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.

12 thoughts on “The Costs of Home Care

  1. Ermintrude- this is a really thoughtful blog and I suspect your experience will mirror that of many front line social workers. Clearly there needs to be a fair system of assessment and payment that is compatible with good care and support. When people do need support it should be well funded and personalised but how do we keep the requirement for paid support to a minimum without all the crude and uncivilised measures you highlight?

    Should love you to input into the TLAP National Market Development Forum in some way?

    • Hi Bill,
      I’d love to input in any way I can but not sure in what capacity I could. I will email you though!

  2. As always, a really powerful, thoughtful blog Ermintrude. For me, this highlights the tensions at the heart of the “personalisation agenda”. The thinking needs to be longer-term, which is really difficult when there is so much pressure to save money now.

    Are we prepared (able?) to really support people to have quality of life or just provide personal care?

    How can the emphasis shift to preventative approaches and enablement? When it gets to the stage of hospital admission, it can often feel like a one-way ticket for older people, whereas more support in the community would have cost more … IN THE SHORT -TERM.

    I love the idea of a “CAN do”, asset-based approach rather than concentrating on what people CAN’T do. But the theory needs to be followed through the assessment and resource allocation …and review.

    I challenge the “powers that be” / theorists: What would THEY say to an assessor?…

    Would they tell them how they are perhaps having a few more ‘better days’, slowly improving, with the right support, having a few social outings etc? Or would they feel obliged to talk about (exaggerate even?) what they can’t do for fear of losing money and independence?

    I see wonderful organisations like Grapevine in Coventry helping people move on to take a full part in the community but then I worry whether they will have the carpet pulled from under their feet by tighter and tighter eligibility criteria.

    As you say, you can’t put a price on quality of life and independence. But that is exactly what is happening. And it is high. But it will be even higher (including literally – ie measured in money) if short-term thinking prevails.

    • Thanks Gill – I find the process of assessment can be humiliating even when carried out by the most thoughtful practitioner because the information needed concentrates on deficit models. I’m not sure yet how this can be changed but that’s where the real power shift may take place.
      I certainly worry that more empowering and creative work will be pushed by lack of budgets – which is why we are seeing more input in terms of user groups with higher funds attached such as learning disabiltiies – as opposed to work with older adults where the eligibility is pushed.

  3. this just about sums up all that is wrong with today’s home care; very well expressed; only wish I had more time to reflect some of these views in my Today prog interview this morning, but so little time. Thank you for writing this.

  4. Excellent post Ermintrude. The costs focused procurement model resonates with me. Though we supply local gov in another area we have seen evaluation models shift from “30% on cost” to “80% on cost” over the past two years, even though for slightly more money we can make larger savings, sooner.
    This approach is positively dangerous when it comes to care
    Note also that, in Bristol which has residential parking areas and parking meters, care workers home visiting are not given a parking permit, have to hunt for parking, and pay their own fines

    • Exactly. I have seen some excellent agencies we’ve worked with pushed out due to the procurement processes which prioritise cost over quality. I wonder about ‘rewarding’ good care with loss of contracts. It worries me. This is about funding and commissioning.

    • Bloody LibDems led by Barbara Janke, rhymes with, well, I don’t have to spell it out, certainly not to someone who lives here. Another point is that some personal care assistants have been compelled to accept employment as such by the DWP, no matter how suitable or unsuitable they might be. The persom who in a communal laundry used to gossip about her clients was bad enough but the angry, middle-aged man who announced, “This is like watching f*****g paint drying!” and put all his client’s wash through together on a hot wash without separating colours, delicates, etc., and then bundled it all from the tumble drier into a bag with no attempt to fold or even roll any of it, had me so concerned a spoke to a City Council Notmyjob about him. Was he interested? I shall do a virtual load of washing onour washer-drier for the first correct respondent. 😦

  5. I agree with this line of yours – 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. We would really know what our priority is or what’s more important and finds steps towards achieving it and soon before it’s too late.

  6. Nice article, Thanks to share that information with us.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.Keep it up

  7. Its not easy though is it really. If you have an aging population, an economy which is stagnant then funding is goign to get reduced isnt it?

    The only way around it is by being frugal and getting the most out of what you do have. Not ideal I agree.

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