- Staff regularly fed back to us of being overworked, exhausted and stressed, sometimes to the point of becoming ill, injured or leaving their job altogether. They say low staffing levels can affect their ability to provide safe and effective care to people.
- Just over a quarter (26%) of NHS staff were satisfied with their level of pay. This is 12 percentage points lower than before the pandemic. Dissatisfaction with pay is linked to industrial action by healthcare staff during 2023.
- Some adult social care providers are struggling to pay their staff a wage in line with inflation.
- Over half of respondents to our survey of adult social care providers in England said they were having challenges recruiting new staff and 31% said they were having challenges in retaining them.
- There has been a steady decrease in staff vacancy rates for care homes, from 11% in January to March 2022 to 7% in April to June 2023.
- In 2022/23, approximately 70,000 people arriving to work in the UK from overseas started direct care roles in the independent adult social care sector, compared with around 20,000 in 2021/22.
- Providers of adult social care services have told us that recruiting staff from overseas has enhanced the diversity and skills of their team and helped resolve staffing issues.
- In 2022/23, we made 37 referrals for concerns regarding modern slavery, labour exploitation and international visas – more than 4 times the number made in 2021/22.
Staff wellbeing and satisfaction
In this section, we consider what affects the wellbeing and satisfaction of staff working in some health and adult social care services. We look at rates of sickness and job satisfaction and some of the reasons behind those findings.
Staff sickness absence
Since July 2021, rates of sickness absence in the NHS have largely remained at around 5% to 6%, although in April 2023 these did drop to 4.5%. Spikes in January 2021 (5.8%) and January 2022 (6.7%) coincided with spikes in COVID-19 infection rates. However, despite the falling number of COVID-19 cases, sickness rates for NHS staff remained high in 2022, and have increased since 2020 overall, with another large spike in December 2022 (6.3%) (figure 14). These recent figures are generally higher than before the pandemic (2017-19), where sickness rates fluctuated between 3.5% to 5%.
As at April 2023, staff in support roles and ambulance staff had the highest sickness rates followed by midwives.
Figure 14: NHS workforce sickness absence rates, April 2019 to April 2023
Source: NHS Sickness Absence Interactive Dashboard
Sickness absence for ‘cold, cough, flu – influenza’ tends to increase seasonally around December, with a large spike seen in December 2022, when 22% of the working days lost to sickness were from these illnesses.
NHS sickness rates are not available for primary care services, but in adult social care, data from Skills for Care shows that the number of days lost to sickness has steadily reduced from 8 days per person in April 2022 to 6.4 days in July 2023. However, these figures are still higher than before the pandemic – for example, the average number of days lost to sickness was 4.6 in 2019/20.
Working conditions – stress and anxiety
Looking at the reasons for staff sickness, over the last 2 years NHS staff have generally been more than twice as likely to record ‘anxiety/stress/depression’ as the cause of their sickness absence than any other reason. This accounts for 20% to 28% of sickness absence. However, the proportion of staff absent for this reason in 2022/23 has decreased slightly from 2021.
In relation to why levels of stress and anxiety are so high, the 2022 NHS staff survey showed the percentage of staff who agreed that there are enough staff has declined to a 5-year low, at 26% (compared with 38% in 2020). This is despite the total full-time equivalent staff rate in the NHS appearing relatively positive (see Staff numbers in the Workforce capacity pressures section).
The NHS staff survey for 2022 also reveals that 15% of staff experienced at least one incident of physical violence in the last 12 months from patients or other people using services, their relatives or other members of the public. This follows similar percentages in recent years.
Figures are even higher for non-violent abuse, as 28% of staff experienced harassment, bullying and abuse from patients or other people using services, their relatives or other members of the public.
These findings are reflected in the views expressed by staff across all areas of health and adult social care who share their experiences through our Give feedback on care service. They regularly fed back to us about being overworked, exhausted and stressed, sometimes to the point of becoming ill, injured or leaving their job altogether. Feedback also included concerns around the management of the workforce and the support offered to overworked staff. Comments included: "The trust is seriously understaffed. Nurses are harassed to hurry up and give medications fast. Staff are constantly told off, with some staff reduced to tears. A lot of staff have quietly resigned and left”, and “The workload is so excessive. No travel time or breaks are permitted on a regular, consistent basis. Clients go without care and are not always informed.”
