Personalised risk: new risk encounters facing migrant care workers
Karen Christensena and Jill Manthorpe*b
aDepartment of Sociology, University of Bergen, Bergen, Norway and b Social Care Workforce Research Unit, King's College London, United Kingdom
Short title: Personalised risk
* Corresponding author Email:
Abstract
Many long-term care systems are seeking to address problems of growing demand, increasing expense and higher user expectations. For many of them fostering care at home and private care arrangements are attractive options. The long-term care sector in England is typical of these systems. Over the last two decades government policy in England has placed stronger emphasis on people’s choice and control when receiving care services. People with care and support needs may be eligible for public funds to employ care workers or to use them in other ways promote their wellbeing. These financial transactions are a major part of the policy of personalisation in adult social care, as confirmed by the Care Act 2014. Drawing on findings from life story interviews with 31 migrant care workers who had worked for disabled or older people in England, conducted 2011- 2013, we note the potential for expanding the sociologically inspired concept ‘personalised risk’. This necessitates an appreciation of risks potentially faced by the multiple parties in the care relationship and a differentiated set of structural risks. Applying a multilevel analysis we highlight the potential risks of ‘informality’ of employment conditions experienced by directly employed care workers, the ‘emotional’ content of care worker-employer relationships, and ‘intimacy’ of employer/employee roles. In this article we offer an empirical based contribution to the wider discussion of risks and risk theory derived from policy changes being adopted by many developed countries that increasingly emphasise individual responsibility for personal welfare within an uncertain and mobile social world.
Key words: Risk, social care, personalisation, migrant care workers.
Introduction
In this article we explore the interconnections between social care, migration and personalisation policies to highlight the concrete dimensions of the concepts of public and private risk. We present findings from a study of migrant care workers to develop a multilevel analysis of risks, including structural employment-related risks, challenges regarding relationships with care users, and finally micro-level (intimated) features of these relationships.
With the growing demand for long-term care in the developed world new delivery mechanisms are emerging. Among these is the direct employment of care workers within domestic settings by individuals or their families. This may enable people in need of care and support to stay at home, sustain informal care provision by family and friends, and delay or avoid more expensive and generally unwelcome moves to long-term care facilities. England presents a case study of such a policy shift since it has been adopted such a policy for over two decades and implemented it under different political administrations. Particular emphasis in England has been given to the meeting of demands for care quality, often defined as being person-focussed and latterly personalised care. Great stress has been given to the importance of meeting individuals’ entitlements to greater choice and control through personal budgets or ‘cash for care’ and thus, in theory, improving their outcomes or wellbeing.
This article draws on the findings of life story interviews with 31 migrant care workers, who had experiences of working directly for disabled or older adults in England to provide social care. Such workers are called home care workers or personal assistants (PAs); they undertake tasks such as personal (bodily) care, housework, as well as providing companionship, promoting socialisation or access to work (Ungerson 1999, Ungerson and Yeandle 2007). The interviews were part of a cross-national study with a parallel data set collected in Norway (reported in Christensen and Pilling 2014). For the purposes of this article, the data are drawn from the interviews of those with care work experiences in England because narratives about risks were much more prominent in the English data, personalisation policy context is well-established in England, and because migrant care work in England is an important part of the care system.
Risk and personal care
Development of personal care
Worldwide, the ageing population is increasing need for adult social care. In England the numbers of social care workers are predicted to grow from 1.85 million in 2011 to 3.1 million workers by 2025 (Skills for Care 2012). In contrast to the National Health Service (NHS) sector, which is primarily publicly financed and delivered within the NHS, the majority of the social care sector is in the independent sector, albeit mostly funded by local government (see Moriarty 2010). This means the majority of workers are employed by private, for-profit agencies and non-profit organisations; but increasing numbers are directly employed by 120,000 personal budget holders (Health and Social Care Information Centre (HSCIC) 2014), with unknown numbers working in privately funded arrangements.
