The Cavendish Review

10 07 2013

Today the Department of Health have published the “Cavendish Review” [pdf] which was an exploration into the role and focus of Healthcare Assistants and Social Care Workers in NHS and social care settings.

Reading through it, I thought it might be useful to summarise the main points and see where the direction of travel may be heading. Firstly I should say that I was always in favour of regulation of social care workers (I had less involvement and knowledge of Health which is why I exclude it here). My understanding was the role of the GSCC (General Social Care Council) was to register beyond social work professionals but it ran out of money/political will. In my opinion that was always a gap – so that’s the direction I’m proverbially shooting from on this.

There are some interesting points to come from the review and I think it’s worth looking at in more detail than the headlines and quick newspaper articles allow. I hope the government give it time to breathe.

The preamble recognises the disparate sectors of ‘health’ and ‘social care’ with social care being forgotten amid the more high profile hospitals. Again, I have to claim some bias because I was a support worker before I was a social worker and I have worked fairly consistently in social care for most of my working life – with an off-shoot into the health service in latter years. Social care though, is where my heart is and it’s certainly the area I know best.

Cavendish makes the key point, that really doesn’t need anyone to make and the sadness is that years into the so-called ‘integration’ agenda, people still aren’t getting it.

“I have been struck by how disconnected the systems are which care for the public. The NHS operates in silos, and social care is seen as a distant land occupied by a different tribe. Yet when Mrs Jones leaves hospital for a care home, or to recuperate in her own house, she is still the same person. She wants to be treated as the same person, and to be looked after by staff with the same core knowledge and core values”

METHODOLOGY

Cavendish conducted her review by arranging focus groups of healthcare assistants, social care workers (residential care and domiciliary care), nurses and social care managers, she went to meet people working in hospitals and care homes, conducted an online survey and conducted some seminars/webinars.  The language she uses is healthcare assistant to refer to those working in health settings and support worker to refer to those in social care settings as a shorthand.

THE FRONTLINE OF CARE

Interesting word, ‘frontline’. Social workers use it. Personally I think it’s not the best word to use to describe people who work closest with those who use services. ‘Frontline’ implies a ‘battle’ or a ‘challenge’ when actually working with people who need the services we provide is a privilege and not about drawing lines or setting out ‘battle scars’ as a sign of honour. Here, though, ‘frontline’ refers to those who deliver health and social care directly. None of the ‘sitting in offices’ that social workers do. I think as a profession we need to regroup what we describe as ‘frontline’ but that’s probably a discussion for another place – back to the review..

Cavendish presents some interesting if unsurprising statistics about the predominance of women in this field (84%) and the low wages (average £13k in social care/£14-17 (band 2) in healthcare).

She presents some of the background to HCA (Health Care Assistants) and their roles in hospitals and tries to break down some of the tasks that are asked of them.  Nurses spend time on care planning, liaison and discharge while HCAs have a stronger role in building up relationships with patients.  She refers to a recent study which found

HCAs spent the majority of their time on a typical early shift carrying out direct and indirect care, whereas nurses spent the largest proportion of their time on organisational tasks such as answering the phone and handovers

Some HCAs are carrying out more complex tasks that would previously have been reserved for nurses and there is some inconsistency between Trusts – and wards – about what tasks are being done by HCAs and there is an increasing blurring of roles.  Interestingly but unsurprisingly she notes a shift of people moving from social care into health care assistant roles, possibly because pay and terms and conditions in the NHS are better than in private social care settings.

Turning to social care she makes a vital point, and one that I’ve made often and consistently

The paradox is that some of the lowest paid care workers are those who we expect to work the most independently, walking into the homes of strangers, and having to tackle what they find there, without any direct supervision. This requires a high level of maturity and resilience. Calling this “basic” care does not reflect the fact that getting it right is a deeply skilled task.

While I try not to despair at the low status of social care work, it is good that it is recognised more broadly what enormous skill is needed to do it well. The average wage in social care support work is £6.72ph. That’s ‘frontline’. Not sitting in an office writing care plans.

While status is low, the tasks demanded can be incredibly complex.

