Regulation of care workers - should personal assistants be included?
Vanessa Davey considers the issues about regulation of personal assistants.
There are plenty of voices in the social care sector advancing views about how the workforce should be improved. This debate is at its sharpest when contrasting the situation of workers in regulated services with those employed by individuals through Direct Payments. Vanessa Davey, PhD, an academic from LSE, with a particular interest in this area shares her views on the subject.
Ever since direct payments came to the forefront of social care policy in the UK, concern has been voiced about the growth of an unregulated personal assistant (PA) workforce.
In England, around 140,000 personal assistants are employed by all groups of disabled people.
Whilst personal assistants are not regulated in the strictest sense such as through formal registration, this does not mean that there are no checks and balances on the care provided by a PA – or on their employers. PAs have a duty of care to the people they work for, as well as the general public. If a PA’s actions were deemed to be negligent or deliberate they could be held accountable and ultimately prosecuted under criminal law.
Equally, individuals employing personal assistants are ‘vicariously liable’ for their employees. As employers, direct payment recipients (or the nominated person in charge of managing the direct payments) need to understand their responsibilities to their employees. They are also required to take out employers’ liability insurance – and personal assistants employees’ liability insurance.
However these safeguards are very much a last resort. Experience suggests that quality is promoted through the approach taken in recruiting and the support that is available throughout the process.
Job descriptions are a basis for personalised care
The process of employing a personal assistant starts with writing a job description. Supporting someone to develop a job description for a prospective PA is a task which has to balance the aspirations of people who access services against ensuring that the individual (or the nominated person in charge of managing direct payments), understand their responsibilities to their employees.
Writing a job description is seen as critical to finding suitable candidates. Direct payments support workers help people to articulate expectations and requirements to a level of specificity that creates a basis for personalised care, within the limits of the care plan agreed with social services.
This process typically starts by asking someone to think about a typical day and list:
- all the tasks they may need help with
- any particular skills or qualifications the personal assistant must have, for example, a nursing qualification, or a driving licence
- an estimate of the number of hours and days the person will be needed to work.
This rapidly sheds light on the particular skills set required – or, the training that will be needed for somebody to do the job. Local authorities are expected to facilitate direct payment recipients to access health & safety/ manual handing training for PAs, either directly or via a direct payment support scheme.
In the more complex cases, where a PA is employed to undertake delegated health tasks, any tasks performed must be signed off by a care coordinator after ensuring that person-specific training has been provided to the PA and person who accesses services by a registered practitioner with the relevant occupational competence (such as a nurse, physiotherapist, language therapist or occupational therapist). Among other requirements, the care coordinator must also ensure that there is suitable access to support and advice for any PAs undertaking delegated healthcare tasks.
In terms of safety, available data suggests that existing measures to ‘regulate’ personal assistants are proportionate to the level of risk. There is no evidence of greater referrals for suspected abuse where PAs are employed. Levels of training among PAs are slightly lower than other care workers, but less so when temporary workers or family and friends are discounted. (One of the flexibilities of direct payments is the ability to pay non co-resident relatives or friends, often resulting in greater support for primary carers. See http://etheses.lse.ac.uk/3867/ )
How do personal assistants differ from other care workers?
Personal assistants are likely to be slightly older than care workers in the domiciliary care sector and have more experience in the sector than other care workers, possibly due to the availability of part-time hours, favourable terms and conditions (including continuity of care) and better pay. Insistence on formal training as a prerequisite to becoming a PA is likely to disincentivise care from family and friends. This accounts for just over half of PAs as well as older PAs who have returned to care in a manner that suits their preferred time commitment and caregiving values.
How registration, training and regulation issues affect personal assistants?
Many argue that the system as it currently stands is sufficient, although arguments in favour of greater regulation of PAs continue to surface. These arguments tend to focus not on the specific process in place to ensure safety of direct payments users and their employees, but on the general issue of registration and generic training of PAs.
Arguments in favour of regulation stem from different stakeholders and different interest groups. A lack of regulation is seen as reinforcing the view that anyone, especially a woman, can become a carer as well as potentially deskilling and fragmenting care workers. The question of whether or not personal assistants should be required to hold minimal qualifications in care or be formally registered is intricately bound to the professionalisation of social care workers in the domiciliary care sector.
In England, back in 2005, quota targets for an accredited qualification in care were introduced in the home care sector: by 2008, 50% of all personal care was supposed to be delivered by staff with an “NVQ” (National Vocational Qualification) in Health & Social Care. The target was dropped as it was found it to be “difficult to achieve” despite the availability of funds for training. Reported barriers to progress included: baseline educational level of staff, the age of staff (25% of care workers are over the age of 55), absenteeism, turnover and staffing shortages.
The targets were scrapped in 2010 and it was not until 2016 that new requirements were outlined. Since this time the onus on providing training has been put entirely on care providers. The new “Care Certificate” is described as a foundation, or, “the beginning of the career journey for those new to care”. As with the introduction of NVQs the focus is primarily on new staff, although the Care Certificate is described as offering, “opportunities for existing staff to refresh or improve their knowledge and skills.”
A pertinent feature of the so-called Care Certificate is its focus on values as well as awareness of people’s physical and psychological needs, and basic technical skills. Employers are encouraged to work through the Care Certificate with each employee using the self-assessment tool. It is sufficiently general to enable it to be adapted to each individual working environment. Like care providers, direct payment users operating as individual employers are encouraged to use the tool to train PAs.
Notably the Care Certificate is conceived as training on-the-job. This approach avoids barriers to entry into care work - a pragmatic stance given a 42% turnover rate and 8% vacancy rate in domiciliary care in England.
