Health and Care Workers Covenant

 The pandemic has seen many key workers going far beyond their contract of employment to keep services running. That is particularly the case for health and care workers who have worked incredibly hard, at no small risk to themselves, to prevent the spread of the virus and treat those affected. It is time we recognised this commitment through a Health and Care Workers Covenant and that employers take action to minimise the impact on workers and their families.

Research shows that people who work in jobs like care, which are often called a calling, tend to have higher levels of resilience against the negative effects of overwork and stress and are less likely to experience burnout. However, that resilience can come at a price, both individually and for their friends and families. In a recent article, the authors argue that the families of workers in such roles also suffer massively. Called people can struggle to switch off after work and are less able to manage a balance between work and private life. Divorces and difficult relationships with children are not uncommon, as are exhausted family members. That is bad enough for the individual workers, but families shouldn't pay the price of their loved ones’ self-sacrifice.

Too many employers in the health and care sector have an operating model that depends on these workers going the extra mile. And we as a society also expect these workers to go beyond their contracts, particularly during the pandemic. They have delivered for us in challenging circumstances through governments' faltering actions and often without proper protective equipment and other safety measures. Employers have a duty of care to address this. I have recently been working with one social care organisation who have recognised this and taken a range of actions. But others take this level of commitment for granted.

NHS workers have had to deal with much larger numbers of critically ill patients than normal. Often in a far from an ideal situation, knowing this may lead to poor outcomes for their patients. This is having an impact on their mental health. A recent study of staff working in critical care during the pandemic showed they report more than twice the rate of probable post-traumatic stress disorder (PTSD) found in military veterans who’ve recently experienced combat. The authors of this study argue that there might be some lessons we can learn from PTSD in military veterans to help NHS workers cope during the pandemic. Both during the trauma and in the recovery period.

The link to the military is one made by a number of Socialist Health Association Scotland members who raised the idea of a Health and Care Workers Covenant. This is modelled on the existing Armed Forces Covenant while recognising the important differences between the groups of workers. Not least gender, insecure work and the wider range of employers and unpaid carers. Their proposal, published today, outlines and promotes the concept of a covenant. The elements could include commitments on pay and conditions, training, safety equipment, and occupational health. It should also engage the wider community as some business have already done with staff discounts. It should be taken forward as a partnership involving government, local authorities, trade unions, care providers, carer representatives and others.

It is important to emphasise that a Health and Care Workers Covenant is not a substitute for collective bargaining and strong trade union organisation. This remains the best way to protect and improve the pay and conditions of these workers. The implementation of the Fair Work Convention recommendations, as supported by the Review of Adult Social Care, would be an important starting point. 

We need to pay workers with something more than just gratitude, and a covenant is an additional way of society recognising the sacrifices these workers and their families make for us all.

The Future of Adult Social Care

The Independent Review of Adult Social Care in Scotland published its report today. It makes a wide range of recommendations that might address the long-standing need to reform this sector.

Most of us would agree with Derek Feeley's summary of the challenge: "This is a time to be bold and radical. Scotland needs a National Care Service to deliver the high quality, human rights-based services people need to live fulfilling lives, whatever their circumstances. Scotland has groundbreaking legislation on social care but there is a gap, sometimes a chasm, between the intent and the lived experiences of those who access support. We have a system that gets unwarranted local variation, crisis intervention, a focus on inputs, a reliance on the market, and an undervalued workforce."

The headline is creating a National Care Service, something many of us have supported for a long time. A national framework setting consistent standards on ethical commissioning, care standards and workforce issues should be the aim, with delivery as local as possible. There will be a concern that the report gets the balance between the national and the local wrong. If you put a senior civil servant in charge of a review, you shouldn't be surprised if he recommends a high degree of centralisation. Democratic local government is to be replaced by what looks like clear direction and funding from Edinburgh of the reformed IJBs. Social care should not exist in isolation from a wide range of other local services, and there is a real risk that those links will be lost. 