VOICE OF THE FRONTLINE

The information from this chapter of the report comes mostly from the feedback and focus groups which inputted into the review as a whole.  Cavendish reports the passion people speaking to her expressed about wanting to help and make a difference to the people they worked with and, she mentions, noone had a negative word to say about the people they provide care for – which is more than I can say for some so-called ‘professionals’ I’ve worked alongside but that’s a different matter.

In both health and social care – they feel that some of the work they do is encroaching into the ‘professional’ (far more highly paid) jobs of social worker or nurse, respectively.

Paperwork was seen as a barrier to providing care and particularly in social care settings, so was staffing levels themselves.

Many raised concerns about the level and quality of training provided to them and the lack of career progression. Personally, (and this is because it was my personal career progression so I admit bias), I’d like to see more steps being taken to allow social care workers to move into social work, if they want to, rather than focusing on ‘elites’ out of school and parachuting them into social work jobs. Another argument for another day, perhaps.

Some people felt they were unsupported by management and some that they were asked to do tasks they didn’t feel they were capable of. I think it’s something for management to reflect on but hopefully the report will provide a spur to those who want to be good employers.

THE VOICE OF USERS

I’m glad this had a discrete section as after all, it is the entire reason that health and social care exists.

Some interesting different themes are set out between health and social care here with the impression given that in some ways, health can learn from social care in terms of communication skills, dementia care and end-of-life care. Interesting with the focus on dementia nursing that skills in social care are sometimes forgotten.

Patients said they weren’t always sure what the role of healthcare assistants was and who was responsible for which part of their care, maybe making healthcare assistants more immediately recognisable as different from nurses.

There was widespread general support for the need for better training for health and social care workers and better support from management structures.  A key factor being

an environment where staff are supported and their emotional well-being is considered once they are in post is also vital in sustaining a workforce that is able to cope in times of stress.

My personal opinion is that an organisation that values it’s staff and it’s staff’s values will embed them when the same staff are delivering care. It’s not rocket science  but it needs empathy from the top down and from the bottom up.

RECRUITMENT, TRAINING AND EDUCATION

There is currently no minimum educational requirements to work as a HCA or Support Worker. Sometimes numeracy and literacy aren’t tested. There was a wide variety in the quality of training from people being given DVDs to watch at home to support workers being asked to pay for their own training. Skills for Care introduced Common Induction Standards in Social Care but these are not mandatory. Not having qualifications or educational levels doesn’t mean someone doesn’t and can’t work well but it is about facilitating someone to learn and understand about their role, their need to reflect on the actions they are taking and how they affect others and the need to allow people to develop to their strengths and support them in doing so.

Qualifications shouldn’t and can’t ‘tick a box’ because it’s about the quality of the training and the effect that the training has on the quality of care provided. That’s the key.

Sometimes training isn’t transferable from one organisation to another, sometimes it actually doesn’t have any value apart from the organisation being able to tick a box saying they have ‘trained staff’.

And sometimes ‘care’ doesn’t feel like it has a progressive career structure – unlike other professions – which may add to the low status.

The review suggests there is a more ambitious programme of training for HCAs and Support Workers, a ‘certificate in fundamental care’.

This would be published by Skills for Health and Skills for Care and would be based on National Occupational Standards.

There is a suggestion that a part of this should be common training to nursing students and HCAs to study together (which I think is an excellent idea – we need more togetherness not professional silos).  This would be the first step, with a follow up Higher Certificate of Fundamental Care attainable and there would need to be robust quality assurance of the training programmes across health and social care sectors.

MAKING CARING A CAREER

The point is made about the lack of career progression

While not many HCAs or support workers will go into nursing, therapy or social work, it is vital that the opportunity exists

As a support worker who went into social work, it’s something I feel very strongly about. I think it was a fantastic route into the profession and one reason I worry about the schemes now being devised to siphon off the ‘top quality graduates’ to go straight into social work. Nothing taught me better than having had the experience of hands-on care work. But I digress..

