The row over rationing home care slots to just fifteen minutes misses the point. What matters for older and disabled people is not just the quantity but the quality of care services
This week, there has been a renewed focus on the practice of local authorities commissioning 15 minute home care slots for older and disabled people. A report by the Leonard Cheshire charity found that two thirds of local authorities use these slots, a 15% increase in five years.
These slots have been a reality for care workers for at least a decade, and always the target for much criticism. But the increase in the practice has raised concerns that the funding shortage in social care is leaving staff stretched to breaking point and many vulnerable people neglected.
The commentary on the issue has been focused on the fact that 15 minutes simply isn’t enough time to carry out basic care, let alone provide any meaningful interaction with those being visited. Leonard Cheshire argued that at least 40 minutes was needed. ADASS countered this by saying that while some local authorities may underestimate the time required, 15 minutes was enough in some cases.
But this entire back and forth debate regarding the ‘right’ amount of time for a home care visit is a red herring. Worse, it is an unhelpful distraction from the real issue at hand: the care system is beset by an obsession with process – 'time and task' - rather than outcome. We shouldn’t be arguing how many minutes older and disabled people need or even want – but rather what do they need and want.
If asked, someone may say they want to be spoken to with respect and patience, they want someone to remember how they like their tea, they want to be made comfortable in their chair. These sorts of outcomes – small and everyday – are the building blocks of quality of life. We may be able to break some down into discreet tasks. We may even be able to estimate how long that task would take to complete. But these are secondary calculations to be made after the outcomes are set – not as a first rule after which all other considerations need to follow.
This isn’t new. Outcome based commissioning has been around as long as 15 minute care slots. But it seems the former has become a well-meaning jargonistic phrase while the latter is now the reality of care. LGIU research from 2012 found that 90% of the councils they spoke to contracted by time spent, not outcomes achieved. Why is that the case?
Well, the adage that ‘what gets measured gets done’ holds true here. Time and task are quantifiable, measurable, readily monetised. In an era where every penny counts, making every minute count must be compelling. But it’s also a false economy.
The fact is, those local authorities using outcomes based home care achieve a better match between what people want and need, and the time needed to do it. Perhaps 15 minute visits are less common, but so too might be unnecessarily long stays. They are also more likely to achieve longer term independence for those receiving care.
Outcome based contracts often specify the outcomes people want, ask a care provider to estimate with their client the time it will take for them to achieve those outcomes, and pay for visits of that length to achieve those outcomes. This might have a contingency of say 10% either way, to take into account different needs and situations that crop up from visit to visit.
Consistently more or less time being required triggers a review of that initial estimate. Providers aren’t rewarded for maximising the number of visits (minutes) that person needs, rather for achieving the outcomes people want – which may, over a longer period, be a reduction in visits as people gain or regain skills to do things for themselves.
It seems intuitively sensible, and perhaps for those outside of the care system, relatively straightforward. But within a system so tightly financed, commissioners and providers are often locked into a relationship which allows no room to consider a different way of working. It is a relationship characterised by firefighting on both sides: commissioners bearing down on costs in a daily battle to stretch resources beyond all reasonable expectation, and providers desperately pushing for more funding to meet their clients’ basic needs and perhaps avoid bankruptcy if they’re lucky.
And thus, a system is created which sees carers having to choose between empting a commode or making a cup of tea before the clock runs out. In such a system, contingencies, flexibility, and any hint of budgetary uncertainty are simply insupportable. Time is money and must be tightly controlled - achieving long term outcomes and potential cost savings are a luxury no one can afford.
The Care White Paper expressed an intention to put an end to ‘contracting by the minute’. But this won’t happen while local authorities are forced to reduce care spending by the penny.
Claudia Wood is deputy director of Demos
