What is home care?
Home care (or domiciliary care) is in the front line of social care delivery in England, with around 257,000 older people and more than 76,000 younger people using publicly funded home care in 2015 and others paying for their own home care. It
is estimated that around 249 million hours of home care are delivered each year. Most of this care is personal care – help with washing, dressing and eating – but the term also covers reablement services for those leaving hospital and broader support, for example to help someone with learning disabilities live independently. It is an essential part of enabling people to ‘age in place’ by delivering care as close to home as possible – where most people say they want to receive it.
Yet the future of home care is uncertain and the market is fragile. Over a third of local authorities report that providers have handed back home care contracts, and some of the largest providers have withdrawn from the publicly funded home care market. Home care agencies struggle to recruit and retain staff. Quality is far from uniform. Local authorities have a duty to ‘shape’ this market and ensure there are enough quality services to meet demand. Yet lack of available home care is a significant reason for delayed discharge from hospital.
Facing a £16 billion reduction in government grant funding since 2010, councils have attempted to control expenditure on adult social care, including by reducing the rate they pay providers for commissioned home care. Though there are signs that this squeeze is coming to an end, rates paid still differ significantly from one part of the country to another, which councils attribute to differing labour costs.
Securing an adequate workforce is one of the greatest challenges facing home care, fuelled by the low status of care work, which in turn is related to poor pay and job security. Competition for staff is intense, with other sectors able to offer higher wages. Competition was also intense within the health and care sector, with employment in the NHS and care homes being more attractive to some workers. There is concern within the sector that some parts of the home care industry pay below legislated minimum wage levels.
Recruitment challenges were not experienced to the same extent in all areas. Availability of staff was more difficult in rural areas, where costs were also higher because of the additional travel time needed for workers to visit clients.
Rates of pay
The decline in overall council funding had led commissioners to drive down the price they paid for home care. However, in areas of low supply of care workers, local authorities often had to pay higher rates simply to secure sufficient cover. In areas of wider supply (often urban and/or deprived areas), the strategy was more effective but had often led to rates being at levels that were seen by some as unsustainable. Many commissioners remained confident that enough suppliers would still respond to their tenders.
There were concerns, particularly from providers, that low fees paid by commissioners had reduced the quality of home care. While this – along with the relevance of having a national benchmark for fees – was disputed by commissioners, our analysis did show a correlation between fee rates and quality. Commissioners were also less likely to accept that there was a direct link between the fees they paid and the wages received by home care workers.
Approaches to commissioning
Many commissioners said they were frustrated by commissioning on a ‘time and task’ basis, prioritising procedures and the amount of time spent on delivering care rather than considering the longer-term outcomes of the care provided. However, attempts to move away from this approach were often only at pilot stage. A key problem was the requirement to collect and monitor outcomes data, which some commissioners doubted providers had the infrastructure to implement.
While some commissioners had worked with clinical commissioning groups to agree a contracting framework for home care, others had not. However, there was wide agreement about the potential of joint working, and some councils were attempting to integrate home care delivery by establishing integrated community services. A common issue concerned which budget – health or social care – costs would be allocated to. There were also ‘boundary disputes’ between health and social care. Differences between systems in ways of working also generated communications and logistical challenges. Home care providers complained that patients were sometimes discharged from hospital before care could be arranged.
New models of home care looked at models such as Shared Lives, in which individuals are supported in a paid carer’s home, and others such as local area co-ordination, which aim to harness a person’s own resources and those of their family and community to support them more effectively. While these models reported very strong outcomes, they were not new and there were doubts about the extent to which they were fully scaleable or could fully replace traditional home care services. The report suggests that they may provide alternatives that work well for some, but not all, people; for example, it raises doubts as to the extent to which models developed by and for working age people with disabilities are easily transferable to older people.
Other alternatives to existing home care models look to exploit technological innovation to improve or even replace current services. Some – which look at how a person can be better connected to wider support system – are best understood as part of broader efforts to improve quality and tackle issues such as social isolation. Others build on existing assistive technology and telehealth, sometimes with the addition of remote monitoring (for example through sensors), analysis and reactive service provision if needed. Overall, we found that while there are many examples of technologies and tools that promote independence and help manage risks, they have had limited impact on statutory home care services and there is a real question about how much demand there would for them from councils with limited budgets or from service users.
Home care is a number of very different markets, often but not entirely based on geography, rather than one homogenous market. Though the conditions in these geographical areas differ, the challenge of staff recruitment is relentless in almost all of them and – without fundamental reform of ‘time and task’ commissioning, it is hard to see how the sector will recruit enough new workers required by 2030. However, the estimated 249 million hours of home care delivered each year in England, much of it publicly commissioned, has rich potential to improve population health. Improving the quality of home care should therefore be seen as part of a wider move towards integrated, preventive heath and care.