Power of the purchaser

Alongside their basic care package, isolated older home care
customers with disabilities often need flexible help to support
their morale. Our research project investigated how home care
services varied in their ability to give such help and then
explored the reasons for the differences.(1)

One of the major findings was that senior social services
purchasers have a pervasive, far-reaching influence on whether
independent agencies provide flexible, person-centred help (see
Flexible Home Care, below).

The relationships that developed when home care workers were
regularly assigned to the same customers provided sound
foundations. Some customers gradually confided in regular workers
about their concerns and aspirations; staff could develop routines
for managing a customer’s household so smoothly that periodically
spare time arose which could be used to do more than just the
routine care plan tasks.

Care from independent agencies is generally purchased in visits of
fixed length. These need to be long enough to allow for unexpected
problems or for replacement staff who do not know the customer’s
home.

All the providers in our in-depth study served customers through
consistent, regular home care staff. At all providers there was
evidence of types of extra help that reflected good relationships
between staff and regular customers – but which did not require
very much time nor deviate greatly from the prescribed care plan.
For instance, staff would include requests like delicatessen items
in their shopping or let customers choose where in their home the
time allocated for cleaning was spent.

But a pronounced difference between home care providers became
evident when talking about more complex or time-consuming flexible,
person-centred help – like taking a customer shopping, replacing a
broken refrigerator, or assisting a benefit claim. Certain
providers regularly gave such help, whereas others did not. We
found that for staff to take these sort of initiatives, support and
legitimisation from management was important.

For independent agencies, such legitimisation required the support
of social services purchasers. Two agencies in our in-depth study
worked for authorities where purchasers saw their goals for older
people’s services in holistic terms. They addressed home care
customers’ morale and quality of life as well as their physical
well-being and expressed this through sometimes commissioning home
care time for emotional or social support. They also approved
occasional flexible departures from the care plan for such
purposes. They encouraged providers to use any spare time flexibly
and diversely, if customers requested. They also accepted providers
giving customers extra privately purchased help, since this could
fulfil the wants of customers that social services could not afford
to meet.

But for two authorities in our study, their purchasers limited
their goals to supporting older people’s physical well-being and
safety in their own homes. They would not commission time for
emotional or social support. They did not want care time used for
purposes other than the physical care tasks in the care plan –
never mind what customers requested. Even though it cost social
services nothing extra, they frowned on home care workers
fulfilling customers’ requests during spare time and also on
agencies giving social services’ customers extra help on a private
basis.

Central to these purchasers’ stance was that their only goal was
customers’ physical health and safety. Avoiding occasional risks to
the smooth running of service mattered more than any broader gains
for customers’ quality of life. If staff met customer requests
during spare care time, purchasers explained, one day a care worker
might suffer an otherwise avoidable accident while, say, cleaning
out a fireplace or putting up Christmas decorations.

To forestall this, these purchasers wanted service strictly
confined to the tasks in the care plan. They saw a problem in the
very idea of a care worker who gave regular customers especially
thoughtful service. Were they to leave, the customer’s
disappointment could complicate subsequent service.

So, holistic, person-centred care depends on the aspirations of
social services purchasers. Regard for customers’ wishes and
quality of life is now promoted by the adult care green paper. Our
research finds a sharp cultural divide among councils as to whether
existing policies towards older home care customers either support
this or oppose it.

• The research was undertaken at the Social Policy Research Unit,
  which receives support from the Department of Health. The views
  expressed in this article are those of the authors and not
  necessarily those of the DH.

Flexible home care

• An isolated customer gets 90 minutes each week during which her
  home care worker can take her shopping, go to the beach or the
  park, as she chooses. Following a stroke, she is awaiting
  re-assessment for her driving licence. In the interim, social
  services commissioned these excursions, which restore some ability
  to travel and support morale.  
• On sunny days home care staff take a customer with arthritis
  for a short walk during her lunch visit, if she has successfully
  made lunch herself beforehand. This is her preferred use of staff
  time, since getting out of the house is important to her.
• At his request, home care workers regularly drive a customer to
  visit his wife’s grave. When requested, these visits occur during
  spare time in daily 30-minute visits to prompt medication taking.
  (Thirty minutes is the minimum length of visit which this rural
  agency provides.)
• A home care team leader drives a customer to a hospital
  appliance centre for a shoe-fitting. He has a physical disability
  and a speech impediment and is very isolated. During the
  appointment she will interpret for him, if needed.
• A customer dies. For a fortnight his regular daily home care
  worker is instructed by her manager to make short daily social
  visits to his widow. Then the manager visits his widow to assess
  any future needs.

Charles Patmore devised and led this research
project. He worked for eight years on the Department of Health
research programme on outcomes of social care for older people,
based at the Social Policy Research Unit, University of York. He is
now an independent consultant  for community services for older
people.

Alison McNulty
was a researcher on the in-depth phase of this research
project. She is now research associate at the School of Nursing,
Midwifery and Social Work, University of Manchester.

Training and learning
The author has provided questions about this article to
guide discussion in teams. These can be viewed at www.communitycare.co.uk/prtl
and individuals’ learning from the discussion can be registered on
a free, password-protected training log held on the site. This is a
service from Community Care for all GSCC-registered
professionals.

Abstract
This article – the first of two – presents research
findings about factors which promote person-centred, customer-led
home care for older people. It describes the far-reaching influence
of social services purchasers over whether independent home care
providers supply such a service.

About the research
The first stage consisted of telephone interviews with
managers at an independent provider and an in-house social services
provider in 12 contrasting local authorities. Six of these
providers in six authorities were selected for in-depth study.
First, older service users were interviewed, then front-line
provider and purchaser staff. Subsequently, interviews took place
with each provider manager and, finally, with a senior social
services purchaser in each authority.

References
(1) C Patmore and A McNulty, Making Home Care for
Older People More Flexible and Person-centred: Factors which
Promote This, Social Policy Research Unit, University of York,
2005. www.york.ac.uk/inst/spru/research/pdf/homecare.pdf

Further information
www.well-beingandchoice.org.uk

Contact the authors
cpconsult@btinternet.com
amcnulty@sah.org.uk