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Issue The development of new generic health and social care roles may be a useful way of providing service users with seamless, holistic care, preventing unnecessary admissions to long term residential care, and responding to pressures on services, such as staff shortages.  The evidence must be explored, however, to learn more about the impact of these roles and the best way to provide them.

Content of this evidence cluster This evidence cluster summarises the evidence around the generic worker role, exploring its impact on service users, staff and organisations.

Definition of key terms For the purposes of this evidence cluster, the term ‘generic worker’ refers to a role where an individual is responsible for carrying out a range of both health and social care tasks in a home care setting. Within this broad definition there are variations in qualifications, employing organisation, and responsibilities. 

Health care tasks undertaken by a generic worker are likely to include simple or ‘low level’ nursing tasks such as catheter care, routine administration of medication, and changing wound dressings.  Generic workers often come from a background in home care or community support worker roles, and have usually undergone additional training for the new role. 

Generic workers tend to work with older people. As Taylor explains, ‘[joint working] is particularly relevant in the care of vulnerable older people where the needs are complex and the line between medical and social care is blurred.  Frail older people…are likely to experience difficulty coping with the multiple contacts with specialist professionals that their needs require’ (Taylor, 2001).

Generic workers fitting the above definition are referred to by a range of job titles, including ‘generic support workers’, ‘rehabilitation assistants’, ‘home care support workers’ and ‘community health and social care support workers’.

Policy background The development of the generic worker role has been attributed to a range of influences, including a policy focus on promoting independence for older people, an increasingly ageing population, staff and skill shortages in health and social care services, pressure to achieve shorter lengths of hospital stays, a need to reduce delays in treatment, and a need for a diverse and flexible workforce to meet demands and respond to these pressures.

In 2000, the NHS Plan recognised that the care needs of older people require joint working between health and social services and other support services, and highlighted a need to examine how people work, in order to improve patient care and ensure best use of staff skills (DH, 2000).  In 2003 The NHS Modernisation Agency implemented its Accelerated Development Programme for Support Workers in Intermediate Care in England, as part of its Changing Workforce Programme.  It responded to the NHS Plan, supporting health and social care organisations to test and implement new and amended roles. The Changing Workforce Programme ‘has striven to support new roles that bridge the gaps between health and social care’ (Ottley, 2005).
 
Also in 2003, Skills for Care implemented Phase One of its New Types of Worker (NToW) Programme.  This is a national programme which aims to: investigate and re-design roles for workers in social care; enable employers to develop and implement new roles; and bring about new types of working.

In 2006 the White Paper Our Health, Our Care, Our Say expressed the government’s commitment to better integration between the NHS and social care services.  This included a drive towards joint service and workforce planning, working across traditional agency boundaries, and creating career pathways across health and social care.  Most importantly the focus was upon ensuring developments were based on the needs of patients and service users (DH, 2006).

The evidence – setting the scene

The following projects demonstrate the potential for wide variation in both the characteristics of generic worker roles, and the ways in which they are evaluated.

Initial evidence on the effectiveness of the generic worker model was presented in the evaluations of the initial care management demonstration projects conducted by the Personal Social Services Research Unit (PSSRU). These classic studies in Thanet (Challis and Davies, 1986), Gateshead (Challis et al, 1990) and Darlington (Challis et al 1995) introduced the role of the generic worker able to undertake a range of tasks and laid the foundation for the introduction of care management.

Studies of two national programmes supporting the development of new roles were identified.  The stage one report of the Skills for Care New Types of Worker Programme provides an overview of the evaluation findings across 28 pilot projects carried out between 2003 and 2006. One of these explores the implementation of a generic worker role – the Leeds Domiciliary Services Project (Kessler and Bach, 2007). Two papers report on various aspects of the Accelerated Development Programme for Support Workers in Intermediate Care in England.  Both report findings from questionnaire surveys undertaken with 50 agencies that had implemented a range of support worker roles, one at the start of the programme (Nancarrow, 2005) and one after twelve months (Ottley, 2005).

