What does Brexit mean for the UK social care workforce? Perspectives from the recruitment and retention frontline.

The UK's departure from the European Union (Brexit) is likely to result in greater immigration and employment restrictions on European Union/European Economic Area (EU/EEA) nationals within the United Kingdom. EU/EEA citizens constitute a significant proportion of the current social care workforce. Research evaluating the impact of Brexit on social care has highlighted potentially severe future workforce shortfalls, but has not engaged in detail with the experiences of social care personnel involved in day-to-day recruitment and retention activities. This article explores how social care managers evaluate Brexit's prospects for future workforce sustainability, through the prism of their organisation's workforce requirements. This qualitative study incorporated in-depth semi-structured interviews and questionnaire surveys with domiciliary and residential care managers. Data collection focused on an urban conurbation in south-west England, with demographic characteristics likely to make post-Brexit recruitment and retention in social care particularly challenging. A key finding is that, irrespective of whether they employ EU/EEA workers or not, research participants have deep concerns about Brexit's potential impact on the social care labour market. These include apprehensions about future restrictions on hiring EU/EEA nurses, as well as fears about increased competition for care staff and their organisation's future financial viability. This article amplifies the voices of managers as an under-researched group, bringing their perspectives on Brexit to bear on wider debates on social care workforce sustainability.

What is known about this topic

European Union/European Economic Area (EU/EEA) citizens make up a significant proportion of the UK’s social care workforce.

The UK’s departure from the EU (Brexit) may result in greater immigration restrictions on EU/EEA workers.

Potentially serious workforce shortfalls could result from Brexit, exacerbating current recruitment and retention problems in social care.

What this paper adds

A detailed, qualitative investigation of social care managers’ perspectives on Brexit.

Insight into their varied concerns about Brexit’s impact, whether their organisations rely on EU/EEA workers or not.

Analysis of how these concerns reflect the labour requirements and conditions of their organisations.

INTRODUCTION

The narrow victory for “leave” in the referendum on Britain's membership of the European Union (EU) in June 2016 produced much commentary about the impact of Britain's exit from the EU (Brexit) on the health and social care workforce. As both sectors’ reliance on skilled and unskilled migrant labour from the EU and European Economic Area (EEA) has grown over the past decade (Independent Age, 2016), concern has been raised about the impact of any future immigration restrictions after Brexit. The health and social care workforce shortfalls resulting from various possible post‐Brexit immigration policies have been statistically modelled (Independent Age, 2016; Marangozov, Williams, & Bevan, 2016), and the dramatic decline in UK registration of nurses from the EU over the past 12 months has received much media exposure (see, e.g., Campbell, 2017, Triggle, 2017). Yet the perspectives on Brexit among social care personnel at the frontline of recruiting and retaining care staff have not yet been researched in detail (c.f. Moriarty, Manthorpe, & Harris, 2018).

This article deepens understanding of how social care managers in the UK perceive Brexit's impact on future staff recruitment and retention within their organisations. Based on research conducted across residential and domiciliary social care organisations in the south‐west of England, this study explores the perspectives on Brexit among social care personnel with detailed working knowledge of social care labour markets, who are directly involved on a day‐to‐day basis with managing and recruiting care staff for their services.

THE SOCIAL CARE WORKFORCE IN ENGLAND

In England, social care is characterised by a decentralised quasi‐market model of provision (Glendinning, 2012). Service users’ eligibility for state support in financing care is determined through tight means tested criteria (Tanner, Ward, & Ray, 2017). The impact of central government austerity measures since 2010 has resulted in reductions to state funding for social care, creating financial difficulties for organisations that rely heavily on publicly funded contracts (CQC, 2016; Kings Fund, 2016; Local Government Association, 2016). Most social care is funded privately from the income and assets of individual service users (Glendinning, 2012; Mayhew, Smith, & O'Leary, 2017).

The majority of the 1.58 million jobs that make up the social care workforce in England are not professionally regulated and entail the provision of front line direct care (Skills for Care, 2017a). Professionally regulated jobs (e.g., nurses, social workers) account for only 5% of the total workforce and supervisory and management roles only 7% (Skills for Care, 2017a). The Care Quality Commission (CQC 2016, p. 58) recently estimated that “non‐British EU workers made up 7% of the adult social care workforce in 2015/16—equating to around 90,000 jobs.”

