Independence day

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.