Taking the values based recruitment approach
This stance is also consistent with an increasing focus on “values-based recruitment”. Values based recruitment (VBR) is aimed at finding people who are willing and interested in helping others in some shape or form irrespective of their age, educational level, previous occupations or available time. VBR is considered to be effective at finding individuals that have the qualities to be great carers, that for a myriad of reasons are not considering a career in care work. This process in many ways mirrors the ways in which direct payment recipients and their support workers often recruit PAs, as well as the kinds of PAs they recruit. Time and time again, people who use direct payments report that it is the persons’ values and finding someone whose capabilities and interests match their needs that is far more important than any qualifications they might have.
While staff training is vital, I would argue that the most important factors in improving quality of care are continuity of care and matching care workers to people who access services. Continuity of care and client-care worker matching is as important for care workers as for people who need care and support. The direct relationship between direct payment user and personal assistant offers this possibility and is arguably the reason why direct payment users report far lower turnover of staff (18% among DP users, versus 42% in the domiciliary care sector). In the wider care sector one of the greatest threats to quality of care is turnover off staff. Evidence suggests that this can be improved by better staff conditions across the board and ensuring that the right people are attracted to care jobs.
Skills for Care data shows that it is the youngest and newest staff members that are most likely to leave, regardless of training. It also shows that care workers on zero-hour contracts (currently 35% of care workers) are more likely to leave, as are care workers that have to travel further to work. Turnover is also likely to be higher in organisations where performance is deemed to be poorer or where there are gaps in staff management. In contrast, recent data suggests that turnover is lower among staff recruited via values-based recruitment, that training costs less and is more effective.
Ultimately the value of stricter regulation of care workers and personal assistants needs to be judged against the extent to which the measures put forward are likely to lead to genuine improvements in people’s care as well as changes in care workers conditions.
Implications of stricter regulation
Stricter regulation may involve a variety of measures. The introduction of accredited qualifications in care as a prerequisite to employment, versus the introduction of optional accredited qualifications in care, or the introduction of accredited qualifications in care that must be completed within a set-time frame upon commencement of work.
The above may or may not be implemented in tandem with official registration of care workers, which may be obligatory, optional or required after a certain amount of time has been spent working in the sector (as was proposed by the all Party Parliamentary Group on Social Care for care workers generally).
Each option (or combination of) is likely to affect the identity and status quo of care workers in different ways as well as the situation for employers but it is likely that none of these alone will necessarily result in better working conditions. This is particularly so for personal assistants whose challenges in the work place are often related to factors such as the solitariness of the work; conflicts or tension arising from differing expectations (between employer and employee), insufficient boundaries, or poor understanding of their rights.
The importance of training and awareness
Rather than regulation, it is training and awareness that hold the potential to overcome these challenges. Employment liability insurance providers state that good local support for recruitment, PA management and access to resources for training make all the difference when it comes to the number of cases that are referred to them and the time it takes to resolve them. Ultimately this saves money for local authorities in social work and admin time and very occasionally in extreme circumstances the cost of financial pay-outs. The questions - to some extent – are, what is good support for people recruiting care, and how can PAs best be supported? Yet none of this can be achieved without tackling the huge disparities in the support that is available which predominantly come down to local authorities’ willingness to fund support. At the moment there are good examples, such as PA training organised by user-led organisations funded through Skills for Care. This works where there is a fully functioning and proactive support service locally, but not where direct payments support has been decimated by repeated decommissions switching between the lowest bidders. It is not enough to focus solely on continuing to explore the most effective means of support for people recruiting care, and means of supporting PAs; we also need to think about how to achieve fair access to support.
It should also be added that neither accredited and transferable qualifications in care or the necessity to be formally registered will combat PAs experiences of low-pay and limited working hours and relatively low pay which are bound up with scarcity of funding. This has a bi-directional impact on PAs as well as the people that employ them, particularly if the inability to offer better pay adversely affects their ability to recruit and retain staff. In addition, generic qualifications in care will not necessarily help PAs deal with specific challenges that they may face.
None of this is to suggest in any way that personal assistants as a professional body should not benefit from career development frameworks. I believe that the sustainability of the PA role will depend on PAs being able to access accredited training, which recognises their existing skill set and permits to work in different settings in health and social care (with the option of undertaking specialist training in each). There are already some great examples of this occurring through Skills for Care individual employer funding (where individual employers have received funding for their PAs to undertake a variety of courses which so far have included the Certificate in Health and Safety at Work, Levels 2 and 3 of the Health and Social Care Diploma, the Care Certificate, Mental Capacity Training, a Diploma in Leadership and a QCF Level 2 DBG Signature Communicator Guide). Each of these examples has exploited existing training options and focused on the specific needs and aspirations of individual PAs.
Improving the value of care workers
Much of the impetus for greater care worker regulation however comes from the collective viewpoint and the desire to improve the status and social value of care workers across the board. There is some evidence, for example, that registration of care workers in tandem with union representation can lead to pay rises – although this issue is complex.
Whatever structures are put in place and to whatever extent personal assistants are impacted , what seems most critical is that it should not lead to the creation of barriers to employing friends, family members, retired people or other members of the local community who do not aspire to a career in caring as personal assistants (and may even have other jobs), or to recruiting students who sometimes welcome PA work as an additional option or a 'stepping stone' towards a career in professions such as social work. Indeed, it is often these profiles of PA that fit best.
Middle ground needs to be found between a framework that provides recognition of transferable skills and pathways to career progression while minimising barriers to flexible recruiting. A hard-line approach in which accredited qualifications in care are a prerequisite to employment in care would pose particular barriers for people managing their care through direct payments.