Demand for social care services in England is growing exponentially, yet recruitment and retention are long‐term endemic problems. Across the United Kingdom as a whole, turnover rates in non‐professionally regulated direct care roles increased from 28.4% in 2012%–2013% to 33.8% in 2016–2017 (Skills for Care, 2017a) with vacancy rates hovering around 7% (Skills for Care, 2017a). Turnover is higher among lower paid and less secure jobs, in particular “zero hours” employment contracts, in which the employee is not guaranteed a minimum number of working hours and may be asked to change their working hours regularly and at short notice (Skills for Care, 2017a). These patterns persist despite the implementation of the National Living Wage which has increased wages in the lowest paid roles, indicating that “employers are struggling to find, recruit and retain suitable people to the sector” (ibid, p. 5). Increased wages not only incentivise recruitment into the workforce but also heighten financial pressures as staff costs represent a high proportion of total costs. Recent analysis by the CQC suggests that “staff costs are around 60% of total costs in residential care homes, and around 80% in domiciliary care” (CQC, 2016, p. 58). The limits on available funding constrain the ability of many employers to offer wages at an attractive level, and low pay in social care remains widespread (Hussein, 2017).

The UK position is mirrored across the economically developed world to a greater or lesser extent. Demand for care and support for managing long‐term conditions linked with ageing populations is on the rise, while waged care workers and informal care providers (such as family carers) are in increasingly short supply (Gammage & Stevanovic, 2018; Hussein & Manthorpe, 2005). In much of the developed world, migrant populations bolster the overall supply of care workers (Glinos, 2015; WHO, 2017; Yeates, 2012). Problems with recruitment and retention of care workers in long‐term care settings have been observed internationally and linked to a common set of issues, including low pay and poor working conditions, low public esteem for the work, and lack of opportunities for career advancement (Chenoweth & Lapkin, 2018; Estabrooks, Squires, Carleton, Cummings, & Norton, 2015; Hussein & Manthorpe, 2005; Razavi & Staab, 2010).

SOCIAL CARE AND BREXIT

The UK/EU referendum and its aftermath focused public attention on EU/EEA immigration to the United Kingdom and amplified calls for its future restriction after Brexit. From the 2016 referendum until the time of writing, the UK government and the main opposition Labour party have remained committed to ending Freedom of Movement, a key principle of EU law which enshrines the right of EU citizens to live and work anywhere within EU member states, free from discrimination based on their nationality. The UK government has recently reaffirmed its commitment to a post‐Brexit immigration system which ends preferential treatment of EU/EEA citizens (BBC, 2018).

Health and social care professional bodies have drawn attention to the challenges that more restrictive immigration policies pose (The Cavendish Coalition, 2017; The Royal College of Nursing, 2017). Statistical research conducted since the referendum has sought to quantify national and regional concentrations of EU/EEA workers in NHS trusts and social care respectively, examining the implications of Brexit for the sector's future workforce. Drawing on large datasets, Marangozov et  al show that NHS Trusts that rely significantly on EU/EEA nurses while serving a rapidly ageing population will be hardest hit by labour shortages, adding that their projections do not take account of “the additional demand for nurses from the social care sector” (2016, p. 12). A report by Independent Age (2016) evidences the sharp growth in numbers of EU/EEA workers within social care over the past 8 years, relative to non‐EU/EEA workers. It estimates future shortfalls of between a quarter of a million and over a million social care workers, depending on the severity of post‐Brexit policies on immigration. Recent qualitative research on perceptions of Brexit from a wide range of social care stakeholders suggests that views of its potential impact vary by region (Moriarty et al, 2018).

AIM

Our research sought to extend the insights of the studies discussed above. We aimed firstly to expand understanding of how “front line” social care personnel involved with recruitment and retention evaluated Brexit's likely impact. Secondly, we sought to examine how this group's perspectives related to their organisations’ requirements for different types of direct care staff (e.g., nurses or care workers, fixed hours or zero hours workers). Finally, we wanted to explore whether personnel that actively recruited care staff from the EU/EEA had greater concerns about Brexit than those that did not.

