How home care works
Care at home or domiciliary care provides help for people to live at home. Home care can be a mix of services that help people live more independently. Care might include activities like help getting out of bed and dressing in the morning or the reverse at night. There might be help providing meals or reminding people to take medication. Home care often includes intimate personal care, such as help bathing or using the toilet. Generally speaking, home care is not meant to include health care, but there may be help with changing dressings or some care that can also be offered in a clinical care setting. Increasingly, though, home care workers are being expected to carry out some ‘clinical’ assistance and, as there is a continued push for further health and social care integration, this will become more common. Care is usually delivered in accordance with a care plan that is drawn up by an assessment team according to specific criteria. A care plan should take account of the support that individuals feel would help them live independently and with specific outcomes focused around an individual’s aspirations. In practice, care plans focus on contact hours and specific tasks that need to be undertaken – such as help with dressing or bathing with allotted times to complete those tasks. This is called time and task commissioning.
Getting help at home
Over a half million people in England receive some paid-for care at home. A small proportion of people pay for their own care (about 12%) but this is probably an underestimate, as some people will be playing for cleaners, housekeepers and other domestic assistance that provide some of the support that home care can provide. Some people purchase care through the direct payments they receive from local authorities to help them live independently, but most home care is purchased through local authorities – for all adult social care managed by councils that is about £19bn a year. If someone has social care needs and wants support from the local authority, they or their carer would contact their local authority for a social care assessment Many councils undertake screening to help divert people away from an assessment if they are unlikely to qualify for assistance based on need or financial criteria. In recent years, threshold criteria have been narrowed by many councils, which means that fewer people are eligible for local authority funded care. The Care Act 2014, Part One of which will be implemented in April 2015, clarifies the assessment and care planning process Assessment must be undertaken for all people who appear to need care and support, regardless of their finances or whether the local authority thinks their needs will be eligible. Local authorities will also be required to give people advice and information about what support is available in the community. The assessment will determine whether or not the person’s needs meet the eligibility threshold and whether they have ‘eligible needs’ for care and support.
From April 2015 there will be a national minimum eligibility threshold. This is intended to be broadly similar to the ‘substantial’ threshold currently used by most local authorities. If a person has eligible needs, and wants the local authority’s help to meet them, the authority will co-produce a care and support plan with them. For those entitled to financial support from the local authority, part of the plan will be a personal budget which sets out the costs of meeting their needs. Most people will be able, if they wish, to receive the personal budget as a direct payment, which they spend on their care and support, perhaps through employing personal assistants. If an individual is not eligible for financial support from the local authority they will be given an ‘independent personal budget’ which will show what the authority would pay for the care and support if it were meeting their needs. Local authorities have a responsibility to review care and support plans to ensure they continue to meet people’s needs and outcomes. Under the Care Act, they are expected to carry out a review no later than every 12 months, with a ‘light-touch’ review recommended six to eight weeks after the care and support plan is implemented. Some people will be eligible for intermediate care, a range of short-term services offered by the NHS and/or local authorities to help people recover their abilities after hospital discharge, or to prevent admission to hospital or care homes. Intermediate care services, such as reablement, are usually offered free for up to six weeks. Some people will be eligible for NHS continuing healthcare, which is provided free by the NHS. To be eligible an individual must be assessed as having a ‘primary health need’ and have a complex medical condition and substantial and ongoing care needs. Continuing care can be hard to obtain and future funding for a wider range of care has been the subject of much interest; most recently from the Barker review which recommended increased funding for chronic conditions such as dementia which are not usually eligible for continuing care but which are often associated with high care needs.
Who does home care?
