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ESRC SEMINAR SERIESCarers in the 21ST Century: Developing the Evidence Base
SEMINAR 2: POLICY IN PRACTICE University of York, 11 February 2013
Unpaid Care and Employment in England:Overcoming Barriers
Linda Pickard, Derek King, Nicola Brimblecombe and Martin Knapp
Personal Social Services Research Unit (PSSRU)London School of Economics and Political Science (LSE)
A project funded by NIHR School for Social Care Research
Unpaid Care & Employment: Overcoming BarriersIntroduction - Policy context
• Focus today is on critically assessing range of health and social care policy initiatives in relation to carers
• Unpaid care and employment is a key policy issue, as first seminar made clear (Milne, Starr & Holzhausen)
• Current Government Carers’ Strategy (2010) “It is crucial that we place a much higher priority on supporting people of working age with caring responsibilities to remain in work, if they wish to do so”
• Dilnot Commission (2011) “As a society we have made great strides when looking at how to support those with children to work; we now need to think how we can do the same for carers”
Unpaid Care & Employment: Overcoming BarriersPolicy context - ‘Replacement care’
• Emphasis to date has been on role of employers in creating flexible working conditions e.g. Work and Families Act 2006
• But there is now increasingly an emphasis also on ‘replacement care’ for the cared-for person
• Carers Strategy (2010) emphasises developing “social care markets” partly to meet carers’ needs for “replacement care to enable them to continue to work”
• Department for Work and Pensions (DWP) now pays for ‘replacement care’ to enable carers to participate in interviews and training
Unpaid Care & Employment: Overcoming BarriersPolicy context - Law Commission
• Law Commission (2010, 2011) – local authorities are already required to provide
some services to meet the needs of carers under certain circumstances, one of which is when a carer’s employment is at risk
• Department of Health (2010) amended statutory guidance on eligibility criteria, Fairer Access to Care Services (FACS)
– local authorities are likely to be required to provide services for cared-for person if carer’s employment is at risk
Unpaid Care & Employment: Overcoming BarriersPolicy context - Reforming care & support
• Government’s response to Law Commission (July 2012)• Part of wider reform agenda - White Paper Caring for our
Future: Reforming Care and Support (July 2012)• Laid foundations for Care and Support Bill – now in
committee stage (until March 2013)– new single duty for local authorities to undertake a
carer’s assessment– assessment must consider whether carer wants to
work - but whether carers are eligible for support will be determined by new eligibility criteria
– support may be provided to cared-for person in form of ‘replacement care’
Unpaid Care & Employment: Overcoming BarriersPolicy context – ‘DCMQC’
• As part of care and support reform agenda, new government programme announced in September 2012 – Developing Care Markets for Quality and Choice (DCMQC)
• Intended to “help local authorities build their capacity to shape a diverse, vibrant and high quality market for social care services”
• Partly response to paper by Carers UK (2012) Future Care - Growing the Care Market
• Carers in Employment ‘Task & Finish Group’ led by Government and Employers for Carers (report by March 2013)
– evidence base for investing in care services
Unpaid Care & Employment: Overcoming BarriersDeveloping the evidence base
• How much do we know about ‘replacement care’ and its impact on carers’ employment?
