The future of home care

Jef Smith asks what gives the President of the Association of Directors of Adult Social Services (ADASS) sleepless nights?

On being inaugurated to the ADASS Presidency earlier this year, Harald Bodmer, Executive Director of Adult Social Services in Norfolk, said: “Sustainability of home care is certainly what keeps me awake at night.”

Mr Bodmer is of course, not alone in his concern. UNISON, the public service trade union, published a report in January which focused on the controversial issue of visits limited to 15 minutes. About 74% of councils still commission calls at clients’ homes of only a quarter of an hour duration. This question has been so thoroughly rehearsed over recent years and there is such a broad consensus that these painfully brief interventions are inappropriate — including even guidelines from the Government’s official advisory body, the National Institute for Health and Care Excellence (NICE) — that one can only wonder that they continue.

Lack of resources

The answer to the paradox rests of course in the poor level of resources for social care generally. Clients who cannot finance their own support depend on local authorities, the bulk of whose funding in turn comes from central government grants. The freedom which councils have just been given to increase their community charge provided that they use the additional money exclusively for care services will, it is widely agreed, come nowhere near to meeting the bill.

This is because the geographical areas with the greatest need are also those with the least capacity to generate income from their own populations. The formula for central government grant allocation has the capacity, at least in theory, for levelling resources between poorer and richer authorities, but the new power to raise additional revenue locally lacks this redistributive factor. Even in relatively wealthy shires and boroughs, it is predicted that the additional money will not match the costs of providing care. The rising number of older people in the population means that local authorities are faced with inexorably growing calls on their limited resources, and those living in areas of greatest deprivation will suffer most.

On the other side of the equation, providers too are under heavy pressure. Implementing the National Living Wage and meeting the proposed increases in regulatory fees feature prominently among their current financial problems. While most agencies have given a slightly tongue-in-cheek welcome to the new living wage levels as enhancing the value placed on their staff, their worries that commissioners will not match the increases with higher payments for services are well-founded. Their reaction to Care Quality Commission’s (CQC’s) hike in fees is much less measured. There has been almost universal condemnation, while CQC itself helplessly bemoans the Government’s insistence that regulation must progressively become self-financing.

The absurd disparity between rising demand and stretched supply derives from the national austerity policies which, it is generally accepted, will continue for the foreseeable future. In his ADASS address, Mr Bodmer went on to say, “We need a social movement about social care, a campaign that starts now and reaches out over the next few years. We need to go into the next Comprehensive Spending Review with it being an absolute given that social care needs to be properly funded.” Fine words, but is there honestly any expectation of success?

The particular challenges of home care

Back in the real world, Skills for Care’s factsheet on Leading and Managing Home Care Teams addresses the situation frankly and with considerable point. Based on research carried out by City University London in 2015, it identifies the conflict between a focus on outcomes and the demands of the “time and task” approach — those 15-minute visits again — as one of the central challenges facing home care managers.

Domiciliary and residential care are often spoken of together in discussions of social services, and it is true that both the client group and the tasks performed by front-line workers are broadly similar. Home care has, however, some unique features including the Skills for Care document notes, “isolation, high workload, erratic schedules, lack of peer support”. There are peculiar work pressures arising from the sometimes almost impossible scheduling of calls along with the journeying between users’ homes, but the additional responsibilities which home care workers experience of operating largely in isolation and having very limited access to fellow workers are less openly recognised. The emotive title of the UNISON report, Suffering Alone at Home, was meant to refer to the experience of service users, but it can also be taken as a reminder that care workers also experience loneliness.

The responses to these issues which Skills for Care’s research identified are hardly new but they merit restating. Staff selection needs to include an assessment of how well candidates will react to the unique pressures of being alone with a client, dealing with crises without immediate facilities for getting advice or backup, and coping with the worrying knowledge of a client’s continuing vulnerability. In domiciliary care, there is no next shift to take over seamlessly.

Training should address the same issues, but there is no substitute for effective and sympathetic supervision. Workers have to know that to seek guidance is not a sign of weakness, feel able to talk through with their managers the difficulties they encounter in the field, and to have opportunities on occasions to share the pressures of the job with others holding similar posts. Perhaps the central quality required of a good supervisor is the ability to generate the trust of those being supervised. Management’s opportunities to observe individual practice directly are inherently limited, so workers need to feel confident that they themselves can bring to supervision their feelings of inadequacy, anxiety or stress without being censured.

Home care and dementia

Few groups of service users test the capacity of home care so acutely as those who have dementia, an area of work which has grown, is growing, and will continue to grow over the coming years. Recent statistics about the incidence of dementia in an ageing population have indicated somewhat conflicting trends, but the most reliable estimate is that the numbers of people with dementia in the UK will rise from the current total of 850,000 to around a million in 2021. Given the continuing pressure to keep people out of residential care — 85% of people say that if diagnosed with dementia, they would want to stay at home for as long as possible — there can be no doubt that an even larger proportion of the home care workload will in future consist of people with memory loss, social disorientation and general cognitive deterioration.

As part of the Prime Minister’s Challenge on Dementia, the UK Home Care Association (UKHCA) published in April the report, Dementia and Home Care: Driving Quality and Innovation. It addresses two audiences, the policy makers and home care professionals, the former because it is their decisions which lead public opinion and determine resource allocation, the latter because the level of their service significantly influences the quality of life people with dementia can continue to enjoy. Lest dementia should overshadow all other problems, however, it is relevant to learn that most people with dementia have at least three other long-term health conditions. Promoting dignity and independence against such a complex scenario is not easy.

The report identifies four major roles for home care — risk reduction, improving diagnosis, supporting people to live well and contributing to end of life care. Reducing the risk of Alzheimers’ onset may seem to be the most ambitious, and it is true that little specific is known about why some people develop dementia while others escape. Nevertheless, the report suggests, home care workers can help to deliver information on diet, exercise and social engagement, can themselves provide mental and interpersonal stimulation, and can both signpost local support networks and make referrals to health services where appropriate.

This leads naturally to home care’s role in improving rates of diagnosis, a prominent if sometimes controversial priority for the Prime Minister and the Department of Health. Workers, it is suggested, can spot and report early signs, reassure clients and their families about the process of diagnosis, and help to break down stigma. Does that sound ambitious? The care worker’s contribution is only one element in the life of an elderly person, but the trust which builds within a good relationship may indeed be the foundation for the sort of honest talk which is needed when such a momentous diagnosis is imminent.

Helping people to live well takes home care onto more familiar ground; this indeed is at the centre of the role. UKHCA suggests that aspects which are of particular relevance include supporting independence, preserving community contacts, promoting positive risk-taking and introducing useful technologies. It is important to remember, however, that a worker’s ability to make significant change is limited by the role — that of someone coming in from outside, with a defined brief and tight time-constraints, often having to work alongside family members who carry a much larger share of the caring task. This is not to limit ambition, just to be sensibly modest about what can normally be achieved.

So to end of life, where many of the same considerations apply; dying well after all is but an extension of living life to the full. Promoting choice, helping people to stay in a familiar environment, making them aware of their options, in short caring with compassion — these are the central elements at this critical and sensitive time, as indeed throughout a professional relationship.

Good dementia care at the end of life then is pretty much what should be expected of quality care whatever the service user’s condition.

Harald Bodmer starts a list of necessary initiatives for home care thus: “We need to up the level of debate about this, increase the volume, share best practice, run innovation masterclasses.” Can domiciliary care rise to these challenges?