In previous elf blogs I have discussed research examining the challenges for care systems arising from an ageing profile for the population and the overall state of the social care system for older people. These presented a challenging picture for society of increasing demand and cutbacks in state-funded social care for older people.
But perhaps at the societal level discussed in these articles things are too bleak or too abstract to tell us what it is really like being in adult social care at the moment – as someone using services or as a worker. Perhaps the quality of care is being unaffected. This is something we don’t know enough about but it is obviously a vital question for people in the services and for us as a society.
Burns and colleagues undertook research to examine the links between the quality of work in nursing homes and the quality of care during austerity cut backs in funding to the homes. They identify that these two themes are often researched separately, but there is a need to understand the interactions between them. What difference does it make to the quality of care for older people in care homes if the work that people are being asked to do and the conditions they work in are better/worse?
Care homes are labour intensive places of work. The pressure on funding for care homes has been terrific since around 2010 as central government grants to local authorities have been reduced. As a result, many are paying lower fees to care homes and, consequently, Burns et al. report, many homes have sought to reduce staffing costs to remain viable. Questions about the interactions between the quality of work in these environments and the quality of care are very pertinent.
Between 2009 and 2012 the authors conducted field work in 12 nursing homes across the UK – including a diversity of the size (from 10- to 65-bed facilities) and forms of ownership. They undertook repeated visits to each home (over 4-6 weeks per home) during which they conducted interviews (total= 175 interviews: 110 with staff; 38 with residents; and 27 with relatives), and observed the daily activities in the homes. Other data about care quality in the homes were drawn from documents including inspection reports.
Data were analysed from within each nursing home followed by comparison across the case study homes to generate a theory about the conditions under which job quality affects care quality.
All 12 case study homes faced ongoing financial pressures arising from cut backs in local authority spending on care home placements and increasing costs. All reacted with broadly similar responses including lower pay and fewer benefits for members of staff (e.g. ending pay for meal times), less training, lower staffing levels, longer working hours and more shifts, and changes in the skill mix in the homes (e.g. reducing the numbers of qualified staff (registered nurses) on duty).
Burns et al. argue that in all the homes the quality of jobs declined, but they found that the quality of care was maintained in 7 homes and deteriorated in 5. What was happening in each group?
Those homes that maintained quality adopted a person-centred approach to care and supported staff, amidst the financial penalties the homes and staff suffered. Staff sought to protect residents from the impact of cutbacks by changing routines, swapping shifts to cover for colleagues, working through meal breaks and after their contracted hours. Staff kept other qualities of work not related to money, including being able to have a voice in the running of the home and having some flexibility to decide how they did their work.
“the care workers absorbed the effects of the erosion in job quality and protected residents from its adverse effects” (p. 1001)
The 5 homes that had rated as deteriorating quality had generally experienced more severe cutbacks in local authority spending and did not have other funding sources to help to partially cover these losses (which the other 7 homes did have to some degree). In addition, these homes had a different care ethos – custodial rather than personalized, and prioritizing savings – and staff came to approach care as a series of tasks to be ticked off, sometimes hurriedly so. Although staff in these homes had initially tried to absorb the effects of the financial cutbacks and erosion of the quality of their jobs, they were ultimately overwhelmed and unable to develop work-arounds to protect the residents from the impact.
“In the homes in which financial cutbacks had severely eroded job quality, workers were less able to voice their concerns or to arrange ways to work around the cutbacks. Instead, the cutbacks spilled over into poor care as workers reduced the time they spent with each resident and the amount of care they provided. “ (p. 1005)
Burns et al. found a group of nursing homes that had all experienced serious financial shocks in times of austerity. They all responded with similar cost cutting approaches – and as staffing is the major cost for homes this bore the brunt of this, meaning a decline in job quality for people working in them.
In some of the homes the quality of care was seen to deteriorate. Homes that were able to draw on some other financial resources (to partially offset other losses in revenue) and which had a personalized ethos of care were able to maintain the quality of care.
However, the extent to which some of the responses of staff that helped to maintain quality (e.g. working more hours, through breaks, and unpaid after contracted hours) could or should be maintained in the long run is very questionable. Even homes that allow staff some voice in how the home is run, and a degree of autonomy to reorganize work to protect the quality of care, are likely to have a breaking point. How far can you degrade the working conditions of members of staff before the quality of care declines?
Burns et al. found in the nursing homes a set of responses to externally imposed financial shocks. Such shocks, as they found, can be absorbed to some degree, but there will be limits to this and it will have an effect on the quality and quantity of supply of social care.
Recently the Family and Childcare Trust surveyed Local Authorities to see how they felt about the level of social care services available in their areas to meet the demands for the support of older people. They present a bleak picture with only 1 in 5 authorities in the UK reporting having enough support services for older people in their areas to meet demand. They found large regional variations in the supply of services and the costs, and a great deal more detail about the sector – more than I can cover here.
Putting this together with the research by Burns et al. we see that although there is undoubtedly much good practice in social care and a great deal of variation in resources and quality, overall the sector is under serious pressure and this can have serious consequences for the quality of work and care.
Taking a slightly wider perspective across health and care systems, the NHS has been leading on work developing local Sustainability and Transformation Plans (STPs), intended to reorganize local services to meet the challenge of demand in the coming years. But deadlines and local histories and politics have meant the local plans are very variable in how they are being developed and the degree to which the process has engaged partners, including local authorities and health and care staff. Any STPs that have been developed without serious consideration of local social care markets, and especially care homes, are in danger of putting additional pressure on a local system that may be at breaking point, and of putting people and their families in intolerable positions in looking for good quality care.
Burns DJ, Hyde PJ, Killett AM (2016). How financial cutbacks affect the quality of jobs and care for the elderly. ILR Review, 69(4): 991-1016. DOI: 10.1177/0019793916640491