Job satisfaction for staff
Linked with the current cost of living pressures, satisfaction with pay has been a key factor in job satisfaction in public services.
The percentage of NHS staff who feel their work is valued has remained static. However, satisfaction with pay has reduced considerably. According to the briefing for the 2022 NHS staff survey national results, just over a quarter (26%) of NHS staff were satisfied with their level of pay. This is 7 percentage points lower than 2021 and 12 points lower than before the pandemic (2019).
Satisfaction with pay is lowest among nursing and healthcare assistants (13%) and ambulance staff (16%), but there has been a downward trend in all occupation groups since 2019 or 2020 (figure 15).
Figure 15: 2022 NHS
The same NHS survey also shows that, related to morale, more staff are thinking of leaving. In 2022, 32% of staff said they often think about leaving their organisation. This compares with 27% in 2020. Staff in ambulance trusts were most likely to say they were thinking of leaving (43%) and staff in community trusts the least likely to indicate this (27%).
The cost of living crisis has caused household expenses to increase dramatically. Since 2021, the UK population has experienced a huge rise in the costs of goods, services, bills, and housing. Care workers have encountered a fall in disposable income, with some facing financial hardship.
We have heard from some adult social care providers through our provider information return that they are struggling to pay their staff a wage in line with inflation:
As with many health and social care providers, the cost of living increases have affected staff members and their own household costs, which are not reflected in their wages and not reflected in packages of the funding authority. Reviews of all packages are being requested, though the commissioners do not have an endless allocation of funds, so the uplift received this year fails to cover rises in costs.
(Feedback from CQC provider information return)
The current situation has pushed some care staff into vulnerable financial positions. Through our adult social care provider information return, providers describe that some care staff are struggling to afford basics, so employers are supporting them with the basics, such as food, fuel and toiletries:
We are trying to support our staff through the cost of living crisis by things like offering to wash uniforms on site, staff meals, and putting a basket in the staff washroom with personal toiletries and sanitary items for their use.
(Feedback from CQC provider information return)>
Dissatisfaction with pay has been linked to industrial action taken by healthcare staff during 2023 – particularly considering cost of living difficulties. But our discussions with providers have shown that other factors, such as working conditions, strongly influence staff satisfaction.
As we have seen, NHS ambulance staff have among the highest sickness absence levels and are most likely to say they are thinking of leaving the NHS. A significant factor affecting the workforce across all ambulance services has been the delays in handing over patients at emergency departments across the country. The delays, which take the frontline ambulance workforce off the road for significant periods, result in longer response times and poorer outcomes for patients. This is a major component of dissatisfaction in ambulance staff surveys.
The frustration and dissatisfaction from prolonged delays at emergency departments have also resulted in higher levels of sickness associated with stress – both for frontline staff and the staff working in control centres. The delays have prompted increasing concerns over work experience and training, as staff may only see 1 or 2 cases in each shift. This is particularly important for students and newly qualified paramedics.
Services need to address low levels of staff satisfaction and high levels of stress and work overload, much of which relate to staff burnout from the pandemic – see our section on Investing in staff wellbeing.
Workforce capacity pressures on providers and staff
This section looks at staffing numbers in health and social care, and the impact of high levels of staff vacancy and turnover.
NHS workforce data shows that, overall, there has been an increase in the number of full-time equivalent (FTE) staff working in NHS hospital and community health service trusts and other organisations in England (excluding primary care staff). The number of all FTE staff increased by 5% between May 2022 and May 2023. Professionally qualified clinical staff (which include hospital and community doctors, qualified nurses and ambulance staff) make up over half of these, increased by 4.4% over the same period.
Looking at General Practice Workforce Statistics, there has been a small overall increase (of 2.6%) between July 2022 and July 2023 in the number of FTE staff across all staff groups. However, numbers of fully qualified GPs decreased over the same period (by 1.2%). Without intervention, the shortfall in fully qualified GPs reported in the NHS Long Term Workforce Plan is projected to be around 15,000 by 2036/37.
