New models of homecare and re-ablement

The context

When someone needs help at home, the support they receive can change everything. But for too long, that support has been reduced to a checklist: often 15 minutes to complete a list of tasks, with no time to talk, listen, or truly help.

This topic area brought together Networks to explore ‘new’ models of reablement home care, including re-ablement, with a view to moving away from the dominant ‘time and task’ model of home care, where home care delivery is reduced to a list of tasks to be completed in allotted blocks of time – usually 15 minutes. This approach often means care is done to people, not with them, and leaves care workers with little room to build relationships or respond to what someone actually needs. 

However, its dominance in council and NHS-funded care suggests that it is not easy to move away from. It is an attractive model for commissioning services, as it is easy to monitor whether tasks have been completed and to make payment accordingly. However, all this must be seen within the context of increasingly squeezed budgets, a shortage of care workers and a complex care market. 

IMPACT Factfile

Network members

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

In England:

In Scotland:
Your Options Understood (YOU) is a consultancy and advocacy service working to support people with disabilities in Scotland.

In Wales:
Vale Community Resource Service (VCRS) is an integrated Health, Social Care and Third Sector Team based at Barry Hospital, working in collaboration with other services across Cardiff and the Vale of Glamorgan in Wales.

Evidence reviews

The evidence reviewed by the Networks summarised evidence from academic research, professional practice knowledge and lived experience. It covers what people want from their care, what care workers need to do their jobs well, and examples of approaches that are already working differently. It also included some examples of alternative models of homecare.

What people want from their care

The review noted that care commissioned on a time and task basis tends to be done to people rather than with them.  It is often reduced to a narrow list of tasks and doesn’t allow for a more holistic caring approach, which might include re-ablement or maintaining social connections, which have been shown to be beneficial to people’s wellbeing. 

Research suggests that people said they want their care to be person-centred and holistic. They want to be involved in planning their care and be able to express their views on how the support is delivered. People often say they want to have continuity of care workers so they can build a relationship with them; however, they often say that they lack information and understanding of what services are available to be able to make informed decisions. 

What care workers need

A major challenge to the homecare sector is around maintaining a stable workforce. Care worker vacancies are high, and there is a lot of churn within the sector as people move between employers for improved working conditions. Care work is often seen as of low status with low skills and poor job quality, including lack of autonomy, low pay, and precariousness, with many working on zero-hour contracts. Worker shortages often mean that those employed work excessively long hours with few breaks. But care workers also like to build relationships with the people they support, so continuity of care is important to them also.

The review identified several examples of alternative ways of working which move away from time and task. These included:

  • outcomes-based commissioning
  • re-ablement 
  • autonomous team working (e.g. Buurtzorg model/Wellbeing Teams) 
  • technology
  • community assets (e.g. social prescribing, community circles)
  • microenterprises
  • family-based support (e.g. Shared Lives, Homeshare)

To read more about the evidence review, you can view or download the full document (PDF) and Easy Read version. These documents were used by the local Networks to spark discussion.

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. 

Policy context across the four nations

The four UK nations each organise and fund social care differently; here is what that means in practice. In England, Wales and Scotland, social care is the responsibility of Local Authorities. In England and Wales, social care support is means-tested, whereas in Scotland personal care is funded, and people only pay for additional services such as laundry and cleaning. In Northern Ireland, adult social care is funded and managed through Health Trusts. It is means-tested, so Health Trusts have the power to charge for home-based care, but in reality, most don’t charge. This results in complex systems of organisation and funding.

Differences in funding regimes and the different degrees of outsourcing of funded care provision have helped to create different homecare ‘markets’ across the four UK nations. The majority of homecare is delivered by independent providers, either to private clients or on behalf of local authorities or health boards. Care providers delivering publicly funded care are more likely to operate on a time and task basis, as local authority funding rates sometimes do not cover the cost of delivery. People paying privately for homecare services are more likely, therefore, to have longer visits, consistent carers and relationship-based care but will be charged more than local authority rates. In areas where there are more self-funders, there is often a greater choice of provider, but there are large regional variations. 

Some people who are eligible for funding towards their care costs may opt to receive the funds as a Direct Payment to be able to employ personal assistants or as a personal budget paid directly to a care provider, where the person receiving care has a say in how it is used. Adults under the age of 65 are much more likely to use a Direct Payment.

Meeting 1 and 2: Engaging with the evidence and sharing new learning

In meetings 1 and 2, Networks explored the existing evidence on the basis of their lived experience and practice knowledge and identified a number of key themes and learning.

Key themes identified across the Networks

A desire to move away from time and task care

There was widespread agreement on the need to move away from ‘time and task’ ways of working where care is done ‘to people’ rather than ‘with people’. However, there was also an appreciation that this is “hard to unlearn”. People said that they want holistic, relational care, and there should be a focus on continuity, relationships and involvement in decisions.

Culture change

Culture change is one of the biggest barriers. It requires a shift in mindset from tasks to outcomes. This requires trust on behalf of commissioners and is hard to measure. However, it was suggested that culture change starts with small changes in behaviour: “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.”

Being proactive, not reactive

A more proactive re-ablement culture, rather than reacting to crises, will allow people to live well for longer. One Network also said that they need to be proactive in developing new models of care: “It’s too easy to blame local authorities for not commissioning us in a way that we want to be commissioned.” “Being involved in a group of people with varying levels of lived experiences has definitely opened my eyes to the size of the problem. As a Network we certainly learnt a lot about what other people go through.”

