“It's been hard… when they talk about frontline workers or whatever, that was me.”
Health and social care was in crisis before the pandemic struck – in 2019 there were more than 122,000 vacancies at any one point in adult social care. When the pandemic arrived, policymakers and employers in health and social care were faced with the challenge of continuing their services with reduced staffing due to exposure to the virus. Given how critical this sector is to society, existing staff shortages and the exacerbated risks to delivery of worker sickness through COVID, the UK Government began to consider a vaccine mandate.
COVID-19 has highlighted the extent to which our society, and the economy, rests on essential but undervalued care work. In parallel, the health and social-care sector has been at the sharp end of the debate around the ethics and feasibility of making mandatory vaccinations a requirement at work, and has had a profound impact on the working lives and sense of dignity experienced by carers across the country.
Building on a design-thinking workshop on revaluing care, we conducted qualitative interviews with five care workers in January 2022 to explore the immediate and wider implications of the vaccine mandate. The primary theme that emerged from the conversations was the importance of meaningful worker engagement and voice, which our research suggests is closely linked to how care workers’ feel valued by their employers and society as a whole.
9 November 2021 – Department for Health and Social Care announced it would be extending the vaccine mandate from care home workers to all health care workers raising significant concern around staff’s willingness to vaccinate as a result.
11 November 2021 – Regulations came into force making two doses of a COVID-19 vaccine a requirement for care-home staff. This applies to all Care Quality Commission (CQC) regulated care homes providing nursing or personal care in England. In addition to highlighting the reduction of transmission levels as a result of having received two doses of a vaccine, the regulation also stressed the expected reduction in COVID-19 related staff absences.
31 January 2022 – Press release published by the Department for Health and Social Care. The department launched a consultation, and it was expected that the requirement for health and care workers to vaccinate would be removed.
15 March 2022 – The legal requirement for Health and Social Care staff to be vaccinated twice is scrapped following the consultation in which 90% of responses were in support of the removal.
A crucial factor was missing from the deliberations around the introduction of a vaccination mandate: the views and insight from the workers that would be affected. This increased risk of losing staff, rather than reducing it.
Several of our respondents reported that their colleagues were walking out of the job quietly for lack of being able to air concerns about the vaccine. At the forefront of their concerns was the sense that a compulsory vaccine would undermine their sense of autonomy:
“I know that lots of people who work in care who refused to take the vaccine … I do know they lost their jobs. This has affected my service too [because] I do believe in free choice….The number of care workers in England has dropped dramatically, because so many people lost their jobs or have voluntarily walked out of their jobs because they didn't want to get the vaccine.” – Care assistant
Although the mandate has now been revoked, care workers have felt the impact of the announcement strongly. The mandate dominated workplace conversations and care workers have seen their workload intensify as a result of their colleagues leaving the job.
“I think there's a split. Some people are for it with some caveats. And some people are not for it, not for anti-vaccine reasons, but for bigger reasons around imposing something, and the mandatory nature of it.” – Senior nurse
None of our interviewees reported taking issue with the vaccine; instead, they were concerned with the mandatory nature of the policy, the practicalities of its implementation and the potential for workers being alienated from this issue. Many welcomed being given priority slots when the vaccines were first offered, and their workplace being accommodating when they went to their appointment.
“We have lots of mandated health related things and I think the vaccine is totally justifiable on all sorts of grounds. I think I worry that it won't be dealt with very well by management…instead of being called in and having decent discussions and…having their problems [...] addressed.” – Senior Nurse
The imposition of such health regulations has the potential impact on care workers, who expressed feeling undermined in their ability to make decisions on their own terms, and for their own personal reasons such as their desire to protect those who they cared for.
“I kind of feel like I'm vaxxed on different terms. You know, I kind of feel as though I didn't vax on the terms that the employer and the Government are asking me to vax on, I am vaxxed from a different...set of wants and needs.” – Nurse
Some respondents spoke about their lack of understanding of the need for the vaccine to be mandatory, especially in light of the high vaccination rate across the workforce compared to the general population.
“I didn't quite understand what was motivating the need for it being mandatory or obligatory, because where I work, the overwhelming majority of people I work with are vaccinated. I don't remember it being that controversial, like culturally.” – Nurse
The vaccine mandate presents a good case study for understanding how rapid policy development can have unintended impacts. Quickly introduced policy responses to emergent challenges, without paying due attention to people’s experience and perspectives, presents a risk to service delivery when workers will not tolerate interruptions to their autonomy, sense of dignity and value.
Meaningful consultation starts with full transparency from the side of the employer, from the earliest point in deliberation. Some respondents stressed that they needed time to reflect on the policy and its application in the workplace context.
“It's a feeling of like, wanting to spend a bit more time with the policy and again with the legislation to try and understand a bit more about how it works for workers.” – Nurse
Meaningful consultation is also based on mutual respect of workers, employers and the Government. Institutionalising workers’ insight and voice from a workplace to a policy level is a central element in ensuring workers feel recognised as free and autonomous beings. The power to make decisions and influence conditions at work are key, as Timo Jütten argues, to a dignified life. These are underpinned by some of our pillars of the Good Work Charter: autonomy, participation, dignity and support.
There is also a technological dimension to the policy introduction. In anticipation of the mandate, respondents reported that the recording of workers’ vaccination status was already integrated in prominent HR systems. In addition, some respondents reported having to disclose their status on online forms when applying for jobs.
So before I [started my job], I got sent a digital form that you fill out about what vaccinations you had [...] and then they asked you to send evidence of the vaccinations. – Healthcare Assistant
Some felt unease with this data being stored and managed via apps, which highlights the importance of considering the data governance and digital aspects raised by the mandate.
I would not feel particularly comfortable with my medical information being digitally accessible from my phone for confidentiality and privacy reasons. – Senior Nurse
This will remain an important aspect as technology features prominently in the adult social care reform white paper. It also points to a need for a human, user-led approach to the design and use of technology at work. This is line with the findings from our design-thinking Social Policy Innovation Accelerator (SPIA) workshop on revaluing social care led by Professor Dale Russell.
Our research also offers insight into how care work is valued – and how we can do better in the future. Even where care work’s importance and necessity are being recognised more widely, our respondents did not feel that the Government, employers or society in general were investing in its functioning. Care workers’ skills – from the affective, the bodily, the strategic, and the know-how to carry out real person-centred and dignified care – are likely to remain under-valued until health and social care workers are fully involved in responding to new and longstanding challenges in the sector.
Michael Sandel encourages us to take a moral approach to understanding work's value from a contributive standpoint. As opposed to understanding the value of work in pure economic terms, it recognises contribution to the common good. Importantly, Sandel centres the question of how we ‘can reconfigure the economy to make life better for the majority of citizens who may not have university education but perform important work’. He asserts that this work is not ‘afforded the dignity and respect and social esteem that it should be’. In a similar vein, Mariana Mazzucato highlights the need to reconfigure our understanding of value to see health and wellbeing as the primary measures of success, which importantly involves the valuing of care work.
The policy announcement of the vaccine mandate has already had a material impact on the working lives of care workers. However, as policy issues within social and health care persist, our research points to the need for higher levels of involvement with carers themselves in processes of decision making and policy development to achieve better, more sustainable outcomes – and demonstrate a real commitment to the value of the work of social and care workers.