There are about 685,000 home care workers in England. They are predominantly female –about 80%. Just over half of them (53%) are part time. They are diverse, just under 18% of staff are black or minority ethnic. They are older, with a slightly higher proportion of staff among older age groups (particularly ages 44-59) than the labour market as a whole ‘Informal’ care The vast majority of care is provided by ‘informal’ carers – such as spouses, relatives and friends. It is hard to know exactly what the value of that care is, but it has been estimated at £55bn a year Family, friends and neighbours have always played an important role in caring and they will continue to do so in even greater numbers. As our population ages, the gap between what can be provided by councils and demand for their services will grow. We need to acknowledge better the contribution that these carers make to our society and there are already some benefits for those who must give up work to care for loved ones. In 2013, the then Care Minister Paul Burstow, MP, commissioned a task and finish group on carers and employment involving Employers for Carers and six UK government departments, including the Treasury and Work and Pensions. It marked an important recognition by government of the value to the economy of personal and household services, including home care. But we must also acknowledge the gap that they leave in our economy, particularly those who have dual caring responsibilities – for children and parents. We acknowledge that parents need help – there are working tax credits, childcare tax credits and salary sacrifice for childcare vouchers. There is evidence to suggest that working families tax credits have increased labour market participation. The Department of Work and Pensions should investigate if a carer’s tax credit, a care tax credit or a salary sacrifice scheme could have a similar impact on those with caring responsibilities, by giving them greater incentives and support to remain in work and help pay for formal care when they cannot be there. And, as many of the people in the care workforce also have caring responsibilities, many of them would benefit directly.
The care shortfall
The number of people who are over 85 is rising faster than any other segment of the population. This is the group of people who are most likely to need some sort of daily assistance to carry out ‘normal’ activities. They need care. In spite of a growing need for care, less money has been spent on care each year since 2008/2009. In a time of widespread local government cuts, adult social care spending has fallen less than most other services (except children’s services), but there has still been a reduction of about 7.5%. Most of these cuts have affected older adults, as services to working-age adults have only been reduced by about 0.2%. This is likely to get worse. Cuts to adult social services now represent 52% of planned budget reductions according to the Audit Commission, but adult social care already represents more than a third of ‘upper tier’ council spending. During that time, in spite of initial enquiries to councils going up, fewer of those contacts are leading to assessments and fewer still of those are leading to a care package being offered to a new service user. Partly this is because thresholds have narrowed to the point that only those with the greatest care needs are offered support. The vast majority (87%) of over-65s live in areas that provide support only for substantial and critical care needs and 1% live in areas where only critical care needs are supported. The result is that 30% of women and 22% of men over the age of 65 who need help carrying out daily activities do not get that support and 43% of those over age 85 need help but are not getting it. rising eligibility criteria have seen many thousands of disabled and older people lose access to care and support. From April 2015, the Care Act will introduce a national minimum eligibility criteria. It will be set at the equivalent of the current ‘substantial’ level. Currently 19 councils still have a minimum threshold below this level, but the national criteria should prevent thresholds from being further tightened in most councils. A ‘moderate’ eligibility criteria has been shown to have a positive economic impact among working age adults with moderate care needs. Some have argued that setting eligibility at the equivalent of ‘moderate’ and funding this appropriately would help to ensure that disabled and older people can access the support they need to live independently and ensure that their care needs do not escalate over the longer term. Further research needs to be undertaken to quantify these savings, particularly in terms of the savings for the NHS such as avoidable admissions. There is simply not enough money in the current system to provide care to everyone who needs it. So inevitably the profile of care is shifting to more complex cases where individuals have a high level of multiple needs. Correspondingly, we should be ensuring the profile of the care workforce takes account of rising need, but there is little evidence of this. Continuity of care is a necessity for those with complex needs, but there can be little continuity in an industry where there is a just over 20% annual turnover rate in staff. This is over twice the average across all industries. Turnover in social care is a matter of life and death. The Care Quality Commission (CQC) found a statistical link between care homes with increased rates of staff turnover and notifications of death. It is reasonable to assume that high staff turnover impacts on care outcomes in home and community care.
Even if the impact was not that stark, care recipients tell us time and time again that they do not like having lots of different care workers in their homes or performing intimate care. Not only is there a high turnover, but providers and their representatives have told the Commission that there are recruitment difficulties in many areas of the country. Moreover, as complexity of need rises and there is further push to integrate health and social care, there is a greater need for care workers with sufficient skills. Angeleça Silversides, who is working with the royal Borough of Kensington and Chelsea, reported particular difficulties in London in obtaining staff with sufficient skills to undertake integrated care. But even at current skills levels, there is likely to be a shortage of care workers. According to the International Longevity Centre,33 if we continue to support current levels of need, with rising demand we will need an additional 765,000 care workers by 2025. Dr Shereen Hussein, an expert in social care demography at King’s College London, told the Commission that she was not optimistic about this demand being met unless there were significant changes in the way that social care was organised and care workers were recruited and retained.