COMMUNITY CARE PROVISION – OLDER PEOPLE AND DOMICILIARY CARE SERVICES
COMMUNITY CARE PROVISION – OLDER PEOPLE AND DOMICILIARY CARE SERVICES
This report will critically evaluate the viability of community care provision in a national and international context. It will also evaluate provision of community care in meeting needs of service users and carers’ perspective. Furthermore, it will critically examine the complex relationships between service user movements, professional bodies and the statutory, voluntary and independent sector services in the development of community care. By doing this it will enable us to identify and justify evidence of good practice in the provision of community care. The main aspect of this report will draw upon issues in the field of older people and domiciliary care services. Drawing upon the schema of personalisation agenda, the report will discuss how well local and national policies address the needs, requirements and expectation of older people and domiciliary care services.
Personalisation refers to the social care approach which means ‘every person who receives support, whether provided by statutory services or funded by themselves, will have choice and control over the shape of that support in all care settings’ (Community Care, 2008). Its core aim is for social services users to have a control over how money are allocated to their care is spent. As the role of advocacy becomes more significant, the necessity is for the social working environment to have a cultural shift. The personalisation agenda, further, aims to formalise and provide wider impetus to changes that is already happening to social service users and providers. For instance, for the older people group, the personalisation agenda creates independence and minimises dependence (Harrison, 2008). As Howell (2006) puts it, personalisation agenda is a complicated concept and appears to be highly individualistic. That is because the agenda does not provide an interface with the greater public and the government especially the latter’s social commitment therefore endangering public ownership. CSCI also noted that several social services providers including that of domiciliary care services for older people feel that market forces and customers are really driving the personalisation agenda, not commissioners or policy makers. In simpler terms, because of personalisation agenda, the policies either local or national are increasingly becoming futile in addressing the problems of the people.
Older people and domiciliary care or homecare services
According to the National Statistics (2005), the entire population is significantly increased by the older population aged 50 and older. Currently, as the 2005 survey reported, there are 20 million people who belonged to this group, and 2.8 million of this are provided with unpaid care. The blurring of the various stages of our lifecycle is perceived to be the reason behind the variation in older people in the UK society today. Nonetheless, there are several older people who are still leading active and healthy lifestyles. In the past decade, the income, wealth and expenditure of older people rose by 28% and 50% of the total number of older people owns home outright. The paradox, however, is that although older people actively participates in the labour market, there are still many barriers that hinder them from participating in other activities mainly because of financial and health reasons and also lack of transport.
Domiciliary care, on the other hand, covers several services which are provided to so that service users can remain as independent as possible in their confines of their homes. The services available depend on the needs and circumstances ranging from personal care and managing at home as well as other personal and practical support. Guidelines from Department of Health govern the conduct of domiciliary care services and eligibility is determined by the Fair Access to Care Services. If an elderly is assessed to need domiciliary care, local council must be contacted. Eventually, a care agency such as Adult and Community Services will going to arrange the visit of a care provider. The services provided are all registered with the Commission for Social Care Inspection. Each request for support is carefully considered; however, priority is given to people with the greatest need. Further, domiciliary care services are paid depending on the income and savings of the service user (Factsheet 51, 2006).
Threshold relating to older people and domiciliary care services
Domiciliary care services play an important role in promoting independence as well as supporting adults and older people to live in the comfort of their respective homes, and in return support the caring role of the carers. The regulation or guidelines set forth by the Department of Health and the National Health Service (NHS) as well as the Care Standards Act 2000 is applied nationally. While also, there are specific statutory regulators and legislations that are applied on a purpose basis including the National Service Framework for Older People and Domiciliary Care Agencies Regulations 2002. Care Standards Act 2000 is an act which provides for the administration of care institutions in the UK aiming to establish a National Care Standards Commission and a General Social Care Council. As well, the act makes provision for the registration and regulation of social services including domiciliary care agencies (OPSI, 2008). National Minimum Standards Regulations for Domiciliary Services is established under the provision of the Act (sec. 23) forms the criteria by which the Commission will determine whether a domiciliary care agency is providing personal care to the required standard (Department of Health and Department of Health Staff, 2003).
Further, National Service Framework for Older People has been developed to look at the problems of older people under the guidance of the Department of Health for the purpose of delivering higher quality services. It requires Local Authorities to ensure fair, high quality, integrated health and social care services for older people and adults. This should be carried out in order that older people and adults are provided to enable to realise the opportunity to remain at home for as long as possible. The framework relates that older people should have access to domiciliary forms of care linked where appropriate community equipment and housing support services are available. Domiciliary services must be regarded as long term care and at high quality standards (Department of Health, 2001).
