I was in Stockholm this week speaking at a workshop looking at Europe-wide experiences of the pandemic on social care. The On the corona frontline – Lessons learned, promises broken? event was hosted by Kommunal (UNISON’s sister union), Arena idé and the Friedrich Ebert Stiftung. It was a follow-up to the paper they published last year, and I wrote the Scotland paper in the series.
As the BBC reported just this week, increased demand and staff shortages mean at-home and care home services across Scotland are overstretched. But unfortunately, the pandemic isn't over, and social care challenges haven't gone away. This was reflected in all the presentations from across Europe at the workshop.
This was the case for our hosts in Sweden, which pre-pandemic had an undervalued, high turnover workforce and health and care that is not integrated. There is a mixed economy of care, although much less private sector involvement than in Scotland - there are 290 councils in Sweden! Their COVID-19 Inquiry has already reported and highlighted structural shortcomings in residential care, including staff training, sick pay (80% of salary after the first day), and precarious employment. However, in terms of action, it is business as usual, although they are hopeful of new legislation soon.
In Norway, social and primary health care is a local government responsibility, and only 10% of providers are in the private or charity sector. Moves to rationalise the numbers of councils (over 400) have been halted. They generally have good conditions, including full sick pay for one year, thanks to strict employment legislation and a strong union movement. However, they have skill shortages and had similar pandemic issues as us over infection control, PPE and testing. Overall, they appear to have managed the pandemic better than most.
My colleague in England described similar issues to Scotland, with all the previous challenges exacerbated by the pandemic. Staff shortages are getting worse and not helped by Brexit, with increased use of expensive agency staff. A significant increase in unpaid carers has taken more workers out of the economy.
Spain has a decentralised care system to the regional level and a mixed economy of care, with 70% of care homes in the private sector. As in Scotland, the pandemic hit bigger care homes harder, and the lack of official data makes analysis difficult. A Dependency Shock Plan has been agreed upon with the government and the unions to reform the long-term care system, including accreditation of residential homes, raising workforce standards, more funding and integration of health and care. However, structural implementation has been slow, while some workforce changes like reducing precarious work have made progress.
Portugal's system is similar to Spain's, with similar data issues. There is considerable reliance on families who get little financial or other support. When the family 'fails', institutions (often the church and charities) may step in, although state support meets less than 40% of residential costs. This has led to a growth in unlicensed nursing homes, which are often small (less than 20 beds) due to regulation thresholds. Their demographic challenges are even worse than Scotland's, leading to skill shortages. There is minimal social care and health integration and little unionisation, leaving most workers at minimum wage levels.
In Germany, the private insurance system couldn’t cope with the costs of the pandemic, so the government stepped in. There is now a debate around how the system should change with less privatisation. Residential care costs are doubling, partly because wages have increased by a third – raising the legal collective agreement in long-term care, with better leave and other conditions. However, church institutions (major care providers) are exempt from collective agreement laws. Mandatory staffing levels are increasing while the workforce is ageing, with 500,000 retiring in the next ten years.
My presentation reflected the Scotland paper I wrote last year. I explained how social care is funded and organised in Scotland, focusing on the workforce and employment standards. I emphasised that Scotland faced significant challenges in delivering social care before the pandemic. Not least an ageing population, budget cuts and limited workforce planning. The pandemic highlighted these challenges and created some new ones. The transfer of untested patients from hospitals to care homes resulted in half the first wave of deaths being in care homes. Home care packages were abandoned or reduced, causing further excess deaths. For the workforce, there was poor PPE, and they were not routinely tested for four months.
I outlined how trade unions had responded to the organising challenges with greater use of social media. Important campaigns on paying the Scottish Living Wage, sick pay, death benefits, COVID tests, better PPE and access to the vaccine demonstrated the importance of trade unions to the workforce. At this stage of the pandemic, it is essential that these lessons are incorporated, along with tackling the workforce shortages. Finally, I explained the proposed reforms to social care around a National Care Service, although delivery is still some way off. Therefore, there is a need to focus on a new workforce strategy, funding recovery plans and strengthening communities being undermined by council cuts.
The Scottish COVID-19 Inquiry needs to examine the lack of preparedness and why the lessons learned from pre-pandemic exercises were not fully implemented. It also needs to consider the broader structural and systemic issues in relation to patterns of disadvantage and inequality as well as care system capacity and capability. The research papers prepared for the Scottish COVID-19 Inquiry are worth a read.
A paper is being prepared after this event and that should contribute to that Inquiry. The pandemic highlighted similar issues across Europe. Poor preparedness, inadequate funding, and an undervalued workforce existed before the pandemic. The pandemic highlighted these issues and made them worse. We need to learn the lessons and take urgent action.