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You Get What You Pay For (Unless It’s Homecare)
This week I had the wonderful opportunity to escape the office and spend some time with friends who know the sector inside out. Having the chance to step away from the madness that is Homecare and the opportunity to reflect is a rare one and the topic of conversation naturally centred around the rapid changes in the industry over the years, with lots of issues in the spotlight…
Image is everything
There are quite a lot of negative views surrounding Homecare, and many people have preconceived ideas generated by the often poor portrayal in the media. This is largely due to the press surrounding isolated cases of poor practice, rather than a daily celebration of the huge number of dedicated workers and the amount of daily visits that occur each day, successfully and to a high standard.
Money money money
In previous years, providers had a healthy profit margin and (most!) would pass this on to care staff. Due to increasing costs and decreasing commissioned prices there is hardly any pay incentive to attract new people into the sector. As the National Minimum Wage has increased, the differential between pay has been eroded away and lots of providers can only afford to pay minimum wage or just above, and the introduction of pensions has added its own additional costs. There is a lot of discussion around paying employees the Living Wage, and everyone I speak to in the sector hugely supports the idea, but the driver for change has to come from local government and commissioners to ensure the Living Wage is acknowledged in their pricing structure.
The demand for a Homecare service is outstripping supply, and workers are quickly recruited to compensate for the dangerous shortfall. Selection of the right staff is absolutely critical, but does not always happen in these pressurised circumstances. The low pay does not endear the vocation to many and Job Centre advisors don’t help when telling the long term unemployed that the “job’s a doddle”; “You only have to work Monday- Friday”; “Fit the job around you”. Arggghh!
Staff retention takes a dent as our skilled, experienced workforce can do exactly the same job in a hospital setting and earn £2 and £3 per hour more - a much more attractive option than trudging the streets in often deprived, and sometimes dangerous, areas of our towns and cities. Considering all the options, Homecare has no hope of competing.
My dining companion asked if we had had these type of conversations with the people that matter - the commissioners/the decision makers/the purse holders.
An honest chat seems a simple solution. But providers and commissioners can be reluctant on both sides. Providers are hesitant to be viewed as “moaners” “trouble causers” for being outspoken and airing their (sometimes) derogatory views on the ways in which care is commissioned and planned, just in case upcoming contracts are not renewed. During one meeting at which I tried to express a concern, the unfortunate response from the Contracts Manager was “Not to tender again”.
And, oppositely, commissioners don’t want to listen to the moans and groans and the humdrum problems inherent in Homecare and the constant calls to pay more for services when they are trying to balance and justify increasingly smaller budgets.
But there is money out there if they use it more creatively. Providers know their local market, they want to engage and support commissioners in saving money where they can.
PCTs are imposing fines of - in some cases - £150 per bed per day that is blocked. Why? Who does this money go to? Why can’t it be directed to buy capacity from Homecare providers? Care staff could be specifically recruited to respond in emergency situations to people being discharged home.
If a small level of capacity or guaranteed block hours was purchased you could offer a level of flexibility for any time - including evenings and weekends - across an identified geographical area. “Bed blocking” and unsafe discharges would be reduced as people were safely supported to return home.
Reablement services could be developed further nationally for service users where short term packages are appropriate. Note to commissioners – those eligible for a reablement service should meet a specific criteria. When you allow long - term packages to be placed on a reablement service i.e. four calls per day with two care staff for a service user with complex needs, you are setting the service up to fail immediately. Providers will not meet their reablement targets as they don’t have a magic wand and the care staff cannot perform miracles.
If a service user advises that their needs have changed and, therefore, their care provision can reduce accordingly, providers can complete a review and risk assessment and liaise with advocates before sharing the detail with social workers. Care management teams should be able to address this quickly and without undue delay, yet I have waited up to 5 months (an extreme case) before a decrease request is addressed and confirmed. But who is paying for this service in the meantime? If the service is no longer required, why continue to fund it as a Local Authority? If they employed one person/team to deal solely with reductions or cancellations of service, this would reduce inappropriate spending and money could be directed to those requiring urgent care and support.
Preventative services should come into sharp focus for commissioners trying to save money in the long term, and invest into developing these services - surely money well spent if successful. High levels of attendance at A&Es could be avoided if GPs were able to commission short - term services from providers for the elderly before they reach a critical level.
But my Dining Companion is right.
Unless there is some meaningful dialogue between commissioners and providers and some real partnership working, both sides have got to listen.
It is in everyone’s interest to strive to achieve excellence in Homecare, and to meet and exceed the standards set by the Care Quality Commission and Local Authorities. But in order to achieve this, the administration aspect of Homecare places pressure on already tight margins. Back office costs are a huge expenditure for providers. But the unthinkable alternative is to strip back the Rolls Royce service and to deliver the Fiesta funded rate.
My fear is that contracts are being purchased from a financial perspective where costs are key and tenders are reviewed with a focus on price.
If I bought cheap toilet paper from my local supermarket, I will expect to receive poor quality paper, probably akin to tracing paper. I don’t expect to be purchasing high quality, super soft aloe vera infused paper that makes the day that little bit better. After all, you should expect to get what you pay for. And that – fundamentally - is what saddens me about the future of Homecare.