‘We need everyone we can get’: The reality of life on the second frontline
Thousands of workers in the social care sector come from overseas – and their value during this crisis is undeniable. But if Priti Patel gets her way, and introduces devastating new immigration rules, the sector will be on its knees, writes Jon Bloomfield
The havoc wrought by the coronavirus in care homes and among the frail living at home across Italy, Spain and France is now sweeping across the social care sector in the UK. The government is currently unable to tell us the number of Covid-19 deaths in nursing and care homes. The most basic protective equipment – masks, aprons and gloves – remain in short supply. The dangers to staff grow exponentially as they do jobs where social distancing is physically impossible. As Donna, a domiciliary care manager in Birmingham admits, “staff are scared”. Suddenly, our society is confronted by the reality of life on the second frontline.
There are one and a half million people – predominantly women – working in adult social care doing arduous and harrowing jobs, usually for low pay and with a quarter on zero hours contracts. That raises the social question: do we value them properly? Then there is the migration question. Earlier this week Boris Johnson rightly highlighted the role of overseas nurses in saving his life. Well, it’s similar in the social care sector where a sixth of the workforce comes from overseas. They’re underpaid, overworked and over here. But if home secretary Priti Patel has her way, none will come here in future.
On 19 February, with her usual swagger, Priti Patel announced the government’s new points-based immigration system. It set out new rules and regulations for who can come to work in Britain. From 1 January 2021, entry will be dependent on a written job offer.
Eligible jobs have to be “skilled”, which is defined as jobs paying above a salary threshold of £25,600. In addition to the job offer and confirmed salary, the applicant must have a proven level of English. Taken together, this will enable the applicants to score the eligible 70 points deemed necessary to confirm entry to the UK. Patel confidently talked about the new system attracting “the brightest and the best” from across the world to the UK. The white paper made clear that “we are delivering on our manifesto commitment to reduce overall migration numbers. We will therefore end free movement and not implement a route for lower-skilled workers.”
The question of who will undertake vital but low-paid jobs at the lower end of the labour market is ignored. The white paper’s response is simply that “UK businesses will need to adapt and adjust to the end of free movement”. Employers organisations warned that the abrupt cessation of a flow of low-paid labour would have profound disruptive effects on key sectors of the economy, including construction, hospitality, agriculture and social care. The Nuffield Trust health thinktank warned that Patel’s proposals risked pushing the sector “over the edge”, yet in her media round Patel claimed that there are “eight and a half million economically inactive people” who could take up the slack, a figure largely composed of the long-term sick, carers, the early retired and students.
The blasé tone of the white paper, the press launch and the casual disregard for its likely consequences has been blown apart by the coronavirus. It has revealed more clearly the soft underbelly of society, where the crucial 3D work goes on: jobs that are dirty, difficult or dangerous. It is demanding work, necessary to the maintenance of a civilised society.
Nowhere is this clearer than in the field of social care. Just a month after Patel’s statement, social care staff were classed as key workers in the government’s list of critical employees whose children are prioritised for educational provision. Suddenly, the world has become aware of the second front line in the war on coronavirus, namely the one and a half million people working in adult social care, low paid, looking after elderly and disabled people in nursing and residential homes and offering domiciliary care to the frail and elderly living in their own homes. And a sixth of these are non-UK nationals, who would have been denied entry under Patel’s new rules.
Care staff have come from all over the world to work in the UK. Since 2004 many have come from eastern Europe. They are found in the care system all over Birmingham. Alicja has been in the city since 2005. She likes it here and now has settled status, the right to stay after Brexit. She’s a nurse looking after one floor of a 70-bed nursing home. She gives medication to patients three times a day; attends to their dressings; fixes consultations with the doctors; and sorts out all the necessary documentation. A trained nurse from Krakow with a decade of experience in Polish nursing homes and hospitals, she initially got a job in a Birmingham factory before an agency found her work as a carer.
