On Homecare Day 2018, I was asked to write about commissioning.

How peculiar I thought, given that the ethos of the day is about celebration yet, commissioning of homecare is continually raised in quite the opposite context.

For many years it seems that there has been little change in the way that homecare is commissioned. At its very worst, it could be described as some updating of statistics based upon a limited dataset pulled together to inform a competitive tender perhaps with the involvement of those who access care and support in the final selection of providers.
Providers, who find themselves torn between continuing to provide a service at a rate which is significantly lower than they require (9 out of 10 home care providers say they do not know if their business will be sustainable beyond the year end), or to leave the market carrying with them the knowledge and emotion of; disrupting the care and support of some of our most vulnerable citizens and, the impact on their workforce.

Of course, this does not apply everywhere, but it is certainly leaning towards the norm rather than the exception.

Indeed, in some areas, the commissioning part has been by-passed completely in the hope of a new national solution, going straight to an extension of existing contracts which may on the face of it seem like a positive outcome in terms of continuity, does not take into account the increased challenges that providers face with a rising cost of living, increased qualification requirements, significant staff vacancies and turnover rate of around a quarter.

I also find that I am writing this in the same week as the strikes in Glasgow highlight the risk of having a majority provider, in addition to the limits placed on a right to choice as intentioned by the Self Directed Support Act.

So what needs to change? How can commission in a way that is worth celebrating?

Remember first of all that commissioning is a whole cycle and not simply procurement.

We need to know who is likely to access home care now and in the future, and what homecare actually means to them. If we are planning for the future now, perhaps you may also wish to ask yourself what it means to you?

Partly this means better data, and better use of data, but it also highlights a need for systems and processes to facilitate future thinking, just as Scottish Care is currently undertaking with the Glasgow School of Art Innovation School on the future of care.

This work is enabling us to couch future thinking in the context of economical, technological and sociological changes amongst others, to develop tangible recommendations for the sector.
Above all, commission in partnership, with planners, providers and people. There needs to be cradle to grave thinking and a person-led approach which supports grassroots involvement in development. There needs to be the establishment and support of a collaborative rather than competitive market, where outcomes focussed and relationship based care takes the place of the inflexible and inhumane time and task model.

And please, don’t unintentionally patronise those involved by shielding them from the economics and the cost. We all know about rising demand in a tightened economy, but knowing exactly what that means locally lends quite a different understanding, which can led to quite different solutions. I have previously spoken at length on how by involving those who access care and support in commissioning amidst the context of careful market stimulation with providers, resource was freed up which led to the local authority that I was a commissioner in at the time lowering the eligibility criteria, thus increasing the numbers of people accessing care and support by 110% at no additional cost.

Incidentally, last week I heard of a pilot on outcomes based commissioning in Wales that led to a reduction in cost because people were able to access what they needed when they needed it, and often this meant better use of and access to existing facilities in the community. It was described to me in terms of an all inclusive holiday. The first two or three days are often about over-indulging on heaped plate loads accompanied by rivers of the local tipple, but by the end of the week we’re reaching for the salad and water.

We find a pattern of knowing what we need and when.

Which brings me to the most important aspects of commissioning – trust. On all levels, if we can trust, then we can foster the transparency and respect required to think innovatively about what the future of care means for the future of commissioning care.

Despite the gloomy start to this blog, I will finish with something worth celebrating. A focus on and a nod to the areas in Scotland where this conversation is beginning to happen and I hope to be able to share some of this in the next few months. As we progress we need to work together to evidence and measure the impact that such changes to commissioning can have, both locally and nationally. We need to share both learning and success when a test of change becomes the norm, let’s make my blog on commissioning for Homecare Day 2019 a celebration from start to finish.

Karen Hedge

National Director, Scottish Care

#careaboutcare #careaboutcommissioning

Earlier this year Scottish Care commissioned a Day in the Life of Home Care. This is a film created in collaboration with Michael Rea, an experienced documentary film maker with a long standing relationship with Scottish Care and a proven ability to capture the diverse voices of those working in and receiving social care.

What better time to revisit this than during Workforce hour this Home Care Day 18?

#homecareday18

#workforce

The Dignity of Rights: Homecare and Human Rights.

Dignity is one of those words which risks falling into overuse and thus into misunderstanding. This is a great pity because it has a real importance within the care and support of people and has a real power when we consider the role of human rights.

When the leaders of the world gathered to sign off the UN Universal Declaration of Human Rights the concept of dignity was at the forefront of their concern and appears many times in that document. Indeed Article 1 of the Declaration states that:

‘All human beings are born free and equal in dignity and rights.’

In some sense then ‘dignity’ is in with the bricks, a foundation marker, embedded at the heart of what we mean by human rights. In the new Health and Care Standards which are relevant for all care services including care at home and housing support we also find ‘dignity’ as one of the core over-arching principles. It states that as someone who uses services:

‘My human rights are respected and promoted. I am respected and treated with dignity as an individual. I am treated fairly and do not experience discrimination.’