Domiciliary Care Agencies Regulations 2002 is a statutory instrument which determines the conduct of domiciliary agencies through regulating quality of service provision, premises and financial matters but only applies in England (OPSI, 2002). Specifically, the Department of Health through the Local Authority circular LAC (2002) (13) on Fair Access to Care Services (FACS) guides councils in performing its duty to provide the most appropriate services for older people and adults and their carers. In the UK, the United Kingdom Home Care Association (UKHCA) is the professional association of homecare providers which oversees the manner of the UK domiciliary care sector. UKHCA aims to promote the highest standards of the care through training, information sharing and membership services.
Local policies relating to older people and domiciliary care services
Local government authorities are one with the recognition that the UK ageing population is both a celebration and a cause for concern. The needs and circumstances for older people are addressed through the strategic planning at the local government level. The local government bodies or simply councils cover provision for domiciliary care and caring for older people. Although there is a report of the Local Councils Association that the quality of health of older people under domiciliary care services is taken into account, councils as well as community care officers are still faced with many criticisms. The legal duty of the local authorities involves everyone in the local area.
One of the local policies in England, for instance, is the Department of Adult Services in Bradford Metropolitan District Council. The Department of Adults Services developed a five-year strategy supporting the ever-growing needs of older people and other adults including those with physical, sensory or learning disabilities, mental health problems, drug or alcohol dependence and those with HIV/Aids, and with emphasis given on carers. There are six key priorities that the strategy established as: equal access to all adults, promoting independence and wellbeing, a shift to home-based support and care for people with more intensive needs, choice and control, modernisation of services and integrated commissioning. One of the major key points of the Department is the compliance with the personalisation agenda. Within the Department is an in-house CSI registered Domiciliary Care Services. Such service provides for around 40% of all Home Care delivered in the Bradford District. At present, Domiciliary Care Services is being reconfigured to provide support for up to six weeks intended for new referrals, stabilising care and achieving service users’ goals.
Although the department is just newly established, the performance of the department is already judged as excellent in areas of improving health and emotional wellbeing, making positive contribution and maintaining personal dignity and respect. However, in particular areas of improving the quality of life, increasing choice and control, freedom from discrimination and economic wellbeing the department could not be considered as a champion. Such condition manifests that in the continuum, there are arising needs and challenges and also expectations that the Department found difficult to respond to. Examples of these dilemmas include demographic pressures, consequent demand for services, national policies and financial investments that are required in delivering the priorities of the Department.
Indeed, for the Department to completely provide for high quality domiciliary care services, new ways of delivering services must be embraced. Nonetheless, the problem would be on prompt delivery of services for the Domiciliary Care Services unit because of the costs constraints associated with it. Although the Department is given £100 million, it will still be divided into different units and activities. This may place the Domiciliary Care Services in a difficult position to focus on specific services and be forced to concentrate resources on older people with most severe needs.
Another local policy which applies to Branford is the Local Authority circular LAC (2002) (13). The circular provides guidance to local councils with social services responsibilities on how they could achieve fair access to care services. The guidance also sets forth the responsibilities of local government bodies including Bradford Metropolitan District Council and the Department of Adult Services and the Domiciliary Care Services more particularly. Such responsibilities includes assessing and care planning for adults seeking social care support and reviewing care plans including reassessment of needs at a regular interval specifically for councils. Issued under section 7(1) of the Local Authority Social Services Act
1970, this guidance serves as the starting point in determining eligibility for packages of continuing health and social care and joint eligibility when local health bodies and councils are operating partnership arrangement under section 31 of Health Act 1999 (Department of Health, 2002).
One of the several authorities questioning the legitimacy of local policies such as establishment of specific departments within councils and development of local circulars is Carl Freeman especially when dealing with the issue of free access to community care as domiciliary care services. Freeman (n.d.) argued that most local authorities have had insufficient money to pay for all the social care services required by people in their area. As such, local authorities are given the right to refuse someone on a service on the grounds that the authority can afford it. Realising this, the paradox is that local authorities based their judgments about whether an elderly’s needs for a service for essential was on the capacity to pay. The four bands of needs are: critical, substantial, moderate and low. Such bands jeopardises the longer-term preventive view especially that assessments does not guarantee the extent of health support provided. Notably, even the Department of Adult Services are provided dependent on the degree of need which may put at risk the lives of many older people as their situation could get worst in the later stage.
National policies relating to older people and domiciliary care services
England, Wales, Scotland and Northern Ireland, more specifically have thresholds intended for the betterment of older people and domiciliary care services. Homecare services in England, Wales and Scotland are received by means of local social services and councils. The former deals with assessing need for help in accordance to specific eligibility criteria while the latter contracts the supply of homecare services to the independent sector.
