Promoting person-centred care at the front line

Recent policy developments highlight the importance of a more 'person-centred' approach within community care services. Within this framework, however, little attention has been given to the role played by frontline workers in delivering on these policy imperatives. Understanding the roles and experiences of frontline workers is crucial in understanding how frontline care can be made more 'person-centred'. The University of Stirling has looked at the barriers to and opportunities for promoting person-centred care for older people, disabled people and people from minority ethnic groups. This research found that:

• The term 'person-centred care' is mainly used in the literature about older people, particularly in relation to dementia care. Although the exact term used varies, there is a general consensus that 'person-centred' or 'quality' care is: user focused; promotes independence and autonomy rather than control; involves users choosing from reliable, flexible services; and tends to be offered by those working with a collaborative/team philosophy.
• Service users identify personal characteristics, such as gender, ethnicity and cultural background, as important to receiving good quality support/care. In addition, they also value personal qualities, such as patience, compassion, sensitivity and empathy.
• The relationship between the service user and frontline worker is pivotal to the experience of good quality/person-centred care/support.
• Barriers to the delivery of person-centred care predominantly relate to bureaucratic structures. A move towards increased management and budget-led services constrains frontline workers. Services which fail to provide person-centred care are often service-, rather than user-, led.
• People from minority ethnic groups experience a range of barriers to receiving person-centred care. These include: lack of accessible information; services which often lack cultural understanding; and language and communication difficulties.
• Management practices tend to overlook the importance of relationships between frontline workers and clients; frontline workers often feel they receive little support from management in their day-to-day work.
• Training opportunities vary for different frontline workers and appropriate training courses are not always available. There is little consensus about the impact of training on practice.

Background

Independent living has in recent years become a policy imperative for disabled people and older people. There has also been more recognition recently of the need for culturally appropriate service delivery for users of community and residential care services, as well as the importance of promoting user involvement in the delivery of community care services. These policy developments highlight a more 'person-centred' approach within community care services. Within this framework, however, little attention has been given to the role played by frontline workers in limiting, facilitating or delivering on these policy imperatives.

This study looks at the barriers to and opportunities for the delivery of person-centred support/care by frontline workers. The principal aim of the study was to conduct a literature review on the role of frontline workers within community care services. The review focused on frontline services for older people, disabled people and people from minority ethnic groups. It highlights concerns about the delivery of care at the frontline, exploring the competencies and qualities of frontline workers and the way they are empowered and supported in their role. The researchers also spoke with frontline workers and service users.

Person-centred care

'Person-centred care' is not a term that is used consistently across the literature. However, there are common elements of what person-centred or good quality support/care involves. It includes taking into account the service users' needs and views and working effectively with family members. This entails frontline workers providing good quality care/support help to support the relationship between carer and service user and building relationships with family members as well as the service user. Working with families can be challenging and difficult for frontline workers and listening to both can raise contradictory views on care/support.

Person-centred services also promote independence, offering flexibility and reliability to service users.

Person-centred care is complex and the range of tasks, duties and responsibilities that frontline workers must undertake to ensure the care/support they provide be considered 'person-centred' or high quality are extensive.

Perceptions of frontline work

'Frontline workers' is an umbrella term including all paid and voluntary workers who work directly with service users in the community. As the term implies, frontline workers have direct responsibility for the delivery of care.

In discussion groups, frontline workers highlighted their personal commitment to health and social care work. They also emphasised the importance of having a range of skills that link in complex ways to their gender, age, ethnicity and general experiences. They felt that managers and others not directly involved in frontline work, however, often relegate personal qualities to second place in favour of formal qualifications.

They also felt that care managers - and society as whole - lack awareness of the range of tasks frontline workers perform and a generally undervalue frontline care work.

This position emerges despite policy documents which emphasise the value of care work. Managers, the public and policy makers are perceived to focus centrally on training and professional status of workers while not sufficiently valuing the personal attributes that frontline workers bring to their work.

This suggests that more attention needs to be given to the emotional labour involved in frontline care work, recognising the commitment and personal qualities individual workers bring to their role: these attributes are valued highly by service users and their families. However, service users' attitudes to frontline workers are often obscured by the professional status of the worker. For example, social workers are given higher status than home care workers.

Systemic and organisational barriers to person-centred care

Increased bureaucracy, tighter budgets and restrictive commissioning of services all limit the ability of frontline workers to provide quality care to service users. These factors were seen as the primary issues of concern by both service users and frontline workers, limiting the time available for care and support.