In adult social care, latest data from Skills for Care shows that, despite an increase of 1% in filled posts (roles with a person working in them) in England between 2021/22 to 2022/23, there are 45,000 fewer filled posts in 2022/23 than in 2020/21. However, the number of FTE staff in post has recovered to 2020/21 levels.
In our recent survey of adult social care providers in England, of over 1,900 respondents, more than half (54%) said they were having challenges recruiting new staff and 31% said they were having challenges in retaining them. Supported living services and extra care housing services reported having the most difficulties recruiting new staff.
Respondents to our survey also highlighted how workforce pressures resulted in reduced capacity in the system. Over a quarter of respondents (26%) said that staff shortages due to recruitment and retention issues were resulting in unused capacity.
Many adult social care services described through their provider information return difficulties attracting new staff to roles to fill vacancies. They cited low pay, high pressure, and staff burnout as key causes of the many care workers who are leaving the sector for better paid jobs in less pressurised environments.
Pay differences are shown in Skills for Care data, which found that, as at December 2022, median social care worker pay (at £10.03 per hour) was 9p lower than the median hourly pay for sales and retail assistants and £1.08 lower than healthcare assistants. Adult social care providers are telling us that this is having an impact on their ability to retain staff, which also affects capacity:
We do get very minimal response from our [job] adverts. There is a national shortage throughout the industry at present. There seems to be a lot of reluctance for people wanting to go into care work as a lot of other sectors, for example retail, can be paying more wages than the care industry, and within the care industry there is a lot more responsibility.
Feedback from CQC provider information return
Due to lack of funding we have lost 50% of our staff in the past 14 months, which means we have also lost 50% of our hours of service delivery. Many of the staff we lost have moved to local authority or NHS homecare teams. As a private provider we can't compete with government department wage rates.
Feedback from our survey of adult social care providers
Recruitment challenges can also be influenced by regional factors. The rising cost of housing in certain areas of England has meant that, even if providers have managed to recruit staff to their vacant posts, new recruits have not taken up the offer of employment as they have been unable to find affordable housing. For example, an NHS trust in the South West had between only 40% to 60% of the adult community-based mental health staff that it should have. The lack of clinical psychologists and occupational therapists led to long waiting lists for patients and long waits for a range of therapies. The trust attempted to mitigate this by building temporary housing to accommodate new recruits.
Recruitment is often worse on the boundaries between local areas offering different wages, such as inner and outer London weighting, where staff choose to work where they can earn more.
One director of a provider of residential and supported living services for autistic people and people with a learning disability told our inspectors they were having a particular problem recruiting quality staff in London, despite offering them a welcome payment. Often, staff move on to another provider with similar welcome incentives as soon as they’re able. This prevents the people who are using the service from forming and developing meaningful relationships with staff.
According to NHS vacancy statistics, there was a slight decrease in vacancy rates in England from 10% for the period April to June 2022 to 9% for the period April to June 2023.
Despite the same general trend across all areas, there was some regional variation in vacancy rates for NHS services. For example, for the period April to June 2023, London continued to have the highest vacancy rate across England at 12% compared with 7% in both the North East and Yorkshire region and the South West region, and a national average of 9% (figure 16).
Figure 16: NHS workforce vacancy rate by quarter, April 2021 to June 2023
Source: NHS vacancy statistics
In adult social care, data from our provider information return shows a steady decrease in staff vacancy rates for care homes, from 11% (January to March 2022) to 7% (April to June 2023) (figure 17).
Figure 17: Care home staff vacancy rate by quarter, April 2021 to February 2023
Source: CQC Provider information returns
Data from Skills for Care shows a small reduction in the overall adult social care vacancy rate from 10.6% in 2021/22 to 9.9% in 2022/23. However, the figures for homecare have remained consistently high, with the vacancy rate in 2022/23 at 13%. This compares with an average for homecare of 9% in 2019/20.
In NHS services, rates of staff turnover (number of leavers divided by the average number of staff in the last 12 months) have reduced from 13% in June 2022 to 11% in June 2023. This followed a steady increase throughout most of 2021 (from 9% in March 2021).
