Long-Term Care Reforms Guide for Unions

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Long-Term Care Reforms
Guide for Unions

Long-Term Care Reforms  Guide for Unions

This guide helps unions understand key indicators of good quality care and principles for decent work in the long term care sector to build the case for reform.

This guide helps unions understand key indicators of good quality care and principles for decent work in the long term care sector to build the case for reform.

Table of contents

This guide helps unions understand key indicators of good quality care and principles for decent work in the long term care sector to build the case for reform.

PSI has published an extensive new independent report, "Decent Work and Quality Long-term Care Systems." by Dr Sara Charlesworth - RMIT University, Dr Ian Cunningham - University of Strathclyde, Dr. Tamara Daly - York University.

The following Guide summarizes this report, outlining key principles and indicators of what contributes to good quality care and decent work in long-term care (LTC).

These principles and indicators draw on a worker-centred typology of care employment and migration regimes in selected Global North and Global South countries. The typology is underpinned by extensive desk research and country-specific case studies from Canada, Australia, Chile, France, India, Scotland, Fiji and South Africa.

What this guide is for

This Guide serves as a resource for trade unions, offering evidence-based insights with which to advocate for practical reforms within national long-term care (LTC) sectors. The focus extends beyond established LTC systems in the Global North to encompass the evolving landscape of LTC services and systems in the Global South.

The content not only provides examples of successful models and reforms that support workers in delivering accountable, high-quality LTC but also identifies opportunities for Public Services International (PSI) and its affiliates in campaigns, bargaining, and public messaging.

What is Long Term Care?

The LTC sector includes both residential and home care services, encompassing paid workers as well as informal, familial and unpaid care labour conducted by households. It spans aged care services, disability services and health services for the chronically ill, with a primary emphasis on care for older adults.

The two principal sub-sectors of LTC for older adults are residential or nursing home care and formal home care services. The report acknowledges the critical role of 'familial care' or unpaid care, which is predominantly carried out by women. Despite being the primary source of support for older adults globally, familial care faces challenges due to demographic shifts such as migration, increased female participation in the workforce, and outbound migration. The changing landscape has led to an increase in formal services provided by the state and outsourced to the for-profit and non-profit sectors in many OECD countries.

Key Principles for Good Quality Care

The report identifies six key principles as a foundation upon which decent work and good quality LTC systems must be built.

Click the headings to see a summary of each principle:

Principle 1: Public funding that meets the cost of care

  • Policy and funding at national and regional levels should be developed with a view to eliminating profit-taking in publicly-funded LTC. Public funding should meet the full cost of care, basing services on need rather than financial eligibility.

Principle 2: Public or non-profit delivery

  • The best form of LTC delivery is through direct public sector services that directly employ workers. The involvement of the private sector brings excessive profiteering, poor-quality care and, as evidenced during Covid-19, a reduced capacity to deal with emergency situations. There were significantly higher rates of mortality in for-profit residential facilities compared to their public sector and non-profit counterparts, due to the minimisation of expenditure on workers and service users.

Principle 3: Public Stewardship

  • LTC is a public good. Public stewardship requires that governments act in the public interest to robustly monitor, assess and enforce good quality care and decent work at the system and organisational level, regardless of delivery. When LTC is delivered directly by public sector workers, it is typically associated with high-quality outcomes. When it is contracted out to private non-profit and for-profit homes, the government must ensure that effective contracting is in place to monitor the expenditure of public funds and non-compliance by providers.

Principle 4: Public Data Transparency and Accountability

  • To support public system stewardship, there must be mechanisms for public accountability for government funding. Data must be publicly reported, including that related to the LTC system’s regulatory compliance, the workforce, type of employment contracts, contractors’ performance, and the quality outcomes of care provided. In order to accomplish system-level improvements and to produce high-quality outcomes for care recipients, providers need to create decent working conditions, publicly report on performance, and make the data available for independent scrutiny. Those providing LTC services should have maximum transparency in their operations and their outcomes data since contracting services to for-profit entities raises significant questions regarding accountability for spending public funds.

Principle 5: Decent Working Conditions

  • Decent working conditions in LTC include pay rates and sufficient predictable hours of work to provide a living wage that enables workers to enjoy dignity at work, provision for themselves and their families, and to be able to engage fully in life outside paid work. In LTC, decent working conditions also include secure job contracts with access to full-time employment where desired; payment for all the time worked, including documentation and travel between clients; access to paid leave and retirement benefits; excellent training and access to meaningful career paths and safe working conditions.

Principle 6: Dignity in Care

  • No matter what the setting, having consistency in care — defined as ensuring LTC workers have time to get to know the service user, their preferences and needs — is critical to dignity. Dignity in care is also dependent on being cared for by workers who are well-trained, skilled and supported. Being able to exercise choice about the care provided and having some flexibility as to when care is received are both critical.