Service providers in England are regulated by the Commission for Social Inspection against certain standards while the General Social Care Council regulates the social care workforce in England specifically their conduct and training. The Domiciliary Care Agencies Regulations, Social Care, England 2002 is the primary legislation which administer the domiciliary care in England. Service providers in Wales are regulated by the Care and Social Service Inspectorate Wales (CSSIW) and Care Councils for Wales. Leading legislations are Domiciliary Care Agencies Regulations 2004 and National Minimum Standards for Domiciliary Care Agencies in Wales 2004. The Scottish Commission for the Regulation of Care is the national regulator, and also the Scottish Social Services Council while legislations include Regulations of Care Act 2001 and National Care Standards 2005. In Northern Ireland, the Regulation and Quality Improvement Authority (RQIA) and the Northern Ireland Social Care Council and legislations include Health and Personal Social Services (Quality, Improvement and Regulation) (Northern Ireland) Order 2003, Domiciliary Care Regulations (Northern Ireland) 2007 Statutory Rule 2007 No.235 and Minimum Standards for Domiciliary Care Agencies 2008.
For the national policies, the report will focus on England and Scotland and consider Domiciliary Care Agencies Regulations 2002 and Regulations of Care Act 2001, respectively. Domiciliary Care Agencies Regulations 2002 regulates care agencies and ensures that service users are protected. In particular, the regulation takes into account the conduct of domiciliary care agencies especially the quality of service provision. England adheres mostly to the idea of triangle of care and so emphasising on the roles of the carers in domiciliary care agencies. The regulation legalises the fitness of domiciliary care workers whom are supplied by agencies, the conduct of the agency and the arrangements for the provision of personal care. Specifically, O’Brien, Blake and Angel (2008) relate that regulation 14 specifies that the older people must be protected at all times against any form of abuse. In accordance with the National Minimum Standards for Domiciliary Care, the agency must have policies and procedures relating to the matter to be followed when allegations of irregularities occur.
According to Lush, Bishop and Clarke (2005, p. 581), the 2002 regulation is timely in view of the increasing amount and proportion of domiciliary care which is now being delivered by the private sector. The authors believe that the policy transform by which England provide safeguards and standards to care workers and businesses offering such care. In addition, their also claim that the regulation has the most appropriate fit with the processes of local authorities when dealing with domiciliary workers and agencies. Concerns such as the minimum requirements that they are expected to adopt when setting charges for the services these agencies delivered are also well-addressed as well as the standards that the workers are expected to reach.
Passed by the Parliament on 31st of May 2001, the Regulations of Care Act 2001, on the other hand, establishes the Scottish Commission for the Regulation of Care and the Scottish Social Services Council. The act will also provides for the registration and regulation of care services as well as the social service workers. The act focuses on care standards of children and older people. It says that the Scottish Commission will take a strategic overview of the care system and its funding for the stewardship of the interests of the older people. Likewise, the act stipulated that support service will include home care or domiciliary care provided to older people in their own homes or in supported accommodation, sheltered housing or elsewhere (Explanatory Notes, 2001).
One of the main criticisms of the Act is the extent to which external scrutiny influences the conduct of Care Commission which was set up under the Act. In some cases where the authenticity of the cares provided older people is perceived to be limited in flexibility mostly in aspects of specifying nature and frequency of inspections or information sharing (Graham, 2006). Notably, a small majority of homecare is delivered by the council’s in-house services. According to the report by Sutherland (2008), since July 2002 older people aged 65 and over have been eligible for free personal care and that the local authorities could no longer charged them for different services in their own homes. However, these people are still charged for domestic services. Laing and Buisson (2007, pp. 106-107) maintain that the policy have contributed to the shift from the use of residential care to homecare which is good provided by the familiar environment. There is a debate, however, regarding the sustainability of the policy. Sutherland (2008) contends that in the long term the Care Commission and the council might fall short of the expectations of the local authorities considering the waiting lists for free services. The author also noted that contract prices offered by the local authorities fail to keep pace with inflation and other statutory burden (p. 68).
International policies relating to older people and domiciliary care services
Modern global health services, systems and structures recognise the vital role of the people surrounding older people especially in domiciliary care setting. The Triangle of Care was seen as collaboration among health professionals, service users and carers where the link between professionals and patients define the service. Assumingly, there is a pre-existence of a bond between the patient and carer; thereby the triangle will only be complete if there is a willingness by professional and carer to engage. Nonetheless, the process requires support the code of practice and protocols (Closing the Triangle of Care, online). Triangle of Care, as a relatively new model of eldercare developed, aimed to provide better health outcomes and in support of promotion of independence among the elderly. The rationale behind the triangle of care scheme is the customisation and individualism of care that the elderly could receive at home, by which the health and social care systems are prioritising as well as the increased interaction satisfaction and safety between the patient and the caregiver.