In the context of the European Union (EU), with its free movement of labour policy, migration patterns to the UK changed substantially amid growing restrictions on migration from outside the EU or European Economic Area (EEA). People not within the EU who wish to work in the UK (see Dobson and Salt 2009) may be permitted to do so only in response to specific staff shortages. With the continuing implementation of the policy of personalisation under the Care Act 2014 in England, the narratives of personalisation (Needham 2011; Glasby and Littlechild 2016) are providing new information on the risks involved. Commentators have detected an unstated social policy shift over who is to be regarded as responsible for risks in this context, including risks of harm, amid a wider emphasis on ‘responsibilisation’ for one’s own personal and family welfare (Clarke 2005; Ferguson 2007) and who should be protected from such risks (Stevens et al 2014). However, rather than focussing on the dichotomous citizen-state balance between personal responsibility and the safeguarding of vulnerable citizens (care users) our aim in this article is to suggest that policy of personalisation in England requires fresh explorations of how to make direct employment of care workers less risky for all parties. This conceptualisation necessitates a perspective that considers all parties to the care relationship as possibly/potentially encountering risks and one that takes into account the context in terms of structural conditions directing the ways care is experienced in everyday life (for the user of care services) or working life (for the care worker). This wider understanding has not so far been specifically articulated and so represents a potential gap in discussions of personalisation. Therefore, the point of departure in this article is the sociological inspired concept of ‘personalised risk’, as framed by personalisation policies that are throwing light on direct employment of care workers more generally. In contrast to researchers’ general focus on care user perspectives (see Salami et al 2016; Junne and Huber 2014), we explore the perspectives of those providing social care.
Care workers support disabled and older people in their homes or in long-term care facilities in activities of daily living. Traditionally this is a highly gendered part of the labour market – an extension of women’s work within families; with consequently low status which relates to its attractiveness to migrants as a labour market springboard (Hussein et al. 2013). While most social care workers in England are British by citizenship, Skills for Care (2014) reported that one in five were non-British citizens in 2013. Of the 266,000 migrants working in social care, the great majority (200,000) in England work in direct care roles. Migrant care workers are particularly relevant to this present discussion because they occupy a position of potential ‘triple’ vulnerability in being migrant, from an ethnic minority, and female doing ‘women’s work’ (or male workers doing ‘women’s work’), thereby at an intersection (Crenshaw 1991) of gender, migration, and ethnicity. While British workers, many of them from black and minority ethnic (BME) groups (Hussein et al. 2014), may face similar risks it may be that migrants are particularly vulnerable (Anderson 2013).
It is government policy in England to promote the ‘personalisation’ of social care and to encourage disabled and older people in need of care and support who are eligible for publicly funded social care to take up personal budgets, preferably as cash, in the form of direct payments (currently under the powers of the Care Act 2014). Through a direct payment money is provided so that the eligible person may employ whomsoever they wish (or to purchase items or services). The care plan setting out these arrangements has to be approved by the funder, the local authority. This policy of increasing user choice and control is designed to promote user empowerment and such aspirations are echoed internationally (Junne and Huber 2014; Christensen, Guldvik and Larsson 2013). However, Land and Himmelweit (2010) suggest that personalisation ‘takes the logic of privatisation one step further’ and argue that ‘By putting purchasing power directly in the hands of the care recipient, personalisation takes this idea [the idea of privatisation based on mainstream economic theory] to its logical conclusion’ (Land and Himmelweit 2010, p. 17). In other words, they depict a linear move of public services to a private care market and, at the end of this line, the operation of care services being taken over by individuals themselves. To a large extent this happens already for people who are not able to access public funding in England, either because their needs are not considered sufficiently great or because they are considered to have too much income or savings.
Personalised risks
The intersections of care, markets and migration are evident in terms of policies that increasingly apply market mechanisms to meet the care gap arising from demographic changes and to take account of the consequences of employing migrant (and other) care workers in different ways (see Williams and Brennan 2012, p. 358). While being useful in understanding the broader intersecting phenomena of this context we suggest that a more concrete theoretical understanding of risks encountered by migrant care workers who are directly employed to provide care offers a helpful adjunct and updating to Land and Himmelweit’s (2010) arguments. Inspired by the general analyses of different ideological and historical public/private dimensions (Weintraub 1997, Newman and Clarke 2009) and directed by empirical analysis of data reported below, we point to three dimensions of change. These underpin our development of a theoretical understanding of the differentiated risks related to personalised care that we suggest are evident in the data presented in this present article.