Key Sector Trends

Marketisation, Work and Employment in Long-term Care

Click a theme below to explore emerging trends across the sector:

Marketisation in LTC

The marketisation of LTC has followed a similar, albeit not identical, trajectory across a range of different countries in the Global North. Strategies towards marketising LTC provision have been influenced by the ideas of New Public Management (NPM). NPM, as illustrated particularly in the Australian, Canadian and Scottish case studies, encourages marketisation and involves the contracting (hollowing) out of public services from direct state provision and employment to networks of private (for-profit) and voluntary (non-profit) providers. The rationale for such outsourcing is multiple and inspired by the ideology of the NPM agenda, which includes: the supposed financial unsustainability of services provided directly by the state; the drive to improve quality in services through the placing of market disciplines and risk onto service providers and their workforces; the introduction of private sector management techniques and innovation into public services; cutting costs and enforcing efficiencies in service provision through competition; the closeness of certain types of provider (i.e. non-profits) to clients and their needs; the undermining of the regulatory reach of trade unions and collective bargaining; and the erosion of terms and conditions of employment for front-line care workers.

Public service supply-chain relationships

Marketised LTC systems bring particular power dynamics to the relationships between private and non-profit care providers, and the state. There is resource dependency by the former on the latter. Directly delivered public services have been steadily ‘hollowed out’ through processes of outsourcing whereby the state, as well as being a provider, becomes an enabler for others to provide LTC. The state, both central, regional and local, creates networks of private and voluntary providers that it leads and coordinates. 

Many of the relationships between the state and providers in LTC can be problematic. Cases such as Scotland, Canada and Australia reveal how state funding awards rarely consider the full cost of care or inflationary pressures. Moreover, the funding is tied to strict key performance indicators (KPIs) which, year on year, may demand efficiencies and, in times of austerity, cuts in funding. Provider organisations are particularly vulnerable in relationships where they have one single dominant funder, with no or limited access to alternative funding.

In terms of security and sustainability, constant pressure from funders on provider organisations to make savings and efficiencies has seen organisations pull out of the market either partially or wholly, thus handing back services to governments. Marketisation has developed through a combination of NPM and neoliberal values but also the human rights campaigns of the disability movement. There are increasing calls for services that place the aspirations and ambitions of service users first. The service user is seen as a consumer expressing individual choice, including over the type of provider (public, private or voluntary), and even down to the individual worker. This agenda leads to decisions over the exact timing and number of hours of delivery.

States (such as Australia, France and Scotland) have further marketised care services by introducing programmes promoting the individualisation or ‘personalisation’ of care, known as ‘cash-for-care’. Here, states have introduced payment schemes where, instead of resources going directly to voluntary and private providers, money in the form of personal budgets is placed in the hands of individuals or care recipients. These schemes are designed to empower those in receipt of care to make choices regarding their lives rather than ‘one size fits all’ services provided by the state or providers.

Gender and the undervaluation of care

Marketisation also perpetuates the gendered undervaluation of care work, the gendered division of labour and the naturalisation of women’s caregiving skills. LTC jobs are poorly paid because they are overwhelmingly held by women and because care work is associated with the gendered role of women, in particular mothers. Subsequently, skills such as nurturing and compassion are taken for granted and undervalued. Funders of LTC services, both the state and public sector agencies, are complicit in the undervaluation of women’s work by not setting costs that include accounting for the skills associated with the characteristics of the work.

The use of Technology in LTC

It is relevant in any discussion of marketisation to highlight the role of new technology in cost-cutting and austerity measures, and the gendered undervaluation of LTC. In marketised care systems, information, communication technologies (ICTs) are characterised as being cost-saving priorities. Managers delivering public services reportedly see technology as a solution that can deliver efficiencies, cost savings, and help them to introduce new forms of control that reduce worker discretion. The urgency among LTC providers to introduce these technologies has accelerated within contexts that demand cost savings.

In 2019, a survey of UK social services directors of adult LTC in public funding bodies found that 96% saw the use of ICTs as important in making cost savings. Indeed, it was seen as a key means by which local governments can maintain statutory services despite drastic austerity-inspired reductions in their budgets (ADASS, 2019).

The prospects for LTC workers experiencing changes to their work, and potential degradation from the introduction of technology, are significant. Technology is a key part of the pressures that bring greater insecurity and intensification of work in marketised LTC work.

The application of technology also has detrimental impacts on care receivers as they, again, experience the diminishment of relational, face-to-face interactions in favour of technological solutions, such as remotes, sensors and robots. Monitoring the time spent in the user’s home through ICTs diminishes the amount of autonomy workers have to engage in the social and relational elements associated with dealing with the most vulnerable.

Profiting from LTC through financialisation

In the case studies conducted in Chile and India, we see emerging interest from multinationals in their evolving LTC systems. This is yet another feature of these marketised systems that contributes to unacceptable employment practices: profiteering by large, private multinationals. Recent research by CICTAR, Fédération Santé Action Sociale CGT and Fédération CFDT Santé-Sociaux (2022) found that the company Orpea has reportedly saddled care homes with large amounts of debt and heavy rental costs. This is undertaken through Orpea selling care homes at a profit and then leasing back the properties from the new owners. This property speculation is done through a complex web of 40 subsidiary companies established in Luxembourg. There is nothing illegal about these transactions but there are calls for greater transparency (CICTAR, et al, 2022). Orpea is not alone in this regard. This form of financialisation is common. The UK alone has care assets worth £245bn, with yearly transactions of £1.5bn over the last five years (CICTAR, 2023).