The report's support for reducing the use of institutional care, early intervention, technology, human rights, and involving people and families is uncontroversial. It also rightly recognises the role of unpaid carers and recommends bringing support for them within the National Care Service scope. However, it does perhaps fall into the trap of listing interesting local initiatives, without clearly explaining how we systemically ensure that best practice is rolled out in a way that reflects local circumstances. A national approach to improvement and innovation is fine, so long as it doesn't become the one size fits all approach that centralisation inevitably entails.

The chapter on commissioning signals a welcome move away from the market towards collaboration in the procurement and commissioning of services.  The trade-off is that providers have to be accountable for new standards of accountability, quality, staff wellbeing and transparency. However, the report is light on how this is to be delivered in practice, particularly in those sections that duck issues of ownership and the culture that for-profit services bring to the process. Sharing the 'unease' about care homes being run on a profit-making basis is pretty weak, and it is unclear what an 'actively managed market' means in practice. There are other ways to shift the balance of ownership than outright nationalisation. It also avoids tackling the sheer number of providers in the system and the duplication that this brings. 

The chapter on Fair Work is one of the strongest in the report. It supports the recommendations of the Fair Work Convention's report on the social care sector. It says that priority should be given to creating national sector-level collective bargaining of terms and conditions. The importance of getting a grip on workforce planning, training and development are also very welcome. A national job evaluation exercise should address many of the inequities in the current workforce pay structures, and bring Personal Assistants into the fold is also positive. The report recognises that the SSSC cannot meet the needs of the workforce in full, and it is right that its role, along with Care Inspectorate in regulation, is reformed.

Separating need from affordability is the right approach, but it brings funding challenges that the report skirts around. It is positive that the report recognises social care as an investment rather than a drag on resources, and the report seeks to identify some of the costs and savings involved in raising standards. Having been involved in previous efforts to cost this, it is not straightforward by any means and the suggested 20% increase in real terms funding is certainly required. Some options for raising the revenue are outlined in the report, but it makes no recommendations.

Overall, the report is a bit of the proverbial curate's egg. The creation of a National Care Service, workforce and investment are all positive reforms. On the other hand, the report is vague on how we are to shift from markets to collaboration, and it fails to address ownership and fragmentation in the delivery of services. I am concerned that it looks and feels like an overly centralised approach, which replicates other initiatives in education, police and fire - few of which have been successful. When in doubt - local is best. How to fund social care was probably too big a task for a review concluded in a commendably short time period.

Nonetheless, the report is an important step forward. We now need some political leadership to move from process to delivery.

On Monday, before the report was published, I was speaking at an event looking at the future of care from a devolved nation perspective with speakers from Wales and Scotland, including Julie Morgan MS the Welsh Government Minister and Monica Lennon MSP. There are some interesting initiatives in Wales, and they are facing similar challenges. The presentations were recorded and can be viewed on the SHA Scotland website.  

Helping small businesses to build back better

I have been doing some work with a couple of smaller businesses, mostly legal and HR issues. This isn't a sector I am very familiar with having spent most of my career working in the public sector and with large companies. So, it has been interesting and provided new insights.

One owner joked that he didn't expect to be getting help from a former trade union official. It did remind me of an evidence session in Parliament when I was seated between the Federation of Small Businesses (FSB) and the CBI. The guy from the CBI asked, light-heartedly if I would be more comfortable swapping places. I pointed out that the biggest threat to small business is big business, not unions!

One of the firms had to close, and furlough staff during the first lockdown, but they recovered well as a hobby business demand was brisk. We sorted out some of their staffing issues, but they are now struggling with Brexit. I was, of course, familiar with the queues of lorries at Dover. Still, I hadn't fully appreciated the problems involved in just sending orders to EU companies that didn't exist before Brexit. Assurances from UK Government ministers don't match up for a firm exporting around a quarter of their products to the EU. As the owner put it, orders from the USA have always been a bit of a pain, but it was an occasional pain, not a constant backache!

The other firm has suffered pretty severely during the lockdown. It has had some help from the UK and Scottish Government schemes. I had heard that these were not always easy to access, and there were delays. However, I hadn't appreciated just how difficult it could be. Particularly for small businesses who don't have the in-house administrative expertise. I also discovered that ministerial announcements don't necessarily mean that the scheme is even up and running, let alone paying out.

