Comparison between personal assistance and home care work

PA evolved from the experience of disabled people who felt confined and oppressed by the traditional care system and sought a way out. The history of PA lies in disabled people’s struggle to be free to choose and control their own lives and those supports necessary to bring their preferred lifestyles into fruition.

The evolution of CW has been professionally driven. In some contexts, CW evolved from the work of ‘home helps’ who were employed to support women’s childcare duties. Eventually, the ‘home help’ was extended to include domestic support of older and disabled people, before taking on ‘personal’ care responsibilities, particularly after the closure of institutional care provision.

PA enables the choice and control of the PA user, which makes it possible for the PA user to live in the community. The PA user tells the PAt what, how, and when to do. PA users with intellectual and/or psychosocial impairments who require additional assistance with making choices and being in control are provided with access to support with decision making and peer support.

CW tends to hinder the choice and control of the CW users. The ‘what’, ‘when’, ‘how’, and ‘who’ of the support are determined by the CWr’s employing agency. The preferences of the CW user may be considered, but the final decision rests with the service commissioner or provider.

When referring to PA, the preferred terms are ‘assistance’ and ‘support’. The term ‘care’ is considered paternalist and patronising. The term ‘(service) user’ is contested, as is the term ‘customer’. The framing of PA renders the PA user in terms of human rights and as the ‘subject’ of support – someone who is in control of their life and lifestyle support mechanisms.

With regard to CW, the preferred term is ‘care’. The framing of CW usually reflects patronising and ableist attitudes towards the service user. This framing renders the CW user as an ‘object’ of care – someone who is helpless and receives care submissively, rather than being in charge of their lives and actively controlling their support.

A PAt has a contract of service with the PA user.

A CWr has a contract with their agency or local authority.

A PA user has the obligation to provide and pay for work and the PAt is under a similar obligation to perform the tasks delegated to them.

The mutuality of obligation of a CWr is between them and their employing agency.

PAts are employed by the PA users. The salary of the PAt is paid by the PA user or by a third party chosen by the PA user or by the person(s) supporting the user with their decision-making. As an employer, the PA user is also responsible for paying tax, insurance, and employer contributions. Support with payroll is best provided by peer-support groups, such as Centres for Independent/Inclusive Living. PAts are usually not unionised but may be able to join a CWrs union.

CWrs are employed by the care agency or the local authority. The salaries of CWrs are paid by the care agency, which is also responsible for their insurance. CWrs are usually unionised.

A PAt has no freedom to send a substitute in their place if, for whatever reason, they are unable to perform their duties. Only the PA user has the right to make substitutions.

The care agency or the employer of the CWr has the right to send out whichever CWr they have to hand.

A PAt is rarely responsible for providing their own equipment. The PA user normally supplies the equipment, with or without the financial support from their local authority or another third party.

The care agency or the employer of the CWr may be responsible for the provision of equipment. However, in most cases equipment is provided by the CW user, with or without the financial support of the local authority or another third party.

PAts are recruited by PA users. Upon request by PA users, they may be supported in recruiting their PAts by a user-led organisation such as a Centre for Independent/Inclusive Living. PA users, particularly those with intellectual and/or psychosocial impairments, may require support with their decision-making in recruiting their PAts.

CWrs are recruited by care agencies or local authorities.

The qualification requirements for PAts (experience, skills, abilities, aptitudes, values) are determined by the PA user. There are no pre-determined lists of qualifications because every PA user has different requirements. Therefore, certification of PAts is either avoided or optional.

The qualification requirements for CWrs are determined by the care agency and/or a third party such as a care quality regulator. CWrs may get certified.

PAts are trained by PA users. Professionals may be involved in the training upon request by the PA user. Additional training may also be provided by a user-led organisation such as a Centre for Independent/Inclusive Living. This additional training is likely to include discussions of the social model of disability and Independent Living philosophy.

CWrs are trained by professionals (other CWrs, social workers, occupational therapists, nurses, etc). Sometimes, there is a hierarchy of qualifications for CWrs tied to renumeration. Professional training is normally given on a general basis and does not involve the CW users themselves, although ‘on the job’ training may happen. In most CW training, the CW user is seen as the ‘object’ of care who receives the care rather than directing it.

PAts are managed by the PA user, or by a third party chosen by the user. PA users with intellectual and/or psychosocial impairments may require support with their decision making in managing their PAs.

CWrs are managed by senior staff in the care agency.

Upon request, PA users may be supported by peers (other PA users) in managing their PAts. Peer support is usually provided by a user-led organisation such as a Centre for Independent/Inclusive Living.

Usually, CW users are not provided with access to peer support.

The tasks of PAts are determined by the PA user, with decision-making support for PA users with intellectual and/or psychosocial impairments, if needed. The range of tasks is wide and may include tasks at home, work, education, leisure (e.g., support during business or holiday trips), as well as support with communication.

The tasks of CWrs are determined by the care agency or the local authority, following an ‘assessment of need’. The range of tasks is limited and mainly restricted to helping at home.

PAts work flexibly – e.g., a PA user may get 4 hours of PA one day, and 8 hours on the next day, depending on the PA user’s needs.

CWrs work fixed hours – e.g., a CW user may get 4 hours of care per day, on weekdays only. In some contexts, CW users complain that they are charged for more time than they receive. This is because travelling time is not featured in the CWr’s time sheet and transportation from one CW user to another remains unaccounted for. This is acutely prevalent in rural communities.

A PA user may have more than one PAt, depending on the requirements of the PA user. The number of PAts per user is not limited. A PAt may work for more than one PA user if the requirements of the PA users allow such an arrangement.

Typically, a CW user has only one CWr, although in some cases two may attend at the same time, depending on ‘assessed need’. A CWr provides care to several users, which usually entails increased demands for travelling. A CW user may be sent different CWrs on different days, which erodes the continuity of support.

PA is funded through earmarked cash allocations (direct payments) provided to PA users by local authorities or by a central funding body. Central funding is preferable because local authority funding may lead to unequitable provision or ‘postcode lottery’. PA users may delegate accountancy tasks to a third party. The PA user may also get HR advice from an insurance company and/or a peer support group in a Centre of Independent/Inclusive Living.

CW is funded through block grants, tenders, or under ‘spot contracts’ provided to care agencies by local authorities or by a central funding body.

PAts are accountable to the PA user. The PA users are accountable to the funding body.

CWrs are accountable to the care agency or local authority.

Research shows that PAts have higher job satisfaction than CWrs. This is due to ‘personalisation’ – the work is directed to the one person and their lifestyles, which develops closer relationships between the PAt and the PA user. Other factors leading to higher job satisfaction include continuity of support and direct management by the PA user.

The lower job satisfaction of CWrs in comparison to PAts is due to regimentation of tasks, discontinuity of support, demands for travelling, and lack of personal relations with the person being supported.