Dr Rashmi Becker recently completed doctoral research at the University of Cambridge examining the role of learning disability support workers in enacting social care policy in England. Her work highlights a gap between policy and practice, the poor working conditions of support workers, and the impact that this gap has on those they support.
The social care workforce has been undervalued and underserved for too long, and reform is urgently required. Without system-wide changes, proper investment, and real engagement with the people involved in all parts of the social care system, government policy simply cannot deliver. The consequences of such failure require action – not just reflection.
If social care was designed today, would that model rely on frontline staff being paid little more than minimum wage? Who work long hours and experience high levels of stress? Whose poor working conditions contribute to low expectations for themselves and for the people they support? Who are disconnected from the very policies that they are expected to implement? And who, nonetheless, are expected to support individuals, with highly variable levels of capacity and capability, to lead their lives to the full?
Successive governments have advocated safeguarding the wellbeing of disabled people, but the wellbeing of those supporting them has often been neglected. The sector comprises 18,500 independent organisations and, unlike the NHS, the social care sector does not have national pay rates or terms and conditions.
In 2019, Skills for Care reported 122,000 vacancies in England’s adult social care workforce; 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. The role and treatment of frontline workers has never been more pertinent than in 2020: Covid-19 has exacerbated social inequalities, and heightened pressures on a sector that was already barely keeping its head above water.
It is in this climate that I completed my doctoral research investigating the role that learning disability support workers play in enacting social care policy in England. My research examined how the social care workforce is represented in policy, and observed and interviewed learning disability support workers in residential and supported living services.
Six key findings can be drawn from my research:
- Disability policy does not accurately reflect the role of support workers.
- The relationship between support worker and the individuals they support is critical.
- The wellbeing of support workers is paramount to the wellbeing of the people they support.
- Support workers rationalise difficult working conditions through a narrative of care.
- Policy advocating choice and inclusion is complex in practice.
- Political will is required to address the funding crisis in social care.
The poor working conditions of frontline workers
Government policy fails to address the deep structural, economic, and social barriers that exist in care work, yet addressing these barriers is fundamental to realising policy ambitions for people with a learning disability. Even when policy recognises the needs of unpaid carers (as in The Care Act 2014), the needs of support workers remain absent. Without meaningful engagement and recognition of support workers, policy risks being little more than a well-meaning but ineffective aspiration.
Policymakers also give little attention to the relationships through which support is provided. If the interactions between support staff and people they support are seen as merely transactional, as nothing more than so many tasks and chores, then the welfare of both is vulnerable.
Inevitably, relationships suffer when there are staff shortages, when staff must shift from a relational approach (supporting people to do things) to a functional approach (getting things done). This is the consequence of policy that does not recognise the critical relationship between the support worker and people they support, and it is inherently disempowering.
Support workers are vocal about the daily emotional demands and physical challenges that they face. Their emotional investment in the people they support can result in great strains being placed on their mental health and wellbeing; nevertheless, support staff interviewed claimed that little support was available to them, and that they were expected to just get on with their job.
Staff wellbeing is central to developing high-quality services for people with a learning disability. How can support staff be expected to care adequately for the wellbeing of others when their own wellbeing is disregarded? Poor mental health may lead staff to make poor decisions, for themselves and for those they support.
Given such challenging working conditions, why do support workers remain in care work? The way that support workers describe themselves, their work, and the people that they support, provides a valuable insight into the culture of care work.
Care staff that I interviewed emphasised personal qualities over professional qualifications; they spoke of making a difference - of family rather than of duty-of-care. This indicates that support staff typically cope with their challenging work by adopting a personal narrative in which they view themselves as innately caring individuals who are making a difference.
The blurring of the boundaries between work and personal life can affect how support workers understand their work, their ability to avoid exploitation, and their ability to advocate for themselves. But in a sector characterised by chronically low pay and prospects, do support workers place such high value on intrinsic qualities and altruistic rewards to substitute for elusive material benefits?
Governmental policy must balance ambition with support
There is a gap between policy aspirations that promote choice and inclusion for people with a learning disability, and their implementation by support workers. The ability or willingness of support workers to prioritise autonomy may be constrained by the daily challenges that they face: stress, staffing shortages, inadequate knowledge, low wages, and the inherent tension between managing risk and promoting independence.
Government policy paints an idealised picture of people with a disability having choice and control over their lives. However, it must be recognised that people with a learning disability may experience choice, inclusion, and independence in ways that are meaningful to them - but that might not accord with conventional norms.
Policy remains rooted in the view that people with a learning disability can be valued members of society only when they adopt the roles and behaviours of the dominant group. But what if they are not able to adhere to such social norms? Policymakers must be ambitious when drafting learning disability policy, but they must also recognise people’s very real dependencies, and the capacity and capability of the care workforce.
Funding is the single most important factor impacting the quality and sustainability of the care sector. Compared to NHS workers, social care workers have largely been invisible, except when brought into the media spotlight by negative reports.
In 2018, when the NHS celebrated its 70th anniversary, research conducted by The King’s Fund and the Nuffield Trust remarked pointedly: ‘The fault line established 70 years ago between health care which is free at the point of use and social care which is means-tested, remains a fundamental source of inequity and unfairness today’. Along similar lines the Competition and Markets Authority found that many care homes, particularly those most reliant on residents funded by local authorities, are in an unsustainable position.
The poor working conditions of frontline carers are unstainable, and have serious implications for the quality of care provision, and the quality of life of both support workers and those they support. In order for government policy to be meaningful and achievable, it must accurately reflect the work and needs of the workforce. In addition, government must engage frontline workers directly when formulating policy that serves the interest of all people with a learning disability, without compromising the wellbeing of the people who support them.