“That was four shifts of 12 hours a day each week and usually a fifth on top, all on the minimum wage.” As her English improved she felt more confident about using her nursing skills and via an agency got a job in a nursing home, where she stayed for five years before moving to her present post. While there were lots of eastern Europeans and Africans in the care home, at the nursing home there are few, although she has a Romanian nurse colleague. When we speak there is clearly apprehension about coronavirus. “At the moment, lots of staff are off sick. We have simple masks, gloves and aprons but we’re hoping for the better ones soon.”
Joanna came over to the UK from Poland in 2007. She had jobs washing potatoes and in an engineering plant before taking the job as a care assistant at a nursing home with nearly 40 residents. “I do everything. I am a care assistant, I clean the apartments; I do the laundry. Sometimes I have to wash and toilet the residents. I have to lift them. I am properly trained to use the hoist. The job is hard especially when people are dying. Sometimes it is physically challenging when people are heavy; sometimes it is hard when people are suffering from Alzheimer’s or dementia and they can be aggressive as well and they hit you. They are ill and you just have to understand that.” She has a proper contract. She works 35 hours a week and then every other Sunday. Occasionally she is asked to do some extra hours and she is paid just a notch above minimum wage.
Both would have been barred entry under Patel’s new system, not just because of the salary level that they began on but also because of their poor initial English, which greatly improved by living and working here. It is similar with Gosia, who has now found her way through the care sector into a specialised role within the NHS. Gosia was one of the early influx from eastern Europe. A qualified nurse, she could get no work in Poland so she came over in May 2004 just a few days before Poland officially joined the EU. She got a job caring for the English husband of a Polish woman. When he died, the woman used her contacts to get Gosia a job as a kitchen assistant in a nursing home in Sutton Coldfield.
Gosia spoke no English but “I let my hands do the talking. My shelves in the kitchen were always shiny.” Gradually, as her English improved she worked her way through the ranks, first as a care assistant, then senior care assistant and on to being the home’s deputy manager. Her pay was low, but it was three times the comparable hourly rate she’d have earned in Poland. She was then poached by a nearby home with the offer to pay all the fees for her university degree in palliative care. She worked there for several years until she secured a position as an oncology and chemotherapy nurse specialist at the Queen Elizabeth University Hospital. She’s now on a senior grade, Band 6, nursing young adults.
I’m just juggling. People are scared. I’ve got carers going off because someone in their household has symptoms. We are following all the guidelines and trying to get protective equipment. Aprons are OK but masks are hard to come by. We’ve had none so far from the NHS
Migrants work in other parts of the social care sector too. Angelina came here from Gdansk in 2015. Her husband, a civil engineer, had got a job with Balfour Beatty and she followed with their two children. After voluntary work, she got a post as support worker for Sifa Fireside, the main centre and support hub for homeless people in Birmingham, and has since become its senior project officer.
Prior to the coronavirus pandemic the hub offered crucial material, social and health support and advice every day to around 160-180 homeless people, rough sleepers and asylum seekers. “They are a real mixture of ages with around a quarter from east Europe and abroad. But 98 per cent are men. We check and register new clients; link them to services – nurses, opticians, solicitors, detox, job clubs, benefits, mental health – as well as offering showers and food.”
Angelina feels that she has been making a real difference with her job. “I enjoy it very much. I am doing something valuable. We try to help all who come here, no matter who they are and where they come from.” These face-face services are on hold during the pandemic. The new government directives enable emergency accommodation for all in hostels and hotels while Sifa continues to provide telephone appointments for its clients and is working to ensure they are able to access what they need to stay safe and well throughout the crisis.
These are just a snapshot of the quarter of a million, non-British nationals who have come from either EU countries or further abroad to work in social care. Currently, there are one and a half million people working in the adult care sector in England, covering nursing homes for the most frail, residential homes and those providing community and home care services. At the same time, official data from Skills for Care indicates that there are a further 8 per cent of staff roles that are currently vacant. Furthermore, there is a very high rate of staff turnover in the sector: every year around 30 per cent of staff, approximately 440,000, change jobs, while overall almost a quarter of the workforce are employed on zero-hours contracts.
