

1. The UK will need some form of visa route that can accommodate social care

The home secretary has suggested that there will be no ‘carve outs’ for migrant care workers specifically. But given the serious pressures facing social care, and the fact that other points-based countries have developed parallel schemes, it’s unwise to think the UK can make do without some form of visa route that can accommodate the social care staff we need.

Australia in particular continues to face challenges in ‘aged care’ similar to here – high turnover, unfilled vacancies, and skills shortages. It continues to rely heavily on temporary migration to help remedy workforce gaps, and Australia, New Zealand and Canada have all, out of necessity, trialled various parallel routes to the points-based system for ‘lower-skilled’ workers. Australia and Canada have experimented with specific ‘carve out’ schemes for care staff, to help providers fill vacancies (see below).

2. Avoid aggravating turnover and disrupting relationships

Australia has a heavy reliance on temporary care workers through its Pacific Labour and Northern Territory Designated Area Migration Agreement (DAMA) schemes. It has also resorted to the use of holidaymaker, student and partner visas to help plug gaps in frontline care. Evidence presented to Australia’s Royal Commission on aged care warns that this makes long-term workforce planning difficult, as a pool of workers who are already transient are locked into “indefinite temporariness”.

UK employers are already struggling to develop a long-term, stable care workforce, and a temporary visa capped at one year may put services that are already fragmented at greater risk. The motivations of migrants vary: some choose to use social care as a stepping stone (e.g. to requalify as a nurse) or to build on previous experience. But it will be difficult to train and get experience if workers are on a visa that only lasts one year.

It can take a long time for a family to find a home care worker for their relative, for people to get to know each other and to establish a routine that works. A ‘cooling-off’ period that forces workers to leave the country for 12 months is likely to mean less control and everyday autonomy for workers and the people they support.

The government could consider a scheme modelled on New Zealand’s Essential Skills visa – which is granted for 12 months, but can be renewed for up to three consecutive years, at which point a 12-month ‘cooling-off’ period applies. Almost a third of aged care assistants who were on this visa in 2008 were still on it in 2012. The UK’s proposal of ‘one year on, one year off’ is more austere than this and could potentially drive applicants away to more prosperous and flexible opportunities abroad.

3. More positive steps to encourage migration

Offering routes to permanent residency could be one way to attract workers in the same manner as Canada’s Home Support Worker pilot (where people must show two years’ full-time employment) and Australia’s DAMA scheme (three years). It’s notable that the Canadian government’s rhetoric is very different from that of the UK: in June the Canadian Minister of Immigration spoke of improving “the lives of caregivers and their families who come from around the world to care for our loved ones”. The UK government should consider trade-offs between the sustainability of these schemes and the continuity they could offer.

Many EEA migrants follow their spouse to the UK and take up social care work. Allowing spousal visas would put us on more equal footing with other countries – such as Canada which offers open work or study permits for immediate family, or New Zealand which allows in dependants.

Lastly, Australia is embracing the recruitment of bilingual care staff (who may be less proficient in English), in recognition that the country’s diverse, multicultural communities are ageing and require staff with specialist skills.

A sector-specific scheme?

An alternative to the above is the creation of a sector-specific scheme that could cover a variety of different jobs in social care. The Conservative Party manifesto pledged an ‘NHS visa’ to fast-track aspiring workers into the NHS. Details will follow in the white paper, but if introduced it is likely to make applicants exempt from some of the tougher aspects of the immigration system. The health and social care workforces are strongly interdependent, and the health sector has a “gravitational pull” on social care staff. With no parallel promised for social care, some applicants might be lured away via the NHS visa.

Developments abroad indicate what arrangements might be possible. The government may wish to follow New Zealand’s progress in reforming its immigration system, where their top priority in 2020 is negotiating an agreement with the residential care sector. As part of this, New Zealand may offer more generous visa terms (for example, longer stay) for a range of key jobs including personal care assistants and care workers, in exchange for plans to be developed by employers to boost the domestic workforce.

This is made easier by the New Zealand government’s willingness to improve terms and conditions, for example providing significant additional funding to pay care workers for time spent travelling between clients. It would be difficult for the UK government and providers to negotiate such an arrangement here, as improvements in pay, terms and conditions will largely depend on additional funding that has not been forthcoming.

The social care sector is very resilient (as the last 24 years in particular can testify), but with insufficient funding, no People Plan for social care, and a more restrictive immigration system looming, the sector is about to be truly tested. The Budget and multi-year Spending Review represent two opportunities on the horizon for the government to act before the new immigration system is introduced.

Unlike other sectors such as retail, agriculture or hospitality, social care revolves around relationships. Julia Unwin has commented that relationships are often the blind spot in public policy, and as the white paper is developed, it’s crucial that the government coordinates policymaking between the Home Office, Department of Health and Social Care, and the Treasury.

Suggested citation

Hemmings N (2020) “A public policy blind spot? The possible futures of the social care workforce”, Nuffield Trust comment.