METHODOLOGY

This was an exploratory, qualitative study (Gray 2014, Hennink, Hutter, & Baily, 2011), which investigated social care managers’ perspectives of the impact of Brexit on their organisation's workforce sustainability. “Social care managers” here refers to purposefully selected research participants who had day‐to‐day responsibility for co‐ordinating, managing, and recruiting care staff within either residential or domiciliary care services. Participants’ formal job titles and roles varied (c.f. Orellana, Manthorpe, & Moriarty, 2017), including registered manager (as defined by CQC, 2015), CEO, director, and human resource manager. The research combined semi‐structured interviews and a questionnaire survey with participants targeted within a specific geographic location in the United Kingdom.

Research location

The choice of research site was methodologically significant, as concentrations of EU/EEA citizens within the UK social care workforce are highly regionally varied (e.g., north‐east—1.4%, London and the south‐east—approx. 10%) (Independent Age, 2016, p.13). Our strategy was to choose a location with the potential to reveal most markedly managers’ concerns around future workforce sustainability. Data were gathered in and around the conurbation of Bournemouth in south‐west England. The social care sector in this area relies on EU/EEA workers to a significant extent, with EU/EEA citizens constituting 17% of the total social care workforce in the Bournemouth area; a significantly higher proportion than that of south‐west England as a whole (8%). At the same time, a larger than average ageing population in this locality (31% of Dorset population being 65 and over in 2016, against national average of 18%) places greater demands on social care services at a time when local authorities continue to reduce budgets (ONS, 2017, see also Skills for Care, 2017b).

Data collection and analysis

Research participants were recruited through a purposive sampling strategy targeting senior personnel within domiciliary and residential social care services in the research location (excluding day care and other social care services). At the outset of the study, a local social care partnership and training hub in Dorset disseminated information to managers in the research location about our research project. Researcher 1 (RR) subsequently emailed an invitation to participate in an interview to 20 managers of domiciliary and residential care services, half of whom had responded with interest to the social care partnership notification. The other half were randomly selected from an adult care services directory for the region. Interviews of between 30‐ and 60‐min duration were carried out between April and August 2017. Questionnaires were distributed at an annual conference for adult social care organisations and practitioners based in the south‐west region in June 2017. This event comprised 170 delegates, of which it was estimated 40 would fit our definition of managers above; therefore, 40 questionnaires were distributed.

Both the interviews and questionnaire were designed to meet two aims: first, to build a profile of each research participant's organisation, in particular its size (numbers of staff and clients), type of service (residential or domiciliary), business model (ratio of self‐funded to contracted services), and proportion of EU/EEA citizens employed in direct care, and second, to explore participants’ perceptions of Brexit's impact on their organisation's workforce sustainability. The techniques were also designed to complement each other and meet accepted validity and reliability criteria for qualitative research (Morse, 2015). Semi‐structured interviews, though conducted with a standard set of guide questions for consistency and reliability, allowed participants space to expand on points they deemed most significant, thereby enabling the researchers detailed insights into their experiences (Hennink, et al., 2011). The questionnaire aimed to widen the number of participants and range of organisations in the study, enabling greater breadth and scope for data triangulation (Flick, 2004), in particular cross‐case comparison and negative case analysis (Morse, 2015).

The questionnaire was designed by one researcher (RR) and reviewed by the other (LAF). It consisted of 12 questions on organisational profile, followed by several questions exploring respondents’ current experiences of recruitment and retention within their organisation, alongside their view of Brexit's future impact on their ability to hire care staff, pay them competitive wages, and provide them sufficient hours. Respondents answered each of these questions by indicating one ranking on a 5‐point Likert scale. Scales were constructed to allow for a wide range of possible responses, from (1) “no difficulties/no impact” through (3) “some difficulties/some impact” to (5) “most severe difficulties/severe impact,” in addition to a “not applicable” option where appropriate. Respondents were invited to provide a brief explanation for the rank they gave.

