WF 13

Ymchwiliad i gynaliadwyedd y gweithlu iechyd a gofal cymdeithasol

Inquiry into the sustainability of the health and social care workforce

Ymateb gan: UNSAIN

Response from: UNISON



UNISON Cymru/Wales response: Inquiry into the sustainability of the health and social care workforce


1.1 UNISON Cymru/Wales is Wales’ largest public sector trade union. UNISON has 100,000 members working in public services across Wales. We welcome the opportunity to feed into the National Assembly Wales priorities for the Health, Social Care and Sport Committee.


1.2 We represent full-time and part-time staff who provide public services, although they may be employed in both the public and private sectors.


1.3 UNISON’s health care members are from all non-medical occupational groups including: nurses and health care assistants; midwives; health visitors; administrative, finance and HR staff; ambulance staff including paramedics, technicians, control room and maintenance staff, therapy and healthcare science staff; estates and housekeeping staff; technicians and maintenance staff; commissioning staff; allied health professionals;  scientific staff; healthcare managers.


1.4 UNISON’s social care members include social workers and social care workers working across residential, non-residential and domiciliary care services. Our members undertake roles in early years and childcare; mental healthcare; care for older people; disabled people’s care; caring for people with learning disabilities.

Is there a clear understanding of the Welsh Government’s vision for health and care services and the workforce needed to deliver this?

2.1 The principles of the NHS in Wales are clear. UNISON welcomes the ongoing commitment of the Welsh Government to keep the Welsh NHS free from privatisation and marketisation.


2.2 However, there are fundamental questions about what the NHS should be expected to deliver. Is the NHS sustainable in its’ current state? Can we afford to sustain all of the services that are currently delivered by the NHS?


2.3 More widely, the direction of travel is towards the integration of health and social care and there is a greater emphasis on health services being delivered in the community. This is only plausible if services within communities are adequately funded.


2.4 Taking homecare services as an example, we have regularly seen homecare services being outsourced to the private sector. This has not increased the quality of care for all patients. It has created an unregulated sector where there is little incentive for employers to invest in training, a high reliance on casual and zero hour contracts, and poor terms and conditions, including low pay.


2.5 Whilst we believe the integration of health and social care would be beneficial, there is a clear need to address the disparity between the culture in the NHS and the culture in social care. In particular, ending the two-tier workforce and raising the generally inferior social care employment conditions should be a priority. In a social care setting, it is often those responsible for providing direct care who experience the lowest pay – this clearly presents problems with regards to recruitment and retention.


2.6 UNISON recommends that one approach the committee could consider is for the Welsh Government to enforce and Ethical Care Charter across the sector in order to unify the culture across the NHS and social care.


2.7 The Charter would place the needs of care users, dignity of patients and investment in the care workforce above profit-making considerations. This wouldn’t “short-change” clients and would allow for the recruitment and retention of a more stable workforce through good working conditions, sustainable pay and high training levels across the board.


2.8 Furthermore, it is clear the marketisation of social care has failed. Any moves to outsource social care, in any form, should be strongly opposed. Care services need to be delivered directly by the local authority. The terms and conditions of social care workers employed directly by a local authority are far more favourable than their counterparts in the third or private sector. It is worth noting that where staff are employed directly by a local authority, staff turnover is far lower.   


2.9 The Welsh Government’s vision for both health and social care should include a concerted effort to bring outsourced care services back under public control.


How well equipped is the workforce to meet future health and care needs?

3.1 The Safe Nurse Staffing Levels legislation, and its ratio of no more than seven patients in Wales to one nurse, is very positive.


3.2 UNISON wants to see safe minimum staffing levels extended to all staff groups in all settings and advocate that this is a key element of ensuring that the workforce is able to meet future health and care needs.


3.3 It is a concern that some health boards have reduced ward cleaning standards to save money on the appointment of the appropriate level of domestic and housekeeping staff.


3.4 The amount spent on agency staff in the NHS is unacceptable and is an indication of poor workforce planning. UNISON believes there should be caps on fees agencies can charge and greater use of existing staff on overtime at enhanced rates.