High turnover rates in an NHS ambulance trust
Turnover rates for call handlers had increased from 17.5% during 2020/21 to 28.3% during 2021 and 2022.
Frontline staff we spoke with described a hard-working culture, with lots of demands and work-related stress associated with their roles.
Staff told us that sickness and vacancy rates had made their roles and workloads much more difficult, and they felt this had increased risks to callers who had to wait longer for responses as they did not have the capacity within the teams.
From a CQC inspection report
For GPs, turnover rates for qualified permanent GPs increased by 2.3 percentage points over the past 2 years, from 6.5% in June 2021 to 8.8% in June 2023.
In adult social care, according to data collected from our provider information return, the turnover rate in care homes decreased from 37% for the period January to March 2022 to 29% for the period April to June 2023 (figure 18).
At a regional level, London has persistently had a lower turnover rate compared with other regions. During the period April to June 2023, the rate in London was 20%, compared with an England average of 29%.
Figure 18: Care home staff turnover rate by quarter, April 2021 to February 2023
Source: CQC Provider information returns
How workforce pressures are affecting adult social care
Our provider information return indicates that staff shortages have led some adult social care providers to reduce their capacity to provide services to people, which in turn was a barrier to providing good quality care over the past year [also see our section on access]. Providers said they are concerned about staffing levels, and that this will be an ongoing issue, as the following feedback shows:
A lack of staff is our biggest barrier to providing good care. It also makes continuity in the carers that those who use our service come in to contact with very difficult.
I feel care work has become undesirable and not sustainable for people to work in this area. This ultimately has a negative effect on the people living in care settings.
(Feedback from CQC provider information return)
In adult social care, different types of providers respond to workforce in different ways. For example, homecare services are better able to ‘flex’ how they provide care to fit workforce resource. Our data shows that workforce challenges have limited the number of care hours that homecare providers in our Market Oversight scheme can deliver, with hours down nearly 15% in the last 2 years.
Feedback from the provider information return shows how different homecare providers are reacting to the challenges. Some providers are focusing on more profitable work, mitigating the effect of staffing challenges on profitability. Others are de-prioritising less urgent visits or cutting them short (see the section on Access to care in this report).
The lack of capacity in adult social care services places further pressure on the wider healthcare sector. For example, staff shortages have made it increasingly difficult for some services to accept referrals, such as people being discharged from hospital.
During 2022/23, some homecare providers told us they had seen an increase in hospital referrals, which they were unable to accept as they did not have the care staff to meet the needs of these people. This can increase the likelihood of people having to stay in hospital for longer than necessary, increase the demand for hospital beds, and affect people’s independence and quality of life:
We have also found that due to high demand from local councils and the NHS and the strategic plan to allow care at home, it has meant a higher need for staff in the community along with a higher push for staff to work more hours.
(Feedback from CQC provider information return)
Less homecare capacity also works against the government’s aim, set out in People at the Heart of Care: adult social care reform white paper. This states, “Wherever possible, care and support should be in a person’s own home.”>
Workforce pressures in adult social care are not new. Two years ago, we highlighted the need for updated national workforce strategies that raise the status of the adult social care workforce to achieve parity with health care, and ensure that career progression, pay and rewards are suitable to recruit and retain the right professional staff in the right numbers.
We continue to call for a cross-sector social care workforce strategy to sit alongside the NHS Long Term Workforce Plan.
Impact of workforce pressures on people using services
Importance of sufficient specialist staff
Having the right amount of staffing resource with the right skills and experience is closely linked to achieving the best outcomes and experiences for people who use health and care services. Some types of service rely on more specialist staff.
We launched the Supported Living Improvement Coalition in February 2022 with people with experience of supported living services, their relatives and representatives, care providers, charities, and local authorities among others. This group has given us learning and insights into the difficulties of staffing pressures in supported living services.
The Coalition stressed that to work effectively and build an understanding with the diverse group of people who rely on supported living services, providers and care staff need a vast amount of active effort and specialist knowledge.
One person using supported living services explained the importance of building that understanding with staff: “They understand me very well, they know what I want in life.”
