5 June 2020 by Rashmi Becker, Department of Psychiatry, School of Clinical Medicine
Learning to Care: The Forgotten Frontline
I was completing my PhD examining the role of learning disability care workers in delivering government policy, when the Covid-19 pandemic became a reality for the U.K. While we were told to ‘Protect the NHS’, there was no mention of our social care workforce or those they care for.
As the impact of the virus on the social care sector eventually became public, much media reporting followed. But the issue is not new: for more than 20 years concerns have been raised about the system of publicly funded social care in England. In 2014, The Kingsmill Review, an independent review of working conditions in the social care sector, observed that ‘Care work is in crisis. People who may be vulnerable are not being treated with the care and attention they deserve… The low status of care work and poor treatment of workers has led to a vicious downward spiral into one of the most difficult sectors for workers, with widespread exploitation’. Just last year, the Association of Directors of Adults Social Services Budget Survey found that: ‘Local government is struggling to balance the books and Directors know that adults of all ages with disabilities are not getting all the care they need. Directors are increasingly saying they can’t meet their legal responsibilities to the public’.
While consecutive governments have produced policies that advocate the independence and wellbeing of people in receipt of social care services, the wellbeing of the frontline carers that play a critical role in enacting these policies has been neglected. The fragmented care sector is characterised by staffing shortages, poor pay, and low status. In 2019, Skills for Care reported that the workforce vacancy rate in adult social care in England was 122,000; the average rate of staff turnover was 30.8%; 24% of the workforce was employed on zero-hour contracts; and the average pay for care workers was £8.10 per hour. Additionally, changes in the commissioning of care have had a great impact on the way support is delivered: while local authorities used to represent the largest employers in the social care sector, the proportion of the workforce located in the public sector is declining, with only 7% of the 1.52 million social care jobs now within local authorities. The sector comprises 18,500 independent organisations and, unlike the NHS, the social care sector does not have national pay rates and terms and conditions.
Government policy does not reflect the full scope of the care worker role, and its impact in the lives of people receiving support. When the care workforce is discussed in policy, the focus is disproportionately on regulation, training and managing risk. Tackling the social care crisis requires policymakers to fully engage with frontline care workers and recognise the poor conditions under which they operate. The care worker role is a complex combination of low-skilled, manual labour (such as the provision of intimate personal care) and highly skilled professional work, including advocacy and enablement. Supporting the needs of individuals who may have severe physical and mental impairments, and lack mental capacity, requires care workers to know the people they support well, to interpret subtle non-verbal communication, to promote potential, and to safeguard wellbeing. This requires emotional intelligence that is grounded in consistent and meaningful interactions between care workers and those they support. This quality of care is at risk if budgetary constraints results in transactional care that prioritises price over people.
The longstanding underfunding of social care and the low status of care work belies an ingrained, inherently negative attitude towards those who are dependent in society. Existing policy stigmatises dependency by idealising independence and self-determination as the markers of a meaningful life. This is reflected in the continual policy focus on outcomes such as participation in education and employment. Policy is rooted in the view that disabled people can be valued members of society only when they adopt the roles and behaviours of the ‘mainstream’, non-disabled group. But what happens if they do not or cannot adhere to social norms? Given the history and negative public profile of social care and the treatment of disabled people, it could be argued that the efforts to promote independence is a well-intentioned bulwark against outdated authoritarian, paternalistic practice. But the promotion of independence should not be to the detriment of those who have dependencies. Writing about the ethics of care, Kittay states that dependency is a feature of all human life and ‘the denigration of care and dependency leads to an attitude that renders the work and value of carers invisible, thus creating one oppression in the effort to alleviate another’. The status of the social care workforce raises questions about the values of a Society that prizes autonomy and devalues dependence, fostering a low-pay and low-recognition environment for frontline carers. Does the complexity of the relationship between the care worker, the supported individual and the State reflect some of the paradoxes of modern life?
The long-overdue reform of social care must address the gap between policy and practice; central to this is the treatment of frontline workers. The material and mental health of care workers is fundamental to ensuring quality of care and quality of life for those they support. Care workers and those they support have been an afterthought in the current pandemic – the consequences of which are yet to be fully appreciated. But this has also created new impetus for change, and to recalibrate our appreciation of the forgotten frontline.
This blog draws on research funded by the National Institute of Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care (CLAHRC) East of England programme, at Cambridgeshire and Peterborough NHS Foundation Trust. The views expressed are those of the author, and not necessarily of the NHS, NIHR, Department of Health and Social Care, or CSaP.
With 20 years’ experience as a communications and public affairs professional, Rashmi has worked in London, Brussels and Dubai and in a range of areas including healthcare, education, the UK government and European Union. Rashmi has advised senior executives and ministers and helped organisations such as the Department for Education and Employment, UK Foreign and Commonwealth Office, the European Parliament and Commission and one of the world’s largest medical research charities the Wellcome Trust to develop and implement strategies that engage people to make informed decisions and bring about positive change.
As an Executive Director and Strategic Advisor for leading UK learning disability and autism charities, Rashmi helped develop relationships with stakeholders such as policy makers, disability groups, carers and the media to improve understanding of the needs and aspirations of disabled people in order to enable them to achieve their potential. This led Rashmi to apply for and secure funding to undertake a PhD in the School of Clinical Medicine at the University of Cambridge, where her research focused on the role of frontline care workers in delivering government policy.
Alongside her policy and communications work, Rashmi is a keen sportsperson and advocate of the benefits of physical activity on health and wellbeing. She is Board member of Sport England, and former Board member of Activity Alliance. She is also the founder of Step Change Studios, which supports disabled people to be active through dance.
Rashmi has received a number of accolades for her work including ‘Outstanding Contribution to Innovation’ at the National Learning Disabilities and Autism Awards in 2016. She has an MPhil in Education from the University of Cambridge where she wrote her thesis on autism education and is guardian to her older brother who has Autism.
 Kittay, E.F. (2011). The ethics of care, dependency, and disability. Ratio Juris, [e-journal] 24(1), pp. 49–58. http://doi.org/10.1111/j.1467-9337.2010.00473.x.