BASW Chief Executive Bridget Robb offers her view on the current model of homecare commissioning.
BASW believes that the current model of commissioning of homecare is not fit for purpose. Social workers are very unhappy about the quality of much of the domiciliary care that they arrange. They feel that they have little power and control over the services and often find it very difficult to develop any sort of meaningful relationship with providers and care workers.
This has a direct impact on the service that they can deliver as social workers. A typical scenario for a social worker is seeing a harassed homecare worker arrive late to support a service user. All the social worker can do is to ring up the procurement department of the local authority, who then ring up the manager of the agency, who then promises that the situation will change – which it rarely does, because logistically it can’t.
Domiciliary or ‘homecare' in England has changed very substantially in the last 25 years. The majority of domiciliary care workers used to be directly employed by councils, but now less than 10% of these workers are employed ‘in-house’. In parallel to that reduction, there has been a substantial increase in both the number of private homecare agencies and in the number of staff employed by private agencies. There are now 7,050 domiciliary care organisations – an average of 46 care agencies for each of the 152 local authorities in England.
Social workers have been greatly affected by the major shift to outsourcing of care provision. Prior to this shift, social workers and homecare managers were usually integrated into teams. That meant that social workers could have frequent and easy dialogue both with homecare managers and with frontline homecare workers.
As the number of private agencies supplying home care grew and the volume of in-house services declined, it communication with homecare managers and care workers became an increasing challenge for social workers.
Contract and procurement departments were established in councils to arrange home care, following an assessment by a social worker. This work could be allocated to any of 50 or more agencies working in a locality, making it virtually impossible for social workers to establish and maintain any form of communication with them all.
Agencies became under huge pressure to deliver services according to what the service user wanted or needed. For example, if the service user wanted to get up at 9.00 am, the request was considered their right and procurement officers would try various agencies until they found an agency that said they could facilitate it.
Agencies find it hard to say no because they can easily get a reputation as uncooperative. Nearly all commissioning is done on a case-by-case basis; with very little block contracting taking place.
Local authorities have developed commissioning departments and contract compliance departments to manage the process. Commissioning departments have developed in a different ways in different local authorities. Some councils have seen it as their role to drive down prices paid to the providers, others have taken a view that for commissioning to be effective, they need to take more of a partnership approach with providers, commissioners and purchasers working together to try and create and maintain this very complex but vital service.
Some commissioning units have employed social workers to use their expertise in the design and delivery of services, while others have approached purchasing home care in the same manner that they order traffic cones.
Present commissioning practices, driven by commissioners who often have no experience of frontline practice is a recipe for poor quality services at best and positively dangerous at worst. Before the views of homecare workers were crucial in reviews and re-assessments, now all too frequently the homecare worker is not event consulted. Homecare workers are forced to be task driven. There is also a perverse incentive not to promote independence – if a service user improves then the agency loses the work and the worker loses their wages.
Social workers see some of the ridiculous procurement practices that take place, such as domiciliary workers dashing from one locality to another whilst other workers are dashing in the opposite direction.
They are also acutely aware of the frequent appalling terms and conditions of employment that homecare workers endure – low wages, no pay for travelling between service users, and use of “zero hours” contracts.
This all has a direct bearing on the quality of care, and the recruitment and retention rates of home care staff. Social workers used to see care workers as their eyes and ears and also as people who could come up with good suggestions to solve problems because of their deep local knowledge.
Homecare workers worked with social workers as people, frequently passing on real insights gathered from getting to know the service user over time. For example, whether a person was capable of undertaking self-care tasks or lacked confidence, which the homecare worker could help build up. They knew about very local voluntary sector organisations that could help for example with combatting isolation and could alert social workers of concerns about the service users.
Some argue that the drive to increase personal budgets and direct payments is a solution. But for many people this is not a realistic option and there is a great deal of “smoke and mirrors” about this policy. The majority of personal budget holders simply contract with the very same home care providers that would provide the service if the service was arranged in the previous way.
There needs to be a philosophical consideration of the role of homecare in society – where does it fit with enabling people to maintain as independent lives as possible and what role should homecare play in supporting and developing community cohesion and social capital? Social workers have expertise in this and should be involved in considering how homecare can complement and support society.
In the past, many people who used homecare services saw themselves as having a role in helping the service run well. People understood that if a homecare worker was delayed it was probably because a fellow human being had had a problem or an emergency. Providing that they received an explanation, people were glad to have indirectly helped someone who on that day may have been in a worse situation than them, with the expectation that when they may be in urgent need they would be helped first. The totally “consumer-based” model has rid home care of that altruistic element.
The commissioning models that are employed need to be urgently re-visited. The hard-nosed purchaser/ provider split rarely works in the manufacturing industry, such a model is not appropriate in the sensitive and, at times, life-and-death world of domiciliary care. Social work is about developing relationships and problem solving. Manufacturing has learnt that having good relations between suppliers and purchasers is essential to enable continuity of supply, to solve problems and to ensure good quality. Manufacturers work very closely with suppliers so that problems can be solved and quality improved.
Social workers need to be able to work with a small number of locally based suppliers of home care in small localities in order to build up relationships with the suppliers, including the frontline homecare staff. Social workers recognise that in order to run a successful business you need to have a degree of stability in the work, not least in order that organisations can employ workers on contracts that give them security. Social workers feel that their knowledge and expertise in how services should be run and organised has been ignored and marginalised, they would welcome input into the re-design of how home care services are commissioned and organised.
The information in the third paragraph derives from the Skills for Care Report: The size and structure of the adult social care sector and workforce in England in 2013.