All interviews were transcribed verbatim. Thematic analysis of the data proceeded in stages. In the first phase, one researcher (RR) repeatedly read and coded the interview transcripts in order to identify emergent categories. These were then tested and refined in phase 2 through a detailed cross‐case comparison with the survey data. In Phase 3, both researchers discussed and reached agreement on the interpretation of the findings. To ensure validity, interviewed participants were invited to comment on the accuracy of the data and findings privately and at two public presentations of the research project in autumn 2017. No amendments were requested. The research was approved by Bournemouth University's Social Sciences and Humanities Research Ethics panel in February 2017.

FINDINGS

A total of five semi‐structured interviews were conducted, and 17 surveys were completed and returned anonymously. Three interviewees and eight survey respondents were managers in domiciliary care organisations (D1–D11), while two interviewees and nine survey respondents were managers in residential care homes (R1–R11). This interview and survey data revealed that the vast majority of research participants had significant levels of concern about Brexit's impact on workforce sustainability. These apprehensions were shaped by managers’ current experiences of recruiting and retaining the type of care staff their organisation required. Domiciliary and residential care managers in this study hired EU/EEA workers in different ways and had somewhat contrasting concerns about how Brexit would affect their staffing arrangements in future. In the following discussion, “care staff” includes all nursing and direct care worker roles, while “care worker” refers to non‐professionally regulated direct care roles, including job titles such as “senior care worker/assistant” and “care worker/assistant.”

Research participants and their organisations were diverse in terms of size, staff base, and area of operation. Eight domiciliary care providers operated regionally and three nationally. The smallest of these had between 11 and 30 staff, the largest around 3,000, with the average (mean) employing 31–60 staff. All residential care providers operated regionally only, except one which operated nationally. The smallest of these had between 31 and 60 staff, the largest 1,500. Eight of the 11 domiciliary care managers hired a proportion of their staff on zero hours contracts (ranging from 20%–100%). Only one of 11 residential care providers in our study hired a small proportion of its care staff on zero hour contracts.

The percentage of client base served through contracts with local authorities or the NHS varied from 95% to none among domiciliary care providers in the study, and 67%–7% among residential care providers. The majority (total 15) of managers in the study felt that such contracts were set at rates which were insufficient and ultimately not sustainable for their businesses (although one negative case is discussed below). Referring to one local authority, a domiciliary care manager remarked that “what they are asking us to deliver from a care point of view is not deliverable” (D1). A residential care employer claimed that the main reason social care businesses in the area failed was because local authorities were “simply not paying sufficient to sustain their service, or sustain them” (R2).

CURRENT ISSUES WITH RECRUITMENT AND RETENTION

Managers of all social care organisations in our study reported current difficulties with workforce recruitment, retention, vacancy rates, and staff turnover, reflecting wider national and regional trends (Skills for Care, 2017a, 2017b ). Domiciliary care managers were experiencing these difficulties most acutely. Seven of eight questionnaire respondents rated their difficulties with recruiting care staff as “most severe” or “severe.” Five had annual staff turnover of between 20% and 40%. Interviewed domiciliary care providers emphasised the heavy costs in time and resources expended on managing high staff turnover, recruitment, and training of new inexperienced staff. One remarked that “recruitment is always a challenge” adding that her organisation was “desperate for employees” (D1). Another said, “above all the odds you have to keep your staff happy, because…once somebody goes, it's hard to recruit [a replacement]” (D2). There was one negative case of a domiciliary care manager reporting no problems with retention of care workers. Exceptionally for domiciliary care in this study, this manager's staff were all employed on fixed (instead of zero) hour contracts, paid a basic hourly rate significantly above National Living Wage, which was earned for total hours worked (i.e., including travel time) rather than per client visit, and uplifted for evening and weekend work. These relatively attractive pay and conditions were made financially possible due to the higher rates this manager's organisation charged the local authority for caring for its “overflow clients”, whose needs could not be met within standard contracts with other domiciliary care providers. Nonetheless, even this manager reported that recruiting new care workers to expand her business was challenging.

