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Integrated community services demands co-design of relationship-based home care

Brendan Martin, 2 December 2014

Amid the gathering gloom of wintry nights and the hospitals crisis everyone in the National Health Service expects before the Christmas decorations come down, a little ray of light from an unexpected quarter.

You might have missed it, and given his government’s drive to privatise NHS services it is hard to believe it, but Health Secretary Jeremy Hunt has declared we need more district nurses and that the market can never deliver the community services essential to the future of integrated health and social care.

If he means that, he will surely give a big welcome to the urgent call for change issued today by the Local Government Information Unit’s Key to Care, the report of the Commission on the Future of the Home Care Workforce.

The Commission, chaired by former social care minister Paul Burstow MP and sponsored by the home care provider Mears, reports (page 16):

“Providers compete fiercely on individual cases and they compete on cost per contact hour, not on the creativity of solutions, outcomes or the quality of their staff.

“Worst of all, there is little incentive for improvement or change in the delivery of care once a client has been secured.”

Far from improving quality, in fact, the report finds that this market structure tends to drive down standards (p.15):

“Methods such as reverse auctioning – getting providers to bid on care and choosing the lowest price to drive down the cost of care – are not an appropriate approach to lowering the cost of supporting people.

“These methods have a profound effect on the quality of care that is delivered and on the quality of people’s working lives.”

With austerity tightening the eligibility criteria for publicly funded home care, the Commission finds (p.13) 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”.

But the answer is not simply to expand eligibility and increase budgets, important though both are. As the Commission points out, radical service redesign is also essential because the ‘time and task’ model has had its day.

The growing recognition of this fact, combined with Hunt’s acknowledgement that the market cannot deliver the integrated community services of quality without which pressure on hospital beds can only grow, presents an opportunity that must be grasped.

The Commission report points out that of the 685,000 home care workers, 60 per cent are on zero hours contracts and a third paid less than the national minimum wage. No wonder staff turnover, at 21 per cent, is double the labour market average, which further undermines quality.

“Home care will not become a career of esteem until we start treating both service users and care workers with esteem – and that really means letting them work together to decide what the best care is in each individual case.”

Public World’s is aiming to deliver just that with LIFT and I’m delighted that the Commission’s report flags it up, albeit while also promoting the ‘outcomes-based commissioning’ favoured by its sponsor, about which we are less convinced.

Our approach is inspired by the experience of our Swedish partner Alamanco, which has worked with health and social care providers in that country to develop relationship-based home care through teams in which zero-hours contracts have been reduced from 60% to 10% per cent (probably an optimal level).

If you think that can only have been possible with increased budgets, think again. In Sweden, in work validated by the European Social Fund, the shift to more regular hours and secure employment cuts costs by improving continuity of care and reducing waste.

It’s a similar story in the Netherlands, where the Buurtzorg model has grown from a single team of four district nurses seven years ago to some 8,000 today, capturing 60 per cent of the home care market there.

The LGIU report points out that in Britain, “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.”

Indeed, and so it should, but that means a shift to nurse-led home care services here too, and to the kind of autonomous team work that has been key to the transformations in Sweden and Netherlands.

It works because instead of being rigidly tied up in ‘time and task’ care plans that no longer fit an older person’s needs almost as soon as they are written, the local multi-disciplinary teams are able to adapt flexibly to changing need.

Team-based autonomy — within a transparently regulated framework that provides vulnerable people with the safeguards they need — is also much cheaper because the administration costs are far lower.

Jeremy Hunt is right: the market cannot deliver integrated health and social care to older people in their homes. But cooperation — between local authorities, providers and clinical commissioning groups, between care workers and their clients, and within multi-disciplinary teams — can do it.

With cuts and commercialisation all around, it’s easy — too easy, in fact — to be pessimistic. The growing recognition that home care must change, allied to our growing understanding that we can improve jobs and services while cutting costs, allows us to reshape the future with optimism -- if we grasp this opportunity.

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