Across Greater Birmingham alone there are over 800 care homes, with nearly half of those caring for people with Alzheimer’s or dementia. In the West Midlands as a whole there are around 150,000 employed in social care, though with a slightly lower non-British staff proportion than the average. (The highest concentrations of overseas labour are found in London and the southeast.) From 2012-13 until 2018-19 the proportion of the adult social care workforce with a British nationality has held steady while over the same period the proportion of EU workers has risen, matched by a fall in the proportion of non-EU overseas workers. It remains to be seen whether this will change as the deadline for EU citizens to apply for UK immigration status through the EU Settlement Scheme approaches.
Across Birmingham and the West Midlands, the proportion of non-UK nationals working in the sector varies considerably between establishments. A large nursing home in south Birmingham reports that it has all UK staff. A smaller residential home with 20 staff says that it is “able to recruit locally”. It is similar with Extra Care, a charitable trust which provides housing villages and care support across Birmingham and the West Midlands to 4,500 people with an average age of 80. They pay their staff relatively well, £10 an hour; put people on permanent contracts; and provide extensive training – 85 per cent of their staff have National Vocational Qualification Level 2. This seems to make their jobs more attractive to UK nationals. Henrietta, one of their senior managers, states that “when they undertook their Brexit risk assessment, they found only 20 staff were EU nationals”.
In contrast, Donna is the care manager for a small domiciliary care business in south Birmingham. A quarter of her staff come from eastern Europe. All her staff are on zero-hours contracts. “It works both ways,” says Donna, “as lots of the staff have children and work to fit in with them. We recruit by word of mouth and give them proper training. The east Europeans are definitely good workers.”
Debbie Le Quesne speaks for more than 500 homeowners – mainly the small and medium businesses, not the big corporates – brought together in the West Midlands Care Association. “Non-UK staff are a feature of our industry. We’ve got everybody from around the world working for us. It’s a fluid workforce.”
All the indicators point to an expansion of the sector in the coming decades. In the West Midlands, the number of jobs has increased by 14,500 – almost 10 per cent – since 2012. Across the region the over-65s are predicted to grow by almost a third by 2035. The population aged 75 and over is forecast to grow at an even faster rate. As this is where the most intensive demand for services will occur, the expectation is that this will require an additional 75,000 jobs by 2035. As Debbie puts it: “We need everybody we can get in the care industry.”
Speaking to managers and workers in the preparation of this piece, the anxiety and fear over Covid-19 has been palpable. The sector sees what has been happening in Italy and Spain and knows the tsunami is about to hit here. When I speak with Donna, she’s snowed under with Covid-19 issues. “I’m just juggling. People are scared. I’ve got carers going off because someone in their household has symptoms. We are following all the guidelines and trying to get protective equipment. Aprons are OK but masks are hard to come by. We’ve had none so far from the NHS.” Debbie says that “a lot of homes are affected. We’re already down on staff by 25 per cent.” On personal protective equipment (PPE) “we hope to get the stuff soon. We are expecting it. But soon we know that our residents with the virus won’t be taken into hospital. We’ve got staff leaving their families and moving into the homes in order to look after people and make sure they are as safe as they can be.”
These are not low-skilled jobs. I don’t like the way these jobs are being described … the rhetoric the government is using. This is a morale issue. It affects our staff who were doing some of the most demanding of jobs. And that’s before the coronavirus epidemic hit
It’s the same across the country. Andrea manages a nursing home on the south coast. “PPE is the main issue. We’re OK with the standard stuff, although we are concerned we don’t have enough fluid repellent masks to follow the single use advice. But we don’t have guaranteed supplies of the full kit. We need the proper respiratory masks and visors for when our nurses are doing aerosol generating procedures which produce the droplets that carry the virus. It’ll be very dangerous for our staff if they don’t have it.” As well as their providers, they are asking the council for help and even looking on eBay.