A coalition partner reflected that “people are very different and have different needs. There seems to be this lack of understanding sometimes in terms of the heterogenous [mixed] nature of people with learning disabilities who might be in supported living.”
The impact on people using supported living services
We heard that issues around staff recruitment and retention have affected the capacity of services to function. This reduced the ability of staff to provide real choice and build meaningful relationships with people.
Coalition partners described the impact of staff turnover, or “churn”, on training needs for new staff and the impact on the care given to people:
It’s that constant having to train and learn, which is a fantastic part of being part of the care sector; but when you have staff that are only there for 6 weeks… you have a workforce that don’t always have the necessary training that we would like them to have to deliver that high quality, person-centred care.
Family members said that a lack of supported living spaces nationally meant that changing care provider would be “very difficult” or “impossible” – even though choice was seen as a key aspect of what makes a good supported living service.
The impact on people using other health and care services
Across the full range of services we regulate, staffing numbers and vacancies was a recurring issue, as significant shortages have an impact on the people who use services. Staff who responded to our online Give feedback on care service have remarked on how low staffing levels were affecting their ability to provide safe and effective care to people.
From our inspections and monitoring, we have seen the effects of severe workforce issues, with examples where staff shortages have meant people haven’t been able to receive care:
- a shortage of staff on a community inpatient ward meant that beds were ‘closed’, which meant people had to wait longer for a bed
- some hospital wards for people with a learning disability have either fully closed, do not accept new admissions, or have reduced or stopped NHS-led respite care
- a shortage of staff has also led to some skill gaps within multidisciplinary teams, which can lead to delays in people receiving the assessments we would expect in hospitals and communities.
Impact of staff shortages in an NHS acute hospital trust
Our inspectors found that the service did not always have enough staff to care for patients and keep them safe. Ward staff said that the actual number of staff working on the ward did not always meet the planned number of staff for a shift. Staff described the effect this had on patient care. This included:
- patients only having hand and face washes rather than full washes
- patients sometimes having to wait for assistance
- a higher number of patient falls.
From a CQC inspection report
We have also seen the deep impact of staff shortages during our inspections of mental health services. We see recruitment difficulties in all areas, such as for psychologists, occupational therapists, nurses, and permanent consultant psychiatrists. Patients are not getting one-to-one time with their named nurses as they don’t have time, risks and concerns are missed, and treatment reviews are not happening often enough.
The use of bank and agency staff to cover vacancies is high. This can put pressure on permanent staff and can increase risks to patients, as staff don’t always know them. Consistent staffing is fundamental to therapeutic relationships. Constantly changing staff is likely to extend length of stay.
There are similar difficulties with healthcare staffing in health and social care services in secure settings. We work with HM Inspectorate of Prisons to protect and promote the interests and rights of people in prisons and other secure establishments. But we have seen that services have to compete to offer higher wages or greater flexibility, and there is competition from other prisons for staff – particularly in the South East of England. Establishments in more remote parts of the country also struggle.
Staffing pressures at an immigration removal centre
A joint inspection of an immigration removal centre in the South East of England in Summer 2022 resulted in issuing a Requirement Notice as the service did not always have enough nursing and support staff. There was a 51% vacancy rate, coupled with difficulties in securing agency staff. The service tried to maintain staffing levels with 2 healthcare practitioners, 2 healthcare assistants and 2 mental health nurses during the day – even though each type of role needed 3 people.
Often, there was only 1 member of the mental health team on duty. This person had to triage new applications, attend assessment reviews and see patients on the team’s caseload. At the time of the inspection, there was no psychology provision as the provider was unable to recruit into these positions.
When we carried out a follow-up inspection in early 2023, we found the provider had made improvements, including making some key appointments to strengthen the service, such as a mental health team lead and a paramedic, and was meeting the regulations and requirements.
From a joint inspection report
A personal experience of working in the NHS
Michelle has been an NHS nursing associate at a women’s prison for the past 7 years. She lives with her partner and their baby.
Michelle enjoys supporting the prisoners in her care, getting to know their stories and helping them to look after their mental and physical health.