One public/private change relates to reduced public (state or local authority) accountability for meeting social care needs since direct payments are leading to more people employing care workers of their choosing rather than being subject to arrangements made through local authorities. As noted above, this changing pattern is in addition to the many people (often termed self-funders in the English context) who pay for their own care but have no contact with local authorities (Ekosgen 2013). Whether they are self-funders, or access direct payments, or use a blend of funding streams to pay for their care, some individuals choose not to employ care workers themselves but make arrangements with care providing agencies or support organisations to provide staff (sometimes termed managed personal budgets, Baxter et al 2013). In particular, in regards to migrant care workers, care agencies play a crucial role as employers. However, staff working for agencies may not have guaranteed hours of work and may have to cover their own travel and training costs (Gardiner and Hussein 2015). Those who are in self-employment or are directly employed by care users, are not required to undergo training, need not submit to criminal record checks, and have to pay their own travel and work expenses. Neither are they by health and safety legislation in the same way as other workers. Being self-employed or directly employed they are not accountable to any authority beyond the usual common law duties of care and similar; and, as the data reported below indicates, they may have further insecurities. We therefore refer to this tendency as implying risks of informality and insecurity of care workers’ employment conditions and rights.
The next dimension is framed by personalisation policies strengtheninghome based care employment which takes place in private spaces. When care work is arranged as personal assistance work (rather than through an agency) this structurally influences the intensity of the power relationship in the direction of what Anderson (2000) observed about domestic labour as:
… that is the worker’s ‘personhood’, rather than her labour power, which the employer is attempting to buy, and that the worker is thereby cast as unequal in the exchange (Anderson 2000, p. 128)
Although domestic work generally remains in the private sphere, there are similarities in regards to the emotional elements of the relationships between employer and worker. In other words, the location of care work in people’s own homes, bought (directly or indirectly) by the user, is an important aspect of the work. It encompasses what has been conceptualised more broadly as ‘emotional work’ and ‘emotional management’ (Hochschild 1983), when workers (and employers) negotiate potential emotionally-laden encounters. We refer to this here as risks of emotionalised relationships. While these characterise much care work and may be very rewarding to both parties emotionally, they are heightened by the direct employment relationship that is not mediated by a manager or by colleagues, or a wider employment infrastructure of human resources personnel.
The third public/private dimension change concerns the blurring of employer(user)/ employee(care worker) roles. While this third dimension has the same structural conditions as our second dimension, it highlights a different dimension - a further step along the personalisation line, creating risks of intimate emotional and physical encounters between individuals. We will refer to this as risks of intimacy of employer/employee roles crossing the boundaries of what is normally expected of people in such roles.
For our multilevel analysis of migrant care workers’ risks in personalised care, these three public/private dimensions are essential. In the analysis we will also show that these dimensions tend to be gendered which means that while the first one is shared by female and male workers, the second and third are increasingly feminised.
Methods
In this article we draw on data a larger study aiming at understanding people’s life projects when these included migration and care work, including personal assistance (see Christensen and Guldvik 2014). As part of this study the research team interviewed 31 migrant care workers. These in-depth interviews were designed to enable the workers to give their life stories. Given our aim in this article to exploring personalised risks as lived experiences in a certain structural context, provided an appropriate and rich data source.
We draw on qualitative data from these face to face interviews as survey or other forms of qualitative data collection such as focus groups would be likely to miss individual and detailed accounts of experience and would be hard to administer. As Salami et al (2016) found in their recent review of the few studies of live-in care workers, most data from such informants have been collected by face-to-face interview methods.
Recruitment
Seeking to elicit the experiences of a group of workers that is hard to find through official sources and to whom employers rarely provide access for various reasons, the present study used a combination of different participant recruitment strategies. These included contacting support organisations (led by disabled people and non-profit groups), accessing websites which are used by disabled people seeking a care worker and potential care workers seeking employment, local newspapers, and personal contacts. The advantage of differing approaches to recruitment was that all, except for one care worker participant, were not recruited through the disabled or older people for whom they worked (see Table 1) and so the research was able to assure participants of its independence. Due to the blurred public/private basis of employment (public money from local authority and from social security sources, potentially mixed with private money, and self-employment) participants did not always know whether the money they were paid was from public or private resources so this type of funding did not form part of inclusion or exclusion recruitment criteria.
Participants
Table 1 provides an overview of characteristics of the 31 interview participants, including their different employment arrangements. As Table 1 show these workers included women and men, many were experienced care workers, they came from EU as well as non-EU countries, they had been in England between a couple of months and 20 years; a majority of them (28) had experiences of personal assistance work but also had a broad range of more traditional care work experiences. Importantly, 15 had live-in care work experiences, that is, they were sharing the home of the disabled or older person they were employed by, and furthermore, many had experiences of being previously employed by a private (for-profit) care agency as well as being directly employed by an individual care user.