Where better to care?

Home care is set to
become more professional and better organised thanks to the advent of the
National Care Standards Commission. But will the focus on serving people with
higher support needs lead to others slipping through the net and disappearing
needlessly into residential care? Ruth Winchester reports.

The
impending introduction of new national minimum standards for the provision of
social care have spawned heated protest from many of the organisations and
individuals who will have to meet them.

But while many
providers continue to protest vehemently about the exact shape of their
regulatory framework, domiciliary care providers seem to be facing the same
sort of upheaval without so much as a cross word. The launch of the National
Care Standards Commission will mean the home care sector is going to have to
submit to registration, inspection and regulation on a grand scale, for the
first time. But there has been very little dissent from a sector which provides
essential care for five times the number of people looked after in residential
settings.

Indeed, there is a
surprising consensus that the new national minimum standards are necessary and
appropriate. There is  concern about
some of the detail within the small print of the mandatory regulations, but
even independent and voluntary sector providers – who will have the most work
to do to meet the benchmarks – are generally supportive of the principles
enshrined within them.

This remarkable
acceptance could be because the sector was heavily involved in drafting the
standards and so feels some degree of ownership. But perhaps the workforce
recognises that the introduction of some form of regulation has also come at a
crucial time.

Far from its
traditional image of unskilled workers doing a bit of cleaning and shopping for
older clients, home care is mutating. Spurred on partly by the government’s
investment in intermediate care, domiciliary care is moving up a gear, to the
extent that people who 10 years ago would have been in residential care are now
able to stay at home with packages of care which may include significant
medical or skilled tasks being performed by home care staff.

According to Bill
McClimont, chairperson of the United Kingdom Home Care Association: “There is
considerable evolution going on. Things that in the past only happened in hospital
are now being delivered by home care – things like cardiac rehabilitation,
intravenous antibiotics and chemotherapy.” He also points to the development of
rapid response “admission avoidance” programmes which help to keep people out
of hospital, and other schemes which offer support for people leaving acute
care environments in an attempt to circumvent the bed-blocking crisis.

But despite this
diversification, some observers suggest that the domiciliary care market is in
the early stages of a significant crisis. There have been massive changes in
home care over the past decade, the most obvious being the change from small
amounts of home care delivered to a large number of people, to a system where
home care is delivered to a small number of clients with higher support needs.
According to McClimont, traditional home care – a bit of shopping and cleaning
– is “all but dead”.

This has a number of
knock-on implications. Firstly, traditional home care has been used as a
preventive service, helping people stay mobile and independent at home. Its
removal from people with lower support needs has resulted in the loss of the
preventive benefits – people who with a bit of support could have managed at
home for a long time are coming into residential care and hospital settings
earlier.

The second is that,
as home care is delivered to people with higher support needs, the demands made
on home care staff have significantly increased. Staff who are expected to
perform increasingly complex health care duties, as well as personal care tasks
such as feeding and toiletting, don’t 
want to work for the sort of wages that someone doing shopping and
cleaning might be expected to accept. Yet that is what is usually on offer, and
these accelerating demands on staff feed into the third problem: a serious
recruitment and retention crisis.

Historically, the
independent sector has had to compete for business almost entirely on the basis
of lowest price. The result is that staff are not only on low wages, but suffer
from poor working conditions. They often work antisocial hours in isolated
positions and have little or no job security. One week they may be offered 40
hours work, another they may only get 10. Many are not paid for their
travelling time between clients and have to pay for their own parking when they
arrive. These deficiencies are by no means limited to the independent sector,
although local authority-run services have often benefited from better public
sector working conditions and training.

There is a hope that
the new standards  may engender a sense
of professionalism around home care – still regarded as unskilled work –
through the requirement for half of all staff to be qualified to NVQ level by
2007. But the downside to the training requirement is that it is not going to
be cheap – particularly for independent sector providers who have further to go
– and it could have unwanted effects. Many of the staff employed as home care
workers are older people – perhaps approaching retirement – who do a few hours
each week. Others are using it as a temporary stop-gap or benefiting from the
flexible and casual nature of the work. Many of these people will think long
and hard before embarking on lengthy qualification programmes, especially when
most of them can earn more stacking shelves.

The standards could
also create turmoil in the way home care is purchased and provided. Care
providers have been complaining bitterly for years at the dictatorial way that
local authorities tell them how to provide care. According to McClimont: “Local
authorities have specified exact times and tasks in their contracts, to the
extent that any deviation from that – changing the time by half an hour or
cleaning the curtains rather than hoovering – requires written authorisation.
It is inflexible for the client, it’s a nightmare for the provider, and it’s a
complete waste of a social worker’s skills and training to be filling in forms
relating to five minutes of home care here and there.”