Since the pandemic, Michelle has noticed that a lot of people don’t want to work in the prison system because it struggles to recruit and retain staff. This puts pressure on the existing workforce.
Michelle is very worried about the cost of living. Her mortgage has gone up by £500 a month because of rising interest rates, as well as “horrendous” electricity and gas bills. She feels like the price of the weekly shop has doubled and that all the household bills feel huge.
Michelle is considering leaving the NHS. She would like to stay, but the cost of living is making it difficult. “I haven’t really got an option”, she said. If she wants to work towards promotion, she has to work full-time, but working full-time means that she has to pay for costly childcare, which doesn’t leave much to pay the ever-rising household bills.
Her two main reasons for wanting to leave the NHS are staffing problems and the rate of pay. She suggests the situation could be improved by focusing on recruitment and retention of staff. She said: “It’s hard to run a service when there aren’t people to run the service.”
What a person told us about their experience
How providers and staff are responding
Providers are responding to workforce challenges in various ways, by being flexible with roles and capacity where possible, and making considerable use of international recruitment.
Adapting and moving roles
Where GP providers are having difficulty recruiting, many practices are increasing their use of roles such as paramedics, clinical pharmacists, advanced nurse practitioners and physician associates, as promoted in the Delivery plan for recovering access to primary care. These additional roles add value to general practice teams in terms of speciality, and improved access to the right professional without the need to refer and wait for further treatment or advice. We recognise that new staff joining the practice will require supervision and support to carry out their roles.
Staff working in adult social care services have also been moving to different roles within the sector. But an issue in the last year has been the number of homecare staff leaving the role to work in a residential care setting. Providers attributed this to the significant increase in travel costs caused by the hike in petrol and diesel prices, which peaked in July 2022, as the following quotes from our provider information show:
The main barrier at this time is the cost in fuel. Since the price has gone up we have lost 2 good carers to local care homes and we feel there will be more to follow due to this issue.
The cost of travel has also increased, therefore our staffing team consists of only local carers who do not have to pay for their travel to work. All of this makes staff retention very challenging.
(Feedback from CQC provider information return)
To improve continuity of care and avoid the movement of staff out of the homecare sector, some providers implemented new strategies, which included:
- increasing mileage allowances
- paying for travel time
- purchasing fuel cards
- carefully planning travel routes to reduce the journey time for staff between people’s homes
We have purchased fuel cards for carers to allow for the high rise in fuel. This has led to carers feeling supported and them also seeing we recognise the difficulties with the cost of living. We have a forward-thinking team where rounds have been re-planned for less travel.
To support the workforce with the ever-rising cost of living, the organisation has introduced a monthly travel allowance. This has been successful in retaining the staff, which in turn offers continuity of support and care that is delivered to all the people using our services.
(Feedback from CQC provider information return)
Opportunities from international recruitment
Internationally recruited staff form a vital part of the health and social care workforce, and recruitment from overseas is an important part of the solution to workforce challenges across all sectors.
The NHS equality, diversity and inclusion improvement plan acknowledges how the NHS has benefitted from the expertise, compassion and commitment of internationally recruited healthcare professionals. As one of the 6 high impact actions for improving workforce equality, diversity and inclusion, the plan includes an action for NHS organisations to implement a comprehensive induction and development programme for these staff.
In oral health care, recent reforms to international registration should start to tackle the backlog of overseas dentists looking to join the dental register, but this will take time to filter through to improving access for people.
The independent acute hospital health sector, which appears to be maintaining good staffing levels, is also recruiting from overseas. For example, one large provider recruited 60 nurses from the Philippines, who were supported to successfully complete their registration and become valuable members of the nursing workforce.
Providers of adult social care services have told us through the provider information return that recruiting staff from overseas has enhanced the diversity and skill set of their team and helped to resolve staff shortage issues.
In February 2022, care home and homecare managers and workers were added to the government’s Shortage Occupation List and the Health and Care worker visa route. This meant that workers who met the salary threshold and had a licensed sponsor could come to the UK to take up care worker roles.
In addition, the government has made available £15 million for the 2023/24 financial year to help local areas establish support arrangements for international recruitment in adult social care and bolster workforce in adult social care.
