Strikes by care workers highlighting the crisis in the sector have been predominately urban - and yet, it is widely accepted that the crisis in adult social care is felt most acutely in rural areas. Can workers in England’s rural hinterlands fight back in the same ways as their counterparts in the city? In this series of short articles, each worker discusses their attempts to unionise hospital and domiciliary care in a semi-rural or rural setting.

The care system in Britain rests on a fractured “supply chain”. Those on the receiving end of care will frequently move between hospital care and care provided at home. The worker who provides care in an NHS hospital will be on completely different terms and conditions than a worker in domiciliary care, whose wages are paid by a private agency. But for those being cared for, both are part of the “same supply chain”.

This piece starts with Rebekah, a healthcare assistant working inside a hospital serving a large semi-rural and rural population. The hospital can be seen as the factory within the supply chain. Visit a hospital and you will see a mass assembly line, which is in the business of producing discharges from its care. Rebekah is based in Carlisle, one of England’s most northerly, isolated cities. While the hospital is located in the town, the workforce is distributed across Carlisle’s vast rural belt.

The View from the Hospital

Cumberland Infirmary is a 444-bed hospital in Carlisle, covering the city centre and all the villages in its massive surrounding rural belt. The hospital was built during the salad days of privatisation, becoming the first hospital in the country to be financed and managed by the disastrous Public Finance Initiatives (PFIs). PFIs were used extensively by the New Labour government in order to get private companies to frontload the costs of building hospitals. In ‘exchange’ - though some might call it a ransom - each NHS Trust had to pay this “loan” back over a number of years, including the massive accrual in interest set by the private firm. North Cumbria Integrated Care, the NHS Trust managing the hospital, is thought to pay more than £23m in annual PFI fees out of taxpayers’ money. At the end of the 35-year PFI contract, it will not own the hospital building.

I’m a Healthcare Assistant working at the Carlisle site. I started four years ago as a stopgap after abruptly leaving university. Originally, I wanted to be a doctor, but I revised my expectations after A-level results, and went to university to study physiotherapy instead. I dropped out after two years, a combination of the upheaval caused by the pandemic and poor mental health. As a physiotherapy student, you were entitled to work on the bank as a HCA. We all joked as we applied about being ‘arse wipers’ to top up our student loans. As a 19-year-old, I don’t think I realised just how important the job was. When I dropped out, I needed a job to tide me over. I never thought I’d still be doing it today. But here I am.

When I start my shift, we receive a handover from the night staff and then go to prepare breakfast. The domestics (outsourced, of course) should do the hot drinks trolley, leaving us to do the food, but their routine doesn’t always align with ours. We are responsible for the feeding of patients, and people want a cup of tea with their toast, so we do that too. Then we get everyone washed and dressed as best we can. For some reason, the ordering system never gets us enough soap, so we often bring in our own. Sadly, most patients are in hospital nightwear. A feature of the area is poor bus services, and with a hospital covering such a large county, relatives can’t get in on a regular basis to visit and bring clean clothes.

Throughout the day, we do a variety of tasks, we reposition patients to protect the integrity of their skin, and assist with incontinence products. We also check blood sugars, immediately treating any lows, informing the registered nurses en route back to the patient. We “1-1” patients who display signs of poor mental health, delirium, or constitute a fall risk. We are often referred to by registered nurses and clinicians as their “eyes and ears”. Some of us also take bloods, place IV cannulas, and even catheterise. We do observations and calculate a NEWS2 score, an early warning system. However, what often goes without recognition is our instinct for a patient ‘just not looking right’, which can often be a harbinger of impending deterioration. The longer you work with a patient group, the more accurate that gut feeling gets.
It’s an unusual trust I work in in some ways, we have two acute hospitals. The Infirmary receives more acutely unwell patients, it’s also an hour away by car from its sister hospital, meaning when patients from West Cumbria get transferred to us, visiting can be nigh on impossible - and expensive. We’re fortunate in some ways to have several inpatient community rehab sites, but they’re often full, and when a patient is ready to go home, we can’t source a care package for them, especially if they’re rural. We had one gentleman who wished to die in his own home, but his only heating was a coal fire, and no care company would take him with that, so he spent his final days with us instead.