Language

This is linked to culture change, but it was noted that often care plans use too much jargon and are not person-centred. In addition, there is a need for a shared language across providers and commissioners to ensure they are talking about the same things. A key insight was the critical distinction between ‘outcomes’ (what matters to the person) and ‘outputs’ (what is delivered to achieve outcomes). It was noted that sometimes these are used interchangeably.

Evidence gap

The evidence gap is critical – a lack of shared understanding, metrics, and economic proof inhibits innovation and slows adoption. There is a continued focus on ‘cost over value’ with an emphasis on hourly rates rather than broader societal benefits of improved outcomes. New ways of measuring the benefits of alternative models of care are needed.

Joint working and co-production

Some Networks expressed that co-production would add value to decision-making when trying to improve services.

Next steps

Each Network identified what they wanted to change, why it mattered, and concrete steps to make it happen. Here are snapshots from each. 

First City Care Group

First City Care Group is aiming to develop flexible, bespoke services that are shaped by people who draw on care and support. They want to put an emphasis on real choice, control and services that are built around individuals’ lives, supporting people to remain independent at home for longer. This will reduce hospital admissions and reliance on residential care. To achieve this, they are exploring the use of digital records, AI and assistive technology to develop hybrid care models and new roles to support people using technology. They will look at ways to improve career pathways for care workers to professionalise the workforce and look at the organisation of work, including neighbourhood teams. Alongside this, they will look at building stronger relationships with voluntary and community groups, commissioners and other providers to develop more holistic, integrated support and reimagine commissioning. Some of the barriers they anticipate include the difficulty of changing culture and the lack of funding to support change.

BelleVie Care

Network members agreed on the need for better evidence of what works to support an economic case for an outcomes-based approach to care. Through their meetings, they identified that outcomes-based care means different things to different people, so they have developed a working definition of outcomes-based care: 

‘Outcomes-focused care is an approach to care that prioritises what matters to the person – and, where appropriate, those close to them – and the difference it makes to their quality of life. It is grounded in personalised co-created goals, trusted relationships, and flexible, responsive support.’

“The person supported by one of BelleVie’s self-managing teams didn’t know what “time-and-task” meant before but liked that the visits were not a pre-set list of tasks. The carer would arrive and ask, “Right, what do you want to do today?” 

They are also working on a values framing which contrasts paired values to help position both what outcomes-based care is and what it is not. They are working with a Local Authority to develop a pilot project to evaluate the benefits of working in an outcomes-focused way, using their own care model and software. They also intend to work with academics to develop an economic model to demonstrate the wider social value of this way of working.

Peterborough City Council
  1. Network members initially voiced concerns that moving to an outcomes-focused way of commissioning care would expose the Council to more requests for care packages and increased support, but some examples of other local authorities which have been able to reduce care packages provided encouragement. Members agreed that changes to working practices should involve more joined-up working with health services. This Network is focusing on a new model of care aimed at filling service gaps for people who are turned away from other services due to multiple complex needs, such as dementia crises or brain injuries. They have consulted with different stakeholder groups, including service users, care providers and social workers, and are piloting their initiative.

The Network broadly supported the advantages of outcome-based working as set out in the discussion materials. They discussed:  

  • Working in an outcome-based way of working could be really validating for care staff. Staff feel like they have a valuable career where they are involved in someone’s well-being, not just turning up and doing tasks. 
  • It would build closer collaboration between providers and Social Workers. 
  • If done properly, it would mean that they are able to reduce care packages. 
  • It would break down some of the power balance between the council and providers. 
  • It could potentially reduce some of the difficult wrangling between the council and health over whether something is a health task or care task.

Reading Borough Council

Reading BoroughCouncil identified improving the quality of care plans as a focus for change and their action plan. They want to improve how care plans are written and explore how care plans can be improved, focusing on person-centred and strength-based care. They will do this by creating guidance and training materials which will be co-produced and co-delivered by the Network group. The agreed activities include:

  • Collecting examples of excellent and poor care plans
  • Creating guidance on writing in warm, person-led ways, removing jargon and including detailed instructions
  • They will focus their attention on improving homecare plans (a longer-term aim would be to extend this to care homes)
  • They will ask for volunteers from staff teams to support the training delivery
  • And pilot the training with the Community Reablement Team and one selected home care provider

Your Options Understood (YOU)

Your Options Understood invited guest speakers to their early meetings to share expert advice and evidence about some issues identified in the discussion materials, including community Networks. Network members were encouraged to hear about the positive experiences, which were also shown to be cost-saving for councils. In light of the current drastic social care cuts in Scotland and councils not taking a holistic view, members want to support people who use services to have a voice. The Network identified areas that they want to work on, including the following:

  • To produce training materials/resources for supported people and their families as well as professionals around ‘good conversations’ and the importance of social care. This might take the form of videos illustrating what good conversations look like.
  • Producing a collaboration guide to enable a range of people to feel able to contribute in meetings. 

Vale Community Resource Service

VCRS members are working on improving integrated working within their service with a particular focus on people living with frailty. This will take the form of virtual joint care assessments to reduce duplication and minimise burden during the first week home from hospital. They are looking at:

  • working with their in-house digital team to streamline online processes and obtain appropriate licences
  • mapping the existing templates used by different health professionals during assessment to create a common framework to reduce duplication of questions
  • identifying training needs of staff