Promoting choice in home care
By Clive Bowman
Home care has traditionally meant various forms of help at home enabling older people to preserve a dignity and independence through assistance with cleaning, laundry and shopping or perhaps help with a bath, hair washing and companionship. Over time this has increasingly meant “care at home” with a vague intention of meeting all the needs of older people choosing to stay at home. An increasing shortage of carers has led to a targeting of available resources to people with the greatest needs and a consequent reduction of support for people with lower levels of need. This targeting has occurred without apparent open debate or ownership. It is now unclear whether care at home seeks to promote independence or to address dependence. This matter has real currency exemplified by questioning whether it is better to promote the independence of perhaps 10 older people with lower needs or to provide extensive personal care and support for perhaps one extremely dependent person. Decisions that effectively make these choices are taken every day with the consequence that the options readily available to many older people are often limited and worryingly inconsistent.
Promoting independence is good for confidence and the ability of people to remain independent at home in later life. What is difficult is determining the reasonable limits of care that should be available for people at home. These cannot be fixed, varying both in the context of individual needs, risks and the practicality of providing care. It is difficult to understand how an older person, “chair fast”, incontinent and significantly confused from intermittent carer visits and significant periods of isolation, benefits from being at home. It is even more difficult to comprehend how it can be acceptable for an older person to have to move from home simply because relatively low level home care is no longer available.
A policy and practice understanding of the spectrum and limits of care and support that can reasonably be provided at home is needed. A more consistent approach may be possible through an assessment of needs determining resource eligibility up to a level commensurate with the cost of a care home bed. How these resources are best used in the context of choice may then be enabled through the use of direct payments. The impact of the scarcity of carer time is also fundamental. In sparsely populated rural areas the travelling time of carers may greatly reduce the amount of home care available and in affluent suburbs the shortage of suitable carers may impose similar restrictions.
Owning a personal secure “front door” is increasingly perceived as defining home. Managers of assisted living facilities (alternatively sheltered accommodation, retirement housing) report that people considering this option generally cite lifestyle for their choice. These may include, a move to be near family, increased security (and this may just be an ability to lock up an apartment and go on holiday) or that the old house has become too big and unwieldy. These are positive planned personal choices that reflect and facilitate independence. New housing options promise innovative and sustainable solutions that further extend independence for some. For example, Extracare housing, through clustering people on a campus promises an efficient deployment of care time and support capacity over and above that found in traditional assisted living.
Whilst new housing solutions are welcome what is urgently required is a renewed resolve to promote independence through a spectrum of care and support. It may be more helpful to consider tools, technology and services for living rather than home care.
Technology presently is used to produce crisis alerts through call systems but it has unexploited capacity to be much more liberating. Young and middle aged people commonly take advantage of shopping via the Internet, whilst the shadow of exclusion is cast over the majority of older people. An innovative collaboration by Bristol City Council and the Somerfield supermarket group however illustrates the potential. Prof. Heinz Wolff of Brunel University has developed a device that he calls a Companion, essentially a computer to which a bar code scanner is attached in place of the normal keyboard and mouse. This makes the computer much more acceptable to those for whom it would otherwise be an object of apprehension, if not outright fear.
Pilot trials are underway with a group of older people who now make their shopping list by scanning bar codes in a catalogue or on tins and packets. The Companion responds with both text and speech. The users send their list to the supermarket as an email. Currently, 13 older and disabled people have tested the system, making a total of over 90 orders. The trial will shortly be extended to a large sheltered housing complex where each Companion will have multiple users.
Mary Breeze the Teleshopping Project Worker reports the Companion has been extremely well received by users. They find the bar code scanner simple to use, and gain a renewed sense of independence. Typical comments from users include,
‘I didn’t like to ask anybody to carry heavy things up the stairs to my flat. Now I can buy tins and bottles – whatever I want.’ It is also a great confidence booster – I am frequently told ‘I’m not so stupid after all’, and ‘Wait till I tell my grandson what I am doing’.
The Bristol project has been possible through grants provided by the European Vivaldi project and by the Dolphin Society that are now coming to an end. Perhaps the time has come for the supermarkets themselves to recognise the grey pound and invest to support older people – and attract their custom!
The Internet is used increasingly for healthcare but many older people could improve wellbeing through web provision of a video linkage providing another layer of social engagement or other support, perhaps tailored exercise classes. Adding technology to the spectrum of home care may increase choice and it may also encourage the best possible use of carer time enabling cleaning and low levels of personal care to become more widely available.
Many may be sceptical regarding the discussion here but they should reflect the impact of the ageing “baby boomer” generation. Expectations will increase and demands on resources are going to grow. The pressure must now be for implementation to start catching up with innovation.
Contact for the Bristol Teleshopping Project