Coronavirus strikes the frail and elderly hardest, above all others. The virus is tough and it spreads easily. Homes full of frail, older people susceptible to illness, living in close proximity to each other are the ideal venue for its speedy circulation. You can’t observe physical distancing rules while you are feeding residents and wiping bottoms. Social care staff are directly in harm’s way. They face this disease danger while also having to offer emotional and caring support to many frightened residents deprived of visits from their family and friends because of the contagion. As the virus moves to its peak, the impact in nursing and care homes as well as hospitals will inevitably grow, as it will amongst the tens of thousands of staff providing community care in peoples’ own homes.
Once this trauma has eased, it seems impossible that Priti Patel can proceed on schedule with her new immigration system. The Home Office has and will continue to have other priorities over the next few months. As with Brexit itself, a deferral of at least a year seems inevitable. As Debbie puts it: “There are already 122,000 care staff vacancies across England.” Meanwhile, Donna is concerned that with the new regulations her supply of staff will dry up. “God knows where we’ll get new staff from. So far, we’ve had no answers.” After such a crisis, cutting the country off from the source of a sixth of its current workforce from January 2021 would seem to be an act of sheer folly.
All the more so when there’s another proposition on the table that chimes with the wider public sentiments that the coronavirus crisis has revealed. The Cavendish Coalition is a group of 36 health and social care organisations working to ensure the social care system is properly staffed after the UK leaves the EU. It argues that it is crucial that the government takes all possible steps to safeguard the future supply of health and social care workers needed to continue delivering safe, high-quality care. It suggests that a future immigration system should assess skill levels based on “public service value”.
This would be a new way of evaluating work and its rewards, which could act as a crucial eligibility criteria, distinct from the cash threshold that the government proposes. The introduction of this element into the post-Brexit immigration system could ensure that post pandemic there are no additional unnecessary labour shortages in social care and other key sectors, while indicating that the UK government welcomes staff from across the world to do work that may be low paid but which offers public service value to the country. The government’s list of key workers whose children are currently prioritised for educational provision could serve as an initial eligibility starting point.
This change would also have profound significance for staff. As Andrea puts it: “These are not low-skilled jobs. I don’t like the way these jobs are being described … the rhetoric the government is using. This is a morale issue. It affects our staff who were doing some of the most demanding of jobs. And that’s before the coronavirus epidemic hit.”
It is already clear that coronavirus will bring about fundamental changes to UK politics. One part of this rethink will revolve around immigration. The value of both new and second generation migrants to the NHS and social care has been revealed ever more starkly by the pandemic. Of the proposed changes to the UK immigration system after Brexit, the nurse Alicja says: “It’s strange. I think us coming here has been good for this country. At the start, my English was not good enough to get a job as a nurse since I couldn’t have earned that money to be eligible. But we’re hard-working. It’s beneficial to the UK if we can come.”
The case for rethinking Patel’s new rules will be stronger with the Cavendish proposition offering a way forward that is both practical and ethical. Furthermore, the pandemic will surely force the wholesale revamp of the funding of social care promised by Boris Johnson on the steps on Downing Street in July 2019 but which successive governments have ducked. This in turn will focus attention on social care itself, which has long been the Cinderella of the health and social care system. Here, opinions are divided. Andrea sees the potential to give adult social care greater prominence and recognition during and after this crisis as the necessary complement to the NHS. “There’s an important recognition needed that care workers are playing an absolutely vital and highly skilled role in keeping vulnerable people safe.”
On the future, Debbie is more sceptical. “I’m sure that this pandemic is changing how people see NHS staff. But as for social care, I fear it’ll continue to be, ‘out of sight, out of mind’.” The outcome will be contested but what is certain is that events are profoundly changing the way the public, media and government see social care and the people who work within it.
Jon Bloomfield is the author of ‘Our City: Migrants and the Making of Modern Birmingham’, £18.99 (Unbound)
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