The Costs of Home Care

Today, the Guardian published an article about the inequitable costs of home care services throughout England and the shrinking of access to council-paid support for care in the home.

The article refers to a survey and report comprised of a number of Freedom of Information requests. It says

The survey, seen by the Guardian, shows the average charge for an hour of home care has risen by 10% in the past two years – from £12.29 to £13.61.

Also stating

…there are wide disparities in the price people pay for care depending on their location. Home care, for example, is free in Tower Hamlets but costs £21.50 an hour in Brighton and Hove.

The data show that fewer older people – in excess of 7,000 – had their care services fully paid for by a local authority in 2011 a reduction of 11% compared to 2009.

This certainly reflects my experience in practice. There are a number of concerns that result from this report which merely confirms what everyone in the sector knows.

Eligibility criteria are moving upwards.

If we look at the Fair Access to Care Services which are the supposed ‘standardised’ entry point to ‘care provision’ in local authorities – the lower ‘access’ point has moved higher. From moderate needs being ‘covered’ more local authorities are moving to only allowing ‘substantial’ or ‘critical’ needs to be covered. This moves a lot of the preventative work away from local authority provision.

This has a significant impact on the manner which personal budgets are implemented. A lot of the leisure type activities we see as examples are being pushed out in favour of budgets which are strictly intended to meet immediate personal care needs. Options for choice are much more limited in this context, particularly if a person does not have support around them.

More people refusing care on the basis of cost

This is something I’m seeing much more as my own council has increased the costs of care. More people whom I assess as needing care are refusing it or refusing discharge from hospital solely on the issue of cost of care. There may be an assumption that ‘working hard all my life’ means that social care provision will be free in the future but it’s very hard to argue the value of a personal budget at (for example) £10 per hour when the charge will be £10 per hour. It is counter-intuitive and yet by bypassing the local authority ‘processes’ there is potential support that can be lost in terms of assistance in recruitment of staff/tax related issues. We are forcing more ‘cash in hand’ work sourced via Gumtree or notes in the newsagent windows.

Longer term costs as people supported at home less

This also means that people remain at home without the support if they do not wish to pay for it and the potential for much higher costs will come at a later point. Either through preventable or delayable hospital admissions or by admission to residential care sooner than might have otherwise been necessary.  Seems obvious but I see it happening every day. We can’t ‘force’ care on anyone (putting the capacity issue aside for one moment) and if someone is adamant they don’t wish to pay for care which is assessed as being needed, we just sit on our collective hands and wait for things to deteriorate –by which case, it may be too late.

Personal budgets and the ‘personalisation’ agenda.

I’ve mentioned some of the counterintuitive ways that services can cost as much as they are charged for – that’s particularly evident if we are considering a direct payment. There’s another problem with the implementation of the systems of ‘personalisation’ as they exist in reality. We were told initially it was intended to be a shift in ‘power’ from professional to user – which is fantastic – however the reality is often far from that. Assessment forms look similar (and ask similar questions in similar formats) to DLA application forms and focus heavily on physical rather than mental health needs.

The RAS (resource allocation system) pushes these assessments through an accountancy system which is non-transparent and spits out an ‘indicative budget’ based on a number of often unknown factors. So you get more money according to lack of ability to do things which perpetuates a top down model which doesn’t build on strengths of what someone CAN do – rather what they CAN’T do.

This process is convoluted and opaque. However well explained, sometimes people want good services delivered. Choice is only choice when it’s actually offers options. Seems obvious but it isn’t the reality.

Commissioning decisions

I am sad to say when I arrange support via a managed personal budget, I can’t necessarily guarantee quality of care to the user. We use agencies that have won their tenders for the contracts with the council purely on the basis of cost rather than quality. There may be carers rushing in and out on minimum wage without being paid travel time, between 30 min visits in disparate geographical locations. Is it any wonder that people are refusing these kinds of services when we can’t guarantee consistency or quality of support. There are some fantastic care workers. Really, they are gems but it can be hit and miss because the way that costs are being driven down mean the agencies cut costs at every moment. We aren’t delivering value for money.

This shrinking of provisioned support for older adults and people with disabilities will lead to much higher long term care costs both with costs shifting to health care services as people are admitted sooner into hospitals and care costs as residential care becomes an option sooner. In some ways, more importantly, it will and does lead to a reduction in independence and quality of life which is much more important and can’t have a price put on it.

Care Quality?

Another day, another report. This time, Which? has done some undercover work into the quality of homecare delivered to older adults as reported by the Guardian.

The team at Which? asked 30 families to make notes and diaries over a week in January and feed back the information, some of it is horrifying but the sad thing is that it doesn’t shock or even surprise me. That’s the real shame of the system.

One elderly woman was left alone in the dark for hours unable to find food or drink. Another was left without a walking frame, leaving her unable to get to the bathroom, while one man was not given vital diabetes medication, the watchdog said.

Which? has not named the agencies which I feel is wrong. I hope they are going straight to the Care Quality Commission (CQC)  with this information because for a consumer organisation which is supposed to be behind us as consumers of care services (oh, it’s coming in health care too – just wait) I’m surprised they feel they need to protect the names of those companies involved.

The reason they do is that those companies will not be removed from their positions of providing care to those who have been subject to institutional abuse such as that meted out in the examples given, because yes, this is institutional abuse.

These companies are probably tied into long term extensive contracts with local authorities than are bound in law and allow for a certain level of ‘default’ that makes them difficult to replace.

So what should and can be done?

1) However admirable Which? is, the fact that we have to rely on  Which? and Panorama to do the job of council quality assurance teams and more importantly the Care Quality Commission is not acceptable.

2) Embedding advocacy into the system far more fully. These people monitored were the ones who had families to complete the diaries. What about those people without families particularly those who may have cognitive impairments. We have to replicate the ‘checking’ role that involved families have to those who don’t have family support and for me I see that as happening through greater advocacy.

3) Commissioning (again, apologies to Guilty Commissioner who I know does things differently). The people who buy into and commission these block contracts aren’t the people who use them. They award on the basis of cost where quality has to have a greater impact on quality of life and quality of care provision.

4) Politicians. People go to their MPs about Forests but not about social care. The people who need the changes aren’t the people who are most likely to be politically active and that’s why this area has slipped so far down the political agenda. Politicians of worth need to advocate for electors who might not be clamouring at their surgery doors. They need to think of those who may be disenfranchised and take the advocacy and representation role more seriously to affect change.

Let’s hope we stop seeing these reports soon but i remain sceptical.

Close to Home – Reporting on Home Care in England

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?
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