Really NICE home care

NICE, which has for some time been the body setting out what good looks like in healthcare, has in recent years been in partnership with SCIE to issue good practice guidelines for social care too. NICE guidelines aren’t compulsory, and their purpose may be changing in an increasingly personalised system in which social care is purchased by individuals and not commissioners, but they are important because they will be used a reference point by councils when they purchase home care. They may give social care providers a new way to push back against the bottom of the barrel prices which social care commissioners have for some time demanded from them, particularly in the care of older people.

One of the recent publications is NICE’s homecare guidelines. The expertise and ethos of SCIE is very obvious in the focus on person-centred, consistent care (interest declaration: I’m a SCIE trustee). This describes homecare as it should be and as the vast majority of homecare providers those guidelines would like it to be. But it is striking that they will be difficult to implement in most state-funded home care as it presently purchased, where councils will not always even pay enough to allow providers to pay the legally enforceable minimum wage and there is a widespread belief that the costs of the new National Living Wage will bankrupt many of those providers which remain in the state funded market.

It is equally striking but how closely aligned the guidelines are with Shared Lives day support. For instance, NICE says that home care should focus “on what people can or would like to do to maintain their independence, not only on what they cannot do… people have preferences, aspirations and potential throughout their lives”. Home care is generally made available to people based on them being able to demonstrate a high enough level of need and contracts tend to specify help to do the most basic tasks to enable someone to live at home with a modicum of safety, not to follow their dreams. Shared Lives day support however, for typically similar costs, enables people to spend much more time together and with much more freedom to do what they enjoy. This is partly because Shared Lives is not paid by the hour and partly because people are matched around a shared belief that they will enjoy each other’s company.

Matching is a key process in Shared Lives and remains rare outside of it, so it is very welcome to read in these guidelines that homecare provision should ‘prioritise continuity of care by ensuring the person is supported by the same home care worker(s) so they can become familiar with them.” Providers should “ensure there is a transparent process for ‘matching’ care workers to people, taking into account the person’s care and support needs, and the care workers’ skills, and if possible and appropriate, both parties’ interests and preferences.” Again most state-funded homecare would struggle to do any of this on current rates of payment, but we would expect every Shared Lives arrangement to do all of this and more. The reality of continuity and matching can be seen in the guidelines about what to do when continuity is not possible, including “informing people in advance if staff will be changed and explaining why, and working with people to negotiate any changes to their care….recognising that major changes (for example moving from home care to use of personal assistants) can make people feel unsafe.”

Shared Lives is one of the few ways in which these aspirations can be met consistently and affordably. Another would be to re-design homecare away from the assumption that it is based around the managed but inevitable decline of an older person’s wellbeing and life, and instead thinking about how home-based care and support from a number of different kinds of organisation could help many people to achieve more independence, resilience and connectivity to their communities, which will cost more in the short term but as models like Buurtzorg in the Netherlands have shown, result in lower rates of dependence and lower system costs in the long term. We hope to see Shared Lives continue to grow as a homecare innovation but we also need more ‘traditional’ models of homecare to be valued, developed and resourced. Without significant social care funding increases, it is hard to see how this will happen.

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