Where I work, anyone hired after around 2012 was hired as a band 2, despite being expected to perform the same duties as the band 3s. For a long time, we all accepted it as just one of those things, the NHS agenda for change pay system can be opaque to say the least, and nobody wants to be seen as the greedy one asking for more from a cash-strapped trust (aiming to save more than £30 million this year). Nobody really did anything about it until stewards in UNISON started getting organised in their workplace and pushed it to become a national priority for the union. UNISON resourced our branch with two organisers from the region who helped us get things off the ground. There were over 800 of us HCAs, spread across a dozen sites, so it was no mean feat.

It’s been quite a difficult area to organise in many ways. First, the geography seriously hampers us. Between North and West Cumbria, we are separated by the Lakes. Interestingly, there is a significant perceived cultural divide as you head towards Cumbrian towns along the West coast (Maryport, Whitehaven, and Workington). In Carlisle, we have always felt that those “out West” were more militant, which had a lot to do with their proximity to Sellafield - a site with huge union strength. These important differences have fuelled a persistent ‘us and them’ attitude between the two acute sites, with baseless rumours about better conditions rampant at both hospitals. At my site, the wards are organised as offshoots from a long U-shaped gallery corridor, which really discourages staff from mixing, the building is said to share an architect with a local prison, and you can tell.

A Broken Conveyor belt

One of the main problems facing the hospital is a lack of beds, often due to medically fit patients waiting for care packages, appropriate living arrangements or deep cleans to make their homes habitable again. Laughably the trust is burying its head in the sand, and closing what it terms ‘escalation’ beds, despite still having the need for them. When I started on my ward, it had 27 beds, we went up to 32 for 18 months and now we’ve been cut to 22. Every weekend, and often during the week we go over capacity by several patients, but this actually still leaves us with empty physical bed spaces, instead of using these spaces, the trust forces people to sleep in corridors on other packed wards, with no toilet facilities, emergency equipment or call bells. As workers who take pride in what we do, we find this inhumane and demoralising. And yet, despite being willing and able to staff the ward for 32 patients, the trust won’t allow it and leaves vulnerable people in public places, scared and at risk.

The crisis in care is so closely linked with the crisis in the health service. In fact, the two can’t really be looked at in isolation. Both are currently operating on a broken conveyer belt. NHS workers and those in care need to work together on this and share experiences of how to build and strengthen local union branches. There will be different challenges in the care sector, where there is little to no union recognition, and employers are generally more volatile. But I think its important to draw from our strengths and to see ourselves as belonging to the same movement. The system is broken. Without the care system being fixed, the NHS can’t do what it was built for. The NHS only came about because we as a union movement had the strength and collective mindset to fight for it. We need to find that strength again.

Care in the Community

The labour process for NHS workers outside of a hospital setting presents a whole different set of challenges. Care assistants and community nurses performing medical care in a home setting are a kind of distributive pressure valve within the supply chain; resourced properly, it could be turned to relieve pressure on the hospital. Jack, an NHS-employed Home Care Practitioner (HCP), describes the decimation of community nursing teams and the increased clinical responsibilities subsequently placed on them as care assistants.

I’ve worked in care since 2010. Back in the 80s and 90s, when I was on the labour market, very few men worked in care. That changed when old industries rooted in the area faced closure. West Cumbria still has its factories, as well as big industrial sites like Sellafield, but the NHS and the care industry is now a massive employer in the area. I’ve lived in West Cumbria all of my life. A lot has changed. Care is still predominately a woman’s place of work, and it took me a while to get here. But there are more and more of us now working in a care setting, people who probably would have worked in heavy industry if we were a couple of decades older, or in the position of our fathers. My father, for example, worked at the second largest chemical plant in Britain, Marchon, which was based in Whitehaven.

