The sector is changing in line with the country’s ageing demographic and policy shifts towards health and social care integration, person-centred provision and independent living, but what will these changes demand of care workers?
The independent Cavendish Review, commissioned in the wake of the Francis inquiry and published in July, looked at the best ways to recruit, train, support and supervise healthcare assistants and support workers in NHS and social care settings.
It concluded that: “Staff need to learn how to build relationships with each individual they care for, not just focus on a list of tasks performed mechanically. The future workforce will need not just to be ‘competent’, but to start learning from their first day about how to act with compassion and respect.”
And as Alzheimer’s Society told the review: “While training … is vital, it is important that a view does not develop that simple one-off training programmes can meet the challenge of ensuring the workforce has necessary skills, either in dementia or elsewhere. Learning should be built into practice and learning should be an ongoing process focusing on upskilling the workforce, rather than an exercise aimed at demonstrating compliance.”
Planning for the future needs to start now. The King’s Fund briefing The NHS and social care workforce: meeting our needs now and in the future? is part of its Time to Think Differently programme that aims to stimulate debate and ideas about how the health and care system can meet future challenges.
It points out that those placing greatest demand on services, both now and in the future, are older people with mental and physical multi-morbidities, who need integrated long-term care, and that: “Many of tomorrow’s workforce are here today. Much greater priority needs to be given to developing the skills and competences of the current workforce, and the quality of team working.”
The definitions of ‘residential’ and ‘nursing’ care are already becoming blurred, points out the Cavendish review. Inevitably this shift demands more of individual care workers.
Sheila Scott, chief executive of the National Care Association, told the review: “It used to be clearly specified what could be delivered in a care home. That was changed because it had meant forcing people to move to a different setting when very ill. But the result is that we are now seeing PEG feeding in domiciliary care, and catheterisation in care homes.”
The United Kingdom Homecare Association says that its helpline is inundated with workers asking whether they are allowed to do invasive procedures, giving insulin, or assisting with medication.
The message running through the Cavendish Review is that a focus on values and behaviours will enable care workers to fulfil their potential – and meet the challenges of future care provision – which may have been stifled by an emphasis on purely practical task-based skills.
“The phrase ‘basic care’ dramatically understates the work of this group,” says the review. “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. 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.”
This thinking is in line with the move towards values-based recruitment, and the idea that bringing in staff with the right attitudes and aptitude to be good carers is the necessary precursor to teaching someone how to undertake specific tasks.
Growing in confidence
But staff, now and in the future, may be held back from developing further through lack of belief in themselves and a full understanding of the incredibly valuable contribution they personally can make to someone’s experience of care.
As one contributor to the Cavendish Review put it: “Individual social care staff often appear to have low self-esteem. When asked about their work the response is generally prefaced with ‘Well I just ...’ They then go on to describe a complex mix of psychological insight, knowledge, practical creativity and skill.”
Increasing individual workers’ confidence in themselves is likely to be crucial for future development, a point reflected in the National Skills Academy’s Careship initiative, which aims to draw out people’s leadership abilities throughout the sector.
The Careship programme for frontline workers explores key values and behaviours and helps to build leadership confidence, including in seeing the relevance of national standards and adapting them to their own working practices and those of their organisation.
Making decisions, taking risks
Feeling more confident and empowered is an important element in other skills increasingly required to meet future challenges posed by growing numbers of frail older people and those with dementia, who need more complex care but may also expect to maintain their independence.
Skills for Care has developed a range of ‘learning to live with risk’ development tools, pointing out that supporting people who use care services to take informed risks is an essential element of personalisation and encouraging 'choice and control’.
Its Keeping risk person-centred support tools focus on people's rights to have the lifestyle that they choose, including the right to make 'bad' decisions, and to help care workers, in partnership with the service user and other carers, think in positive and productive ways about how to achieve the changes they want while keeping the issue of risk in its place, and come to decisions guided by what is important to the person, what is needed to keep them healthy and safe, and what the law says.
From the care worker’s perspective this means developing the ability to assess risk and consider decisions that are right for the individual service user, rather than necessarily fit the system. For instance, all Bupa Care Homes staff undergo Person First … dementia second training to ensure care revolves around each person’s needs, not fixed rules and routines.
With the confidence to make decisions and live with risk can often come greater willingness to question assumptions and practices, including your own. As care workers take on more complex roles and responsibilities, self-reflection and consideration of wider issues will be important.
This is already a part of some training, such as Alzheimer’s Society’s two-day interactive person-centred dementia care workshop, which encourages thinking around factors that can affect interactions with people with dementia, challenges some preconceived ideas about dementia care, and puts participants in the shoes of a person with dementia and asks them to take a fresh look at what they do.
Learning from each other
The King’s Fund argues that instead of individual professional development, the focus must be on collaborative development, and it foresees the creation of new roles in the area of care coordination, where staff work across organisational and sector boundaries.
The Social Care Institute for Excellence (SCIE) includes communication and partnership among specific areas of development for frontline staff, pointing out: “The ability to work collaboratively is one of the most important things that social workers and social care workers learn.”
Service users recognise this too; as one person told the Cavendish Review: “If you have a disjointed team the residents really pick up on that, so communication is really important.”
Some training already incorporates an element of sharing learning with others. The Cavendish Review highlights MacIntyre’s Great Interactions project as an example of not just a good but innovative form of development. It involves observing and videoing the ‘natural’ staff who are best at building relationships with service users, then using that information to develop a strategy to help all frontline staff emulate these care workers’ behaviours.
A relatively new role, but one growing in importance, is that of care champion or ambassador, promoting awareness and support for the sector, and specific aspects of it, to a wide audience. As well as communication skills this generally requires the ability to view factors affecting care in a broader context. The Alzheimer’s Society champions in dementia programme, for instance, encourages reflection on practice and explores the difference between institutional and inclusive approaches to dementia care.
Providing meaningful support
The NHS and social care workforce: meeting our needs now and in the future? also suggests there is a strong need for staff to develop the skills to act as partners or facilitators, rather than the traditional ‘authority’, and to support the informal care workforce.
TheDementia: workers and carers together guide and other resources developed by Skills for Care and Dementia UK demonstrate the importance of understanding family carers’ perspectives and providing support tailored to their specific needs.
As personal budgets become more widely available, and direct payments are used by more individuals to buy care, care workers are going to need skills in supporting self-directed care.
Skills for Care’s common core principles provide a framework to help care workers support individual empowerment and communicate effectively, enabling service users to assess their own needs and gain confidence to self-care, use technology and access support networks.
Ultimately, what service users are likely to want more of in future is someone who understands them and tries always to act in their best interests.
Care workers who took part in Cavendish Review focus groups talked passionately about being advocates for the people they look after, such as “interpreting for non-verbal clients; for example, when someone goes into hospital, we go in at key times such as mealtimes to support”.
As Relatives & Residents Association chair Judy Downey told the review: “Often, the role is one of brokerage and representation, not something which is apparent in most training programmes.”