Abstract

As in most industrialised countries, the population of England is aging rapidly, causing the number of frail and care dependent people to increase. Nonetheless, while demand for LTC services is rising rapidly, the labour supply is lagging behind, with significant implications on the health and care systems. Moreover, high turnover rates, in particular for front-line staff such as care workers and personal assistants, has led to concerns for the sector’s workforce sustainability and quality of care.

Although it is often argued that care staff see their jobs as a vocation and report feelings of reward mostly from the altruistic motivations of helping others, there is empirical evidence that the low pay levels, limited career progression, and challenging working conditions have significant negative effects on job dissatisfaction, job quitting and workers’ wellbeing, with direct implications on recruitment, retention, productivity, work ethics as well as care outcomes. Understanding the drivers and effects of staff recruitment, retention and motivations in social care is important for the sector to achieve sustainable provision of high-quality services for an increasing demand. Furthermore, any positive outcomes would have positive spillover effects on the health care sector, e.g., through the reduction of avoidable hospitalisations and delayed transfers of care.

This session will present findings from the Retention and Sustainability of Social Care Workforce project (RESSCW) funded by the Health Foundation. By bringing empirical evidence on drivers of recruitment and retention of LTC staff, this work is filling an important gap in the understanding and the discussion on what measures and policies are feasible to improve labour supply and staff stability in LTC.

Presentation 1: Factors associated with retention in the LTC workforce: A scoping review of the international literature

Catherine Marchand, University of Kent

Grace Collins, University of Kent

The LTC sector is characterised by high vacancy levels and high turnover across the world (OECD 2020). In addition to the cost associated with recruitment and induction for employers, high turnover can also have negative organisational consequences including an increased burden on the workforce, weakening of social support and informal networks in the workplace, and a disruption in the continuity and quality of care. Furthermore, it also constrains the sector’s ability to expand in the context of demographic ageing and growing demand for care.

These longstanding challenges are observed across countries with diverse LTC systems and welfare state models. LTC workers are also among the lowest paid in the economy across the OECD, where they earn less than their counterparts in the health care sector. This was accentuated greatly during the Covid-19 pandemics, whereas the healthcare organisations and workforce were often more protected than their counterparts in LTC due to the regulations. Poor recruitment and retention are often associated with low pay; however, these are not the only factors. Several factors shape people’s decision to stay or leave their job or the LTC sector altogether.

Our international scoping review set out to answer three main questions: 1) What are the main factors associated with retention and turnover in long-term care? 2) How do these factors shape retention and turnover? and 3) How the Covid-19 pandemics impacted these main factors and relationships?

To answer these questions, we have searched and reviewed the international literature published in English since 2007. The review methods included eligibility criteria, information sources, search strategy, record management, study selection, data extraction, and analysis.

In total 290 studies were identified that met the inclusion criteria. Half of the research identified came from the United States, with a substantial contribution from the UK, Australia, and Canada. In total, more than 15 countries were represented in the review. Studies were evenly spread across residential care (incl. nursing homes), domiciliary/home care, and those looking at the LTC care workforce in general. The reviewed research was varied in their methods and included qualitative and quantitative, as well as mixed methods research. The scoping exercise identified a number of factors such as personal characteristics, intrinsic and extrinsic motivation (i.e., pay and reward), job satisfaction, decreased in workload and well-being as predictors of LTC staff retention.

Understanding factors and mechanisms influencing workforce retention would help greatly in planning LTC sector workforce for the future, with some studies implying that health and LTC workforce needs should be planned jointly.

Recruitment, retention and employment growth in the LTC sector in England

Hansel Teo, University of Kent

The LTC sector in England faces significant challenges in recruiting and retaining a workforce to meet the increasing demand for care. Existing studies have largely focused on staff turnover and retention. However, staff turnover forms only part of the picture as the impact of staff turnover on the care workforce is mediated by care providers’ replacement hiring ability. Given their interconnection, this paper studies the twin issues of retention and recruitment and assesses their relationship with changes in care worker employment in the English LTC sector.

Using the Adult Social Care Workforce Data Set (ASC-WDS), a large panel dataset of LTC establishments in England, we quantify the relationship between the in/outflow of care workers, changes in vacancies and the expansion/contraction of the care workforce within establishments. To do so, we exploit the longitudinal structure of the data and use fixed effects estimation methods to account for unobserved employer heterogeneity. This approach also allows us to identify and quantify the key non-growth factors underlying care worker turnover, hiring rates and unfilled vacancies amongst English care providers.