• Subject of Overcoming Barriers: Unpaid Care and Employment study
– focus is on support and services for cared-for person (‘replacement care’) as a means of supporting working carers to remain in employment
• Study at PSSRU at LSE from January 2011 - April 2014• Began with scoping study, including literature review
and analysis of secondary data• Now carrying out follow-on study, including further
analysis of secondary data & collection of primary data
Unpaid Care & Employment: Overcoming BarriersStructure of presentation and session
• Three parts to presentation
1. Evaluate existing research evidence about ‘replacement care’ and its impact on carers’ employment
2. Present new evidence on effectiveness of ‘replacement care’ in supporting carers in employment
3. Identify outstanding research issues around caring and employment
• Structure of session– Presentation followed by discussion of research gaps
and challenges around caring and employment
(1) Existing evidence about ‘replacement care’ and its impact on carers’ employment
• Caring and employment is topic on which much research already carried out, but remains important, as first seminar made clear
• Many carers leave employment to provide unpaid care– around 315,000 carers of working age have left work to
provide unpaid care in England (Pickard et al 2012, cited by Starr & Holzhausen)
• Public expenditure costs of carers leaving employment are high– estimated at £1.3 billion a year in England (Pickard et
al 2012, cited by Starr & Holzhausen)
Existing evidence - Access to ‘replacement care’ by working carers
• Our literature review identified many studies showing that working carers want greater access to services for cared-for person (Mooney et al 2001, Phillips et al 2002, Yeandle et al 2007)
• But access to services is currently low– only 4% of carers working full-time, and 6% working
part-time, are currently offered assessment or review (Information Centre (IC) 2010a)
– Majority of those receiving assessment are not asked if want to do paid work (Arksey et al 2005, Arksey & Glendinning 2007, Vickerstaff et al 2009, IC 2010a)
Existing evidence-Access to council support by working carers
• Our scoping study also showed that carers’ employment is at risk when care is provided for lower intensity than previously identified
– study just published, using English Longitudinal Study of Ageing, shows that carers’ employment may be at risk when care is provided for 10 or more hours a week in England (King & Pickard 2013)
• But councils target support at people providing care for 35 or more hours a week (IC 2010b)
• Therefore many working carers, whose employment is at risk, lack access to council support and services
Existing evidenceImpact of ‘replacement care’ on carers’ employment
• Scoping study identified small body of international evidence on “relationship between the use of paid (formal) home care services and unpaid caregiver employment” (Lilly et al 2007)
• Six studies of relationship between use of paid services and carers’ employment in United States
• One cross-national study by Organisation for Economic Co-operation and Development (OECD)
Impact of ‘replacement care’ on carers’ employment : US studies
• Three US studies show positive relationship between use of paid home care services and carers’ employment (Doty et al 1998; Enright 1991; Scharlach 2007)
– care-recipients of employed caregivers receive significantly more paid help (home care, community services) than care-recipients of non-employed caregivers
• Two US studies show little relationship between use of paid services and carers’ employment (Bullock et al 2003, White-Means 1997)
• One US study (Covinsky et al 2001) suggests paid home services supplement rather than replace informal care
Impact of ‘replacement care’ on carers’ employment: OECD study
• Cross-national OECD study (Lundsgaard 2005, 2006)
– countries with extensive provision of formal home care, e.g. Scandinavian countries, tend to have higher employment rates for women aged 50-59 than countries with limited or average formal home care e.g. UK, Germany, Austria
• But availability of formal home care is not only factor determining employment rates of women in their 50s
– e.g. the Netherlands has extensive provision of formal home care but employment rates are comparatively low
Impact of ‘replacement care’ on carers’ employment: England, UK
• Robust quantitative studies in UK have not focused on employment as outcome for carers (Pickard 2004)– evidence showing services provided for cared-for person
are effective/cost-effective in supporting other outcomes for carers, e.g. reduction in carer stress (Davies et al 2000)
• No scientific (published, peer-reviewed) papers on effectiveness of services to support carers in employment in England
• Evidence from other countries inconclusive and not necessarily applicable to England owing to differences in labour market and community care conditions
(2) New evidence on effectiveness of ‘replacement care’ in supporting carers in employment
• Effectiveness of ‘replacement care’ in England is now being investigated as part of Overcoming Barriers: Unpaid Care and Employment Follow-on Study
• Effectiveness investigated using existing large-scale survey data
• Study is also collecting new primary data on unmet needs for support and services among working carers
• Focus today is on analysis of effectiveness using secondary data – findings tentative
Effectiveness of ‘replacement care’ in supporting carers in employment: Introduction
• Dataset used is Personal Social Services Survey of Adult Carers in England 2009/10 (PSS SACE)
• Objective is to examine association between employment rates of carers and receipt of social care support by cared-for person, controlling for key variables
• Analysis of carers under State Pension Age (SPA) by gender (SPA = 60 for women, 65 for men in 2009/10)
• Analysis focuses on unpaid care for 10 or more hours a week because care at this threshold has negative effect on employment (King & Pickard 2013)
• Data analysis by Dr Derek King, PSSRU at LSE
Personal Social Services Survey of Adult Carers in England (2009/10) (PSS SACE)
• First national survey of carers known to Councils with Adult Social Services Responsibilities (CASSRs)
• Carers aged 18 and over caring for someone aged 18 or over
• Voluntary – 59% of councils took part– analysis by NHS Information Centre suggests survey
is representative of England• 35,000 respondents (40% response rate)• Services for cared-for person in survey include: care
home, Personal Assistant, home care, day care, lunch club, meals on wheels
The PSS SACE sample All sample Carers under
State Pension Age (SPA)
Under SPA and caring for 10 or more hours a
week
WOMEN
N 22,351 8,907 6,940Age in years: mean(st. dev.)
