The Employment Relationship between DP service users and their personal assistants

1
The Employment Relationship between DP service
users and their personal assistants

• Clare Ungerson
• Honorary Professor of Social Policy, University
  of Kent
• Professor Emeritus, University of Southampton

2
Cash for care schemes international terminology

• Consumer directed care
• Personal budget schemes
• Companion payments
• Dependency subsidies
• Independent Living
• Direct payments

3
Origins of the ESRC project the founding ideas

• Boundaries between paid and unpaid work shifting
  and blurring
• Empowerment of care users potentially in
  conflict with social rights and income of care
  givers/workers
• How do different policy regimes impact on the
  care relationship and the labour market for care
  work?

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The five country study

• Austria unregulated
• Anyone needing continuous care for more than 6
  months and minimum of 50 hours care a month can
  apply for a long-term care allowance.
• 2001 343,782 care users in receipt, of whom 82
  were 60
• Italy unregulated
• 2001 5.8 of population aged 65 in receipt of
  companionship payments plus 42 of
  municipalities provide additional payments

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• Netherlands Personal care budget for people
  needing more than 3 months home care
• Highly regulated work contracts, payments
  through Social Insurance Bank, but can pay
  relatives
• 2002 34,544 personal budget holders
• France Prestation Specifique Dependance (PSD),
  now changing to Allocation personnalisee a
  lautonomie (APA)
• Regulated - cannot pay spouse
• Currently 150,000 elderly care users in receipt
• Expected more generous APA will expand numbers to
  600,000

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• United Kingdom Direct Payments
• Highly regulated cannot pay relatives, have to
  produce invoices for employed care assistants and
  evidence of National Insurance contributions
• 2002 just over 1000 elderly care users in
  receipt of direct payments

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Figure 1 The Cross of Routed Wages
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Figure 3 Schemes for Organising Routed Wages
Type of Payment and Time Availability
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A.Fully commodified informal care

• Both care users and care givers report high
  levels of satisfaction
• A care user things are excellent..and I am
  happy if she receives some money.(Dutch care
  user)
• A care giver You can only say that I simply
  felt as if I had been promoted. Society also saw
  it totally different then. Suddenly it was Aha,
  youre doing a job.(Austrian care giver)

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A.Fully commodified informal care

• What about exit for both care users and
  caregivers?
• Assumes informal care good enough care
• Encourages care by individuals known to care
  users rather than by strangers within
  organisations
• What about dead weight?
• Note that new right wing Dutch government trying
  to control cost by introducing maxima, tougher
  needs tests, higher co-payments

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• May increase supply of care by
• tapping into labour supply that would otherwise
  engage in other occupations in conventional
  labour market
• encouraging hybrid form of work based on
  contract and care based on moral obligation and
  affect so carers work well beyond contract
• supporting carers over long term
• ameliorating recruitment problems and hence high
  take-up of personal budgets

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B. Regulation plus credentialism

• Typically delivered by workers formally employed
  by agencies credentialism and regulation built
  into recruitment and monitoring procedures
• Delivered over short bursts of time
• Bureaucratic time and body time do not coalesce
• Care users feel rushed
• Care givers complain they cannot give holistic
  care, which is what they are trained to do

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B. Regulation plus credentialism

• Exit and voice are possible You can always say
  that you are not happy (French care user)
• A distanced, contractual relationship
• We have a certain consideration, esteem, I
  cannot say affectionshe is very kind, very
  competent.
• (French care user)

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B. Regulation plus credentialism

• Care workers are in a hierarchical profession
  with possibility of career advancement.
• Encourages care delivery within an organised
  infrastructure of care agencies
• May lead to
• greater efficiency of quality assurance process
• Higher quality of care delivered (but depends
  what users want)

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C. Direct Payments - a mixture

• A care labour market characterised by low wages,
  lack of skill, agencies may be absent or fly by
  night.
• Care users commonly find recruitment difficult
  improvise, use existing networks, word of
  mouth, agencies if they exist
• Many Care workers prefer working one-to-one -
  Here it is sometimes like I am part of the
  family (UK Care Worker)
• Care users are empowered Your own carers, you
  have got control of what time you want to get up,
  what time you go to bed, thing like that. (UK
  care user)

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C. Direct Payments - a mixture

• But care workers have difficulty in establishing
  own time and space Its just across the road,
  and he rings me up a lot. Oh can you just do
  this and that, like out of my time (UK Care
  worker)
• Very limited employment and social rights and
  knowledge of them.
• Examples in our sample of care workers being
  sacked on a whim.
• If Direct Payments to become crux of UK system,
  have to make decisions re
• Whether relatives can be paid to care
• How best to support care workers and which
  arrangements work best
• Whether want to encourage individual or
  organisational care delivery

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D. Additional income flows into the household

• Lack of regulation money flows into household
  and not necessarily to the carer
• When two people are married, theyre married.
  Previously we existed on his pension and mine.
  Now we exist on this money as well.. (Care
  user, Italy)
• Money as favours lubricates social
  relationships
• Small scale, discrete, caring tasks delivered by
  friends and neighbours
• Parallels with UK Disability Living Allowance and
  Attendance Allowance can be used as symbolic
  payments for informal care and hence may embed
  and support informal care

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E. Use of undocumented grey labour

• Lack of regulation allows for development of
  undocumented labour
• Labour is cheap care users can employ 24/7 care
• Care workers can feel trapped in this occupation
  Even if I dont like it, what can I do? It is a
  stressful job, not easy work. Here the only work
  that one can do is to care for old people (Care
  worker, Italy)

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E. Use of undocumented grey labour

• But the position of undocumented labour can
  depend on the context
• Italian labour drawn from third and fourth world
  Austrian labour drawn from transition economies
• Well, its good pay for me and he gains as well
  - it isnt too much for him either. He would
  have to pay more for an Austrian woman. Its
  quite a good deal. (Care worker, Austria)

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E. Use of undocumented grey labour

• Cost efficient form of labour for social care
  expenditure but overall fiscal losses
• Relies on an idea that experience rather than
  expertise basis for social care delivery but
  compare with basis for informal care
• Where source of labour is global rather than
  local, may be problems of communication
• But global migration and employment of
  undocumented workers may be cost efficient way of
  providing for care deficit
• Contingent on exploitation of very vulnerable
  workers

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Some conclusions and policy issues

• Some bigger questions
• If fully commodified informal care works best,
  what about dead weight?
• Is care a skill?
• If caregiver/workers are to receive full social
  rights, what are the cost implications for
  long-term care systems?

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Related Publications

• Clare Ungerson, 'Whose empowerment and
  independence? A cross-national perspective on
  'cash for care' schemes', Ageing and Society,
  24, 2004, pp 189-212
• Clare Ungerson, 'Commodified care work in
  European labour markets', European Societies,
  5(4), 2003, pp377-396
• Clare Ungerson and Sue Yeandle chapter in D.
  Houston (ed), Work/Life Balance in the 21st
  Century, Palgrave, 2005
• Clare Ungerson, Direct payments and the
  employment relationship some insights from
  cross national research, in J.Bornat and D.Leece
  (eds), Developments in Direct Payments, Policy
  Press, 2005
• Clare Ungerson and Sue Yeandle (eds), Commodified
  Care Work in Developed Welfare States,
  forthcoming Palgrave 2006