3.5 The key to cutting agency costs however is to fill vacancies and reduce sickness across the service. Making bank rates of pay more competitive would encourage staff to use the bank rather than going to agencies for additional shifts.


3.6 Welsh Government has funded additional nurse training places, which is a positive step, but the benefits will not be realised for three years.


3.7 One solution could be the reinstatement and extension of in-service, fast-track training of healthcare support workers to attain professional qualifications whilst continuing to receive full salary. This would provide an additional pool of staff and a preferable option to agencies.


3.8 Access to professional development must be a priority in order to ensure the workforce is well equipped. As a part of this, a meaningful personal development review process needs to be in place. UNISON is aware of many scenarios where members of NHS Wales staff have not undergone a personal development review for a significant period and this is unacceptable. Without a robust development review process in place, it will be impossible to establish whether the workforce is truly equipped to meet future health and care needs.


3.9 It is well documented that the NHS workforce is an aging workforce. Much needs to be done to ensure that working for the NHS is an attractive option for young people as the current situation is unsustainable in the long term.


3.10      It is essential that workforce succession planning builds in the use of long-standing and experienced members of the workforce, but there must be a concerted focus on bringing new people into the workforce.


3.11      In addition, it must be noted that there are a significant number of EU workers from outside of the UK who work for the NHS in Wales. It is essential that these workers are protected post-Brexit and these protections must be offered as soon as possible. The vote to leave the EU could prove to be a hugely destabilising factor for the NHS Wales workforce and efforts must be made to safeguard against this.


3.12      The issue of an aging population is particularly relevant for both health and social care. The issue of staff turnover is clear concern in social care settings – including both home and residential care. As the population ages and the focus is more heavily on care in the community, demand on these services is inevitably going to grow.


3.13      There is a clear lack of funding available for domiciliary and residential care. Without appropriate funding it will be impossible to ensure the workforce is able to meet future demand. More money must be made available for the sector.


3.14      A series of prominent providers in Wales have said highlighted that there is no slack built into the system and they simply do not have enough money to meet the terms of their care contracts and the introduction of the national living wage.


3.15      Local authorities have refused to release additional funding on the basis that the care contracts have already been awarded. Two third sector companies have reduced sick pay benefits as a direct result of the national living wage.


3.16      It is a scandal that low paid care workers are caught in the middle and their conditions attacked in this manner. In addition to sick pay, payment for shift enhancements and weekend working is under threat. Gains made on the basis rate of pay are lost elsewhere.


3.17      Furthermore, there is no clear career structure for the social care workforce. UNISON remains of the view that healthcare workers across the board should be registered. A professional register would allow the healthcare support role to be underpinned by professional standards, clear role definitions and expectations, stronger links to qualifications, and a more defined career structure. We believe that this, in turn, would allow for the greater fluidity of workers between NHS and local authority and so work towards the Welsh Government’s ‘one public service Wales’ ethos.

What are the factors that influence recruitment and retention of staff across Wales?

4.1 Decent levels of pay and fair terms and conditions of employment are obviously key factors that influence recruitment and retention of staff in Wales. Workers delivering essential services need to be adequately rewarded for the important work they do.


4.2 UNISON is supportive of degree based nursing. Wales took a decision to move nursing towards an all degree profession in 2004, this was followed in 2010 by the Nursing and Midwifery Council taking this approach across the UK.  There is no doubt that there is a need for degree level thinking when caring for complex cases and in responding to rapidly changing conditions.  This coupled with the pace of science requires staff to be able to practise within ever-changing environments.


4.3 However as important we need to maintain a wide entry route into nursing and midwifery across the country.  Wales has a rich history of recruiting prospective staff from some of the most socially deprived communities.  If they aspire to enter into professional training we need to make it easier for them to gain accreditation of their prior learning, this would enable them to be credited for their learning and not automatically have to start a programme of learning at the beginning.  This approach would be benefit them and the public purse as it could see them graduating and entering the work environment quicker.


