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Care Workers
Another enormous issue is one that will run throughout this book: the low status, low pay, and generally poor conditions and training of those who provide care for the elderly and other vulnerable groups. Over the last thirty years or more we have seen the professionalization of nursing. Nurses are now university graduates whose training has made them technically very proficient. At the same time, they are often unskilled in basic hands-on procedures, which are increasingly undertaken by care assistants whose training is often minimal and whose security of tenure, and relationship with other members of staff, tends to be poor.
This is a complex issue. Originally, health professionals–particularly nurses–had their hierarchy modelled on the military. After the Second World War nurses came to see themselves as being on an equal footing with doctors. The result has been that nurses’ status has risen. The former slave labour demanded of student nurses has, by and large, disappeared, and student nurses are now spending a great deal more time actually studying. There has, however, been a downside to this. Nurses no longer provide the discipline and structure of a ward or a hospital in the way that they used to do; in addition, routine tasks such as emptying bed pans, giving patients their meals, or turning them and making them comfortable in bed has been handed ‘down’ to care assistants. Nurses are now too expensive a resource to be allowed to feed patients, make beds, or plump up pillows and are too busy giving drugs and injections to empty bedpans. Nor have they been trained to talk to patients and find out what is really worrying or concerning them.
All this is a cause for deep concern, because so many patients will be older people whose recovery rate will be slower than that of younger people and who will inevitably be worried about what will happen to them when they leave hospital. Many will not be fit to go home. Many will be classed as ‘bed blockers’, as if it were their fault that they have nowhere to go and not that of the system that has failed them by not supplying enough nursing home and care home beds. Nurses could be the ones who listen to the fears of elderly patients, who reassure and comfort, who try to speed up social services, who use their position to get things done–and often they are. But because they have so much less hands-on experience than in former times, because they have not been routinely talking to their older patients as they help them eat, or change, or wash, or make their beds, they often do not have the closeness, the intimacy–in its true sense–with their patients that could be used to allay some of these fears.
The people who are currently performing the most intimate tasks for the patients, most of whom are old, are the care assistants. However, they do not have the status to allow them to tell relatives and social workers what is worrying a patient. It used to be said that the people who knew most about what patients were really feeling were not the nurses at all but the cleaning staff, who would chat to patients while they mopped round their beds. The gradual contracting-out of cleaning services has removed even this degree of contact. The people who are left to hear the patients’ stories are very often the care assistants. Yet many of them are largely untrained. National Vocational Qualifications are increasingly common, and many hospitals, care homes, and nursing homes encourage their care assistants to take those exams. But not all hospitals pay for the training or allow staff time off, and many do not offer more pay when a qualification has been gained. If care assistants were actively encouraged to study for NVQs and then, where appropriate, to move on to more advanced qualifications, the whole atmosphere might change. Care assistants would then be seen as embryonic nurses rather than skivvies. Though this happens to some extent with the skills ladder the NHS has in place, there seems to be a remarkable amount of resistance to letting people through the various ‘glass ceilings’ and allowing them to move from care assistant to nurse, and from nurse to manager.
Transferring such a scenario into the main care sector for older people, nursing homes and care homes, where there will probably be only one qualified nurse on duty, would similarly have a transformative effect on care assistants. They would no longer be seen as short-term employees doing dirty work for little money and no emotional and ‘respect’ reward, but people who may go into nursing eventually or who may choose to remain as care assistants, at the top of that particular tree, with all its attendant qualifications and respect. The government has set itself the target of half of all care home staff having reached NVQ level 2 by the year 2005. It is pretty unlikely that the target will be reached, but the government’s intentions are good, and grants given to care home owners to help them pay for courses and study leave would speed up the process. It is, after all, well attested that training care home staff can reduce the amount of abuse, both intentional and unintentional, quite considerably.
Providing that hands-on, day-to-day care is hard work and can lead to stress and frustration. It is no surprise that nurses, who cost the system a lot to train, do not want to wipe bottoms and change beds, or feed patients or help them wash. Until care assistants have real status, recognizing them as the people who actually provide this vital and difficult hands-on care, they will not–as a group–necessarily give of their best. Until they are trained properly and achieve professional recognition there will always be the risk of deficient care, even abuse, from care assistants who have no vocation or professional dedication and who have only taken on the job because they can get no other work.
Example after example of poor care, often not abusive as such but insensitive and uncaring, emerges from CHI reports, from local newspapers, and from anecdotes from friends and relatives. And these must be just the tip of the iceberg. Typical is the case of a nursing home in East London which had a complaint against it upheld by the National Care Standards Commission because of the ‘unprofessional’ attitude shown towards a lady just minutes after her relative’s death. Care workers did not sympathize or help her come to terms with the news of her relative’s unexpected death (she had already complained about unexplained bruising on his arm). Instead, she was told that ‘there was not much point’ in an undertaker taking his body away that night because of the extra cost (of after-hours collection, presumably) and was told that his body would have to remain in the room he was sharing with another man–a piece of insensitivity about the effect on the other man which beggars belief.*
Insensitivity and uncaring attitudes. Yet something can be done about them, and care staff can be trained and encouraged to think differently, if employers make it worth their while. Care assistants should know that the ladder into nursing is available to them. Nurses, and their organizations, should celebrate the contribution care assistants make and welcome those who climb the ladder into nursing to join them. There has to be another way into nursing that does not require a university degree, and there has to be recognition that caring is of equal status with providing hi-tech interventions. Equally, care assistants will have to accept that they will be regulated and checked by the police for any record of abuse and that they will be expected to work in a care home or nursing home for a considerable period, rather than hopping from one agency to another.
These would be major changes. Care assistants have been appallingly badly treated. We have allowed our most vulnerable older people to be cared for by people to whom we do not show respect. The challenge is to pay care assistants properly, train them properly, and support them properly without the cost of care becoming so prohibitive that no one can afford it. Yet without this the existing situation will get worse. As Janet Street-Porter argued fiercely in her article entitled ‘I’ll do anything except go into a care home’: ‘The whole culture of care for the elderly gives me cause for concern. If we don’t value teachers, we insult carers. The pay is appalling, the job unattractive, the prospects pathetic.’* Quite so. And it is our fault.
The fact that we think it acceptable to put our old people into care homes at all is another issue that needs consideration. Yasmin Alibhai-Brown, redoubtable