These limitations cause additional stress for frontline workers already working in stressful conditions. In response to increasing constraints, many frontline workers work flexibly to better manage the formal structures imposed on them.

Managers' focus on budgets and commissioning means that they often have different concerns to frontline workers. The research evidence suggests that good management of frontline staff can significantly improve the quality of care service users receive.

There is a mixed picture of the training opportunities available to frontline workers. Lack of training and poor supervision contribute to the undervaluing of frontline work. Training for frontline workers working with minority ethnic groups was particularly scarce.

Systemic and organisational barriers to good quality care are compounded for people from minority ethnic groups. Systems may be harder to access, and language and cultural barriers intensify the difficulties in providing quality care for minority ethnic service users.

Conclusions

From this study three broad themes emerge that highlight gaps or limitations in the focus taken in research to date.

First, limited attention has been given to the specific role performed by frontline workers in delivering care services. With most studies focusing on health and social care delivery by specific professions – for example, social work, domiciliary care, or home care – research into care work has been within a hierarchical or system context. As a consequence, the focus has been on both managers and frontline workers, or on service users' perceptions of the services they receive. There is therefore little focus on the roles performed by, and perspectives of, frontline workers who regularly perform direct care tasks, working centrally with families and service users, while also working to deliver services in an often changing policy and practice environment.

Second, there is evidence of divergence in the quality of care offered between generic and specialist health or social care settings, and between statutory and voluntary sector providers. Specialist services are perceived to be of higher quality, better resourced and able to offer a wider range of services than generic/statutory providers can deliver, given constraints of time, resources and expertise. Concerns about a lack of co-ordination and joint working in care services are reduced where specialist workers take a holistic perspective, focusing on the person rather than the service. Fitting well with a person-centred perspective, this approach is seen in relatively positive terms. However, there is a need to understand better the particular challenges facing generic care workers and how these can be overcome within their particular organisational contexts. There is also a need to know more about why specialist providers are perceived as offering a higher quality service, and the extent to which this perception is based on actual differences in practice between workers rather than on having more time and resources available.

Third, with the constantly changing policy and practice context of health and social care work, more attention needs to be given to the role performed by frontline workers in implementing policy change. While policy and practice change is reported through statutory instruments, policy documents, good practice guidelines and critiques of policy change, the absence of attention to those workers who implement change means little is known about how policy change impacts positively or negatively on frontline workers' ability to deliver quality care services that meet service users needs. There are related questions also about the extent to which policy change meets service users' needs, and whether and how service users are consulted on planned policy change prior to it occurring.

Further research is therefore required to develop understanding and knowledge about the role of frontline workers in promoting person-centred care. This would help to fill gaps in knowledge about:

• The roles and requirements of frontline workers from the perspectives of both workers and service users.
• The motivations, satisfactions and frustrations frontline workers experience in their day-to-day work, as well as the drivers and challenges facing frontline workers; all of this needs to take account of the diversity of frontline workers both in relation to the tasks they perform and their age, gender and ethnicity.
• Service users' views and experiences of frontline care and support, with a more detailed picture required of the potential divergences between different service users' requirements to help better understand the complexity of delivering care and support packages in practice.
• How frontline workers navigate the often contradictory demands of policy and practice change and the needs of service users.

Policy and practice issues

There are four areas where further policy and practice work could be undertaken to enhance understanding of:

• What frontline workers and service users define as 'good quality support'. This information would both improve knowledge relating to the notion of 'good quality support' while specifically gathering the views of service users and frontline workers rather than managers and policy-makers on these issues.
• Innovative and best practice and where this is taking place.
• Frontline workers' views on their training needs and how these could best be met. This offers one route through which to gather frontline workers' views on the knowledge gaps they identify as preventing them delivering high quality care.
• The views of those at the grassroots – e.g. public sector frontline workers, specialist voluntary sector organisations and service users – about why practice is lagging behind policy rhetoric and ideology. These groups could offer suggestions from the grassroots perspective on how best to implement change effectively.

About the project

This study was undertaken by Anthea Innes, Suzi Macpherson and Louise McCabe from the Department of Applied Social Science, University of Stirling. It draws together a review of the literature about frontline work and a consultation exercise with frontline workers and service users. The literature review drew upon a systematic review approach. The consultation exercise consisted of four discussion groups at the outset of the project and three focus groups towards the end of the project. The consultation process included older people, disabled people, people from minority ethnic groups and health and social care workers.