The acceleration of marketisation that allows dominant funders to place cost-cutting at the heart of relations with providers, continues the gendered undervaluation of women’s work, encourages the introduction of technology focuses on cost control, and allows exploitative forms of financialisation by multinationals has led to a ‘race to the bottom’ in the terms and conditions of employment. Recent years have further seen the introduction, in some countries of the Global North, of austerity funding (e.g. Scotland and Canada), which has accelerated and exacerbated these pressures.

Working Conditions

Below is a summary of the key trends in working conditions.

The decline in familial care

There are also overlaps between the decline in familial care and the trends towards marketisation. Globally, women engage in the three forms of familial unpaid care work) far more than men, taking up approximately 80% of such labour (ILO, 2019). The contribution of unpaid care work to LTC is far more pronounced in the Global South. At the same time, as the case studies reveal, changing demographics plus socio-economic and political trends are seeing a greater fluidity in the traditional reliance on this labour. Each of the Global South cases reveal how industrialisation, urbanisation, greater educational opportunities, shifting population trends, and the creation of global care value chains are diminishing reliance on familial care. As these changes become more pronounced, however, large amounts of expenditure in such case s (e.g. in Fiji, South Africa and India) remain primarily dedicated to health services for mothers and young children. Yet, despite rising demand, scrutiny of LTC provision among the case studies from the Global South reveals huge gaps in coverage.

Moreover, as forms of marketisation spread from the Global North, the depletion of familial care brings several threats to LTC workers and care receivers in the Global South. The first comes from the growth of global care value chains that lead to migrants replacing local workers from the Global North in what is perceived to be devalued care work. The migration streams from the Global South to the North have, in turn, led to shortages of health and LTC workers across states in the former, taking further resources away from an already limited provision.

The second threat comes as population ageing occurs in the Global South case studies. These cases reveal how new markets are beginning to be identified by multinationals (e.g. in India and South Africa). Without proper state regulation and commitment to engage in building an LTC system, this leaves states, workers and care receivers vulnerable to the financialised strategies of multinationals familiar in countries such as France, Australia and Scotland. The growth of private forms of delivery in countries of the Global South threatens parallel efforts to organise as the case studies indicate what appears to be a largely informal workforce operating in circumstances familiar to unpaid work. The growth of LTC activity by multinational corporations in the Global South, such as the financialised practices, such as the extraction of value from real estate transactions, the creation of two-tier systems of care and the degradation of working conditions, will present significant additional work for unions campaigning to regulate informal, unpaid LTC labour.

Poor job quality in LTC

Pay and Working Conditions

A range of studies into the marketisation of LTC have highlighted that pay and conditions are generally low compared with other occupations and rank among the lowest paid occupations in most economies. A study by the ILO in 2017 found that, in general, LTC workers receive low wages, and enjoy worse working conditions and less social security than other care workers. When care jobs become too demanding, workers move to similarly low paying sectors of retail and hospitality where pay may be slightly better and/or have fewer responsibilities. According to Eurofound (2020) in the EU, LTC workers are often paid well below national average wages, with pay in the private sector being worse than in public providers.

Across OECD countries, turnover among LTC staff is higher than among the general workforce.

Of equal concern is how marketisation has led to a further undermining of employment pay rates compared to those in the public sector. Marketisation has led to the erosion of other benefits that were comparable to those received by public sector workers undertaking equivalent roles. These are benefits such as pension entitlements, sick pay benefits, holidays, overtime and other unsocial hours payments. Increasingly, there are reports that care workers fail even to receive statutory minimum wages. Such underpayments have occurred as price competition among outsourced providers has meant that funding has not been sufficient to cover costs such as travel time. The result is that workers in community LTC services travel unpaid between visits, meaning that their average hourly rate of pay falls below the statutory minimum. Technology assists these cost-saving measures. ICTs are used for workforce surveillance, monitoring how long workers visit each user. 

Such unacceptable practices in the Global North present clear lessons for activists across PSI affiliates embarking on ensuring LTC workers’ status and conditions are formalised and come under minimum wage guidelines. Workers in some LTC services may also be asked to contribute to things such as the purchase of uniforms, and even fees associated with training and professional qualifications. The steady erosion of working conditions in marketised adult LTC heralds an end to the standard employment relationship, and that all employees are offered is a basic rate of pay and some commitments around induction, training and health and safety.


Work and employment in marketised systems of LTC can also be insecure. Funding uncertainty can stem from changing government priorities and fiscal retrenchment. The austerity in funding renewal that is facing non-profit and private providers leads, in many countries, to higher-than-average rates of temporary contracts (e.g. in Scotland), or groups of workers being particularly vulnerable to being hired under precarious contracts during specific points in the funding cycle (e.g. in Chile).

Almost two-thirds of OECD countries have identified the retention of LTC workers as a great political challenge.

Across OECD countries, non-standard, temporary employment is almost twice as high among LTC workers as the health sector. Data from Europe reveals how more workers in the LTC workforce are looking for another job than are those in health, and that the reasons for this are linked to job insecurity and dissatisfaction (OECD, 2022).

