Quality home care provision in England is still an aspiration into the second decade of the 21st century. That’s the thrust of the ‘Close to Home’ report published today after a year-long inquiry by the Equality and Human Rights Commission. Frankly, that’s not a good place to be but we seem to be moving backwards instead of forwards in terms of promoting quality care which adheres to human rights considerations. How have we, as a nation, found ourselves here? The report offers some insights and I’d say it is a vital read for anyone working in the sector or with an interest in the sector and the role that finances and private sector provision have on social care.
I read through the full report this morning and while being constrained by work commitments mean I can’t devote as much time as I’d like to analysis, I do want to pick up a few key points.
The introduction starts with a background and context of the inquiry explaining how the intended (or perhaps not) legal ‘safety net’ of the Human Rights Act (1998) does not cover home care agencies in way it did at the time that legislation was introduced.
Obviously being a long report, I just want to concentrate on a few issues.
Choice and Control – or where is this so-called ‘personalisation’ agenda?
Personalisation and ‘choice and control’ seems to exist in some kind of parallel fantasy land when compared to the experiences of those whom this survey covered. Yes, there are discreet examples but it remains a whole systemic failing of those who were responsible for the programme of transforming adult social care that there was little thought, effort and consideration given to improving the access to ‘choice and control’ of older adults who do not want to have direct payments.
The report explains
A wide range of interviewees from providers, local authorities and voluntary sector organisations flagged up a concern that there appeared to have been a rush to put older people onto personal budget – either by way of direct payments or managed accounts – without always making sure they had the information and support they needed
This certainly reflects my own experience of a system designed to ‘fit onto’ the needs of all rather than appreciate and work with the needs for all. The other issue raised by the roll out of personal budgets and its limitations is a familiar one for everyone working in older adults services who becomes frustrated by the proverbial ‘use your personal budget to go to a football match’ type examples we are fed on training courses.
We were also told that the level of direct payments from local authorities often does not allow for creative, flexible packages of care that people had been led to expect from this system of funding. Our evidence suggests that these packages, clearly of huge value to service users, are more readily available for younger disabled adults. Interviewees… stated that funding for older people only covered essential physical care such as support to get up or eat.
For example, the daughter of one older man wanted to spend some of the direct payemnt on support with assisting her father to get out and walk his dog so he could keep his pet. This was not only very important to him emotionally.. but also a key way for him to get out and socialise.. and would therefore make a fundamental difference to his quality of life. However his personal budget was only enough to cover his essential physical care needs, such as washing and dressing’
Sad, isn’t it? With all the hope we had for the personal budgets really making a difference and while it’s easy for me to say ‘I told you so’, I’ll resist because I genuinely believed we would get a better system. More fool me.
The report also links to the issue of Resource Allocation Systems (the way these ‘budgets’ are determined) ‘marking’ older adults lower in relation to the amount of money provided – in fact, the system recommended by ‘In Control’ weights younger adults towards an emphasis on social involvement while the one for older adults emphasises health conditions. Because we all know when you reach 65 you just want to sit at home and watch TV despise so much evidence about the danger of isolation and loneliness post-retirement. Sigh. It’s an inbuilt ageist institutional discrimination .
Role of Commissioning
The report has a section devoted to commissioning that I felt was worth picking up on. It states categorically that there is ‘evidence of poor commissioning’ which won’t come as a surprise to many in the sector. The cost-driven block contracts which are meted out to provide home care services are driving prices down and down and expecting more for less.
This is competition. This is the market.
The ECHR is critical of lip service paid by commissioning teams to human rights considerations saying
It is clear apparent from our interviews and detailed analysis of commissioning and procurement documentation that local authorities have a patchy understanding of human rights and their own obligations in protecting and promoting these rights for older people.
Not a great starting point. The report explains there has been a bias towards principles without linking them to specific duties under the Human Rights Act and it remarks on evidence gleaned that place as much as an 80/20 split on cost to quality when decisions are being made about commissioning.
Contract monitoring is crucial too and this is an area that is being cut as a ‘back office’ role. That’s certainly my own experience.
Regulation, Monitoring and the CQC
Oh, look, we cry, yesterday the CQC announced increasing inspections on home care agencies. Well, what a coincidence – they did that the day before this report comes out. Cynical? Never. There are roughly 6000 home care providers in England and 250 will be inspected. A local authority respondent to the report is quoted as saying
‘Over a period of time, CQC’s role in the regulation of home care appears to have reduced with the responsibility of monitoring falling more onto commissioning departments in local authorities. As much as commissioning needs to monitor, it is essential that this is supported by any regulatory bodies who can take action if human rights are not being protected by home care providers
There is criticism of the models used by the CQC to regulate this sector but is a large task to undertake. Perhaps there is a role for other models of regulation as the CQC is under-resourced and over-stretched.
The report goes on to say
.. the (CQC) reliance on providers self-assessing by using questionnaires was seen as inadequate because it could be completed as a ‘tick-box’ exercise. Although this is a model used in hospitals, it is not sufficiently probing for regulating home care’
But I blame the government, and the previous government for always wanting more for less when it is unrealistic. We want better quality but are not prepared to pay for it. The other issue raised specifically about the CQC was related to the expertise of the inspectors to actually carry out this role and their own knowledge and understanding of human rights.
There’s a lot more to this report than I’ve given but much of it can be picked up in the daily newspapers about the issues that will ‘headline’ the report about people being treated as if they are objects and being dehumanised. I won’t explore that at length because professional journalists can do much better than me but I wanted to look at some of the areas I know and see and try and explain and expand on them.
I’m sure I’ll come back to this report but despite the government’s pleas to the contrary, it’s hard to get away from the issue of more money and more investment being needed.
Society is ageist. Advocates would help. We need to work on the basics but it can’t always be done on a budget.
The report ends with a series of recommendations which I won’t go into in too much length because it would take too long but most important, I think, is the proposal to extend the ‘public functions’ under Section 6(3)b of the Human Rights Act to the provision of home care functions by private and voluntary sector organisations.
As for me, the thing I’ve learnt is that as a social worker, I have to be more aware of drawing on Human Rights legislation to hold providers (and my employers) to account when I see breaches and potential breaches.
I do recommend reading the full report.