Job Quality and Job Separation of Direct Care Workers in England.

Background and Objectives: Most job leavers in the long-term care (LTC) sector in England do not leave the sector, but rather move to other LTC employers. Nevertheless, the high "churn" can have a negative impact on continuity and quality of care, care providers' recruitment and training costs, and the remaining staff workload and motivation. This study aimed to provide quantitative evidence on the drivers of direct care workers' job separation in England, with a focus on job quality. Research Design and Methods: We used yearly data (2016-19) from the Adult Social Care Workforce Data Set, the leading source of LTC workforce data in England, including information on both LTC workers and employers. The analysis considered panel data econometric methods that accounted for unobserved heterogeneity at worker and employer levels. Results: After controlling for observed individual, organizational, 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 reduce job separation. For example, a 10% wage increase from the sample mean would reduce the job separation rate by about 3 percentage points. This wage effect was more than halved (i.e., downward biased) when not accounting for unobserved effects. Discussion and Implications: The persistent high staff turnover in LTC in England highlights the need for finding practical solutions faced by care providers and policy-makers. Our findings showed that improving pay and employment conditions can be the way forward while methodologically stressing the importance of accounting for unobserved variable bias.

The Impact of Wages on Care Home Quality in England.

BACKGROUND AND OBJECTIVES: In many countries, a large proportion of long-term care staff are paid at, or near, minimum wage, leading to concerns of negative effects on care outcomes. This study analyzed the effect of staff wages on care home quality ratings in England. RESEARCH DESIGN AND METHODS: A national staffing database of long-term care providers was matched with local-area information on needs and supply to construct a 3-year panel (2016-2018) of English care home observations. Using multiple imputation methods to address missing data provided a data set of 12,055 observations of 5,556 care facilities (both residential and nursing homes). We analyzed the effect of the facility-level average hourly wage of care staff on national regulator quality ratings. A measure of the impact of exogenous changes in the national minimum wage on care facilities was used as an instrument for wage. RESULTS: We find that wages positively affect care home quality ratings. Other things equal, a 10% increase in the average hourly wage of direct care workers would lead to a 7.1% increase in the likelihood that a care home will have a high-quality rating. The wage effect on quality was significant when controlling for staff skill mix, measured as the share of registered nurses in nursing home staff. DISCUSSION AND IMPLICATIONS: This study provides important evidence of the positive impact that staff pay can have on the quality of long-term care. Our finding has important implications for appropriate levels of pay and the funding of long-term care.

Recruitment, retention and employment growth in the long-term care sector in England.

This paper studies the relationship between turnover, hiring and employment growth in the long-term care (LTC) sector in England and sheds light on how challenges in both recruitment and retention affect the sector's ability to meet growing demand for care services. Using the Adult Social Care Workforce Data Set (ASC-WDS), a large longitudinal dataset of LTC establishments in England, and fixed effects estimation methods we: (a) quantify the relationship between the in/outflow of care workers and the expansion/contraction of employment within establishments, (b) establish the role of staff retention policy for workforce expansion, and (c) identify the role of recruitment frictions and its impact on hiring and employment contraction. Our analysis indicates that care worker turnover and employment growth are negatively related. A one percentage point increase in employment contraction is associated with a 0.71 percentage point rise in turnover, while a one percentage point increase in employment expansion is associated with a 0.23 percentage point fall in turnover. In contrast, we find that hiring rates and employment growth are positively related. A one percentage point increase in employment expansion is associated with a 0.76 percentage point rise in hiring, while a one percentage point increase in employment contraction is associated with a 0.26 percentage point decrease in hiring. We argue that the negative turnover-employment growth relationship within expanding establishments provides evidence that better staff retention is associated with higher employment growth. Using information on establishments' annual change in vacancies, and controlling for changes in new labor demand, we also find rising year-on-year vacancies amongst establishments with declining employment. This provides evidence that recruitment frictions drive the declining rate of replacement hiring amongst contracting establishments. Across sectors, we find that the employment growth-turnover and the employment decline-hiring relationships are relatively stronger in the private and voluntary sectors compared to the public sector, suggesting that the impact of staff retention and recruitment frictions on employment is more acute in these sectors.