In 2022/23, an estimated 70,000 people have started direct care roles in the independent adult social care sector, having arrived in the UK during that period (figure 19).
This is a substantial increase in international recruitment on previous years (20,000 in 2021/22) and has helped to fill more posts and reduce vacancies over the period.
Figure 19: Estimated number of people arriving in the UK that start direct care roles in the adult social care independent sector, April 2020 to March 2023
Source: Skills for Care estimates
Note: Skills For Care defines the ‘independent sector’ as any service that is not run by the local authority, so includes private, not for profit and charities etc.
The most common countries of birth for these workers were India, Nigeria, and Zimbabwe.
Challenges and risks from international recruitment
Recruiting from overseas provides a valuable workforce across health and care. It also requires providers and the wider system to provide appropriate support and education for international recruits to ensure safe delivery of services and good staff wellbeing:
The increasing number of overseas staff means we have had to work with our existing team to talk about the needs of incoming staff. Overseas staff do not have the same background or experience and often aren't familiar with the types of food people eat, or the way it's served or eaten. There are also challenges with language sometimes, where staff have good written or spoken English, but may struggle with more colloquial styles of talking. We have appointed a training manager to provide additional support to new staff.
(Feedback from CQC provider information return)
Practical issues with recruiting staff from overseas included acquiring staff accommodation, obtaining company vehicles and insuring the staff to use them. Although, it’s clearly vital to train internationally recruited staff and make sure they are fully integrated into the service and community, providers tell us these additional tasks are time-consuming and could take senior leadership teams away from other managerial duties.
Over 40% of all GP trainees are international medical graduates (IMG). However, many are finding that difficulties with obtaining a visa are causing them stress and anxiety. A 2022 survey by the Royal College of General Practitioners found that around 30% of all IMG trainees considered not working as an NHS GP because of difficulties with the visa process.
Our interviews with midwives from ethnic minority groups for this report also highlighted the risks of staff not being fully embedded within organisations. Several interviewees felt that the experience and knowledge of internationally trained midwives was not respected and there were perceptions of hierarchies and a Western-centric attitude in terms of delivery and training:
People from another country are learning to navigate the system. I think we need more recognition that they respond to situations differently, based on their experiences, and that doesn’t mean it is wrong just because it is different. The NHS is amazing but it was built by white people for white people. We need to adapt, because now we have a diverse population and workforce.
Interview with a midwife from an ethnic minority group
Over 2,700 providers and locations registered with CQC across all types of health and care services hold a UK Visa and Immigration sponsor licence, most of which are adult social care providers. Changes to immigration and visas have been a positive step to help ease the workforce shortages in health and care, and the Code of practice for the international recruitment of health and social care personnel in England aims to promote high standards of practice in the ethical international recruitment and employment. However, over the past year we have started to learn of some abuse of both the immigration process and the migrant workers themselves.
There is a growing trend of unethical international recruitment practices, which sees the international worker being controlled and coerced through their immigration visa or through debt bondage. The Independent Chief Inspector of Borders and Immigration has issued a call for evidence to assess the extent to which the Home Office’s immigration functions support the social care sector.
A particular concern is when services, either knowingly or unknowingly, become involved in modern slavery and human trafficking. Data from the Home Office’s National Referral Mechanism showed that in 2022, nearly 17,000 referrals about potential victims of modern slavery were made by authorised first responder organisations, including local authorities, police forces and specified government agencies. This is a third higher than the previous year, and the highest annual number since the Referral Mechanism began. Of all these referrals this year, 41% were for potential victims who claimed exploitation as children.
We fully support the government’s objective to eradicate modern slavery and human trafficking. As a public sector body, CQC must align its work with the Human Rights Act (1998). This includes the right for people to be free from slavery and forced labour. We also have a duty to report criminal activity. In 2022/23, we made 37 referrals through our national enforcement team to relevant agencies for concerns regarding modern slavery, labour exploitation and international visas – this was more than 4 times the number made in 2021/22 (8 referrals).