62.5 (13.1) 49.8 (8.0) 49.8 (8.0)
Ethnicity: % BME 9.3 % 14.5 % 15.0 %In employment (%) 26.0 % 49.6 % 46.4 % MEN
N 11,333 4,692 3,644Age in years: mean (st. dev.)
67.4 (14.1) 51.1 (8.5) 53.7 (8.9)
Ethnicity: % BME 7.4 % 10.8 % 11.0 %
In employment (%) 20.4 % 41.7 % 38.1 %
Employment rates of carers under SPA – association with receipt of services by cared-for person, by genderBivariate association is significant, except at lowest intensity
Under 10 hours pw
10+ hours pw
20+ hours pw
50+ hours pw
Under 10 hours pw
10+ hours pw
20+ hours pw
50+ hours pw
Women Men
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
No service used by cared-for person
At least one service used by cared-for person
Proportion of carers under SPA providing care for 10 or more hours a week whose cared-for person receives
each service, by gender
0%
10%
20%
30%
40%
50%
60%
70%
80%
women
men
Employment rates of women providing care for 10+ hours a week – association with receipt of individual services by cared-for person
Home care Day care Care home Personal Assistant
Meals on Wheels
At least one service
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
Service not used by cared-for person
Service used by cared-for person
Employment rates of men providing care for 10+ hours a week – association with receipt of individual services by cared-for person
Home care Day care Care home Personal Assistant
Meals on Wheels
At least one
service
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
Service not used by cared-for person
Service used by cared-for person
Multivariate analysis of factors affecting employment rates of women carers under SPA providing care for 10 or more
hours a week (including home care receipt by cared-for person) (N=3,717)
Odds-ratioCared-for person receiving home care… relative to not receiving home care
1.69 **
Age 35 to 49…Age 50 to 64…… relative to age 18 to 34
1.74 **1.49 *
Health: does not have illness or disability…… relative to having an illness or disability
2.53 **
Ethnicity: from Black or minority ethnic group…… relative to White
0.75 **
Constant 0.27 **
* p < 0.05; ** p < 0.01
Multivariate analysis of factors affecting employment rates of men carers under SPA providing care for 10 or more hours a week (including home care receipt by cared-for
person) (N=1,994) Odds-ratioCared-for person receiving home care… relative to not receiving home care
1.75 **
Age 35 to 49…Age 50 to 64…… relative to age 18 to 34
1.09 0.72
Health: does not have illness or disability…… relative to having an illness or disability
2.52 **
Ethnicity: from Black or minority ethnic group…… relative to White
1.35
Constant 0.35 **
* p < 0.05; ** p < 0.01
Multivariate analysis - association between employment rates of women and men carers providing care for 10+ hours a week and receipt of individual services by cared-for person, controlling for age, health and ethnicity (* p < 0.05, ** p < 0.01)
Service used by cared-for person
Women Men
Home care ** **
Day care not significant not significant
Care home * *
Personal Assistant * not significant
Meals on wheels ** *
At least one service ** **
Effectiveness of ‘replacement care’ in supporting carers in employment: tentative findings
• There is a positive association between carer’s employment and receipt of social care services by cared-for person
– this association is a necessary condition if services for cared-for person are effective in supporting working carers
• Carers most likely to benefit from services are those caring for 10 or more hours a week
• Of all services, association between carer’s employment and receipt of home care by cared-for person seems strongest
(3) Outstanding research issues around ‘replacement care’ and carers’ employment
• If ‘replacement care’ is effective in supporting carers in employment, is it also cost-effective?
• How far would providing ‘replacement care’ reduce public expenditure costs of carers leaving employment?
• Or would investing in social care support for cared-for people be cost-neutral?
• Need more information on costs of providing ‘replacement care’
– second strand of Overcoming Barriers project is looking at costs of meeting needs for formal care of care-recipients
Outstanding research issues around ‘replacement care’ and carers’ employment (continued)
• Beyond Overcoming Barriers project…
• Overcoming Barriers study is using cross-sectional analysis to look at effectiveness of ‘replacement care’ as means of supporting working carers
• Ideally need longitudinal analysis
– likely to require further primary data collection
– pilot project or trial in which care-recipients of working carers offered service support and impact on carers’ employment measured
Future research around caring and employment:Gaps, questions, challenges and priorities
• Towards discussion about research gaps, challenges, questions and priorities in research on caring and employment
• Example research question: What is impact of new technology on employment rates of carers?
• Example research challenge: How does current economic climate affect research on caring and employment?
• What do you think are the most important research questions and the biggest research challenges around caring and employment ?
