Home First: re-enabling homecare.

Next week Scottish Care will be holding our Homecare Festival. This is the second such event which explores and examines the major issues, challenges and potential facing the care at home and housing support sector in Scotland. It is once again a virtual event because of the continuing pandemic which we are all experiencing.

The theme of this year’s event is Home First and each of the days from the 15th to the 17th will have a specific focus. The first will Home First: issues of vision, sustainability and practice; followed by Workforce First: the critical role of homecare workforce and ending on Thursday 17th with Independence First: homecare and personal independence.

The phrase ‘Home First’ has become ever more commonplace in the last year. It describes a desire on the part of most individuals that the place where they would want to be supported and cared for is their own home. The emphasis upon the increased use of homecare is an important if subtle change in both social messaging and political commentary. But what lies beneath the catchphrase?

Homecare has undergone some dramatic change in Scotland over the last couple of decades and not all of it for the best. We have seen the gradual stripping away of non-personal, preventative and relational care and its replacement by a transactional, functionalist and reactive approach to care and support in one’s own home. The numbers simply do not lie.

Since the introduction of Free Personal Care we have witnessed a dramatic change in the way in which home care has been delivered in Scotland. This is evidenced in Scottish Care’s 2015 report, ‘Home Delivery’, which was premised on independent research on the home care sector in Scotland. It outlined that:

  • In 2002, clients receiving Free Personal Care accounted for 56.9% of all care at home clients aged over 65
  • By 2013, those receiving Free Personal Care accounted for 93.6% of all care at home clients over 65

A later report Bringing Home Care said of this:

“In 2004/5 there were 16,440 clients who received home care provision out-with the Free Personal Care criteria. By 2014/5, this figure had fallen to 3,410. We can therefore deduce that a dramatic reduction has taken place in relation to the number of clients receiving publicly funded support for areas outwith the definition of ‘personal care’, such as ‘mopping and shopping.’ Instead, those who access services are narrowed significantly to those with high level personal care needs and often, those with lower-level needs are left without support.”

What this effectively meant is that non-personal care has been squeezed out from prioritisation, eligibility and therefore public funding. This change in dynamic and delivery has had real consequences not just for the nature of the care but for its impact upon the individuals being supported.

The same Scottish Care report summarised this well in stating that:

“Care at home services have tended to be developed almost accidentally; in part as a reaction to the market, whether that be a shaping in response to social care commissioning or a reaction to health and wellbeing policy development.

This has caused many problems; a lack of commissioning for innovation and new developments, a stereotypical assumption of the contribution of care at home and housing support and more worryingly, a diminution of its central importance and the effective marginalisation of the capacities and skills of the care at home workforce.” (page 4)

Undoubtedly one of the casualties in the re-orientation of homecare has been the loss of an emphasis upon preventative care and support. The Christie Commission and more recently the Feeley Report articulated just how critical such an approach was not solely on fiscal grounds but for improving personal outcomes for individuals and for the wider wellbeing of community and Scottish society.

Nowadays preventative homecare is virtually non-existent because we have stripped out from the system the ability for frontline workers to form natural and meaningful relationships with those who they support. The ability to spend time with someone, to consistently get to know the needs of an individual cannot happen within the constraints of a functionalist approach to a task and time-oriented form of care. You cannot build a preventative model of care which fosters wellbeing within the constraints of what is commissioned as homecare today. Indeed, the last few months have witnessed the obscene rise of commissioned 15-minute visits – and given it takes 7 minutes to don and doff PPE – what chance is there for care and support delivered in a manner which affirms human dignity and individual autonomy, and which can embed a preventative approach to care?

If we are serious about enabling people to be independent and autonomous for as long as possible then we need to invest in that reality. Ultimately that involves significant fiscal prioritisation. It means that we invest in creating and retaining a talented workforce who are more autonomous, professionalised and enabled to do what they are best at, caring through relationship. It means that we in this Carer’s Week need to put our money where our mouths are and actually make the task of caring for a loved one less onerous and demanding, by properly funding carers, both paid and unpaid, and by developing meaningful respite supports and maximising the commitments we already have.

I attended a European meeting a couple of weeks ago which had as its focus ‘re-ablement’. It described a growing movement in Europe which we have seen here, which is all about less dependency upon long-term support and a shorter focus on enabling people to re-discover or develop skills of self-reliance and self-management that they may have lost. Now no-one can be in disagreement, I would suggest with such reablement approaches. Indeed, there is a lot of academic and research evidence to show both the fiscal, personal and societal benefits of such an approach. However, as I sat and listened to the growing reablement movement in Europe I could not help but reflect on the reality of care at home and support in our own country. Yes, reablement is the essence – not fostering dependency but encouraging independence, not doing for but enabling someone to do for themselves, autonomously, free and self-directed. But that is not what we have.

For in truth what we have in Scotland are not true reablement models but an elastoplast approach to enabling independence. We constrain reablement to within a defined time period, often twelve weeks, rather than moulding the support offered to the needs of the individual.

Homecare at its best is always about relationship. Reablement should be a process without time constraint but one which involves a multi-disciplinary team with diverse skills and mutual respect for each other’s competences. Such teams should include practitioners such as a homecare worker, community nurse, GP, community geriatrician, AHPs and others. They should be allocated a case load of individuals whose journey to reablement is not limited by the constraint of time or resource, or commissioned models, but is flexible and relational in nature. Workers regardless of role should be autonomous and trusted to make appropriate local, person-led decisions. Such a model has a built-in rhythm where the person is followed up at regular intervals and where real preventative care ensues to the benefit of society and the individual alike.

We need to be adventurous enough in Scotland to embed a re-visioned model of care at home which fosters independence, breaks down the barriers between professionals and different parts of the health and care system. We see some of this in the hospital to home model, but it is much wider and more holistic than that especially when it focuses as much of psychological, emotional and relational wellbeing as it does on physiological needs and frailty.

There is a real opportunity in the talk of a National Care Service for us to re-imagine homecare in a way that fosters independence through continuous personal care and care accompaniment. Preventative care at its best doesn’t create dependency but enables independence.

The concluding words of the report mentioned above still ring true:

“Preventative care is the only way in which social care can deliver – for current and future demand, for constrained budgets but most importantly, for people’s lives. Preventative care is not the opposite to greater self-management but a natural ally and requirement. And preventative care can only be enabled through the valuing and prioritisation of relationships, time and home care services.” (page 36)

 

Donald Macaskill

Details of the Home First event this coming week can be found here