I started as a care worker at a company called Walsingham, where I was based in learning disability support in a bungalow in Frizington, a small village north of the Lakes. I had been working here for about six months when I applied for a bank contract with Cumbria County Council, which involved a supported living bungalow in Workington. After a few years working for the council, I saw a job come up in the local NHS Trust for a ‘Home Care Practitioner’. At this point, I was now set on working for the NHS. For me, I saw it as the “holy grail” of care.
I had seen this Home Care Practitioner job come up before, but I assumed ‘Practitioner’ meant you needed to have gone to university. Many of the new job roles and job descriptions in the NHS appear vague and broad, particularly in lower-paid positions. But when I read the job description, I thought, actually, I could do that. I became one of ten Home Care Practitioners who were initially hired by the Trust to provide at-home support for those who had left hospital. Our role is to support rehabilitation and prevent those who have recently been discharged from being readmitted. We are often working with dementia patients who forget to take medication, and so we directly administer medication for these patients. Historically, this type of work would have likely been undertaken by a community nurse.

There has been a massive increase in demand for care in our area (Cumbria has an ageing demographic and it’s growing faster than in lots of other parts of the country). Staff are getting burnt out as a result. Since I started in the HCP role in 2018, I have witnessed the community nursing teams battle a major staffing crisis. Out of around fourteen community nurses, there’s now only one nurse left who I would actually know. Some have returned to a hospital setting, others have left the NHS entirely. It’s really hard to see these brilliant teams collapsing in front of you. My daughter was a healthcare worker in one of these community nursing teams, and she just watched everybody leave around her. She was absolutely set on being a nurse, but she saw a different side to how the care system is run in this country, and so she ended up leaving too.

Solidarity and Hierarchy

For us in the HCP team, our morale is probably more intact than it is elsewhere in the Trust. This is probably down to the fact that we do more lone working and have a bit more control over our working day. In contrast to HCAs in the hospital, the vast majority of whom work 12.5-hour shifts, we work split shifts (8 am-2 pm and then 4 pm-10 pm). The kind of worker-to-worker conflict you see in a hospital setting over issues of hierarchy and rank aren’t as present for us because of this.

Our line manager has protected us from many things, but we are quite isolated as a group of workers, and the Trust executives have been able to take advantage of that. From day one of the job, I started conducting ESGs and taking bloods from patients - I was also administering medication. Under the national job evaluation scheme in the NHS, these clinical duties are graded at Band 3. Yet we were paid at a Band 2 rate (which is the lowest-paid band within the NHS). This meant I had been paid incorrectly right from day one.

When I first started as a HCP, we would often work alone with patients who only needed 1:1 care, but as the demands of the service have evolved, we are increasingly called to assist with end-of-life care, and we often have to double up in twos for that. Working alone in these settings comes with huge responsibility. When I enter people’s homes, I have to monitor whether a patient is deteriorating and decide whether I need to call a nurse, doctor, or make an emergency 999 call. I haven’t got anybody at a desk who can help. I have to make that call.
Our caseload can vary massively, so it’s difficult to describe an “average” day of a Home Care Practitioner. Each call to a home takes around an hour (this includes travel, time spent with the patient, and writing up notes). If we are working at capacity, we would do six calls in the morning and six calls at night. However, there was an occasion when I made sixteen calls in one day.

Colleagues who came to join us from a private employer in a social care setting told us they were expected to do something like 30 calls in a day. So if you look at the broader picture, those of us working in the NHS are protected time-wise. But we still have a heavy and increasingly complex caseload. Sometimes you don’t get the chance to really spend time talking with patients – and this social aspect is so important, because for some of those we look after, we are the only contact they have.

Public transport in Cumbria is notoriously ropey due to the terrain and the weather. We have to drive to see patients in all seasons. There are huge areas in Cumbria where there is just no signal on your phone. Some of our calls include visiting farms on the sides of mountain and fell passes. I often think the working conditions we are used to would be unrecognisable for someone doing a similar role in Merseyside or Manchester. It can be dangerous work, and we’ve got women as young as 18 and 19 going out and doing this.

While we spend a lot of time on our own in this job, we are tight as a team. We all help each other, and we don’t sit back and watch anyone struggle. This became apparent during the Pay Fair for Patient Care campaign, which we ran locally as UNISON members with support from our regional organisers. During the campaign, we would often have meetings anytime between 2 and 4 pm - this hit the sweet spot of patient visiting times in the hospitals and the break in our split shift. In my team, I was able to bring about 7 or 8 out of the 14 of us to every worker meeting. We were an incredibly strong force in those meetings. We also had huge leverage, even if there was a small number of us. Very few healthcare assistants employed in a hospital setting could be shipped out to do our role if there was a strike, just because of how specialised it is. It’s not like moving hospital staff from ward to ward. You’re going from an institutionalised hospital setting into someone’s home – and you need training for that.

