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A recent survey of home care providers by the Social Policy Research Unit raised challenging questions about the future of the sector.

One notable issue was widespread opposition to a highly prescriptive approach to care management. Some care management services prescribed for each customer the number of home care visits per week, the length and tasks per visit, and the exact time of day at which each visit was made. Any changes sought by provider or customer required care management approval. Since some care managers routinely closed cases soon after assessment, delays could occur while a new care manager was assigned to assess such requests. A quarter of the providers interviewed still worked within such a model, including some social services in-house providers, and they voiced deep frustrations.

A particular complaint was care management controlling the times at which visits should be given. Interviewees described how a customer could need care manager permission to vary the visit times that the customer had themselves requested at assessment, occasionally years earlier. Social services providers in particular sought to escape pronounced control by care management. They felt it denied their professionalism.

Consequently, less prescriptive care management arrangements have been developing -Êand there are important questions about where this trend is heading. A common change was for care managers to allow providers to negotiate the time and duration of timings direct with customers. Sometimes they needed simply to tell care managers about changes, sometimes not even that.

But some changes went further. One independent sector provider received a list of tasks and a weekly time budget for some customers. It was then free to negotiate with each customer on the number, length and timing of visits whereby this personal time budget was used. Some social services providers had even been given discretion to vary the amount of time spent on each customer. Sometimes this meant freedom to change by small amounts the time assigned to a visit. Sometimes, more radically, care managers would simply name tasks to be done and outcomes to be pursued and the home carer spent whatever time necessary, varying visit lengths if a customer's health changed. "Task-centred, not time-centred" was how this approach was described.

But whatever the merits of provider autonomy, the survey points to a possible downside if fixed visit lengths for home care visits are abandoned. Some providers named these fixed periods as crucial to the quality of services. Care management set them visit lengths that were slightly longer than the specified tasks required, and instructed staff to spend any spare 10 or 15 minutes either talking to customers or doing small extra tasks as requested. Such providers felt this was crucial to good relationships and to customer-perceived quality of care. In task-centred services, in contrast, such "quality time" did not arise so readily since staff left a customer as soon as they completed the listed tasks.

Of course this quality time aspect of time-centred services will not occur unless staff stay for the full time-slot and some providers did not require this. Nor will it occur if care management systematically commissions minimal visit times or constantly tries to reduce time, as some providers described.

Variations were described in the purposes for which care managers commissioned home care. In seven of the 12 localities, home care providers commented on differences between the help commissioned for older people and for people aged under 65.

Older people were much less likely to be bought services aimed at quality of life for isolated disabled people -Êsuch as accompanied outings or "baking together" sessions at home. "Once you get to 65, all those sort of services stop", said a social services home care manager regretfully. There are issues here for the stand against age-discrimination made by the National Service Framework and Fair Access to Care Services. But there were other local authorities where accompanied outings were sometimes commissioned for older people or social events were routinely organised by home care staff for their older customers.

Provider attitudes, as well as care management policies, affected home care's impact on older people's quality of life. Provider managers were asked about various common requests, which matter to many older people but which home care services sometimes refuse -Êlike finding a trustworthy plumber, changing light-bulbs or help with pet care. A few explicitly required their staff to give such comprehensive help. A larger number officially restricted or prohibited such help but seemed unconcerned, even reluctant, to enforce their own rules. A third group sounded serious about enforcing their prohibitions. The providers who were most responsive to these requests were independent sector. But so were those who were least responsive. Social services providers came somewhere in between. It may be significant that the most helpful independent sector agencies had a large minority of private customers, whereas the least helpful had few or even none. Possibly the former have developed customer-friendly habits with their private customers and then treat customers funded by social services in the same way. Some of the least responsive independent agencies seemed to view social services departments as their customers, rather than individual service users.

There were few consistent differences between independent and social services providers, since there was much variation and change in both sectors. Only social services providers used frequent meetings of care staff as a tool for co-ordinating service. A comparable independent sector hallmark was systematic canvassing of all customers' views by agency heads, via regular postal questionnaires or phone surveys or home visits by quality assurance staff.