We heard of a number of concerns about potential victims working in health and social care settings from our inspectors, as well as complaints against providers, and workers who have left comments through our Give feedback on care service. From this feedback, it would appear that a small number of providers are exploiting victims of modern slavery, and the wider system, through:
- financial abuse, including: low pay, accommodation, transport or food that is tied to the job; excessive sponsorship fees, having to pay for their own registration or training, long working hours, lack of breaks and holidays, and tax avoidance
- physical, sexual, and psychological abuse
- racial and religious discrimination
- threats and blackmail, often using the person’s sponsorship or visa status as leverage to exploit and degrade them.
Investing in staff wellbeing
Earlier in this report, we discuss how leadership plays a key role in shaping the culture of organisations. Our engagement with health and care services shows that the importance of providers building this culture by really investing in their staff and considering their wellbeing.
For example, in general practice, new workforce and wellbeing indicators under the Quality and Outcomes Framework take steps to create a compassionate and inclusive culture, improve wellbeing and resilience, and reduce the risk of staff burnout.
In adult social care, we see how services that successfully develop career progression and training for staff have higher retention rates. The same goes for providers that develop wellbeing initiatives to retain staff and avoid using agency staff. Examples include offering flexibility such as part-time working, engaging with the community, and supporting staff with childcare or supporting them through the menopause.
These measures should be further supported through the government's workforce reforms, set out in the Next steps to put People at the Heart of Care. The reforms include £250 million of investment to better recognise social care as a career, partly through a plan to introduce a new Care Workforce Pathway and Care Certificate qualification.
Some adult social care providers are going the extra mile to support their staff to combat the current cost of living crisis. Initiatives from both residential and homecare providers that have helped retain staff, included:
- paying a good hourly rate above the living wage for the area
- providing a free breakfast bar for staff before or after their shift, and free meals during shifts
- inviting all staff to talk to the manager if they are experiencing financial hardship, resulting in weekly boxes of free food and support with things like children’s clothing
- giving bicycles to staff
- reward/recognition schemes to make their employees feel valued and appreciated for their work.
To explore what good workforce wellbeing looks like, we carried out a survey with a range of providers and professionals working in health and social care, the organisations that represent them, and wider stakeholders.
We received 2,420 responses – over half of which were from the adult social care sector:
- 91% agreed that assessing workforce wellbeing is an important part of CQC’s new assessment approach, which suggests that providers saw staff wellbeing as a real priority
- 74% said the organisation they work for monitors data and collects feedback on the wellbeing of its workforce – this was highest in adult social care (82%)
- for the question ‘Does your organisation involve staff in co-designing workforce wellbeing initiatives?’, 61% answered ‘yes’, 23% said ‘no’ and 16% ‘don’t know’.
Our survey asked professionals for examples of workforce wellbeing initiatives in their organisations. The main types of initiative were:
- professional wellbeing, including learning, development and training, supervision and performance management, wellbeing champions and teams, flexible and hybrid work schedules, and staff networks and groups
- psychological and emotional wellbeing, such as counselling, reflective staff groups, mindfulness, and occupational health and therapy
- financial wellbeing, through pay increases, bonuses and awards, extra paid holidays, free food and drink, support with housing and transport costs, and financial support and advice including pay advances
- social wellbeing, including team awaydays and gatherings, and celebrating religious and other holidays.
We engaged further with health and care professionals through focus groups. The frontline staff we spoke with, many of whom worked in the NHS, called for improvements in meeting the basic needs of staff, such as regular breaks, places to rest, safe working environments, and flexible work schedules to enable caring and other responsibilities, alongside their psychological needs.
They told us they want employers and leaders to:
- be visible in championing workforce wellbeing
- demonstrate a proactive as well as a reactive response to workforce wellbeing. For example, implementing a wellbeing strategy that understands the needs of their workforce with supportive measures to allow them to thrive – rather than focusing all resource and initiatives on reacting to burnout
- provide a culture where the workforce feels listened to and has regular opportunities to give feedback
- understand their workforce and to be able to meet the needs of different staff groups, especially those who might need tailored support, such as internationally recruited staff or those with certain protected equality characteristics
- nurture the professional development of staff through training and regular appraisal