So what exactly does this oft mentioned concept of dignity really mean? The Oxford English Dictionary states that dignity is:

“The state or quality of being worthy of honour or respect”

Every human being is worthy of respect for who and what they are. By virtue of their very existence a human person deserves to be treated with value and worth, concern and protection. We are not saying that it is only some who have dignity, we are proclaiming all humanity has dignity. There is something in our status as human beings that makes us worthy of respect and necessitates us to give respect to others. We do not require a person to change, to grow into their dignity, they are born with full dignity, as and who they are. Every person has within their being a sense of dignity which is, as it were, part of their DNA. It is inherent. It is a human right.

Closely linked to both respect and dignity is the view that we have of our own identity. Our understanding of who we are as a human being and as an individual is formed and nurtured by a whole series of influencers. It is the classic nature and nurture debate. We are influenced by our upbringing, by the development of our attitudes and values, by our emerging personality and character. We are shaped by the encounters we have, the relationships we form and the experiences we share.

We mould our self-understanding into something which either includes or excludes. We can become individuals who accept and recognise the inherent worth and value – the ‘dignity’ – of those we come across – or we can become someone who puts conditions and restrictions on the full humanity of another. We can go through life developing a robust sense of self which gives us esteem and self-love, or circumstances and encounters can serve to limit and demean us to the extent that we consider ourselves as having little worth or value.

There are so many people in today’s society whose identity, their self-understanding, is one which emphasises their own ‘self’ to such an extent that it causes arrogance and narcissism. Some psychologists have argued that we are in the midst of the ‘selfish generation’, a time where the necessary and healthy concern and attention for your own self is out of balance and replaced by an over-emphasis on your own ‘self’ and the arrogant advance of the ‘me.’ It’s all about my needs, my desires, my priorities. It is as if we have stopped growing up and are stuck with a toddler sense of the self.

Dignity is a human right. Dignity demands that the individual recognises worth in another. As a consequence dignity requires humanity to be mature in how it sees the individual, how it values the self, and how it celebrates difference.  These are fundamental requirements for those who would want to work in homecare – they are the essence of care.

But it goes even further than that. A human rights concept of dignity says to us that not only should we recognise the inherent value of other people, but that it is actually the degree to which we are able to relate to, engage with and include others that marks us out as being human. I recognise that recently some have criticised the concept of dignity being inherent within humanity and a given in terms of human rights but I think this is to miss the point that at a profound psycho-social level there is something in the marrow of humanity that requires respect and value.

If this is true, and I would argue it is, then the task of caring is one which is a paramount example of human rights in practice. To care for another is to give of your ‘self’; to care for another enables you to become a better version of who you are, it nurtures an openness to encounter and a willingness to be changed by interaction and relationship with someone you care for. The more we give of ourselves in the care we do, the stronger that ‘self’, that ‘humanity’ at the heart of me becomes.

To treat someone without dignity, with no regard to their needs and dignity, is what we describe as ‘inhuman treatment.’ To care for, to have regard to someone else by caring for them is a glorious illustration of what true humanity really is. It is not a truism to suggest that by caring for another we become more fully human. And it is not just in the actions or tasks we undertake but it is in the being with and the attending to someone who is not your own self.

The poet John Donne famously wrote:

No man is an island entire of itself; every man

is a piece of the continent, a part of the main;

if a clod be washed away by the sea, Europe

is the less, as well as if a promontory were, as

well as any manner of thy friends or of thine

own were; any man's death diminishes me,

because I am involved in mankind.

Now without getting into a debate about Brexit, what Donne articulates is a view of humanity which says that if someone is missing, if we do something that cuts off another from society, then we cannot describe our community as whole, our humanity as mature.

But there are now and always will be threats to the human right of dignity.

Dignity is so tied to our conceptions of humanity that we use terms like ‘inhuman treatment’ to describe acts that breach our human rights. There is a sense that treating someone humanely means behaving towards them in a way that is consistent with their humanity and dignity.

So in homecare today are there threats to dignity, a dignity inherent within our humanity?

Is our dignity threatened when at the point of vulnerability society decides because of fiscal budget and austerity that the supports I used to get to enable me to be independent, to be part of the community I live in, are to be withdrawn? Where is dignity in eligibility criteria in homecare provision which makes it harder and harder for the majority to access free care and support?

Is our dignity threatened when the increased use of technology leads to a situation where human presence is being replaced by technological interventions? Or do we need to re-define dignity for a technological age?

Is dignity threatened when we make decisions to give greater value to some because of their youth compared to others who are old?

It is easy to recognise the assaults on human dignity that come by means of ‘inhuman’ treatment, by torture, by punishment, by violence and force. But what are the potential ‘inhuman’ assaults of dignity that come by means of less subtle interventions?

The delivery of care in whatever context is a superb example of dignity in action. The fulfilment of human rights within any society demands the nurturing and support of the care for others. For unless we adequately resource and seek to develop a workforce able to deliver cradle to grave quality care, then we risk being ‘inhuman’ in our treatment of the most vulnerable and to diminishing the ‘dignity’ of all.

Dr Donald Macaskill

CEO, Scottish Care

@DrDMacaskill