The evidence for generic workers – key messages

There are a range of models for the generic worker role

A number of models of generic worker were identified, the majority combining a range of social care and low level health care tasks.  A particularly distinctive model was the Rehabilitation Assistant role, reported by Stanmore. The following models are discussed in this evidence cluster:

• the Rehabilitation Assistant, within the Northwest Project - this worker’s role included assisting with the provision, fitting and safe usage of equipment,  supervising and assisting activities of daily living, monitoring and feeding back patients' progress to professionals, and maintaining records (Stanmore, 2006; 2007)
  
  
• the Health and Social Care Worker, within the Southwest Project – a role which involved personal care (bathing, dressing, feeding and grooming), skin and foot care, application of ointments and medication administration (Taylor, 2001; Hek, 2004)
  
  
• the home care support worker within the Augmented Care at Home Project in Ayrshire – this role included domestic tasks, social care tasks, promotion of continence, assistance with self-medication and other health care tasks such as catheter care and stoma care (Curtice, no date)
  
  
• the generic worker, within the Darlington Community Care Project – a role combining the functions of home help and auxiliary nurse (Challis et al, 1989; Challis et al, 1995)
  
  
• the Community Support Assistant, within the Leeds Domiciliary Services Project – this role involved ‘low level’ nursing and therapy tasks such as changing dressings and routine administration of medication, alongside the traditional community support assistant role (Kessler and Bach, 2007)
  
  

Role may help service users maintain independence

The generic worker role seems to have enabled service users to maintain their independence and remain in their own home for longer than would otherwise have been possible.  This aspect of the role was explored in different ways by our studies.  Challis and colleagues (1989; 1995) showed that, in the Darlington Community Care Project, of 101 older people who had received the service for six months, two thirds had remained in their own homes, three were in residential care, and the remainder had died. Service users who took part had been identified because they had been receiving continuing care in hospital, and were likely to be admitted to long term residential care, so this data demonstrates that the scheme had been successful for a large proportion of them.

The level of physical dependency of service users was explored by researchers in the Augmented Care at Home Project.  They found that service users had a high level of physical dependency compared to respondents in a previous national study of residential homes, but that they had a lower level than a local comparison group of nursing home admissions (Curtice, no date). This suggests that the scheme may have successfully been targeting a group of service users who would otherwise have been admitted into residential care, but the evidence is not conclusive.

Service users themselves reported that they felt the service enabled them to remain in their own homes longer than otherwise would have been possible (Curtice, no date; Hek, 2004).  Interview data suggests that generic workers had an important role in encouraging and reminding service users to take their medication, were crucial in providing personal care  (Hek 2004), and were also in an ideal position to promote the philosophy of rehabilitation, as opposed to doing things to or for people.  They were successful in helping service users increase their confidence and ability (Stanmore, 2006). 

Service users report a positive experience of the new role

Service users in three of the projects reported a positive experience of the service they received from generic workers (Curtice, no date; Hek 2004; Stanmore 2006).  In the Augmented Care at Home Scheme, service users reported that they welcomed the good humour and caring approach of the home care support workers and their willingness to do whatever was needed.  The remaining studies did not report service user views.

While service users did not necessarily recognise the job title ‘generic worker’, they identified with the individuals who provided the service and recognised the distinctness of the role in terms of providing both health and social care (Hek, 2004). 

Where there were criticisms of the service, they were not related to the generic workers themselves, but to organisational issues such as fees.  These issues are discussed in more detail below.

Emotional support is an important aspect of the role

As well as having an important role in helping service users to reach their physical goals, generic workers played an important role in promoting mental health, and listening to, encouraging and motivating service users. Curtice (no date) and colleagues demonstrated that service users receiving support from generic workers had higher morale than service users in a comparison group. Qualitative data from Hek’s study showed that rehabilitation assistants were able to develop good relationships with services users and spend time talking to them - staff and service users saw this emotional support as being as equally important as physical support (Hek, 2004).

Interview data suggest that there was a close relationship between the emotional support provided by the generic workers, and achieving physical goals.  Service users felt that the social contact provided by the generic workers helped them to achieve their goals. Both staff and service users considered the trust and familiarity that was established to be extremely beneficial (Taylor, 2001; Hek 2004; Stanmore, 2006).

In one project, however, generic workers highlighted that their training had lacked any mental health component; this would have supported them to carry out the emotional support aspect of their role (Taylor 2001, Hek 2004).

Effective partnership working supports generic workers

Where a positive relationship between health and social care organisations already existed, it contributed to the success of the new role.  Taylor (2001) reported that an existing rapport between the home care manager and district nurses helped with communication and sorting out problems informally . Ottley’s survey (2005) of teams involved in the Accelerated Development Programme revealed that 39% reported that good partnership working already existed. 

Some approaches to partnership working were identified which benefited the generic workers in their new role.  These approaches included a weekly meeting of generic workers, district nurses and the homecare manager (Taylor, 2001) and joint supervision arrangements (Ottley, 2005).