With this experience, I paid a bit more attention to an article by competition lawyer Michelle Meagher in the RSA Journal's latest edition. She argues that as large global companies accumulate more power, competition laws are no longer fit for purpose. She uses the analogy of a combine harvester, in which big business sucks in the land, capital and people and churns up the world as it goes. This is reinforced by limited liability, short term shareholder value maximisation and executive remuneration. All of this has led to a concentration of markets, channelling power to a few companies in each industry. Instead of protecting the public interest, competition law is aligned to the needs of the combine harvesters. She proposes three solutions around dispersing, democratising and dissolving power. It reminded me of the, admittedly more radical, arguments in Andy Cumber's book The Case for Economic Democracy.

Wearing a different hat, I discussed the FSB's manifesto for the Scottish Parliament elections this week. I can remember when I might have struggled to find much that I agreed with in a small business manifesto. However, there are plenty of decent progressive ideas in this paper, which is well worth reading. Not least the call for a bigger share of public procurement. 

The discussion has reinforced my view that Community Wealth Building is a critical economic initiative, and that more can be done to support smaller businesses that keep wealth local. My recent experience has also taught me that the vast number of schemes aimed at helping small business, often confuse and complicate access. In my last Reid Foundation paper, the public service hubs idea could also be developed to provide a one-stop-shop for business support.

Scotland's economy is built mainly on small businesses with more than a million jobs dependent on the sector. Like so many other areas, the pandemic has highlighted long-standing problems and created new ones. If we are to build back better, we have to support small businesses to be part of the solutions.

Moving pension funds past the greenwash

The investment industry is responding to the demands of pension funds for investment strategies that address climate change. However, we should seek to distinguish between meaningful action and greenwash.

I have completed a couple of projects with pension funds in recent months looking at Environment, Social and Governance (ESG) strategies. These are a set of standards for a company’s operations that socially conscious investors use to screen potential investments. Advisors have been developing ESG ratings, which should make it easier for pension fund managers and trustees who don’t have an in-house capacity to assess investment funds. However, these are very broad and, in my experience, often overly generous.

There are also a growing number of initiatives that seek to align investments with the Paris agreement. This committed most of the world to limit global heating to 1.5C above pre-industrial levels, even if progress has been decidedly mixed. The latest includes Legal and General Investment Management, Fidelity International, Schroders, Wellington Management, Axa Investment Managers and M&G. They have signed up to a pledge that they will aim for all companies in their portfolios to be decarbonised by 2050 or earlier. They have also set interim 2030 targets to decarbonise their portfolios.

Some are rightly sceptical about these initiatives. As the Reclaim Finance campaign group, said: “We seem to have a lot of platforms and not enough trains. Without question, what we do need is a truckload more ambition from investors. Will this group deliver that? It seems unlikely, given that there is no collective commitment to exclude coal or to halt the expansion of oil and gas, both seriously at odds with the stated goal of this coalition.”

Scepticism is also a feature of an excellent report by the Association of Member Nominated Trustees (AMNT), which says that pension funds are often blocked by fund managers, who not only ignore the wishes of their clients but often take contrary positions. The report sets out practical solutions that allow pension schemes to meet their stewardship obligations. 

The report’s author is Professor Iain Clacher, who also wrote a ground-breaking paper on reforming Scottish local government pension funds. His main conclusions are:

· The barriers presented to split voting in pooled funds are not insurmountable, especially as some fund managers have already been doing this for some clients. 

· There needs to be a simplification of the voting chain and investment in technology to enable the effective stewardship of pension fund investments for the long run.

· Asset owners need to be more proactive in their stewardship approach, but they cannot do so without the support of their fund managers and investment consultants. So far, this has been sadly lacking.

· In the short term, asset owners should develop their own voting policies on ESG issues they deem to be financially material, as well as benchmark their fund managers’ voting policies against their own, and hold them to account for it accordingly. If their investment consultants do not support them in this endeavour, they should consider changing advisors. 

