New models of homecare and re-ablement

The context

There has been an increased focus in home care provision to move away from ‘time and task’ commissioned care towards more personalised ‘outcomes’ focused care. However, the dominance and persistence  of ‘time and task ‘commissioned care demonstrates just how difficult it is to move away from.

IMPACT Factfile

Network meetings

Networks are meeting across the UK, co-ordinated by:

In England:
BelleVie Care Ltd
First City Nursing Services
Peterborough City Council
Reading Borough Council

In Scotland:
Your Options Understood (YOU)

In Wales:
Cardiff and Vale University Health Board

Key terms

This term refers to a way of paying for and delivering care services in the home. Care provider companies are paid in blocks of time (often 15 minute blocks) to deliver a specific list of care tasks such as helping someone get washed and dressed, feeding or medication. 

Each of the four UK nations has a slightly different approach to homecare funding, and the degree of outsourcing of services, which has influenced the ‘market’ for care. Care providers delivering publicly funded commissioned care are more likely to operate on a ‘time and task’ basis, whereas private paying clients are more likely to receive longer visits, consistent carers and relationship-based care. Care providers supporting private clients typically charge more than Local Authority commissioned rates.

People using home care services say that they want more person-centred care which meets their needs in a holistic and integrated way. They want to be involved in their care plans and have their voices heard. They also want to be cared for by caring and compassionate staff, who are well-trained, and consistently by the same people so they are able to build relationships. There needs to be good information about the services available, so that people can understand their care options. Overall, people want to see a focus on wellbeing, prevention and promoting independence, as well as to maintain connections within their communities. 

What do alternative and new models of care look like?

There are many examples of care being organised differently and care providers who are trying to work to the principles of good care outlined above, and who do not operate on a time and task basis. Some of the ways that the move away from ‘time and task’ are being addressed are described here with some examples.

Outcomes-based commissioning has been a focus of a previous IMPACT Network, Commissioning Differently. While there have been some attempts to move away from commissioning on a time and task basis, the fact that this is not widespread highlights the difficulties in moving away from this model. The approach used by Wiltshire Council is offered as an example, which includes the difficulties faced in trying to implement something different.

This is an approach where people in need of care and support live within a household, either on a temporary basis or more permanently. This includes schemes such as Shared Lives and home share.

Technology-driven care has also been a focus of a previous IMPACT network, Technology for Prevention and Independence. This includes commercially available technology such as Alexa and smart devices, to apps which help unpaid carers to stay connected. Many care providers now use technology to record and monitor care, but it has also been used to develop online platforms which help to connect care workers with people looking for care.

This has seen a renewed focus in policy over the last few years which calls for a greater integration between health and social care. Research suggests problems arise when poorly designed models target the wrong population or they don’t take into account patients’ preferences.

This is an approach which draws on the skills and strengths that exist within communities to provide support. One example is Community Catalysts which help establish single points of contact for support and also help establish microenterprises to create social care jobs.

Social prescribing brings together GP surgeries and local assets to support people within the community. Evaluations of these programmes have shown that it improved people’s sense of wellbeing and made them feel more connected.

Reablement is a specific enabling approach that focuses on helping individuals with physical or mental disabilities to adapt to their condition by learning or re-learning daily living skills. Reablement is different from ‘traditional’ homecare because it is about “doing with” as opposed to “doing for” someone, and is a “risk aware”, as opposed to “risk averse” approach. An example of developing this approach within homecare services is that of Vale Community Resource Services in Wales which works with individuals in their own homes to maximise functional independence in daily activities, thereby reducing the need for hospital admissions and long-term social care services. It involves multidisciplinary teams offering tailored support. 

Developed in the Netherlands with nurses, this model of care has developed as wellbeing teams within social care in the UK. It centres around small groups of autonomous care workers who are responsible for the care of a small geographic area or neighbourhood, which reduces travel time and means that people receive consistency in the care workers who support them. BelleVie Care based in Oxfordshire and Northumberland operate based on this model.


First Network Meeting

In the first Network meeting, people got to know each other and find out a bit more about how Networks work. People had read the discussion materials, which summarised the evidence on the topic, and were asked to share their experiences and thoughts. 