The individualisation or personalisation of LTC adds further dimensions to insecurity. Such approaches to care add an intensification of market pressures as the recipients of services are seen as ‘customers’ with choices, including in the selection of who will deliver services. Again, this adds an element of insecurity into the working lives of employees as they may be moved around, or even lose their job, if they do not exactly match up with service user requirements. There are examples of workers having their job security threatened in circumstances where service users have requested a change in provider if they do not ideally match their requirements. 

Work intensification

Work intensification arises in a number of ways in LTC. A failure to fund travel time adequately, and the tendency of workers to stay until the job is done, so going over prescribed time limits, means they are undertaking unpaid work. As with the Australian, Canadian and Scottish cases, rising demand for services, coupled with underfunding and staff shortages, combine to intensify work for workers. Early studies in LTC show how shortages of staff meant that it was common for workers to work through breaks and do additional hours unpaid. Another common practice was where staff shortages and absence meant that workers would take on double shifts. Again, these sacrifices or unpaid labour donations were seen as part of a largely female workforce’s infinite elasticity to care. Sacrifices were made in the name of the service user, labelled ‘compulsory altruism’, and these contain gendered, taken-for-granted assumptions that women will undertake unpaid work.

Work intensification due to high turnover or absence also has its costs in terms of quality and staff and service user well-being. In the first instance, studies have revealed that workers undertaking too many hours can suffer ‘burn-out’ and stress, impacting on their mental and physical health. Absence can then occur, putting further pressures on already understaffed services. Physical health can also be put at risk from the effects of work intensification and accompanying fatigue in services where there is challenging behaviour and lapses in concentration can lead to physical assaults on staff. Highly demanding jobs, and exposure to physical and mental health factors, lead to low job satisfaction and are seen as a prime cause of low retention rates in the LTC workforce (OECD, 2022).

Poor support, training and skills development

Supervision of workers is compromised in these marketised environments. Underpayment of fees means that time to devote to direct and formal face-to-face (or digital) interactions between front-line workers and their supervisor/line managers are squeezed. Regular and adequate supervision are seen as one of the key elements in providing workers with the support they need to work in challenging environments. And yet marketised systems and the persistent squeeze on costs allow limited funding for time for workers and their supervisors to come together to engage in supervisory activities. This undervaluation of supervision and subsequent gaps in support have been repeated in Australia. The study identified how organisations had fewer line managers and, for those that remained, they experienced increasing spans of control, which meant less time to devote to supervision. Overall, limited access to supervision training etc. means that many workers in marketised care systems operate without full competence in dealing with dangerous situations and emergencies with clients.

The fragmentation of working time

The organisation of working time is a key component of funder and management efforts to reduce labour costs in LTC. As outlined in the previous section, the application of ICTs can be a tool for organisations to monitor and control working time. In addition, under marketised systems of care, how time is managed, through the introduction of flexible forms of contracts and the scheduling of shifts, further contributes to cost reduction and the degradation of work. Part-time work is sizeable in the LTC workforce, being twice as high as the average rate in the wider economy. For example, 45% of LTC workers in OECD countries work part-time. In the EU, LTC workers undertake rotating shifts, with reports that they feel they have no say in their working time and often have requests to take up shifts at short notice during unsocial hours (Eurofound, 2020). The trend among public service funders to only pay workers for time actually spent delivering care has led to the introduction of forms of insecure contracts. These pressures for greater flexibility in order to reduce costs are intensified in individualised and personalised approaches to care provision. Personalisation means that the ‘customer’s’ preferences regarding when services are to be delivered lie at the centre of the care model and play an increasingly important role in the organisation of working time.

Short-hours, part-time, relief, or zero-hours contracts (ZHCs) can proliferate in this kind of marketised environment. The increasing use of these forms of contract to match the demands of funders and service users for flexibility and cost savings means that the hourly rate of pay for which a worker is hired may have limited impact on whether they receive a decent wage that they can survive on. It is the number of hours that is crucial, and these contractual arrangements can make workers ‘hungry for hours’. Part-time work is also linked to ‘hours poverty’. A proportion of LTC workers in the EU (30% in non-residential LTC, 20% in residential LTC) report that they take up part-time contracts because full-time work is not available (Eurofound, 2020). 

The introduction of new forms of platform work in care

The organisation of care work can now be undertaken through digital platforms, where service users select from a range of independent, casualised carers. Australia has had the most recent experience of the growth in these forms of casualised, platform care worker. The application of this technology means that digital platforms enable employers to act as an electronic interface between workers and care recipients. In these marketised systems, employees face increasing risks in terms of costs and fragmented shift patterns. Work is individualised through the movement of care from an agency setting to largely private homes, introducing isolation among workers. The income of workers in these roles is compromised as the funders do not adequately fund care packages, meaning service users cannot pay for wage rises. These forms of work mimic many of the issues faced by other precarious forms of work i.e. last-minute cancellations or short shifts with long commutes that are uneconomical. The organisation of workers’ shifts is increasingly being undertaken through phone apps, which can mean random changes to shift patterns reflecting a shift to on-demand, platform work.


Migrant labour

In terms of understanding the levels of vulnerability suffered by different groups in the care labour force, attention must be directed towards the situation of migrant labour. Care provided by migrant workers fills gaps in the LTC systems of richer countries. Again, migrant care workers are overwhelmingly women. Most migration occurs for financial reasons, or because of poor working conditions or an inability to find a job in their home country. As in the Indian and Fijian case studies, migrants largely supplement paid and unpaid work in higher income, developed countries in order to fill national labour shortages caused by the undervaluation of care work.