4.4 We must ensure that those staff who wish to remain in their role - loving their part in delivering compassionate care – are not treated as poor cousins. They should have access to learning and development with comparable career pathways as those who go onto train as nurses, or occupational therapists. 


4.5 The need for Masters level thinking in particular in specialist and senior roles also plays an important part in the delivery of care.  To achieve this support staff need access to financial support and time to learn and complete studies.


4.6 Within the NHS there needs to be a better utilisation of band 3 and 4 roles. This would allow a better skills mix across the sector and allow for more suitable delegation. It is important that staff are operating appropriately within their job band in order for the NHS to run as efficiently as possible. In addition, people should be paid appropriately for the work they undertake. A better use of these bands 3 and 4 would allow for a more efficient distribution of work as well as a clearer career pathway for those working on lower bands. In addition, the workforce is being deskilled if opportunities are not provided for progression.


4.7 Wales is a low income nation. People should not be expected to pay for their own training to enable them to work in the health and social care sector. We welcome the Welsh Government’s commitment to continue to fund bursaries for nurses and urge this practice to keep on. However, whilst nursing and midwifery is an extremely important element of the healthcare workforce, it is only one element.


4.8 The success of health and social care across Wales depends on the entire workforce and so it is essential there is access to training and development opportunities across the board. Arguably, those in or working towards lower paid roles are in greater need of financial aid.


4.9 UNISON is seeking the formal registration of care workers, paid for by the Welsh Government. We believe this would provide an opportunity to ensure care workers have professional support and consistency. A professional body would provide the opportunity to produce role descriptions and expectations across the care sector as a whole, as well as professional standards.


4.10      This is a key issue when we consider care workers who work in a social care environment, particularly in a home care setting. The expectations on staff employed within a homecare environment, compared to those who work for the NHS, can be vastly different – even where both of those provisions are delivered in the community.


4.11      There are countless situations where homecare workers, who often have limited training and receive minimal pay, are expected to undertake involved levels of personal care which may be inappropriate for their role, but there is no benchmarking mechanism to allow us to measure this effectively. There is a vast difference between this environment and the experiences of NHS employed care workers, and this is reflected in the retention rates of the workforce.


4.12      There is also much greater clarity around the boundaries of different job roles when we compare the NHS and homecare. There appears to be a much clearer career path available to those who work for publically delivered public services – including the NHS and local authorities – compared to those who have been outsourced. For many homecare workers, there is no apparent career path at all. In addition, workers who are employed directly by local authorities or the NHS have a better sense of how they contribute to the overall care service – they feel a greater sense of empowerment and confidence when undertaking their roles. Many homecare workers in the third and private sector are isolated from the wider workforce and this has an impact on morale and confidence.


4.13      In fact, for many homecare workers in particular, there is a sense of stigma attached to their work. Clearly, the work homecarers undertake is extremely valuable, but is not recognised by the employment standards they experience. How can we realistically expect people to take on such high levels of responsibility for such low employment standards?    


4.14      The poor state of homecare is well documented. In order for there to be a true integration of health and social care services there needs to be parity across the sector both in a cultural and practical sense. We believe that this will have a positive influence on the recruitment and retention of care staff across the board. Without a wholehearted commitment to full integration, we are likely to see more problems than solutions. UNISON remains committed to working towards a one-public service Wales and view this as a positive approach in ensuring the long term sustainability of the health and social care workforce.


4.15      Quality of care must always factor as a higher priority than financial savings. The workforce is at the heart of ensuring quality services and they must be appropriately rewarded for the essential work they undertake. Furthermore, it is imperative that the entire workforce is recognised for the value they provide – the safe and effective delivery of healthcare in Wales is very much a team effort and each member of the healthcare workforce contributes to that team work.



5.1 UNISON Cymru/Wales welcomes the opportunity to feed into the inquiry into the sustainability of the health and social care workforce.


5.2 We would welcome the opportunity to feed in further detail and evidence to this inquiry as the committee deems fit.