· Fund managers should at a minimum report against client voting policies on a comply or explain basis so that asset owners can make more informed decisions.

In my experience, this paper is spot on. Too many reports to trustees are either too complicated or oversimplified greenwash. These recommendations are an important step in the right direction.

Procurement failures

The UK Government is mired in a series of procurement scandals that go way beyond poor practice. While not on the nearly on the same scale, all is not well in Scotland either. In recent months I have completed a couple of projects that examine specific procurement programmes. Similar issues cropped up in both projects, which reflect some long-standing lessons that organisations have failed to learn.

 

Barely a day goes by without UK Government procurement stories being reported in the media. Some examples include:

 

·      Sourcing PPE from factories in China where hundreds of North Korean women have been secretly working in conditions of modern slavery. They have no days off and the North Korean state seizes 70% of their wages. It also breaches UN sanctions.

·      PPE contracts involved a £253m deal with Ayanda Capital, a London-based investment firm whose senior adviser was Andrew Mills. At the time, Mills was also an adviser to the Board of Trade. The government paid Ayanda £155m for face masks with ear loops, which could not be used by the NHS.

·      A Spanish businessman was paid more than £21m in taxpayers’ money to act as a middleman in the sale of personal protective equipment to the UK government by a Florida-based jewellery designer.

·      A contract, without a tender, paid £550,000 to the policy consultancy firm Public First for polling and focus groups. No formal contract was put in place until 5 June. The NAO found, “no documentation on the consideration of conflicts of interest, no recorded process for choosing the supplier, and no specific justification for using emergency procurement.”

·      The Ministry of Housing, Communities and Local Government (MHCLG) awarded a £600,000 research grant to a consortium whose members include a fire testing specialist whose research has been funded by Kingspan, the company that made some of the combustible foam used in Grenfell. As well as a fire engineer who has publicly opposed outright bans on combustible materials.

 

A National Audit Office (NAO) investigation into pandemic procurement concluded that normal standards of transparency were waived as departments awarded 8,600 contracts worth £18bn to tackle COVID-19. Deals worth £10.5bn were granted without competitive tender and companies recommended by MPs, peers and advisers were given priority. As the chart below shows, 58% of contracts value was awarded directly to a supplier. Even allowing for the urgency, this is well below the standards taxpayers have a right to expect from public procurement. An issue which is now the subject of a legal challenge from the Good Law Project.

In a recent report for Prospect, I highlighted a number of poor procurement practices in the plan to centralise Highlands and Islands Air Traffic Control. In that report, I listed a range of IT procurement failures in Scotland. One of those failures was Disclosure Scotland, which is continuing to spend millions of pounds to manually deal with disclosure applications more than a year after an IT system £44 million over budget went live. The Scottish Government has also had issues with PPE procurement. The alteration of use-by dates on vital PPE equipment has raised concerns that the Scottish Government is short-changing key workers by providing out-of-date equipment. 

Procurement is important because the spend generates around £10bn of economic activity for Scotland. However, too little of this spending is linked to creating jobs in Scotland, with only 100,000 jobs supported. SME’s have also long complained that they get a disproportionate amount of this spending, and the latest procurement report shows that SME’s get around 1% of total procurement spending. As Richard Leonard MSP recently said, “The SNP Government have handed billions of pounds of public money over to contracts, with little job creation and SME support in return".  

 

I was closely involved in the development of the Procurement Reform (S) Act 2014, which attempted to use procurement as an important lever to deliver broader government objectives, including employment standards and sustainability. Progress has been made in delivering the real Living Wage in contracts, ironically one of the most contested features of the legislation. Outwith this improvement, the latest annual report is full of process and ambition, but limited hard evidence that real progress has been made.

Public procurement properly managed is an essential lever for devolved administrations to deliver their policy priorities. UK Government's pandemic procurement has been a shambles, and in Scotland, the scorecard remains at ‘could do better’. 

