Jef Smith discusses the state of domiciliary care provision in rural areas.
The idyll of a country cottage enjoyed for short periods during the warmer months of the year was brought cruelly down to earth by a publication last November from Rural England, an independent body which describes its main objective as, “to build the strength and resilience of rural England by helping to inform and engender better rural policy making”. The research detailed in Issues Facing Providers of Social Care at Home to Older Residents in Rural England is a harsh corrective to anyone who entertains hopes of retiring peacefully to a country retreat in their old age, particularly if they have sufficient foresight to think that they might, at some stage, need domiciliary care services to back them up.
In Cornwall, for example, despite the Council’s paying home care fees at levels above the national average — £16.13 an hour as against £14.28 in 2015/16 — the number of providers is steadily shrinking and several contracts have recently been handed back as uneconomic. The scarcity of the population and the distances between service users’ homes impose additional expenses through both travel costs and time. Geography has also had a significant effect on the structure of the market with typically small firms providing very local services and no big national companies at all. The Council’s attempt to encourage large providers to operate in the county appears to have backfired, having allegedly had the effect of actually reducing fee levels for some small existing companies without increasing their client numbers in compensation.
Staffing is particularly difficult, with competition from retail, from the County Council and, especially of course in the summer season, from tourism. Clients’ needs have become progressively more demanding and the support urban workers might expect from community nurses and GPs are often much more difficult to access. Pay, however, remains the dominant issue, zero-hours contracts are widespread and most staff are not paid travel time. One provider freely admitted that, “People are forced out of the job they love because they can’t afford to keep doing it.”
The problems are worst in the most remote areas, but the whole of the county is essentially rural. For people dependent on public funding, delays in assessment and in the organisation of care packages are frequent. Self-funders can, to an extent, buy their way out of difficulty by paying quite commonly over £20 an hour for services, but they too suffer from staff turnover estimated at 37% annually. Having family living nearby brings the benefit not only of direct help but also of advocacy with official bodies, another point to consider for people retiring to such an area who may in the process distance themselves from long-established support networks.
Cornwall is one of three case studies featured in Rural England’s report. North Yorkshire, superficially a quite different area, exhibits, however, many of the same problems. “There are an increasing number of people with multiple long-term conditions, frailty and complex social, emotional, medical and psychological problems … too many frail and elderly people are attending emergency departments with conditions that could be managed in the home setting with the right level of support”; that is a quotation from the local Better Care Fund Plan, but it could in fact apply to just about anywhere in the country.
Again, much of the provision comes from very small and unevenly distributed companies, and it is difficult to find anyone wanting to set up in remote inland areas such as Craven and the Dales. As a result, the County Council has been forced to retain an in-house home care service to act as a backstop when required. Its commitment to developing the market, however, remains strong; fresh bids for provision are invited on the basis of a three-price structure — urban, rural and super-rural, and consideration is being given to paying a premium to cover travel time.
The problems of recruitment and retention are very similar to those encountered in Cornwall; zero-hours contracts, variations in seasonal capacity, and summer competition from tourism all feature, while near-full employment generates additional pressure. From a customer point of view, fuel poverty, social isolation and increasingly complex needs also echo Cornwall’s situation.
The County Council’s budget plan for social care up to 2020, A Vision for Health and Adult Services — People Living Longer, Healthier, Independent Lives also has a familiar ring for those of us who have to read such documents produced by official bodies. A new Care and Support Pathway promises, among other objectives, “Independence and Reablement — supporting people to maximise their independence” and “Planned Care — supporting people with long-term social care and support needs and their carers”.
The complexity of the strategies needed to achieve such aims is demonstrated by the Council’s Stronger Communities Programme, which provides small injections of cash — average grants are £15,000, tapering off over three years — to encourage locally-based programmes within the voluntary, community and social enterprise sector. Ryedale Carers, for example, set up a communal breakfast service to help reduce the isolation of retired farmers; a local Trust then added benefit by sponsoring visits to a mobile eye clinic. The resulting provision is of course never more than a patchwork, uneven in both distribution and quality, but by that very token it recognises the diversity of very local needs and the human resources which respond to them.
Can conventional domiciliary care agencies play a part in such community development programmes? Most will of course ask themselves where the commercial interest lies and the answer may be not in immediate profitability. One advantage of the fact that care providers in rural areas are generally small scale and locally based, however, may be that they are better placed than the large national conglomerates to make alliances and experiment with new ways of working. When resources are tight but the demand growing, nimbleness is the name of the game.
The third case study in the Rural England report is Shropshire, a county where the population is so widely dispersed that many settlements are over 45 minutes travel time from a hospital. In several other respects, once again, this county displays similar characteristics to those present in Cornwall and North Yorkshire:
low unemployment rates
poor pay, status and careers prospects for care workers
competition from the catering and retail sectors (though, without the seaside, there is less seasonal tourism here).
Providers also report similar problems to those facing the other case study areas, with higher winter demand and an increase in frailty featuring prominently. One factor making its first appearance in the report is some client resistance to male care workers; are country people more traditional than sophisticated townsfolk in their views on gender? Elsewhere, it had been claimed that rural communities particularly value self-reliance, which might be regarded as a positive but suggests too that help is sometimes sought only when a need has become critical, for example, requiring emergency residential care which support at home might earlier have averted.
Key challenges in rural areas
One should not, of course, make too much of the differences between towns and cities on the one hand and mainly rural counties on the other. All English councils with adult social care responsibilities are experiencing the yawning gap between, on the one hand, the growing demand for care as the population ages and deteriorates in health, and on the other the supply of resources severely constrained by central Government austerity. All face the problem presented by providing services traditionally regarded as low status and still with little chance of achieving anything like professional recognition. All are experiencing the skewing of their priorities arising from having to work alongside the demands of the much more influential health services, a disparity from which the pressures to respond to delayed hospital discharges often trumps all others.
Nevertheless, this report does demonstrate that the bodies in rural areas which carry responsibility for financing, managing and providing care for older people in their own homes face some unique challenges. A 2013 report on rural ageing carried out for the Department for Environment, Food and Rural Affairs identified what it called “two key challenges”. These were first lower population density, which stands in the way of the sort of economies of scale which can cut service delivery costs, and second, the penalty of distance, which brings higher travel costs and a loss of productivity. Care providers in rural areas have to tackle both of those challenges. Nevertheless, as Rural England has shown, the countryside does offer also some unique opportunities, particularly for collaboration with small-scale community groups and enterprises. Planners and managers of care, sitting predominantly in their city bases, need to see that the country consists of rather more than just green hills and beaches.
What can care agencies do to improve rural services?
Perhaps the large national organisations are missing a trick by largely ignoring the deep countryside; reaching profitability may require a longer-term strategy.
Small locally-based agencies are well placed to work collaboratively with even smaller community initiatives, though such co-operation may require new ways of working.
Committed front-line staff are the key to providing good care; offering only zero-hours contracts and failing to pay travel time will lose the battle with competing employers in retail, catering and tourism.