Migrant workers are characterised by multiple forms of disadvantage. There are risks of human trafficking and abuse, as well as challenges to the LTC systems of source countries in terms of creating or adding to shortages of such workers. The pressures among source countries will increase as their own populations begin to age and require services in the coming decades. In addition to gendered disadvantages, they face discrimination based on race, ethnicity and nationality. They may belong to an economically disadvantaged class, and their immigrant status may prevent them from accessing specific labour, social, welfare and political rights in the country in which they are settling.

The case studies in Fiji and India reveal how so-called sending countries also suffer disadvantage in these ‘care value chains’. In particular, although countries such as India may benefit from remittances sent back to families in their country by LTC workers, these migration flows lead to shortages of workers in their own countries. 

Unacceptable working conditions and poor care quality

The underpayment of wages and the insecurity faced by care workers in marketised systems is a false economy as many services then suffer from chronic turnover and shortages of labour, thus impacting on public sector budgets through perpetual recruitment, induction and training cycles. In personalised services, low prices, or the parallel implementation of austerity measures, has a number of implications for care quality. Workers are often unable to deliver the types of services envisaged by disability and human rights advocates associated with cash-for-care schemes.

The link between staff shortages and service quality is profound. For example, during lockdowns in the height of the Covid-19 pandemic, higher staff ratios in LTC residential care units led to fewer deaths. This was a consequence of workers having to move around less between care recipients, thus reducing the risk of infection. However, during the pandemic, poor pay and access to other benefits reportedly contributed to increasing infections among vulnerable people. In the UK, for example, among workers on low pay and insecure contracts, the transmission of the virus was spread by employees largely working for private providers who were not reporting infection, or who were asymptomatic. This non-reporting was linked to workers not being entitled to receive sick pay. Over the years, savings made by private providers in order to generate profits have included cutting back on sickness benefits. Care workers in many cases may also have multiple jobs in order to make ends meet. Again, during Covid-19 this meant that workers transmitted the virus to vulnerable people because they were moving between multiple institutions/care homes.


Covid-19 and long-term care

The Covid-19 crisis raised significant issues in LTC across the globe as historic underfunding meant national systems were generally ill-prepared to respond to problems related to the pandemic, such as taking on rigorous infection prevention and control measures, absorbing the costs of PPE, coping with the training needs of staff, and dealing with worker absence due to sickness. The majority of Covid-19 deaths were among older people, with 93% being among those aged 60/65 and over and 58% among those aged 80/85 (OECD, 2021a).

While vulnerability among the elderly population partially explains these deaths, it has increasingly become evident that it is the place of care that is a major contributor. Overcrowded and high-density facilities, with shared occupancy, were the common characteristics of LTC residential services that showed higher death rates. Linked to this were poor-quality instruments, as the same study found that, at the start of the pandemic, only half of the countries had guidelines in place for infection control (OECD, 2021a).

The pandemic had a significant impact on the employment regime. Commentators place a significant proportion of the blame for the high number of deaths among people in LTC down to the undervaluation of care and its workforce. The low priority given to LTC and its workforce was illustrated in the delays in distributing PPE and undertaking testing for staff in the early stages of the pandemic. In countries such as Colombia and the Czech Republic, workers had to contribute to the purchase of their own PPE (OECD, 2021).

Staffing ratios

The funding deficits experienced by most LTC systems filtered down into insufficient staffing resources on the front-line. Some studies have found the risk of death from Covid to be higher than average in for-profit facilities, associated with particularly lower staffing ratios and older design of facilities. Moreover, the training of workers in detecting and isolating Covid cases was slow to be implemented in some LTC settings. 

Unsurprisingly, nearly all OECD countries took measures to recruit LTC workers to tackle the aforementioned shortfalls in staff. This included providing funds to LTC facilities that they could use to cover the costs of recruitment and which could include efforts to recruit retired staff, the unemployed or students. In addition, there were increased one-off payments made to reward workers operating under significant pressures. Around 40% of OECD countries provided one-off bonuses to their workers for exceptional service. A small number of countries improved wages permanently (Germany, Czech Republic, Korea and France). Other measures, related to the migration regime, included temporary extensions of visas for foreign LTC workers. Only Colombia, Greece and Latvia took no specific measures (OECD, 2021a).

Sickness absence

One way that the virus was spread through the movement of workers was because many held more than one job. Across OECD countries, 45% of LTC workers are part-time and many have multiple jobs to earn a decent living. LTC workers were more likely to take more sick leave than non-LTC workers or have higher recorded sickness levels compared to the pre-pandemic era. Staff absence made it difficult to ensure that services were properly resourced or had the requisite levels of expertise. Those left in work experienced greater workloads and gaps in staff-care recipient ratios, which subsequently increased the movement of workers and thus LTC infections (OECD, 2021a;).