Commissioning
authorities have argued that pinning down providers under a minutely detailed
contract is a necessary evil. According to John Hall, vice chairperson of the
National Home Care Council which represents local authority providers and
commissioners: “It has been useful from our point of view in terms of us being
very clear about what we are paying for. But in practice it’s not all that
helpful. The new standards should enable commissioners to have confidence in
the quality of home care being provided, so they won’t need to be so specific.
In the past that caution was probably justified – now we’ve got a lot of
extremely good independent providers and the way we purchase needs to be looked
at again.”

It seems eminently
sensible that commissioning practice should change to reflect the new
environment. When a local authority places a client in a residential home, the
purchaser doesn’t tell the home when Mrs Bloggs should have a bath and how long
for. The contract, providers argue, should specify outcomes rather than inputs
– ie Mrs Bloggs should have good personal hygiene – and it should be negotiated
between the client and the provider, rather than between the purchaser and the
provider.

The eminently
sensible concept of the person receiving the care being at the centre is
supported by the new national standards, which conclude that the key
relationship should always be between provider and user. But whether this is
going to be upheld in practice remains to be seen.

Lucianne Sawyer is a
commissioner for the National Care Standards Commission and an independent consultant
with an interest in home care. She is also president of the United Kingdom Home
Care Association. “My worry is that, with time, we’ll get a further
polarisation of the market – local authorities won’t want to be doing business
with hundreds of small providers, as they are at present. They’ll increasingly
prefer to work with large single providers. But where organisations are working
like that, the result is that the key relationship is still the one between the
commissioner and the provider. I’m concerned about service users – about how we
get them back onto centre stage.” 
Sawyer is researching the development of purchasing strategy and service
user involvement in domiciliary care in two local authorities, and other
authorities are working independently on more “outcome-focused” domiciliary
care services.

The domiciliary care
standards and regulations are still being finalised by the Department of Health
after the consultation process ended, and are expected to be launched on 1 July
this year. At that point the mammoth task of registering about 3,000
independent providers and more than 600 local authority providers will start.
According to Sawyer, the Commission’s stance will be about “helping people to
reach the standards. We are very willing to talk to people about how they
achieve them, and that may not always be by the most obvious route.”

The upshot is that
the standards will prove challenging, will solidify the advances home care is
already making, and will raise a new debate about exactly where the boundaries
between social care and health care merge. And that may be the key question.

Lesley Bell is
chairperson of the joint advisory group on domiciliary care which drew up the
standards, and director of Initiatives in Care, an independent organisation
specialising in organisational and staff development in the personal care
sector. She sees home care as the future for a great many people. “It’s a
slightly trite phrase, but I think in future we are going to be taking care to
the people, not moving people to the care. A lot of people who are in
residential care now could live in their own homes with the right package of
support – and it’s amazing how little help frail people need to stay
independent.”

– For the draft
national minimum standards and regulations, see www.doh.gov.uk/domiciliarycare/domiciliary
care.pdf

My home
care is a lifesaver

Norma Cail is 58, an
ex-nurse, and wheelchair-bound after a stroke. She spent six years in a nursing
home before moving into sheltered accommodation in Bournemouth.

Norma has a “home
care dog” who helps her get undressed, puts her to bed, fetches the phone and
Norma’s inhaler, pulls the washing out of the washing machine and even strips
the bedclothes.

Norma receives an
hour’s home care every morning, as well as an hour and a half’s cleaning on
Monday and an hour and a quarter on Thursday, for which she pays £17.80 per
week from a basic income of £125 per week. Her home carer sometimes helps get
her out of bed, showers her, and washes her hair.

Norma’s home care has
been reasonably consistent, although in the past she has had problems because
of carer turnover. “I had to keep getting to know new people and it wears you
out – I’d have to tell them what to do all the time, and one or two have been
very rude.”

Since she transferred
to the home care service run by not-for-profit Dorset Trust she has been very
happy with the consistency and the 
quality of the care. She has had the same home carer for weekdays for
nine months, and her previous carer was around for 12 months.

Home care has made an
amazing difference to Norma’s life – she describes it as “life-saving”.

“It keeps me in my
own home – without it I’d still be in the nursing home. It means I can have a
pretty much normal life,” she says.

There are problems
but a solution is usually found. “I’d be lying if I said it was absolutely 100
per cent – there are always going to be problems. But I can ring up and
complain and they act on it. You do have clashes with people but if I say I
don’t like someone they never send them back. I don’t find it intrusive at all
– I’m very grateful that they are here.”