Domiciliary care in the firing line

The recent Panorama programme, “Britain’s homecare scandal”, has rekindled debate over the quality of domiciliary care and, in particular, the level of funding for services.

Using hidden cameras and undercover reporters, the BBC investigation revealed agencies were providing carers with scant training, while tight schedules between appointments were “causing havoc” for staff who were given no time to travel from one client to another.

Visits were often far too short – one lasted only three minutes – and carers were forced to ask their clients what they needed as the necessary care plans had not been made available.

This dangerous mix of inexperienced carers struggling on low wages, with poor management and high caseload pressures led to some shocking stories. One 89-year-old woman with dementia was left without a care visit for 24 hours as she lay in her own faeces and urine.

On the back of the programme, new regulator the Care Quality Commission said home care services in England were improving, but warned it would use its statutory powers against agencies who failed to provide acceptable standards of care.

And the General Social Care Council pointed to the potential gains for services if the Department of Health’s longstanding plan to register home care staff comes to fruition. This would set training requirements for staff and, according to the GSCC, protect users from unsuitable worker s.

However, for many sector leaders, the key lesson is that home care is suffering from a chronic lack of state funding.

The majority of home care in the UK is funded by councils but it is mainly delivered through private and voluntary sector providers.

The trade body the United Kingdom Homecare Association has long argued that providers have been consistently under-funded by councils, and claims services are currently under-funded in England to the tune of £920,000m.

The result, it says, is poor pay and significant levels of staff turnover.

Cost pressures

It is not just providers who take this view. Charity Action on Elder Abuse chief executive Gary FitzGerald, a former local authority domiciliary care manager, says responsibility for poor services lies “with a system whereby local authorities drive down costs at the expense of the most vulnerable”.

With a nod to the fact that councils are predominantly funded by central government, he adds: “Fundamentally, the problem rests with the failure of government to intervene in this situation and they have known about it for years.”

FitzGerald also says council commissioning practices over the past decade have significantly contributed to the problem. “Ten years ago you would not have seen 15-minute pop-in visits, they just did not exist,” he says. “They were introduced as a way of cutting costs, not of providing quality care for people. They’re a commissioning practice that really should be banned.”

Besides short appointments, Panorama also raised the spectre of the increasing use of online reverse auctions by councils to procure services, with contracts awarded to the lowest bidder.

FitzGerald does not let providers off the hook, however, warning that agencies have colluded with unhealthy commissioning practices because they know full well they are unable to provide a quality service at the price offered.

However, he says programmes like this month’s Panorama should not reflect badly on staff.

“There are many thousands of people working very hard in domiciliary care services and doing their best in a difficult environment,” he says.

“What I don’t want is programmes to focus exclusively on the practices of care workers when they’re not actually in control of what’s going on.”

Figures from the NHS Information Centre showed councils spent an average of £12.30 an hour last year on home care in the independent sector in England.

Efficiency savings

The UKHCA says this should be raised to £15 to £16 to more accurately reflect the price of care services and cover training costs.

However, vice-chair Bill McClimont says he has some sympathy with councils due to the government’s target for authorities to make 3% annual efficiency savings a year from 2008-11.

He says this is “irrational” in relation to domiciliary care because of the increasing demands brought on by an ageing population and the drive to enable more people to be cared for in their own homes.

McClimont says there is a mixed picture on commissioning across the country. On the positive side, some English councils are taking account of the CQC’s quality ratings for home care providers, under which agencies are rated as poor, adequate, good or excellent, in their procurement processes.

However, he warns: “Reverse auctions appear to be becoming more prevalent, trailed by electronic online mechanisms for tendering – it doesn’t do anything for the quality of service for the user.”

He adds: “What we’d like to see is incentives for quality. For example, giving differential prices based on the proportion of the workforce that are NVQ trained – which would be a good quality indicator.”

Local Government Association programme director for community well-being Anne McDonald says there is “certainly room for improvement” on commissioning, but insists the use of electronic auctions as opposed to paper-based tending processes is not an issue.

“The issue is; do councils always take the lowest price?,” she says. “Yes, I’m sure a lot of them do, but they do have a duty around quality and value for money as well. Looking for value doesn’t necessarily mean the lowest price and a lot of councils do have a method of rewarding quality by building incentives in to commissioning procedures.”

Fee rises

According to McDonald the average home care fee has gone up 3.2% over the past year, whereas residential care has seen a fall. “That suggests to me that at least some councils are taking it seriously,” she says.

However, as FitzGerald points out, the crux of the issue lies with how much money governments across the UK are prepared to give councils to spend on adult social care.

Action on Elder Abuse has contacted every elected member of the Westminster and Scottish parliaments, and the Welsh and Northern Irish assemblies, recently to keep the issue alive.

“We’re getting very strong, positive messages back from individual politicians,” says FitzGerald. “So far the Department of Health appears to be silent. We need to hear what [care services minister] Phil Hope and [health minister] Ann Keen have to say – and then we shall see whether we need any more Panorama programmes.”

Home care – the facts

● In 2007-8 English councils spent £22.30 an hour on average on in-house home care services and £12.30 on external providers.

● Gross annual spending by English councils on home care in 2007-8 was £2.7bn, a cut of 1% in real terms on 2006-7.

● Turnover for care workers in English independent agencies was 22% as of April 2008.

● From 2007-8 the proportion of national minimum standards met by English home care agencies on average rose from 78% to 82%.

● 81% of council-funded home care was provided by the independent sector in England in September 2008.