”we talk about shifting models, we’re talking about changing culture. And culture change is hard, but if you focus on behaviours, and then when behaviours change, that creates culture change,,

Key themes identified across the Networks

1. The ‘Time and Task’ model.
  • All the Networks agreed that there was a need to move away from the ‘Time and Task’ model of homecare. Time and task was described as ‘disabling’ and not liked by younger people with care needs.  
  • There was a general agreement that working towards outcomes and more flexible, person-centred care was needed but that it is difficult to change systems when care is commissioned in a time and task way. 
  • Discussions highlighted that ‘time and task’ can be a ‘safety net’ for some staff, particularly if they are less confident or lacking experience.

2. Benefits of Alternative Models.
  • The Buurtzorg model: This was of interest to some Networks as autonomous team working gives care workers greater flexibility to provide the care that meets a person’s desired outcomes rather than a tick list. It provides greater consistency of care workers, and also has the potential to reduce travel time for workers. 
  • Re-ablement: It was acknowledged that people decline in health and mobility as they age but that re-ablement programmes can help people to live a better life. This was said to be where staff can ‘add magic’. However, it is more difficult to measure a delaying or slowing down of decline.
  • Multidisciplinary Teams: These were seen as important and valued, whether they were connected to health or community groups. 

3. Risks and Barriers to Alternative Models.
  • Culture: Several Networks noted the need for a change of culture to be able to implement change, and ‘time and task’ can be difficult to unlearn. Culture change is hard to do, but if you focus on behaviours, you can start to change the culture. 
  • Language was highlighted as important and linked to culture, reflected in the need for a common language between professionals of different backgrounds. It was suggested that language in care plans and note taking should reflect what people can do rather than what they can’t do.
  • Funding was seen as a barrier to change. Preventative care is harder to evidence so is a more difficult ‘sell’ to commissioners. Some issues raised about Direct Payments as people worry about being an employer.
  • Staffing can be a barrier to change due to training needs and attitudes to working in non- time and task ways.  Staff shortages a problem, particularly in expensive areas, alongside visas for overseas staff.
  • Public transport is a problem for both care workers and supported people. Some of the transport issues for care workers can be addressed through a Buurtzorg model as above.
  • Digital systems can be a barrier to new models of care. Most software for homecare providers to record and monitor care is based on time and task ways of working. BelleVie solved this by building their own software.
  • Evidence: it was discussed that what is counted in care quality is not necessarily what matters to people. In Wales, they have ‘what matters’ conversations to look at what people feel has been the most significant change. This creates stories which can drive change or provide a focus for what is funded.

Potential areas for Change and Next Steps

Looking ahead, Networks are beginning to narrow down their discussions to focus on a particular aspect of homecare and re-ablement. This includes how outcomes-based care might be evaluated and shown to be of benefit for commissioners:

“it’s too easy to blame local authorities for not commissioning us in a way that we want to be commissioned”.

A key focus for some Networks is on language and training for frontline staff.

Second Network Meeting

The discussions in the second meeting built on the previous discussions. Although each Network had very different discussions and focus, there were some common themes which emerged:

Language

The need for a common language was identified. The diversity in how participants defined outcomes-based care was “greater than anticipated”, which highlighted the need for commissioners and providers to ensure they are “talking about the same thing”. A key insight was the critical distinction between outcomes (what matters to the person) and outputs (what is delivered to achieve outcomes), which had previously been used interchangeably. 

“Outcomes are often in the small things”.

Importance of Assessments

The desire to capture the voice of the individual in care planning, but also being able to take people’s stories to policy makers to help to develop services as it makes it easier for those people making decisions to see the impact of changes.

Systems and processes

Participants cited “entrenched commissioning practices, financial constraints, and the rigidity of existing rostering and finance systems” as fundamental barriers. There is a need for greater flexibility and autonomy in service delivery.

Funding

The focus often remains on “cost over value,” with an emphasis on hourly rates rather than the broader societal benefits of improved care outcomes. There is some recognition that measuring positive outputs like reduced hospital admissions is essential for securing further funding and growth. There is also some evidence that community-led support can save local authorities money.

Commissioning

Questions around how we can commission new models of care. Some of this is down to trust and greater collaboration and improved working relationships between different stakeholders.

Workforce development and culture

Staff need support to move away from time and task ways of working and to not revert to this way of working over time or when under pressure.

In meeting 2, the Networks have also begun to explore ways that they can implement change and turn their discussions into actions.

  • While there is a strong focus on moving to ‘outcomes’ there are issues in how these can be evaluated to show value for money.
  • Several Networks are wanting to look at how care plan recording can be improved to capture outcomes

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