Effective partnership and multidisciplinary team working had a number of positive effects for generic workers and for organisations as a whole.  In Hek’s study, the health and social care workers felt positive about their relationship with the district nursing team, and felt valued (Hek, 2004).  Stanmore (2006; 2007) reported that because of their involvement in all aspects of care, the generic workers themselves had an important role to play in promoting inter-disciplinary communication and the ability to liaise with a wide range of professionals and other agencies. This resulted in improved accessibility to and delivery of care for service users Stanmore also reported that, while it took time to build up, trust between generic workers and professional staff allowed greater levels of autonomy and delegation.   In the Accelerated Development Programme, working in partnership was found to raise common issues and increase understanding between agencies – most teams stated that links within partnerships had improved as a result of developing new roles (Ottley, 2005).

Some potentially problematic organisational issues were raised which influenced the success of implementation of new roles, and which may have important implications for the future of these roles.

Stanmore (2006) reported that there was a lack of established infrastructure and resources to support new ways of working , and that there was inconsistency, in that that managers varied in their levels of commitment to the role. Some gave it more time and promoted it more than others (Stanmore, 2007).

In the Leeds Domiciliary Services Project, the implementation of the generic worker role was an ‘extremely difficult and protracted process’, with community support workers successfully taking on new low level health tasks in only a few small areas (Kessler and Bach, 2007).  It was felt that, while a steering group can be an important feature in taking new ways of working forward, in this project those present from the local Primary Care Trusts were not senior enough to have the authority to take key decisions.

The difference between free health care and charged social care caused some difficulties. As Hek writes, ‘the distinction between health care “free at the point of need” and “means tested” social care has led to increasing problems in two services working together’ (Hek, 2004).  Taylor (2001) reported that primary care staff were frustrated by the role of eligibility criteria for homecare, and the associated bureaucracy while Stanmore (2006) reported that one criticism from service users was the time limit imposed on the generic workers, relating to the six week time limit for non-charged services .

Issues around pay were also raised.  Ottley reported that there was a range of salaries for generic workers, from £10,300 to £20,000 per annum, and 23% of respondents felt that pay was a barrier to implementation of roles (Ottley, 2005). 

Implementation of generic worker role
reduces numbers of visits by different professionals

The introduction of a generic health and social care worker resulted in reduced numbers of different professionals being seen by service users, better use of resources and a more seamless service (Ottley, 2005; Stanmore, 2006). This benefited service users, who did not need to repeat the same information to different professionals, and who may have experienced less confusion as a result of seeing one individual who would support them in all aspects of their care. Taking this idea further, Taylor (2001) reported that generic workers were in an ideal position with regular service user contact to identify changing needs and preven deterioration, whereas if a number of professionals were visiting a service user at different times, they may each be less familiar with the individual service user and therefore less likely to identify change.

Training is a fundamental feature of a generic worker model

Training is a central feature of the implementation of generic worker roles.  It was reported that all services in the Accelerated Development Programme had some form of training in place at baseline (Nancarrow 2005).  Training was important in a number of ways.

Training gave generic workers the knowledge, skills and confidence to carry out the broad range of tasks that were required of them in their new role.  It was reported to have resulted in increased health and social care knowledge, as well as assessment and observation skills among the generic workers. Most importantly, it was felt to have subsequently improved quality of care (Taylor, 2001; Hek, 2004; Ottley, 2005).

Where training was provided by district nurses with whom the generic workers were subsequently placed in multidisciplinary teams, interview data suggested this resulted in a positive relationship between the two groups. Time spent together in the training process extended contact, broke down barriers and created trust (Taylor, 2001; Hek 2004).

Training could help to recognise and formalise the knowledge and skills that staff had already been employing in their traditional roles, and  improve their confidence in carrying out these tasks, as was the case in the Southwest study of Health and Social Care Workers (Taylor, 2001).  It was reported that new roles and their accompanying  training packages contributed to a new career pathway for support staff (Ottley, 2005).

There is the potential for problems to arise, however, if trained generic workers carry out nursing tasks outside of the project for which they are employed.  One case of this was reported, where a generic worker who was temporarily filling a traditional home care role added to the nursing notes of a client who was not part of the scheme.  A complaint was made by a district nurse who was not involved in the scheme and was unfamiliar with the generic worker role (Hek, 2004).