Residential care managers in our study reported moderate difficulties with recruitment and retention, with only two of nine questionnaire respondents rating their difficulties with recruiting care staff as “severe.” Annual staff turnover ranged from 10% to 30% for these providers. However, recruiting nurses posed particular challenges for this group. As one manager remarked, recruitment in her organisation was “definitely getting harder, for nurses in particular…advertising for someone is definitely taking longer” (R1).

EU/EEA WORKERS AND RECRUITMENT STRATEGIES

The proportion of total care workforce that were EU/EEA citizens varied considerably across the organisations managed by research participants, from 0%–50% for domiciliary care to 0%–40% for residential care. Taken as a mean average across all organisations in the study, these proportions aligned with Skills for Care data indicating that 17% of the social care workforce in the Bournemouth area are EU/EEA citizens (Skills for Care, 2017c).

However, the presence of EU/EEA citizens in an organisation's staff did not imply active international recruitment. In this study, only the managers of residential care services with a nursing arm advertised and hired from outside the United Kingdom in order to fill roles for qualified nurses (NMC, n.d.). One of these provided local accommodation for international nurses joining his staff. In contrast, care workers across both types of service were recruited exclusively from the nearby resident population, through advertisements in local press, job websites, and word of mouth. Such practices resulted in the hiring of EU/EEA citizens already settled in the area. Managers’ current recruitment practices had an important bearing on how they evaluated Brexit's impact on their future workforce challenges, as explored below.

LOOKING TO THE FUTURE: BREXIT'S PROSPECTS

As previously discussed, calls to curb EU/EEA immigration have gained traction since the referendum result of 2016 and the two largest UK political parties are both committed to achieving this. Given the UK government's current commitment to end their preferential status under the Freedom of Movement rules, it is likely that EU/EEA citizens not already settled in the United Kingdom prior to Brexit will be subject to the same immigration restrictions as currently apply to non‐EU/EEA workers. We asked research participants to consider the impact of such a scenario on their organisation in terms of future recruitment and retention of nurses and care workers, and on their ability to competitively pay and provide sufficient hours to both categories of worker.

The vast majority of participants viewed Brexit as likely to have a negative effect on their workforce sustainability. Residential care managers were most concerned about any curtailment to their ability to recruit EU/EEA nurses, with five of nine anticipating the “most severe” or “severe” difficulties in hiring nurses and care workers from the EU. For example, one participant remarked, “my fears for Brexit are that if they are going to make these workers harder to bring in, then I think very quickly these services are going to go on a downward spiral” (R2). Hiring internationally from outside the EU/EEA was highly costly, bureaucratic, and slow, he added.

It’s literally like, head in my hands, you know. If the process is anything like Tier 2 [UK work visa arrangements for non‐EU/EEA citizens], it’s a nightmare (R2)

A further three anticipated the “most severe” or “severe” problems with paying nurses and care workers competitively. Others anticipated moderate difficulties, with only one predicting no problems resulting from this scenario.

By contrast, domiciliary care managers anticipated that Brexit would bear most heavily on their ability to pay care workers competitively, with five of the eight survey respondents anticipating “most severe” or “severe” difficulties in this area. Two respondents felt the impact on recruitment of care workers would be “severe.” These managers were acutely aware that difficult working conditions within domiciliary care, such as the requirement that workers use their own vehicles to work to demanding home visit schedules, mostly on zero hours contracts, diminished the attractiveness of this work. They feared that workforce shortfalls resulting from Brexit would place them in unsustainable competition with larger employers.

Employers that currently use Europe to recruit from…they will all be fishing in a far smaller pool of people…those carers we have trained …will be pulled by hospitals, residential homes and other care providers. Particularly here…it’s a very difficult place to recruit from because it’s an expensive area to live in (D1).

[Hospitals will] pull out all the stops to make good incentives to work for them, and [my] staff are going to go. Why would they want to have wear and tear on their vehicles and do all that? It’s going to be really, really difficult (D2).

While others anticipated more moderate problems, all domiciliary care managers anticipated additional difficulties for recruitment and retention of care staff in their organisations as a result of Brexit.