Poor or no sick pay creates a significant financial cost for employees and provided many LTC workers with a reason to be in work while infected with Covid-19 (OECD, 2021a). Vulnerability is pronounced among workers on zero-hour contracts if they become infected. Their contractual status can mean that they are among those who do not receive any form of payment due to illness. In the UK, even where sick pay is available, many employees, especially in private LTC facilities, only receive Statutory Sick Pay (SSP), one of the lowest payments for sickness across Global North countries. These issues have received attention from organisations (i.e., the OECD) and trade unions, as well as academics (Elsen, 2020) who report the nee for absence management and structural paid sick leave to re-appear on trade union bargaining and policy agendas.

Following Covid-19, PSI affiliates pointed to the PSI campaign in South Asia for community health workers concerning better health and personal protective equipment. As part of this campaign, they used the ILO’s C149 Nursing Personnel Convention, which requires ratifying states to commit to the education and training of nursing-qualified staff and the improvement of employment and working conditions, including career prospects and remuneration. Regionally, PSI has been promoting ratification of this ILO Convention and has strategies for its campaigns.

Migrant workers were vulnerable during Covid-19 as countries quickly closed borders, resulting in isolation from their families (WHO, 2020). However, as can be seen from the individual case studies, LTC regimes in Global North countries have been impacted by Covid and other external shocks, and are now more heavily reliant on migrant workers. This begs questions concerning the working conditions and rights of these workers.

Going forward, the issues of addressing staff shortages, working conditions and awareness and compliance with occupational health and safety in LTC are seen as priorities. At least 30 countries have developed policies to improve access to PPE and 24 have prioritised the testing of care home residents and staff. Policies to boost staff numbers exist in at least 26 OECD countries and include funding to hire new staff and students. There is also a greater emphasis on hygiene, which includes the training of workers (OECD, 2021a).

With Covid-19 remaining an active threat, workplace activists and PSI affiliates need to investigate how organisations are managing their sickness absences and workplace attendance. A focus on sickness absence policies is needed due to an observation that recent approaches to managing non-attendance can be coercive and punitive, focusing solely on non-genuine absence. Such workplace absence cultures have led to workers attending work when sick, behaviour that is worrying during a health crisis.

Low Levels of Unionisation

The existence and representativeness of workers’ organisations covering care workers, as well as the coverage of social dialogue mechanisms, including collective bargaining, play an important role not only in determining the pay and working conditions of care workers (ILO, 2018) but also campaigning for better LTC provision.

In marketised care systems, union influence is limited as employment is outsourced to areas where collective bargaining has a weak presence compared to direct employment through the public sector. Private and voluntary sector LTC care providers have traditionally been largely non-union. Anti-union values stem from fears that activities such as strikes and other forms of action can disrupt services and mission, or the generation of profits in the case of private providers. In addition, there are problems with mobilising the LTC workforce in private and voluntary organisations to join unions. This is due to a lack of tradition of joining unions, and the number of organisers are therefore quite low compared to other sectors. There is a lack of ‘a factory gate’ or, in the public sector, a school, hospital, or administrative offices at which to engage with workers in a collective manner. Workers in LTC work part-time, fragmented shifts, sometimes alone and in the community or in people’s homes and are therefore difficult to contact. They have limited tradition of unionisation within their ranks and so are unsure what the movement can offer them. There is also some perception that LTC workers fear unions because of the impact strikes and other disruption may have on the service user.

Where unions have a presence in private and non-profit providers, the supply-chain and resource-dependency effect make the prospects for effective collective bargaining quite limited. Specifically, the below-inflationary funding settlements offered by governments to providers make the prospect that collective bargaining for wages in outsourced providers will keep up with public sector workers’ conditions very unlikely.

This limitation in collective bargaining is for several reasons:

  • Firstly, unlike the public sector, collective bargaining can generally be at the enterprise level and not subject to national agreements.

  • Secondly, at the enterprise level, the state acts as ‘third-employer’, determining the funding settlement that shapes pay agreements while having no direct involvement in negotiations. Unions in decentralised bargaining arrangements therefore do not have the power to hold to account or negotiate with the state agency(ies) that hold the purse strings. Moreover, it means that it is difficult for unions to apportion blame and mobilise collective action for poor pay rises on the immediate employer.

Individualisation and personalisation also have implications for collective bargaining and organising in the sector.

The case studies highlight how approaches to collective bargaining can offer protection to hard-to-reach LTC workers. In France and Australia, for example, sector-wide collective agreements negotiated by unions cover LTC workers who may not be union members. Moreover, Scotland is currently pursuing a policy of constructing sector-wide collective bargaining in its LTC. In Chile, unions are placing workers’ rights in their wider campaigning linked to constitutional change and the creation of a rights-based LTC system.

The case studies point towards the crucial importance of PSI affiliates having the resources to pursue the above agendas, including market intelligence. This includes Global North countries such as France, Australia and Scotland having the capacity to bring greater transparency regarding the activities of multinationals. The case of India, however, highlights the need for unions to be able to access resources that will provide them with more basic intelligence, e.g., regarding the type of provider, and how they organise work and employment in LTC. In addition, the Indian case reveals how unions in the Global South need basic labour market intelligence on the size and demographic make-up of LTC workforce as well as the degree of formality and informality in employment relationships.

