James Cuthbert is a member of the Commission on the Future of the Home Care Workforce and a consultant working with councils on better commissioning of social care. The Commission is chaired by Paul Burstow, MP and supported by LGiU and Mears.
Reform in health and social care is preoccupied with reorganising management; creating and abolishing commissioners and regulators; and inventing new methods of procuring, contracting, rationing and paying for services.
I am not competent to judge the efficacy of those reforms. Nor is that the point of Paul Burstow’s Commission. But you will probably agree, it is at least unclear that reform has improved home care. Those most affected by the reforms of the last few decades—senior managers, commissioners, planners, inspectors, etc—don’t do care. A huge and little-understood workforce does that. And it is hard to see what reform did for them.
We know that there is poor home care. We suspect there is far too much. But we don’t know nearly enough about the causes. We know that the state supports more than 600,000 people with care at home. Their quality of life depends hugely on the quality of services for which the taxpayer pays around £6BN/year. We know that poor home care is a misery for the people who use it; and it helps to fill expensive hospitals and care homes with people who don’t need to be in them.
The workforce surely has something to do with it. Perhaps 210,000 home care workers (about 60%) have a zero-hour contract; and we think minimum wage, at best, prevails. Recently the scandalous working conditions of some care workers attracted some welcome attention in the media. This gave welcome context to frequent stories about abysmal care. The debate about zero-hour contracts helped there.
I suspect that pay, conditions of employment, training, management are behind many of the problems of quality in home care and some of the problems of rising demand in the NHS. I believe recent social care policy reform has failed to take the home care workforce seriously. The absence of policies to improve it combined some of the perverse consequences of policies like personalisation and declining local authority budgets, probably exacerbates the day-to-day problems faced by home care workers.
I recently worked on home care reform at Wiltshire Council. Wiltshire’s new “Help to Live at Home” care service has been going for two years. It is well known for lots of reasons. It uses few suppliers. It tries to hide the wiring and integrate the services like personal care, housing support and assistive technology into one service that is designed to help people regain and retain an independent life when illness or disability threatens it. It is probably best known for its focus on “outcomes,” especially those that help people live well and stay independent.
Wiltshire’s aims are good. Few disagree with them. Some of its means were controversial. National policy wants a diverse market, with lots of people buying their own care and lots of organisations offering care. Wiltshire uses big, exclusive contracts with a few companies that it pays well, despite big pressure on its budget. Big contracts make for economies of scale and they give providers confidence to invest in their services. Help to Live at Home also uses payment by results, which is rightly unloved in the NHS. But paying for good outcomes shifts the financial consequence of poor care from the commissioner—the Council—to providers. It gives them a big incentive to deliver good care.
For all these grand ideas about outcomes and financial incentives, Wiltshire was clear from the beginning that care will not improve, and people will not stay well and live as independently as they safely can, unless care workers are recruited, trained, paid and managed better than they were in Wiltshire and are in most other places I have worked. Wiltshire is still in the middle of these radical changes. But their experience might give us some clues.
No method of improving any care—commissioning for outcomes; tougher regulation; “personalisation”; nor even integration—will produce an affordable, quality care system without a clear picture of the workforce we have and a plan to develop the workforce we need. So I’m delighted that Paul Burstow has formed this commission. I’m glad to have the chance to better understand the problem and, perhaps, contribute something to the solution.
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