As mentioned above, given the importance of emotional support and promotion of wellbeing in generic worker roles, it will be important to ensure that appropriate training for this aspect of the role is given. In one project, workers in the new role expressed some dissatisfaction that mental health was missing from their training programme (Taylor, 2001; Hek, 2004).

Staff report a positive experience of the new role

On the whole, the new role was valued both by the generic workers appointed to the posts, and their colleagues in various professions, although in some cases it seemed to take the latter group some time to adjust to the new roles being in place.  Generic workers appointed to the new roles found their work more interesting than their previous roles, and had greater confidence, motivation and job satisfaction (Hek, 2004; Ottley, 2005).  Hek reported that staff appreciated the fact that they were no longer seen as cleaners, they felt positive about their relationship with their colleagues in other professions, and felt valued.

There was some negative feedback from the professionals working alongside the generic workers, predominantly restricted to the early stages of implementation.  Stanmore (2006) reported that professionals sometimes complained about their own reduced contact with patients, and that they felt their own workload had increased because of the need to supervise the new workers (Stanmore, 2006).  The generic workers themselves felt that sometimes their work was not understood by mainstream colleagues and management.  They reported that they experienced initial resentment from nursing staff as their role was viewed as easier but rewarded more highly (Stanmore, 2007).  Similarly, Hek (2004) reported that there was some hostility from existing nursing auxiliaries at the start of scheme, who may have felt that their role was threatened.  These more negative reactions were generally seen to dissipate as other professionals gained a clearer understanding of generic workers’ roles and responsibilities.

The evidence – is missing A number of local pilot studies are currently being carried out exploring various models of providing a generic worker role.  As these studies are evaluated, further evidence will be welcomed on the impact of the roles on service users’ quality of life and their levels of independence. An emphasis on quantitative evidence of the effects of generic worker roles on service user outcomes will be particularly valuable. 

Conclusion As generic worker roles are increasingly recognised as an important way of providing a more seamless service, promoting joint working between health and social care and responding to common pressures on services, it will be crucial to maintain awareness of the impact of these roles on service users, staff and organisations, as well as the most effective ways of providing these roles.

Studies have demonstrated that generic worker roles are welcomed by staff and service users, who have a positive experience of the schemes.  The services do have the potential to improve service user independence and maintain them in their own homes for longer than would otherwise have been possible, at the same time reducing the numbers of different professionals that service users see.

Suitable training is a core feature of any new generic worker model, but the importance of the emotional support aspect of the role must be recognised in the training process.  Effective partnership working between health and social care can help to support the implementation of the new roles.  Organisations must be careful, however, to ensure that barriers around pay, charges for services, and demand for the new role are addressed. 

 References

Challis D, Darton R, Johnson L, Stone M, Traske K and Wall B (1989) Supporting frail elderly people at home: The Darlington community care project. Canterbury: PSSRU

Challis D, Darton R, Johnson L, Stone M and Traske K (1995) Case management and the health care of older people: The Darlington community care project. Canterbury: PSSRU

Curtice L (no date) Extending the boundaries of community care: evaluation of Augmented Care at Home in Ayrshire. Glasgow: Nuffield Centre for Community Care Studies

DH (2000) The NHS Plan: a plan for investment, a plan for reform. London: The Stationery Office

DH (2006) Our Health, Our Care, Our Say: a new direction for community services. London: The Stationery Office

Hek G, Singer L and Taylor P (2004) Cross-boundary working: a generic worker for older people in the community. British Journal of Community Nursing. Vol 9, No 6, pp237-244

Nancarrow S, Shuttleworth P, Tongue A and Brown L (2005) Support workers in intermediate care. Health and Social Care in the Community. Vol 13, No 4, pp338-344

Ottley E, Tongue A and McGill M (2005) Redefining the role of support workers in intermediate care: Key findings from a national project. Journal of Integrated Care. Vol 13, No 1, pp28-34

Stanmore E, Ormrod S and Waterman H (2006) New roles in rehabilitation - the implications for nurses and other professionals. Journal of Evaluation in Clinical Practice. Vol 12, No 6, pp656-664

Stanmore E and Waterman H (2007) Crossing professional and organisational boundaries: The implementation of generic Rehabilitation Assistants within three organizations in the northwest of England. Disability and Rehabilitation. Vol 29, No 9, pp751-759

Taylor P (2001) Meeting the holistic needs of older people in the community: An examination of a new generic health and social care worker role. Local Governance No. 4 Vol 27, pp239-246