New thinking on constitutional options for Scotland

With immaculate timing, Boris Johnson blunders into the devolution debate on the eve of the Scottish Conservative conference describing devolution as a "disaster north of the border". Fortunately, we have several more considered contributions to the debate in recent weeks.

 

The Prime Minister’s comments are, even by his own standards, bizarre. Even the UK Government's own website says, "devolution has made a real difference to the lives of people in Scotland - and recognises the wishes of the people to have more say over matters that affect them". As one veteran Scottish Tory told the BBC: "This is dire - it's totally out of touch and reflects a Westminster-centric view of 1992, not 2020”. Another said: "The anger tonight is palpable and the worst I've ever seen towards a Tory PM."

 

For a considered view of the constitutional question, I would recommend a paper the Jimmy Reid Foundation commissioned from Professor James Mitchell to outline and assess the constitutional options for society in Scotland from a left perspective. He argues that Scotland’s constitutional question has become stuck in a rut and the primary focus should be on the impact of proposed changes on citizens’ wellbeing. His broad international analysis points out that states and nations are artificial concepts which change and evolve; just as the UK has with its series of unions.  

The UK’s diversity has still resulted in a highly centralised state, despite Johnson’s, and in fairness some previous prime ministers’ frustrations, at not being able to direct everything from London. James Mitchell goes on to set out the need for rules on any future referendums and the need for a new constitutional convention on how they are triggered. He argues that having more options would empower voters by increasing possibilities, encourage constructive voting allowing people to vote for first preference option rather than a least disliked option; signal views across a wider range of options; and potentially identify an underlying, and otherwise hidden consensus.

 

This is not the same as John Major’s recent suggestion that Westminster could agree to another referendum based on two linked votes, the first to vote on the principle of negotiations, and the second on the outcome of them. Although it does indicate some moderate Tory thinking in the light of the Brexit referendum.

 

As someone who is neither a unionist nor a nationalist, I am naturally attracted to James Mitchell’s argument, ever hopeful (God loves an optimist!) that a consensus could be achieved. While nationalists may be buoyed by recent opinion polls, I would argue that reflects the political case for independence. An actual referendum would also highlight the economic case, which as Laurie Macfarlane has recently argued is much weaker.

 

Another interesting contribution to the debate comes from Ben Thomson in his book ‘Scottish Home Rule’. He defines Home Rule as “a bilateral arrangement between one area within a nation state and the rest of that nation state. This is distinct from federalism, which represents an equal relationship between all constituent parts of a country”. This makes Home Rule a more practical option for the asymmetric UK, although he argues that it could provide a template for the UK to move towards federalism. The difference between Home Rule and devolution is that people in Scotland would know control over domestic matters is decided solely by them, and that this cannot be unilaterally overruled by Westminster and its Prime Minister.

As the secretary of the Keir Hardie Society, I have to regularly explain that Hardie’s support for Home Rule is not the same as independence. He came from the Liberal tradition of Home Rule, largely focused on Ireland during his lifetime. So, I welcome a modern exposition of the concept in Thomson’s book. 

 

Finally, Neil Findlay MSP reminds us in the media last weekend that constitutional powers have to be for a purpose – a society with social justice at its core. He makes a case for Devo-Max, the devolution of powers to the lowest possible level unless there is an overwhelming reason not to. This means that powers do not stop at Holyrood – we need to devolve power to councils, workplaces and communities.

 

Getting past the entrenched positions that many people take in Scotland over these issues is not easy. However, at least there is some constructive thinking on what the alternatives are. 

Contrasting approaches to the crisis of care

The COVID-19 pandemic has inspired several new books, which seek to analyse the impact on our healthcare systems and broader society and propose reform. I have read a number of these as background to a paper for a European wide study of the impact of the pandemic on older persons and other work. In this blog, I will share two contrasting examples of these.