In the UK, an array of domiciliary care services is provided for older people and could be achieved in two ways. First is through direct provision and funding by the state or external agencies and second, by individual (or through family) buying either through state funding such as Attendance Allowance or privately. There is also an established direct payment system intended for personal assistants that requires no training or registration from the government. Compared with Italy, older people who needs care depends on free health care from the NHS including those which will come from municipalities, social welfare benefits, disability pensions and care allowances. Recently, however, free health care is increasingly becoming limited to primary care by general practitioners, exacerbating long-term care costs for older people under domiciliary caring (Triangle of Care, online).
In putting the older people under domiciliary caring in the context of triangle of care, the care provision could involve complex interplay of dependence and independence. A policy should ensure that in any means the quality of healthcare for older people in home-setting must not be jeopardised. A set of checklist that guarantees quality caring was created for the carers, the private domestic assistant and the older person. How Italy and UK could take advantage of the triangle of care framework, as an international threshold, could be manifested in addressing complementary and conflicting needs. For the former, the necessity of round-the-clock caring and provision for the migrant workers are two among the issues that could be addressed. But nevertheless, requires the conciliation between round-the-clock demands and legitimacy of migrant workers. While for the UK, relationships between the carer and the patient is at the forefront, centering the need to be independent on the side of the patient and the psychological needs on the side of the carer. Issues raised, however, are the older people’s need for flexible round-the-clock caring and the life outside the domiciles (Triangle of Care, online).
Whether UK has come to full circle when it comes to older people and domiciliary care services policy-making is still a big question. Most of the barriers to either national or local policies are evidently focusing on the operational level of arranging, delivering and receiving domiciliary care services. One of the prevailing, however, is the multifaceted feature of the UK domiciliary care market where policies dealt with carers, managers and users. In the context of recent policies, the approach to commission and providing domiciliary care is not on the basis of outcomes but is more tended on the roles of the three players identified, thereby increasing the inflexibility and responsiveness of the policies. The next step would be to develop key outcome indicators evaluating the quality of health care of older people undergoing domiciliary care services. In this way, the authorities from local to national would acquire the information whether policies are effective.
Closing the Triangle of Care. Retrieved on 13 December 2008, from. www.nimhe.csip.org.uk/silo/files/triangle-intro-framedoc.doc.
Department of Health and Department of Health Staff. (2003). Domiciliary Care: National Minimum Standards – Regulations. The Stationery Office.
Factsheet 51 – Domiciliary care services and how they are arranged. (2006). Care Direct. Retrieved on 26 November 2008, from http://www.devon.gov.uk/fs51_home_care_services_121206.pdf.
Fair Access to Care Services. (2002). Guidance to Eligibility Criteria for Adult Social Care. Department of Health.
Freeman, C. (n.d.). How fair is the Fair Access to Care (FACS)? Social Services and Rehabilitation.
Graham, M. (2006). The North-South divide: A review of care regulation. Nursing and Residential Care, 8(6): 265-267.
Harrison, D. (2008). Enabling self-directed adult care. Social Care.
Howell, C. (2006). Problems with the Personalisation Agenda.
Independent Review of free personal and nursing care in Scotland. A report by Lord Sutherland for the Scottish Government. (2008). Retrieved on 27 November 2008, from www.scotland.gov.uk/Publications/2008/04/25105036/0.
Laing and Buisson. (2007). Domiciliary Care UK Market Report. Laing & Buisson Publications.
Lush, D., Bishop, D. and Clarke, H. (2005). Elderly Clients: A Precedent Manual. Jordans Publishing.
National Service Framework for Older People. Modern Standards and Service Models. 2001. Department of Health.
National Statistics. (2005). Focus on Older People. Retrieved on 26 November 2008, from http://www.statistics.gov.uk/focuson/olderpeople/.
O’Brien, D., Blake, D. and Angel, C. (2008). Adult Protection Toolkit for Domiciliary Care Agencies. UKHCA.
Personalisation. (2008). Community Care. Retrieved on 27 November 2008, from http://www.communitycare.co.uk/Articles/2008/11/18/109083/personalisation.html.
Personalisation Agenda. CSCI. Retrieved on 27 November 2008, from ww.csci.org.uk/docs/workshop_4_notes.doc.
Public Acts 2000. Care Standards (c. 14). Office of Public Sector Information (OPSI). Retrieved on 26 November 2008, from http://www.opsi.gov.uk/acts/acts2000/ukpga_20000014_en_1.
Regulation of Care (Scotland) Act – Explanatory Notes. (2001). Retrieved on 27 November 2008, from http://www.opsi.gov.uk/legislation/scotland/acts2001/en/aspen_20010008_en_1.
Statutory Instrument 2002 No. 3214. The Domiciliary Care Agencies Regulation 2002. 2002. Office of Public Sector Information (OPSI). Retrieved on 26 November 2008, from http://www.opsi.gov.uk/si/si2002/20023214.htm.
The Triangle of Care – Domiciliary Care for Older People. European Social Fund. Retrieved on 13 December 2008, from www.eurocarers.org/triangle_of_care.pdf.