Strategic positioning by unions is crucial, as is ongoing union advocacy for public sector management of LTC. In France, the exposure of the gouging of public funds by for-profit providers such as Orpea, resulting in appalling conditions for vulnerable older people, unacceptable forms of work for LTC workers, and a lack of adequate numbers of workers prepared to work in the LTC sector, has been crucial in this advocacy. The CFDT has also made a compelling case for greater community and political awareness of the socio-economic value of the care provided by LTC workers, arguing that financing the LTC sector, including through additional staffing, professionalisation and skill recognition and better remuneration should be seen as an investment in the dignified care of the dependent elderly (CFDT 2019).

Lessons were learned from the Covid-19 crisis that can permeate into union organising campaigns and bargaining agendas within the LTC sector. These include:

  • A higher staffing ratio is associated with lower infection and deaths;

  • Reducing staff movement (through higher ratios) reduces infection from the virus;

  • Staff shortages can only be resolved through better recruitment and better job quality, especially more pay and better conditions.

  • Begin improvements in pay with the consolidation of bonus payments awarded during the peak of the pandemic.

  • Development of safety standards and proper training for staff along with monitoring and enforcement.

  • Staff mental health and well-being should be a priority, including training of managers in psychological as well as physical well-being.

  • Recognise the uncertainty for workers suffering from long-Covid (OECD, 2020; OECD, 2021b).

Key Challenges to Organizing

Click a theme below to explore existing challenges for unions in the sector

Collective Bargaining in the public sector

Several wider contextual and sector-specific issues will make organising in LTC difficult for trade unions in the coming years, issues such as attacks on the organising capacity of unions. Unions have been under pressure for a number of decades in terms of their capacity to organise and protect their members. The range of factors that have influenced this greater vulnerability includes the economic and political context and labour market changes. The public sector unions have traditionally been seen as more resilient in terms of sustaining their bargaining position, membership, coverage and organising capacity.

Nevertheless, public sector unions are facing problems in organising LTC and representing employees. Firstly, they have not been immune to the forces that have led to some diminishment of influence and strength across many countries. The global financial crisis (GFC) lay at the origin of many of the neoliberal economic policies that have undermined the strength of public sector unions in the last ten years. The GFC and the resulting austerity policies provide a convening point from which governments have further consolidated the ideology of free market’s hold on society and one of its chief forms of resistance – trade unions and collective bargaining. A common trend across nation states has been to identify GFC as a public debt crisis, blaming unions and their members (especially in the public sector) for the crisis.

This rhetoric has led to a series of public policy reforms to collective bargaining in the public sector and union security designed to reinforce deflationary austerity policies. In the EU, for example, the coverage of collective bargaining, i.e., the proportion of employees having their terms and conditions determined by collective negotiations, has declined as a result of job losses and various reforms.

In addition, EU countries has been subjected to pressure to moderate pay claims and engage in forms of concession bargaining, i.e., unions accepting a decline in terms and conditions, in many cases on a temporary basis, in exchange for employment security. The above pressures have also been evident at the level at which much of LTC is delivered, i.e., at local government level across the EU. Nation states enforced austerity cuts on this tier of governance.

In North America too, assaults on unions followed the GFC, with long-standing political hostility to the movement finding greater impetus in the US and Canada (a country that did not suffer the same degree of financial problems as the former or the EU). The GFC opened up opportunities for conservatives to advocate fiscal discipline, downsizing and privatisation of public assets, as blame for the crisis shifted to unions and their members in the public sector. In both countries, pensions and salaries were attacked, and unions faced state or province-level efforts remove the right to bargain over specific areas such as pensions and health benefits, as well as limitations to pay increases. Such attacks on unions and their members were also predominantly gendered, i.e., falling on occupations largely occupied by women, including care for the elderly.

Competition for resources

Firstly, even where unions are traditionally strongest and/or have a history of organising in the public sector, their regulatory reach and therefore their capacity to influence public service workers in LTC is more difficult. Many countries also outsource a significant proportion of their LTC to voluntary and private organisations, where unions do not have as great a presence.

Outsourcing to private and non-profit providers, along with weakened public sector unionism, implies some difficult choices for unions in terms of resource allocation. Unions in the public sector may organise across public, private and non-profit sectors. Unions will want to rebuild and strengthen their traditional public sector workplaces, where LTC workers still have a presence. In marketised care systems, union influence is limited because for-profit and non-profit sector care providers have traditionally been largely non-union. There will, therefore, be competition for resources within unions across the sector but also with other areas of the public sector domain.

Anti-unionism in outsourced services

Anti-union values stem from fears that activities such as strikes and other forms of action may disrupt services and mission, or the generation of profits in the case of private providers. In the case of private sector LTC companies, there has been limited work on unionised private providers because so few recognise unions. However, where unions are present, they have to contend with a number of issues. Some provider profit margins may be small, making it extremely difficult to bargain over pay. In others, where private equity may be present, the complex financial engineering associated with such forms of ownership makes it also difficult to bargain because of a lack of transparency in the funding of such enterprises.

Non-profit organisations bring their own specific problems. Attachment to particular values and mission and the rights of certain client groups can often lead to the rights of workers being compromised. Unions are perceived as a barrier to the kind of flexibility and forms of sacrifice that are expected of non-profit workers in order to deliver services. In response to resistance from unions, some non-profit providers have been known to exhibit anti-union attitudes similar to those of the worst for-profit employers. This has led to incidences of bargaining rights being removed.