The Pandemic Effect

When I look back on the Pay Fair campaign, I find myself thinking about the importance of the pandemic. We were demanding that our role be regraded to reflect what we were actually doing in our jobs, and not what was listed on some outdated job description. We wanted the same deal which HCAs had secured in other parts of the country (especially in the North-West, where many Trusts had agreed to backpay which went back to 2018). We weren’t asking for a pay rise, we simply demanded the bare minimum; to be paid for the job we were doing. The Trust initially tried to impose a backpay deal, which went as far back as September 2021. For those of us who worked all through the pandemic, this was a slap in the face. After months of building up our membership and identifying leaders, we ran a two-week consultative ballot in which hundreds turned out to vote and expressed their willingness to take industrial action. It was an overwhelming turnout (80%) with 98% saying yes to action.
We subsequently won the battle on backpay and regrading. But there are still lingering issues over how our job is valued and assessed. The Pay Fair campaign has made us all scrutinise our job descriptions, and we’ve learnt that there are some tasks we perform as HCPs which are even beyond the new Band 3 job descriptions, such as administering medication.

When the pandemic ripped through our hospitals and care homes, banding and rank went out the window. Everyone went above and beyond. As HCPs, we were very much on the frontline. We were sent absolutely everywhere. We would be sent into these privately run care homes where there were no directly employed nursing staff to perform venepuncture and do swabs. When I went into these care homes, I swabbed hundreds of people who died from COVID. It was such a terrifying and hazardous situation, and there we were putting our bodies on the line while being paid a few pennies above the minimum wage.

Care in this country is undervalued. I think most people would agree on that. The pandemic put us on a pedestal for a very brief moment. It showed us how reliant the country and the economy were on care workers. It also showed us how quickly these moments of opportunity to bargain for more can disappear. We need to have a serious conversation about how care is done in this country, and it needs to be those working on the shopfloor leading it. Nationally, across the health service and the care sector, we are still divided. Even within the NHS, terms and conditions aren’t the same in every Trust. To build serious industrial strength, we need to work together across the shopfloor, with every staff group, regardless of rank or responsibility.

Domiciliary Care

Most of the care now provided to people in their homes will be performed by domiciliary care workers. This is often where care is purchased directly by ‘customers’ or ‘clients’ in the supply chain. Danii, a domiciliary care worker based in Norfolk, explains how he got organised against a hostile employer.

I came to the UK as a trained care worker through the Skilled Worker visa because I really wanted to work in the health and social care sector. The person-centred part of care is my passion. Back in Sri Lanka, no such role exists, so I thought the UK was the best place to follow my career and for my personal and professional growth. I like the person-centered side of care, where I can use my expertise and experience to make a difference and be like a hero to support people to achieve their goals. Back home, I thought working here would mean I could actually improve people’s lives while also building a better situation for my family and me.

The company I worked for wasn’t great. We worked really long hours, but the pay wasn’t good. Often, I had to return to work even when I was sick, and they didn’t seem to care much about our well-being. As domiciliary care workers, we didn’t get paid for the time we spent travelling, and the gas money they gave us was nothing. Fixing and keeping my car running cost me so much, so I was always broke. Although we were paid as domiciliary care workers, we weren’t helped to obtain our licences, have our cars’ MOTs, or even get insurance. This all came out of our pockets, which left us in a bad financial position. They paid for fuel, but only 32p per mile - peanuts.

The job was tiring, and I barely had any time to hang out or see friends. The work was stressful from the start, as we were bound to our employers by the sponsorship visa, and the boss made us work continuously, not allowing me to get a proper rest. I had to work very long hours, which separated me so much from my social life. This triggered my anxiety, and since I spent most of the time at work, I could not continue a healthy eating pattern. Due to financial issues, I sometimes needed to eat unhealthy, cheap food, which made me physically weak and ill.