Our analysis finds that positive employment growth is significant and positively related, while negative employment growth significant and negatively related to both hiring and turnover rates. Establishments with negative employment growth and those with no year-on-year employment growth have low hiring rates of around the same level. In contrast, hiring rates increase steadily with employment growth. The relationship between turnover and employment growth has, however, a ‘V-shaped’ pattern. Establishments with no year-on-year employment growth experience the lowest turnover rates of around 0.25 per cent, while staff turnover increases with both negative and positive employment growth. The fact that expanding care establishments are experiencing both higher hiring and turnover rates suggests that increased hiring is associated with poorer job matching in the English LTC sector. This, in turn, could arise because expanding care establishments use a hiring strategy of ‘casting a wide net’ at the cost of poor job matches.

Applying the same analysis to study the year-on-year change in vacancies and controlling for changes to utilisation, we find that unfilled vacancies are negatively related to employment growth. Establishments with contracting employment tend to experience a rise in unfilled vacancies, while expanding establishments tend to experience a fall in vacancies. Because we account for the confounding effect of utilisation growth, this negative employment-vacancy growth relationship can be attributable to recruitment difficulties.

Finally, the patterns discussed are replicated across public, private and voluntary sectors. Nevertheless, we find that turnover and hiring rates are consistently higher in the private relative to voluntary and public sector care providers, across the entire growth distribution. This implies systematically higher levels of staff churn in the private sector, which may be related to differences in employment practices.

Presentation 3: Job separation of LTC frontline staff in England

Florin Vadean, University of Kent

Staff turnover in the LTC sector in England is perceived to be relatively high (over 30 per cent). Although, most job leavers do not leave the sector (but rather move to another LTC employer), there are concerns that the high ‘churn’ has a negative impact on continuity and quality of care, care providers’ recruitment and training costs, and the remaining staff workload and motivation. While the government and care providers support the idea of improving staff retention in LTC in England, there is very little evidence on what determines it. This study aims to contribute to fill this gap. It provides quantitative evidence on the drivers of LTC staff retention, with a focus on job quality (e.g. wages and contract types).

The study used yearly data (2016 to 2019) from a large, linked employer-employee dataset: the Adult Social Care Workforce Dataset (ASC-WDS). The analysis considered panel data econometric methods that accounted for unobserved heterogeneity at job-spell level.

After controlling for observed individual, organisational and local market characteristics as well as unobserved worker and employer heterogeneity, we found that, everything else being equal, wages and employment conditions (i.e. full-time contracts and contracts with guaranteed working hours) significantly improve staff retention. The wage effect was significantly underestimated when not controlling for unobserved heterogeneity. Everything else being equal, a 10 per cent wage increase from the sample mean would reduce the job separation rate by about 3 ppt. A wage increase can, however, be combined with other aspects of job quality to improve retention even more. Being employed on a full-time contract reduced the probability of leaving by -2.6 ppt for residential care staff and -4.3 ppt for domiciliary care staff. Moreover, employment on contracts without guaranteed hours (i.e. zero-hours contracts) increased the likelihood of leaving the employer by 12.5 ppt for residential care staff and 3 ppt for domiciliary care staff.

Our findings show that improving pay and employment conditions for care staff would reduce the staff turnover in LTC. A coherent strategy for England could be to close the large gap in pay (30-40 per cent) and conditions (e.g. contracts with guaranteed hours and more generous contractual sick leave in the public sector) between the independent and public sector. This will come, however, at a cost to the local and central governments, as tariffs paid by local councils will need to increase in order for independent care providers to be able to afford to pay higher wages, improve pay progression, and offer contracts with guaranteed hours and more generous sick leave.

Presentation 4: Determinants of turnover and vacancies of personal assistants in England

Katerina Gousia, University of Kent

Increasing demand for LTC and a shift towards greater personalisation of care has seen a rise in the demand for Personal Assistants (PAs). These are social care workers employed directly by Individual Employers (IEs) and deliver much needed support with activities of daily living. Despite their growing importance, recruitment and retention of PAs can be challenging. The factors affecting these trends, however, are not yet well understood.

In this paper we use a new survey of IEs from Skills for Care to explore empirically how factors such as employer and local market characteristics affect the turnover and vacancies of PAs. We find that the greater personalisation of care via the rollout of personal health budgets (PHBs) is associated with a higher probability of PA turnover and vacancies and that those markets with lower unemployment and higher alternative sources of LTC supply are more likely to suffer from PA recruitment and retention challenges. The paper discusses possible strategies for a more sustainable PA market. Given the characteristics of this market, these are more likely to include efforts to change the working conditions, contracting and training of PAs.

Slides