Migrant workforce

The growth of migrant workers in the care sector is another related complication for unions in the sector. These workers are some of the most vulnerable in LTC due to exploitation around working hours and other terms and conditions. And yet they are difficult to reach for many of the reasons outlined above. In addition, recent migrant workers may come to the workplace with limited knowledge or experience of unions. In some cases, their experience of unions may be negative, as has been the case with some Eastern European migrants where collectivism was associated with former communist regimes. The vulnerability of migrant workers also makes them harder to organise because they may be reluctant to be seen as ‘causing trouble’ and may have limited rights.

Lack of bargaining power

Even where unions have a presence in for-profit and non-profit providers, the supply-chain and resource-dependency effect limits the prospects for effective collective bargaining. Specifically, the below-inflationary funding settlements provided by governments, such as in our selected OECD countries, dampens prospects that collective bargaining for wages in outsourced providers could keep up with public sector conditions. This limitation in collective bargaining is for several reasons. Firstly, unlike the public sector, generally collective bargaining can be at the enterprise level and not subject to national agreements. Secondly, at the enterprise level, the state acts as ‘third-employer’ determining the funding settlement that shapes pay agreements while having no direct involvement in negotiations. In decentralised bargaining arrangements, unions therefore do not have the power to hold to account or negotiate with the state agency(ies) that holds the purse strings. Moreover, it means that it is difficult for unions to apportion blame and mobilise collective action for poor pay rises on the immediate employer. Even where unions have a presence, the combination of resource dependency in a climate of austerity therefore means that unions may be working in a context of almost perpetual ‘concession bargaining’ and consequently struggling to make an impact on raising the pay of workers, as has been the case in Australia in terms of enterprise bargaining in LTC.

Individualisation and personalisation

Individualisation and personalisation also have implications for collective bargaining and organising in the sector. Previous research recognises how care recipients can influence the nature of work and industrial relations processes in public services across three levels. The first is co-design, where the service user inputs their needs and contributes to the development of a service. The second is co-production, which allows the service user to influence the operational delivery of services. Third and finally, co-supervision enables the service user to hold those responsible for service delivery to account (Bellemare, 2000). The power and authority of service users in these individualised schemes are not all-encompassing, however as much depends on the relative strength and influence of the other industrial relations actors – employees, unions and management (Bellemare, 2000).

Implications for Union Influence and Organising in LTC

The existence and representativeness of workers’ organisations that cover care workers, as well as the coverage of social dialogue mechanisms, including collective bargaining, also play an important role in determining the pay and working conditions of care workers (ILO, 2018). Lydia Hayes (2017) outlines eight reasons why collective bargaining is needed in LTC sector.

These reasons are:


·       Because adult LTC is an industry

·       Care work is highly skilled and increasingly complex

·       Terms and conditions of work are precarious

·       Poor quality jobs mean poor quality care

·       Individual rights (statutory or otherwise) are insufficient to remedy these problems

·       Care workers are silenced by the structure of care markets

·       Government has to raise the quality of employment across social care

·       Collective bargaining would create decent work and raise the quality of care



What can unions do?

In the light of the findings in the independent report, including its case studies, we recommend the following campaign focus:

  • Campaign on the principle that decent work underpins high-quality LTC.

  • Adopt the six principles outlined in this Report as a pathway to campaigning for decent work and decent, quality LTC.

  • Campaign for the principles of decent working conditions to be incorporated into the decision-making of public bodies responsible for LTC procurement and commissioning.

  • Bring all external providers under some form of collective bargaining, where possible. Sector-level collective bargaining is preferable but attention needs to also be given to workplace representation and voice.

  • Evaluate current organising strategies in the LTC sector in order to effectively target workers for membership across the public, private and voluntary sectors.

  • Advocate for appropriate client-staffing ratios in LTC, further underscored by lessons from the Covid-19 pandemic.

  • Campaign for greater transparency in the financial transactions of multinational corporations to ensure that public funds are invested properly into LTC.

  • Campaign for a decent wage, on that recognises the gendered undervaluation of paid care work, the disparity between private, public and voluntary workers, the erosion of career paths and pay classifications and relativities.

  • Campaign for the full costs of care to be met so that home care workers are paid for the time they travel between clients.

  • Improve other non-wage benefits, with particular attention given to increased paid leave, pension entitlements and job security.

  • Reorganise staff working hours to ensure decent working time arrangements and end under-employment.

  • Avoid work-family conflict by addressing problems of fragmented shifts.

  • End the use of exploitative forms of contract such as zero-hours contracts (such as those common in the UK).

  • Ensure there is worker voice/representation when introducing new technology.

  • Campaign to improve LTC provision by building and strengthening within current health care systems. For countries in the Global South unlikely to have an integrated LTC system, this means ensuring that health provision can offer services to older adults.

  • Gather accurate data from Global South countries on the formal and informal care workforce.

  • Focus on ensuring the employment rights of informal workers in countries of the Global South, including the payment of a proper wage rather than stipends.

  • Focus on migrant workers’ rights in receiving countries, as well as supporting a greater reliance on creating and sustaining a local care workforce.

To explore our research in more detail, check out the full extensive report here (english only)