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.

• 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