Photo: Invisibility from Wordshore flickr photo stream

Book Review: Support Workers and the Health Professions an International Perspective, the invisible providers of healthcare

Support workers are:

‘a worker who provides face-to-face care or support of a personal or confidential nature to patients and/or service users in clinical or therapeutic settings, community facilities or domiciliary settings, but who does not hold qualifications accredited by a professional association and is not formally regulated by such a body’ (Saks and Allsop, 2000)

according to the editor of the recently released ‘Support Workers and the Health Professions an International Perspective, the invisible providers of healthcare’, published by Policy Press. This definition is explored, expanded and challenged across the 11 chapters of the book, covering the working conditions, expectations and limitations of support workers in the UK, Sweden, Australia, Brazil, Portugal, Japan, Canada and the Netherlands. The common feature across the collection is the use of neo-Weberian theory relating to professional social closure, though authors also draw on the wider (largely white and male) sociological canon, including Marx and Foucault.

The book offers a comprehensive discussion of support work in all its complexity. It does an excellent job of making clear just how ill-defined the work can be in regard to governance, sector, workplaces, job roles and regulations. It illustrates the economic uncertainties of the work, including reflections on the informal, unpaid care that sustains much of the global economy, the precarity experienced by support workers who are paid, but often not for travel time between services, or are expected to provide additional voluntary labour based on their relationships to the people they care for, and the various labour market contingencies that limit the progression or upskilling of the workforce. Though these issues are present across the entire collection chapters 2, 3 and 10 in particular draw attention to the economic vulnerabilities of a necessary, and yet under-researched occupational group.

Chapter 3, in particular, reflects on the impact of reduced budgets brought about by increased marketisation in health and social care. New managerialism demanded more for less, with an emphasis on performance and targets demanding increased efficiency, that has previously been discussed here on this blog. This drive has resulted in concerns relating to the overwork of support workers, partnered with inadequate supervision and training.

It is possible to see the connection between this discussion of managerialism, and the discussion of risk to services users which is the focus of chapter 5. Outcomes of inadequate support work provision have also previously been discussed in this blog in relation to the premature deaths of adults with learning disabilities, but this chapter focuses on the Mid-Staffs Hospital scandal. This risk, posed by support workers to those that they support, as a workforce devoid of meaningful professional registration, is handled sensitively in the chapter, and is couched in terms of regulation and association – questioning what, in the UK context, is the appropriate regulatory body for support work, or how an association would be formed. The limited economic power of the labour force would imply paid membership to an association would be unlikely, and its heterogeneity/lack of defined working responsibilities would make external regulation challenging. Unfortunately, the result of this lack of clear leadership (also discussed in chapter 4) manifests in a lack of specific training or good practice regulations, which can differ between services commissioned even within the same locality.

The authors clearly communicate how, essentially, the defining feature of support work is that the role is not definable. The workforce is not professionalised in any organised, institutionalised sense. As is compellingly argued in chapter three, any demand for the formalisation or registration of support workers is largely not to elevate their professional autonomy or demand pay increases, but to better address needs relating to their management and governance in health and social care settings. Specific support worker roles, especially those in health care settings, have assumptions tied to their conduct that reflect the medical professional project. The workforce is assumed to be strongly motivated by professional-type values, largely client/patient care at a high standard, alongside a willingness to take responsibility for the delivery of such care – with little professional discretion or association. Support workers are fluent in the language of the clinic, or of social work, but are not part of those respective professions.

The professional relationships between medicine, allied health, social work and complementary and alternative medicine (CAM) and health/care support workers are covered in chapters 4, 6, 7 and 9 respectively. These chapters highlight how support work staff, who make up the majority of the health and social care workforce across the globe, are necessary both as a response to New Managerialism and increased marketisation of healthcare, as well as enabling the (attempted) social closure of the professions they work alongside. For example, health care auxiliary staff in the UK increasingly complete tasks previously associated with nursing, allowing nurses to take on more specialised tasks previously the remit of medics. This switching up of tasks lower the overall costs of health and social care services, as the labour of support workers, which is considered low skill economy, is invariably cheaper than that of their more qualified colleagues.

These complicated relationships, influenced by policy, economy and infrastructure were replicated in many settings. In chapter 11, authors present qualitative data collected from a Tsukisoifu worker in Japan. With a literal translation of ‘attendant woman’, this chapter exposes the reader to a number of issues relating to gender, workplace expectations, shift work and emotional attachment alluded to throughout the rest of the book. Though fascinating, even with the limited introduction of raw data, the delivery felt somewhat detached. However, what the chapter did illustrate was the complicated relationship between various support worker providers and professionals, in the context of an ageing society and respondent policies. In Japan, a three-tiered support work provision between quasi-professional support workers who are required to access specific training and accreditation, and those who remain unqualified and unregulated – the roles are paid at different rates to reflect this, but it is possible to work in all three positions, often within the same employment setting. The interviewee who provides the data for the chapter describes difficulty in comprehending which role she was in at any given time, and so was not sure what hourly rate to charge at any given time. When her main employer died, she explained how she harboured a desire to leave care work.

Several of the chapters reflect of this high employee turnover within support work and draw attention to the key causes including poor working conditions, overwork, low pay and limited progression. The authors comment on how in some instances individual employees are not paid for travel between their various worksites and as a result, earn less than their national minimum wage, or reduce the time they stay with individual service users. Throughout the book issues such as this are illustrated, and the editor and authors effectively address the contradictions in the sphere of health and social care in that one person’s home is another person’s workplace, such that people’s private lives are intertwined with public responses to those lives (i.e. the state provision of care and support offered to someone living with an illness or disability).

It is difficult to read the content of the book without feeling angry that support workers globally are not afforded more respect and support, and, perhaps, surprise that the authors do not necessarily communicate stronger feelings about this in the text. What the book does offer though, is a significant insight into a precarious labour force on which so much rests, especially in the time of pandemic and shielding, where support workers have been valorised and demonised simultaneously in their handling of vulnerable populations. Where claps were considered acceptable remunerations for working through a pandemic in risky conditions, there was also disgust expressed at support workers who abandoned care homes and their residents. Perhaps it is not the role of the authors to display anger, but to offer us the information – and we can decide for ourselves whether we are angry or not.

Support Workers and the HealthProfessions an International Perspective, the invisible providers of healthcare edited by Mike Saks is published by Polity Press (Hardback £60, Ebook 21.95).