Author
COMMISSION FOR SOCIAL CARE INSPECTION
Title
Time to care?: an overview of home care services for older people in England , 2006
Publisher
Commission for Social Care Inspection, 2006
Summary
This report summarises evidence about the current performance of home care in England , and draws conclusions about the overall state of this sector and its capacity to expand and develop. Its target audience is social services directors, adult services directors, chief executives and councillors of local councils with social care responsibilities in England , health care professionals, academics and social care stakeholders
Context
Recent Government policies have described a vision for older people's services in a society where far more people will be living well beyond retirement age. They stress the right of older people to be helped to lead full lives and to continue to play an active role in communities. For those experiencing frailty and ill-health there should be a range of services that offer people support in their own homes, respecting the fact that most people choose to remain there as long as they can manage. Home care services are likely to be key to the delivery of this vision. There has already been considerable expansion of home care, to the extent that the amount funded by councils has almost doubled over the last decade - to over 3.5 million hours per week. The implication of Government policy is that further expansion will be needed in the medium to long term, as well as changes to the way these services are organised and delivered.
Contents
An executive summary give the report's background and purpose. Although home care services support a range of people of all ages, the report focuses on older people as they are the largest group of people using the service. In doing so, it looks at the roles of different players in the home care market, including the people who use services, local authority commissioners and registered service providers. It draws upon a range of evidence collected by CSCI over the last two years, including evidence from its engagement with older people, its regulatory and inspection work, and its performance assessment of councils. The report aims to make a contribution to the debate about what kinds of changes are needed, by setting out some of the evidence that will help national and local policy makers and commissioners make decisions about what home care services should be offered to whom, and what form they should take. It summarises the matter by saying that home care is an essential service which is enabling thousands of older people to remain safely at home when they may otherwise be unable to cope. Older people who use services, and their carers, usually stress that they would be unable to carry on normally without this support.
The report provides many examples of the relationship between the individual and their care worker being inspirational and rewarding for both sides. Excellent outcomes are being achieved, ranging (at individual level) to an increase in people's health, confidence and quality of life to (at strategic level) thousands of people being helped to live quite independently without recourse to more expensive interventions. However, there is evidence that the current arrangements for commissioning and providing home care are likely to be unsustainable, for a number of reasons. Firstly, the tight targeting of statutory support towards those with critical levels of need has resulted in a gradual reduction in the numbers of older people receiving state-funded home care, to the extent that the proportion of older people receiving this kind of support is low by international standards. This pattern of 'intensification' of home care is resulting in missed opportunities to prevent crises and to promote the well-being of older people living in the community. The recent Department of Health White Paper - Our Health, Our Care, Our Say - places a new emphasis on early intervention, but there is no sign that councils' expenditure on social care for adults is shifting in this direction. More thought will need to be given to how this aspect of Government policy can be resourced and implemented. Secondly, the sector itself is fragile and struggling already to provide services of sufficiently high quality for those who need them now. There are concerns that the sector may find it difficult to rise to the challenge to expand and improve from here. At the heart of the problem is the challenge to recruit, train and develop care workers both to replace the older workers who are leaving the sector, and to meet new demands and ways of working. Thirdly, the system has to date given councils responsibility for arranging services on behalf of older people - even where people themselves are contributing financially. A gap appears to be developing between what people themselves want and need and what is on offer from statutory services. The study found that many older people were asking questions about whether the current arrangements offer value for money. It is likely that these questions will continue to be asked. Older people - particularly those paying substantially towards the cost of their own care - are beginning to press for more choice and control.
The main part of the report consists of seven chapters. An i ntroduction explains the p urpose of the report, the policy context, the role of home care, and the scope and methodology for the report. 'S etting the scene' gives information on the changing demand for services, trends in the provision of home care, privately purchased home care, trends in expenditure on and supply of home care, and the home care workforce, concluding that the sector is fragile, still reliant on small private providers and in a prolonged state of flux. ' Older people's experience of home care' gives s ources of evidence, asks what older people want from services, and discusses levels of satisfaction with home care and aspects of people's experience of home care. 'T he quality of registered domiciliary care services' describes o verall performance against the national minimum standards, regional variation, analysis of performance in five domains, and enforcing the regulations. ' Commissioning and procuring home care' discusses s trategic commissioning, procuring home care, and the role of care managers, concluding that councils and their partners - through engagement with local communities - should give more thought to their strategic objectives for older people's services, and to the role to be played by home care overall. Rigid care plans that focus on inputs - the time and the task - often provide an unsatisfactory basis for arranging people's care. These aspects may be much easier for commissioners (and indeed policy makers and regulators) to measure, but they result in a focus on the volume of a service rather than its effectiveness. Consultation for this report has provided evidence that good outcomes for people may be complex, long-term and not directly attributable to any particular set of inputs or any one organisation. The challenge for commissioners is to find ways of arranging services that are flexible enough to respond to people's dynamic and very individual needs, whilst still meeting demanding budget targets. ' Commissioning for improvement' discusses p utting people in control, advice and signposting for self-funders, outcome-based commissioning, focusing on reablement, making good use of new technology, engaging with older people to improve the quality of services, offering culturally sensitive services, a community enterprise scheme, investing in workforce development, and a multi-agency approach to planning. Finally, ' The role of the regulator' is about f eedback on the role of CSCI and CSCI's developing methodologies. An a ppendix gives 33 tables containing the most recent data available from a variety of sources that illuminate the state of the home care sector.