The Association between Staff Retention and English Care Home Quality.

This paper examines the association between workforce retention and related staffing measures and the quality of English care homes using a national database of social care providers' staffing. The analysis finds significant correlations between quality and the levels of staffing vacancies and retention of both residential and nursing homes, but no association was found between quality and the use of temporary contract workers nor the resident to staff ratio. Only for staff vacancy rates was there a significant difference in the size of these relationships between types of home. The findings suggest that quality could change for the average care home with a relatively small alteration in staffing circumstance. Long-term care is a labor-intensive industry and many countries face relatively high levels of staff turnover and job vacancy rates. These findings are therefore of interest for policy internationally and for England in particular, where the development of social care recruitment and retention strategies are ongoing.

Measuring the outcomes of long-term care for unpaid carers: comparing the ASCOT-Carer, Carer Experience Scale and EQ-5D-3 L.

BACKGROUND: The ASCOT-Carer and Carer Experience Scale are instruments designed to capture aspects of quality of life 'beyond health' for family carers. The aim of this study was to compare and validate these two carer care-related measures, with a secondary aim to compare both instruments to the three-level EQ-5D (EQ-5D-3 L) measure of health-related quality of life. METHODS: An interview survey was conducted with 387 carers of adults who used long-term care (also known as social care) support in England. Construct validity by hypothesis testing was assessed using Pearson correlation coefficient. Exploratory factor analysis was also applied to investigate the dimensionality of the combined items from the ASCOT-Carer and CES (as measures of carer quality of life 'beyond health') and the EQ-5D (as a measure of health-related quality of life). RESULTS: In the construct validity analysis, hypothesised differences in correlations were observed with two exceptions. The exploratory factor analysis indicated that the ASCOT-Carer, CES and EQ-5D-3 L items loaded onto three separate factors. The first factor comprised the seven ASCOT-Carer items plus two CES items (activities outside caring, support from friends and family). The second factor comprised three of the six CES items (fulfilment from caring, control over caring and getting on with the person you care for). The third factor included four of the five EQ-5D-3 L items. CONCLUSION: The findings indicate that the ASCOT-Carer, CES and EQ-5D-3 L capture separate constructs of social care-related quality of life (ASCOT-Carer) and carer experience (CES), which partially overlap in relation to activities outside caring and social support, and health-related quality of life (EQ-5D-3 L). The ASCOT-Carer and CES are both promising measures for the evaluation of social care support for carers that capture aspects of quality of life 'beyond health'. The choice of whether to use the ASCOT-Carer or CES depends on the study objectives.

The impact of long-term care on quality of life.

Long-term care services are provided to help people manage the consequences of impairment, but their impact goes beyond the meeting of basic needs. Accordingly, the main aim was to explore the marginal effectiveness of care when measured in terms of people's overall care-related quality of life (CRQoL) and assess changes in marginal effect for increasing intensity. The associated aim was to refine and apply an observational method to estimate marginal effectiveness. A "production function" approach was used with survey data, including Adult Social Care Outcomes Toolkit-measured CRQoL, whereby we statistically modelled the expected relationship between service utilisation rates and CRQoL. This method seeks to limit endogeneity issues by controlling on observables and using instrumental variable. Using a survey of publicly funded long-term care service users in England, we found that community-based long-term care significantly improved people's CRQoL but with diminishing marginal effects and effects differentiated by baseline impairment levels. There are implications for how the care system should respond to changes in global public budgets. For example, where there is unmet need, a system aimed to maximise (unadjusted) CRQoL would put more emphasis on access (more recipients) than intensity of support compared to a system operating on a needs basis.