The report states categorically

HCAs and support workers in social care must have a clear line of sight from the most junior rungs of their careers through to jobs in nursing, social work, physiotherapy or occupational therapy, if they want to. It is vital that the move to all-degree nursing does not cut off opportunity. The Review recommends that bridging programmes proposed by the Institute of Vocational Learning should be commissioned.

I hope this is embraced by those tasked with changing social work education. Again. We don’t need to be blinded by elitism. We need good social workers. It’s not an either/or necessarily but we can’t exclude one group in favour of other groups we claim we want to see as ‘leaders’.

GETTING THE BEST OUT OF PEOPLE: SUPERVISION, LEADERSHIP AND SUPPORT

Rightly the point is raised that it isn’t enough to train people. There has to be a context in which to support people on the day to day basis.

The important point made is this

In the airline safety industry, human factors studies show that the most junior staff can be the most important links in the safety chain56. HCAs and support workers are the backbone of many parts of health and social care. So the question of how best to manage and support them, to make them the best they can possibly be, is paramount.

Let’s think about that and how we value people who do the most direct patient/user work. I have come across some very unpleasant and frankly, patronising/snobby attitudes to care workers. Of course the people talking to me now in those ways, don’t really get the fact that I used to do that job myself so am never going to collude but I fear there is a perception of low paid work as being low skilled when it’s anything but.

The review looks at the importance of team building and supportive teams existing across ‘hierarchies’. A clinical team includes health care assistants as equals not as juniors as all have important roles to play.

There is an important pivot role of the ‘frontline manager’ addressed here and how crucial they are to people’s experiences of work and support at work. The review is very clear in this recommendation – which I like and can be transferred equally into equivalent social care settings

: Trusts should empower Directors of Nursing to take greater Board level
responsibility for the recruitment, training and management of HCAs, from day one

There is a role for mentoring within organisations and for accountability to be directed at the top of organisations if they don’t nurture the culture which allows care to thrive. Good, I say.

TIME TO CARE

Interesting point about whether 12+ hour shifts are ‘conductive to compassionate care’. I think there are a few organisations that will need to think long and hard about that and what it might mean in terms of potential costs. There’s no avoiding that ‘lack of time’ is a barrier to quality care. We can think about the home care workers who are shunted between visits with barely time to catch their breath. Again, treating staff compassionately feels into better treatment for those who use the services provided.

And here the point is made

Care is increasingly being bought “by the minute”. Figure 9 shows 15 minute visits are commissioned, with the average visit lasting 30 minutes. Not surprisingly, service users report services being rushed, or lacking compassion, dignity care and respect, and little continuity of care. Elderly people with dementia are particularly upset by seeing so many different faces; and very high attrition rates place a real cost burden on employers

Everyone knows this is wrong, it’s easy to say but hard to change as LAs have been squeezed of money. We need to push responsibility back to the govt as well as the commissioners who think this is an acceptable way to provide tickbox care. Of course the effect on the user is horrific but I would wager that it’s also a pretty horrific effect on members of staff and it embeds a lack of compassion in care.

But changing that costs money. There’s a rub.

The review looks at commissioning by outcomes but this has only happened in very small NHS based pilots and has leant heavily on direct payments. We need these models to be extended to people in social care funded settings and people who may not be able to manage direct payments. But it’s a start.

The review also raises the utter immorality of care agencies not paying workers for travel time and some excessively long shifts which all have an effect on quality of work and the feeling of being valued as a member of staff. The thing is though, time costs. Are we willing to pay for it through our taxes? I know I am (although I don’t trust the govt not to spend any increased tax receipts on cutting billionaires capital gains tax).

CONCLUSION

I’ve summed up each part of the report so I won’t dwell on the conclusion. It’s an easier digestable and useful read that is necessary to challenge some perceptions of health care assistants and support workers and I’m very glad to see it.  I would wholeheartedly urge people to read through it and reflect on that way we value some of the most critical work done in the health and social care sector.

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15 07 2013
The Meaning of Words | Aisling's blog | Certitude

[…] was struck when reading a recent article by @Ermintrude2 Twitter extraordinaire summarising the Cavendish Review and the reference she makes to some of the inappropriate language we use in health and social […]

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