 

The Care Manifesto (Verso Books) has been written by a group calling themselves the Care Collective. It analyses the impact of the marketisation of care, which has resulted in those most at risk from COVID-19 receiving too little support. This has allowed multinational corporations to make huge profits out of financialising and overleveraging care homes while work in the care sector was subsumed into the corporate gig economy, mostly at the expense of women as workers and carers. This has been achieved because “ideas of social welfare and community had been pushed aside for individualised notions of resilience, wellness and self-improvement, promoted through a ballooning ‘selfcare’ industry which relegates care to something we are supposed to buy for ourselves on a personal basis.”

They argue for a model of ‘universal care’, which puts care at the heart of our society from our kinship groups and communities to our states and planet. Chapters explain how this would apply to our politics, family, communities, the state and the world. It addresses care in its broadest context, rather than looking specifically at systems or structures. I thought the communities chapter was strong, chiming with a number of the themes I set out in my recent Reid Foundation paper. They propose four core features to the creation of caring communities: mutual support, public space, shared resources and local democracy.

 

While it is hard to disagree with most of the content, even if it is prone to assertion rather than evidence, the language is likely to jar with the general reader. As they say, “The Care Manifesto offers a queer–feminist–anti-racist– eco-socialist political vision of ‘universal care’”. Fine, but this is not likely to find its way into a political programme. Overall, it’s a concise and broad picture of what a different society could look like, but too few practical steps to really call it a manifesto.

 

In contrast, Madeline Bunting’s, Labours of Love: The Crisis of Care (Granta Books), is a more personal argument about the invisibility of care, and its historic under-valuing – based on extensive interviews with people caring for others. The purpose of the book is to make visible the nature of the vast web of care – its importance, extent, subtlety and complexity.  She too hopes the pandemic will see a new politics of care emerging which recognises our interdependence as families, friends, communities, nations and as a human species. 

 

The chapters take the reader through various aspects of care with a final section in each chapter on what we mean by key words, kindness, compassion etc. I enjoyed her story of the manager who, “advised staff to ‘populate the document’ with the ‘likes and dislikes’ of the ‘service user’ as a form of person-centred care: it amounted to getting to know someone with the help of tick boxes”. To be fair, I have seen much worse management speak in the sector.

The hospital chapter includes a story about a snap session with a consultant, which had to be followed by the nurse spending time finding out and sorting the patient’s problem; “Once he (the consultant) has gone, the work of nursing starts. Sam (the nurse) sits down, and places a hand on Derek’s arm to try and calm his anxiety. Finally, he can start to explain”. This is something every nurse can relate to. Time to care is a key issue as the pressure to free up beds is intense and becomes one of the main preoccupations of nurse managers. Hospitals are clocking up record, and potentially dangerous occupancy levels as the number of hospital beds have declined - by a quarter in Scotland since 2009. The chapter on GP services shows similar time constraints.

 

When it comes to time to care, the chapter on home care highlights much that is wrong with social care. Even in what looks like one of the better care organisations in the private sector, “More than half the clients left every year, and the turnover of staff was just as high. The instability necessitated continuous marketing and recruitment, requiring full-time dedicated staff, a substantial cost for this small business”. In another company, home-care visits were fifteen minutes. A new care worker was shocked, ‘I was very green and willing; they trusted me with very vulnerable people after only three hours of basic health-and-safety training. I had no training in moving and lifting, and it’s left me with historic back pain. I wasn’t paid for travel time”. Another care worker highlighted a common response that I used to see in UNISON surveys, “A lot of people literally pleaded with me to stay for a moment, just to have a cup of tea”.

 

This is a beautifully written book that balances traditional evidence with the stories of care workers and communities, all in language we can readily understand. She spoke to individual care workers who are expected to reconcile market principles with their own understanding of people’s needs and their responsibility, and it is those at the bottom of institutional hierarchies who felt the contradiction most keenly. It is also an overwhelmingly gendered role, which in itself says much about our society.

 

Bunting concludes that the marginalisation of relationships may be most graphic and disturbing in low-paid parts of the care economy, but it has infiltrated virtually every dimension of care. Paperwork has become the way to avoid blame and manage risk and marketisation, bureaucracy and technology, is diminishing the primacy of people and the care relationship. 

 

Two contrasting studies reach similar conclusions through different routes. Well worth a read.