Jef Smith looks at the latest government attempt to confront the training and support needs of workers on the front line of health and care services.

Let us begin with a quotation: “Helping an elderly person to eat and swallow, bathing someone with dignity and without hurting them, communicating with someone with early onset dementia; doing these things with intelligent kindness, dignity, care and respect requires skill.”

To anyone working in social care that sounds like a pretty obvious description, though expressed on this occasion with particular sensitivity. Its significance lies in the fact that it comes from an official report commissioned in the spring of 2013 by the Secretary of State for Health. If he and others in authority were to take it seriously and act on the implications for policy that flow from that basic statement, the day-to-day practice of providing care and support for vulnerable older people in their homes would be transformed. Will this happen? I doubt it.

The paragraph I’ve quoted continues: “Doing so alone in the home of a stranger, when the district nurse has left no notes, and you are only being paid to be there for 30 minutes, requires considerable maturity and resilience.” That’s tantamount to saying that the task of caring in people’s own homes is even more demanding than when it is carried out in a residential home or hospital, a judgment with which most home care workers and their managers will certainly not argue. The isolation, the lack of anyone immediately to hand to consult if things look dangerous, the constant movement from one environment to another: all of these are unique features of domiciliary care.

The quotation comes from the Cavendish Review, a document named after its author Camilla Cavendish, who is an associate editor of The Times and, incidentally, an old friend of the Prime Minister from university days. The review was set up following the highly critical Francis Inquiry into the Mid Staffordshire NHS Foundation Trust, which more or less coincided with a series of reports into serious failings in other health and care settings.

Ms Cavendish’s task was to consider what could be done to ensure that the 1.25 million or so front-line staff, who deliver most of older people’s hands-on care, do so with thought and compassion. The review was conducted in just 14 weeks; perhaps journalists should be employed more often to analyse tricky policy issues for Government — or perhaps not.

Camilla Cavendish consulted widely in the course of her investigation. She used focus groups and roundtable discussions, a seminar for employers, an online survey which attracted 4000 responses, various meetings around the country, and a consultation exercise to which 100 individuals and organisations submitted evidence. So while getting a thoughtful and independent commentator to spend three months intensively studying a controversial issue has been achieved, getting a Minister to take the consequent policy decisions, which would have significant personal and resource implications for everyone in the care industry, is a very different process. Well into the autumn of 2013, the Government’s response to the review was still awaited.

Bringing health and care closer together

Among the review’s “guiding principles” was a resolve “to try to reduce complexity and bureaucracy”, not an uncommon aspiration, but one not easily achieved. Ms Cavendish expressed surprise at how the systems set up to help vulnerable older people seem “disconnected”, noting that “the NHS operates in silos”.

Social care, she added, in a particularly telling phrase, “is seen as a distant land occupied by a different tribe”. It was not central to her remit to suggest how that divide could be crossed, an objective that has eluded many brave people for more than half a century and which still preoccupies contemporary politicians, but the core of her proposals would go some way to closing the gap and, for the workforce, could significantly affect its impact on career development.

The number of unregistered front line workers in social care many times exceeds that in health, but in recent years, care providers have suffered from a serious leakage of their staff into the NHS, largely because the wages are higher on that side of the fence.

Oddly, the recommendations for bringing health and care closer together might even exacerbate the difficulties for social care employers. Cavendish recommended the creation of new common training standards and a common “Certificate of Fundamental Care”, which the Care Quality Commission would require all workers to have achieved before working unsupervised. This would, for the first time, link a basic level of training to nurse education generally, thus providing a relatively accessible promotion path into the higher levels of the health service hierarchy.

For the care sector, however, such a basic introduction would do little more than systematise the induction that the better employers already provide; as things stand, any real progression for front-line staff would still depend on working for diplomas, as at present.

Training and induction

A decent induction for care workers is by no means universally available. Cavendish quotes workers “who were given a DVD to watch at home before being sent straight out to the front line” and others “who were asked to pay for mandatory training out of their own pocket”. Though she acknowledges that “employers are striving to train, retain and motivate staff under considerable financial pressure”, this is clearly highly unsatisfactory.