My mental and physical health were declining. When I got sick, management focused solely on getting me back to work, calling me every day to ask for a return date. I had to submit a sick note to my employer, and they told me they would only pay me when I came back to work. After this bullying, I decided to resign.

A day as a domiciliary care worker

A normal day started super early and ended late. I would start at 7 am and often run through to 10 pm at night. I’d drive from one person’s house to another, helping them with tasks like washing, getting dressed, eating, taking their medicine, and just spending time with them. The work itself felt important, but the way they scheduled things didn’t give us time to breathe. Sometimes, I’d be rushing all over town without enough time to even eat. By the end of the day, I’d be totally worn out.

I would spend 30 or 45 minutes at a service user’s house, a maximum of 1.5 hours. I found that the time is kind of enough, as they allocated extra time for calls. More time means more money, so companies make sure we spend more time in households. I would usually see five to seven people a day. This does mean we work closely with service users and see the same people every day, we talk and interact with each other. Because I worked rurally, I spent a lot of time driving. Depending on traffic, I could be driving as long as 45 minutes between houses. This travel time was all unpaid, so in a 13-hour workday, I got paid only for 6-7 hrs.

We get our rota from an app. We use it to log in at houses, upload the care notes, and complete the tasks set. The app works well, but sometimes, as we work on the road, the signal can be difficult. As we use our personal handsets, which we are not paid for, we sometimes run out of data. In those cases, the office won’t receive updates until we are in signal range or under Wi-Fi. So we face the risk of being falsely accused of falsifying the records, which does happen. We are required to turn on our location, which means these apps and the office can track our whereabouts. These are our personal mobiles, and this is done without our consent.

Some service users see us as housekeepers and we have to do tasks beyond care sometimes. In the contract, most companies mention that we have to do light domestic work, but I think that’s a trick. Light domestic work involves tasks such as washing service users’ cups and possibly putting away their clothes, simple domestic tasks related to them. But most service users live with family or their partners, so sometimes you need to do loads of dishes. On some occasions, you cook food as well and, let’s say, in the festive season, sometimes you will end up washing up after guests as well. Some care jobs seem to be primarily focused on domestic work.

We get a two-hour break, but mostly we spent it on the road or in car parks. It’s very stressful because the weather is not friendly most of the time. The area I worked in was rural, so I had bad signal and I couldn’t use my mobile or speak to my family. Sometimes, I would just have lunch in the car or sleep.

Life When I Wasn’t Working

Life outside of work wasn’t easy either. Finding a place to live was expensive, and places were really small. Because I worked so much, I didn’t have time to make friends or feel like I was part of things, and I would spend my off days doing laundry, weekly shopping, and meal prep. Because of this, I was draining myself. I was always trying to take care of my family and do what the job needed. Sometimes, it felt like I was taking care of everyone but myself. I could see myself draining and losing every day.

Getting Organised

The rest of our care team experienced the same problems I did, and one of our group members mentioned PAWA to us one day and provided us with some information to Google. The team then decided to go ahead and join this union, and with support from the helpful reps, we started a campaign to stop being taken advantage of and get what we deserved, like fair treatment, pay, and returning our stolen wages. Initially, many of us were concerned about losing our jobs, being singled out, or not being taken seriously. But by talking to each other, sharing our experiences, and sticking together, we realised we were stronger as a group. We formed a group, went to meetings, and supported each other publicly. We gained more people’s attention to what we were dealing with, and we had a better chance of receiving fair pay and respect at work.

Previously, I didn’t do much with unions, but this campaign taught me the importance of working together. It showed me that things can get better when workers unite.

There are still many problems. Many care workers are migrants who are scared to speak up because they think it might affect their visa or whether they get to keep their job. The long hours and low pay don’t leave much time or energy for involvement. Some companies try to stop union activity or make people afraid. But I think that if care workers stand together, share what’s happening to us, and help each other out, we can make sure every care worker in the UK has a voice and is treated with respect.

Life as a domiciliary care worker is hard. I can’t wait to get my right to live in the UK, have a normal work life and not being a modern slave anymore. I thought I could do this for five years and get status, but they are now debating in parliament making it 10 years.