Another difference between sectors is, of course, pay and conditions. Independent sector care staff are paid less well and paid only for hours actually worked, whereas social services care staff have pay guaranteed for a core number of hours, whether or not work is available. The challenge for independent agencies is whether they can guarantee service without guaranteeing staff hours. The challenge for social services providers is whether they can fill all guaranteed hours with work commissioned by purchasers. If not, they risk paying staff for unused downtime hours, to purchaser dismay.


However, some social services-style pay and conditions had appeared on a small scale at two independent agencies. One had introduced some care staff posts with guaranteed hours because the usual independent sector pay incentives could not guarantee staff for weekend work and for rural work involving much unpaid travel time. Social services themselves had funded guaranteed hours posts to ensure agency response to rural referrals, plus mileage pay and new, high hourly pay rates for agency staff covering rural areas.

Another independent agency had negotiated social services funding to pay mileage and a weekend pay premium of 50 per cent, to ensure cover. Fifty per cent was the typical social services weekend pay premium in the survey, compared with 10 or 15 per cent among independent sector agencies.

These two agencies are interesting in view of arguments that, as time passes, privatised home care will increasingly resemble the state-run services that it replaced. If this were happening, an early sign might be block contracts, now commonplace, and purchaser policies to limit the number of providers per locality. The two agencies illustrate how pay and conditions resembling social services can appear, when purchasers accept that some roles cannot be reliably provided more cheaply. Aside from these two agencies, many independent providers routinely used managers to provide care when staff could not be found. While some certainly gained from the resulting contact with customers, it can also suggest that incentives for care staff need improvement. Some independent sector managers felt this strongly.

Strikingly, many social services in-house providers were hoping to leave general home care for specialised, high skill roles that would justify their higher costs in Best Value competition with the independent sector. Half had already secured purchaser assent for such change to their service -Êand two were well advanced in their transformation. The latter, for instance, were converting into four or five teams that specialised in six-week intake or post-hospital re-enabling or rehabilitation programmes for older people; co-work with district nurses; and conditions like dementia, learning difficulties or progressive diseases. There were other social services providers seeking a specialist niche, but purchaser agreement was not evident, maybe even unlikely.

Such changes would take social services providers away from long-term supportive care for most older people, and increase their involvement with younger people and with health staff.

The greater ease with which purchasers can grant autonomy to social services providers makes them suitable for the rehabilitation services now promoted by government. For rehabilitation, staff need autonomy to vary service day by day in response to a service user's progress, since service reduction is an important goal. But can these specialised roles provide enough work for all staff of the many services that seek them? An open question exists too about how many purchasers would choose this division of roles. Some of this survey's independent sector agencies also undertook some specialised roles, such as post-hospital care, terminal care or respite for family carers. Just like social services providers, independent sector agencies aspire to skilled roles. At one council in the survey the in-house provider had already been transferred to the independent sector.

Whatever the answers, clearly the independent sector will be providing a lot of long-term home care for older people. Use of the independent sector requires robust, coherent care management arrangements. The new domiciliary care standards entail more flexible, more person-centred care. Reconciling the latter with necessary care management processes makes the development of innovative care management systems a key challenge for the future. 

Charles Patmore is a research fellow at the Social Policy Research Unit, University of York. The survey is funded by the Department of Health, although the views expressed here are those of the author and not necessarily those of the Department of Health. 

Survey issues

Questions facing the sector that the survey cast light on included:

• What direction are home care services moving in?
• Will it be service providers or care managers who call the shots in future?
• Will independent sector agencies eventually provide pay and conditions as good as today's social services providers?
• Could social services providers hand over long-term work with frail older people entirely to the independent sector?

About the Survey

In-depth phone interviews were conducted in 12 contrasting English localities. In each locality one interview was sought with the social services in-house home care provider and another with an independent sector agency contracted by social services. Twenty-three providers were interviewed in total.