She also reflects the widespread dissatisfaction with vocational qualifications as currently constituted, reporting that managers “find it burdensome to navigate the sea of vocational qualifications and training courses, which has developed in response to changing fashions in government funding”. This has brought “costly duplication, as employers develop their own in-house courses, and retrain new staff irrespective of what training they have had elsewhere”.

With resources so limited, this is madness, but I am not persuaded that the Cavendish prescription for “a rigorous quality assurance mechanism for training courses and vocational qualifications” and the introduction of a “Higher Certificate of Fundamental Care ... linked to more advanced competences to be developed and agreed by employers” provides a solution. Surely that is just more duplication. The current vocational qualification system’s credibility has to be restored, not just by-passed, and cracking that nut will take a much more thorough exploration of what has gone wrong than Ms Cavendish had time for.

Perhaps she hopes that her recommendation that “the main trade associations and social care employers [should] lead a process to agree on core national competences that go beyond the minimum” will set such a process in motion. The suggestion that “employers should be supported to test values, attitudes and aptitude for caring at recruitment stage”, however, is just silly; what does Ms Cavendish think they do now, or does she know of some magical, psychological testing kit that will root out potential abusers before they get into post?

The Cavendish recommendations on recruitment and training are often no more than tentative, but those that relate to career development do very little more than lay out well-known problems, and then suggest that various bodies — the Nursing and Midwifery Council, Skills for Care, the employers’ organisations — should give them more thought.

Various people are enjoined to develop new programmes, set out implementation plans, explore ideas and so on, but this is really no more than an agenda of points everyone already knows need to be tackled, with no new solutions on offer. It does not get anyone anywhere simply to assert that higher education establishments should “look at how care experience can be recognised in enabling people to enter social work” or that social care support staff need “a robust career development framework”. The question is: how precisely are these worthy objectives to be achieved?

The section of the report that considers issues relating to leadership, supervision and support, which in best Department of Health (DH) style is given the jaunty heading “Getting the Best out of People”, is no more specific. It is widely recognised that current systems for “managing the dismissal of unsatisfactory staff, the legal framework around this, and the relationship with referrals to professional regulators” are unsatisfactory, but Cavendish’s only proposal is that DH should commission someone else to look into it.

Registration and pay

The review was, understandably, excluded from considering the old chestnut of workforce registration, a subject that has been debated for more than a decade without any serious progress being made. At one point in the discussions, domiciliary care workers were to be given priority for registration on the grounds that their clients are that much more vulnerable to poor practice, but nothing came of those promises. The truth remains that registering a workforce of about 1.5 million workers with an annual turnover of 20–30% would be an administrative nightmare, even with modern technology, and that all the exercise would show would be a list of names, contributing nothing at all to the standard of the service delivered.

Furthermore, the growing numbers of personal assistants directly employed by service users under direct payments, most of them untrained and unsupervised, escape any official recording systems; even their numbers are unknown, let alone the quality or otherwise of the service they provide.

One of the most significant issues relating to the quality of both social and healthcare assistants is almost completely ignored by Cavendish; that is the level of pay, which, it is widely agreed, is derisory for the responsibilities carried out but which DH studiously refuses to face. So, for example, while discussions continue about how GPs might be rewarded for the early detection of dementia in their patients, the staff who provide day-to-day care for people in the last, and generally most distressing, stages of the disease often work for levels of pay which do not compete with even the lowest-paid workers in retail and catering. There are references, it is true, to the scandal of domiciliary care workers not being paid travel time, a subject which has attracted even more attention since the review’s publication, but there is no attempt to tackle the now-widespread evasion by social care employers of the National Minimum Wage.

The situation of workers in social care is even more desperate than that of health service support workers. While the DH could raise the pay of the latter if it had the will, remuneration for social care assistants is caught up in the complex system through which social services are funded. Providers insist, with some justice, that they can only pay wages in line with the fees that local authorities pay. The adult services departments of local councils, who commission and finance a large percentage of the care, claim, again fairly, that its expenditure is being tightly squeezed by central government.

In addition, central government — not the DH, but the Department for Communities and Local Government, which otherwise has little involvement in social care — says that the Government’s austerity programme requires ever tighter control of expenditure. It is a vicious circle that the publication of the Cavendish Review singularly failed to address.

Last reviewed 6 December 2013