DISCUSSION

In this study, the vast majority of managers had significant concerns about Brexit's impact on workforce sustainability. Apprehension about restrictive post‐Brexit immigration policies was expressed not only by managers that actively recruited staff from the EU/EEA but also by managers hiring solely from the local area, in some cases with a staff base comprising entirely of UK citizens.

The nature of managers’ apprehensions about Brexit related strongly to the labour requirements within their organisations. Those managing services with a nursing arm (only residential care in this study) were more likely to hire nurses from the EU/EEA and were consequently more concerned about future curtailment to this means of recruitment. Yet equally, managers employing only care workers recruited from the local resident population (both UK and EU/EEA citizens) foresaw intensified workforce shortages as an indirect but no less disruptive consequence of Brexit. These managers anticipated that their organisations would struggle to retain or replace care workers in the face of increased competition with larger providers in a stronger position to offer higher pay, particularly the NHS. Domiciliary care managers were acutely aware of challenges posed by the prevalence of low pay and difficult working conditions in their services, but claimed it was not financially viable for their organisations to raise wage levels.

In short, managers perceived Brexit as likely to seriously exacerbate endemic problems with recruitment and retention of key sections of the social care workforce, that is, registered nurses and care workers on the lowest pay and most insecure employment contracts (Skills for Care, 2017a). Yet equally, managers recognised that these recruitment and retention problems were in existence prior to the 2016 UK/EU referendum and were ultimately rooted in the structural arrangement and resourcing of the social care system.

This study's findings, therefore, challenge the view that recruitment and retention in social care can be viewed as a discrete managerial issue, separate from the material conditions of the social care sector as a whole. For research participants in this study, finding and keeping good quality care staff were not only matters of the leadership, communication, and professional values they displayed as managers (e.g., Skills for Care, 2014) but also of the pay, hours, and conditions they were able to offer their employees. International evidence points to how low wages, stressful working conditions, and lack of career development have been linked to poor recruitment and retention in nursing and care worker roles around the world (Chenoweth & Lapkin, 2018; Estabrooks et al., 2015; Razavi & Staab, 2010), yet there is evidence that job satisfaction among care workers is strongly linked to levels of remuneration and benefits (Hussein & Manthorpe, 2005). Moriarty et al (2018) similarly emphasise the significance of material and economic conditions to social care recruitment and retention in the United Kingdom, adding that this has been insufficiently recognised at a strategic level. In the words of one of their research participants, “to have a successful recruitment and retention strategy…there has to be money in social care” (2018, p. 26).

This study was intentionally conducted in a region with higher than average EU/EEA citizens working in social care. The nature and extent of managers’ concerns about Brexit highlighted here may not be representative of their counterparts in other UK regions with lower levels of EU/EEA social care workers. The correspondences drawn in this study between managers’ concerns about Brexit and their organisations’ staffing requirements are based on a relatively small sample size. The wider applicability of these findings and could be established by further research with a larger sample of social care managers.

CONCLUSION

After Brexit, greater restrictions on the recruitment of EU/EEA nationals in the United Kingdom are likely. Although the outcome of UK‐EU negotiations with the EU are uncertain at the time of writing, the UK government is committed to a post‐Brexit immigration system which grants no preferential rights to EU/EEA citizens to settle and work in the United Kingdom, vis‐à‐vis non‐EU/EEA citizens (BBC, 2018). This article has explored how social care managers in England perceive the consequences of Brexit for workforce sustainability. It has amplified social care managers’ concerns that future restrictions on hiring EU/EEA workers will exacerbate already existing challenges with recruitment and retention of registered nurses and care workers on low pay and insecure employment contracts. Yet it is also recognised that creating a sustainable workforce in social care depends on much more than post‐Brexit immigration policy. The recruitment and retention challenges highlighted by managers in this study are not caused by Brexit, but linked to the ways nurses and care workers are valued and remunerated in the social care system. A government Green Paper setting out proposals for creating a more sustainable funding model for social care in England has been promised for autumn 2018 (Jarrett, 2018). This must systematically address social care recruitment and retention challenges, and set a clear course towards fairer systems of remuneration as a means of creating a truly valued social care workforce.

CONFLICT OF INTEREST

No conflicts of interest have been declared.