Modernising community care: an action plan

Modernising community care: an action plan

Chapter 3 Caring for people at home

A modern, flexible home care service

"Most people want home-based care. We need to shift the balance of current funding and target new resources to increase home-based care."

3.1 One of the central aims of our community care policy is to allow people to be cared for at home, or in homely surroundings. Home-based care, combined with suitable housing, is what most people and those who care for them prefer. Some groups have achieved this aim by resettling users in the community and closing long-stay hospitals.

Shifting resources to home-based care

3.2 However, there has been less progress in helping people, particularly frail older people, to remain in their own homes. Between 1990 and 1996 the volume of services to support these people has increased, but by considerably less than for nursing home care. In some key areas (for example, home help and day care), increases taper off after 1993. Also, in 1996-97, community-based services provided for 84% of people but received less than half of the community care budget. This pattern is not acceptable. We need to increase home-based care by shifting the balance of funding and targeting new resources.

3.3 Improving the levels of home-based services is one of the main aims for social care, health and housing. In health, 'Designed to Care' aims to bring care as close as possible to people who need it. Close links with the primary health care team are most important, and this includes working with GPs and other clinicians to carry out joint assessments of need and draw up joint care packages.

3.4 In housing, community care continues to be a priority, including housing adaptations. We are adopting 'Barrier free' as our preferred standard for mainstream housing. And we have agreed with COSLA that 'Care and Repair' should be a shared priority for central and local government. (We have made £5 million available for this in 1998-99.) Scottish Homes' revised policy on community care also emphasises the importance of supporting people in their own homes.

3.5 By combining suitable housing with effective health and social care, we can provide the basis to support people at home. Local partnerships are the way forward.

3.6 When changing the balance of services to home care, statutory organisations need to make sure that they meet carers' needs properly. Increased and more flexible day and home care are vital for those who care.

Modern, flexible home-based service

3.7 We expect to see major changes in the home care service. We want a modern, flexible care service which can meet a wider range of needs and provide support when it is needed. The service may be provided directly or bought in.

3.8 Home care services and suitable housing can help prevent the need for more expensive measures such as residential care. They can also help a person to return home from hospital as part of a package of rehabilitation and independent living, when the alternative may be a permanent move to a residential or nursing home.

3.9 Home-based care packages can often meet needs best and be cost effective. For example:

a hospital bed costs £33,000 a year;
a nursing home bed costs £16,000 a year; and
a place in a residential care home costs £13,000 to £17,000 a year.

In comparison with these figures the table below shows the cost of actual home care packages for people with predictable or unpredictable patterns of need.

Older person	Family carer	Health problems	Help needed	Services provided	How often	Total package cost for a year

81-year-old woman(unpredictable pattern of needs)	Daughter (lives separately)	Stroke, poor eyesight, dementia, heart problems, incontinence, fits and convulsions	Bathing, washing, going to the toilet, feeding, medicine, getting in and out of bed, going up and down stairs	Local authority home care (6 days)	10¹/₂ hours a week (including evenings and weekends)	£6,500
				health visitor	once a month
				meals	weekdays

85-year-old woman (predictable pattern of needs)	Daughter (lives separately)	Dementia	Shopping, transport, heavy housework, taking medication, relief for daughter, managing money	Local authority home care(5 days)	2¹/₂ hours a week	£7,450
				day care	twice a week
				district nurse	every three months
				chiropodist	every three months
				respite	six weeks a year
				meals	lunch clubs (twice a week)

81-year-old man (unpredictable pattern of needs)	Wife	Severe dementia, stroke, high blood pressure	All activities of daily life and care	Local authority home care (6 days)	4¹/₂hours a week (including evenings)	£8,150
				day hospital	twice a week
				district nurse	once a week

85-year-old woman (predictable pattern of needs)	None	Arthritis, diabetes, high blood pressure, incontinence	Bathing, going up and down stairs, shopping, meals, housework, transport	Local authority home care (7 days)	14 hours a week (including evenings and weekends)	£14,800
				meals	daily
				district nurse	five times a week
				physiotherapist	once a week
				chiropodist	every three months

One of the joint Ayrshire Augmented Care Schemes provides social care for between 18 and 60 hours a week. It costs £129 to £390 a week. One independent care agency provides 24-hour cover for an older person who needs intensive support at home following surgery. This costs £95 a day.

3.10 Many authorities are reviewing their home care services. Some health boards are reviewing their community health services. Social work, health and housing organisations should review together the support service needs of their local community to provide more suitable and flexible services. Home care, community nursing, home paramedical services and supported housing should join forces to create a 'tartan' of services which provide the support people need.

3.11 We now consider in more detail what makes a good home care service.

Home care

3.12 Home care services must provide:

a range of domestic, personal and nursing care;
flexible support, day or night, depending on needs;
intensive support at critical times (for example, during acute illness or following an accident or leaving hospital) which may taper off as the user becomes more independent;
a joint service without artificial boundaries between health and social care, and support co-ordinated with housing services;
support which is targeted at those most in need and those who will benefit from help;
support for carers; and
targeted results.

Several areas have already been successful with elements of the list above. Examples are:

the support available for those discharged from the Edinburgh Royal Infirmary;
the joint scheme in Dundee to support early discharge from hospital;
the joint home care teams in Ayrshire and West Dunbartonshire;
the joint dementia teams in Aberdeenshire;
the health and social care partnership in Dundee to prevent unnecessary admission to nursing home or hospital care;
the Homelink Project funded by several agencies, which provides accommodation and support for people being discharged from hospital; and
the combined housing, leisure, education and support provided for people discharged from Lynebank Hospital in Fife.

Rehabilitation teams

3.13 Older people in particular rely more and more on the support available when they return home from hospital. We want joint health, social work and housing teams to target people who are at risk of being placed long term in a residential or nursing home following a stay in hospital. These teams should provide rehabilitation support, special equipment and adaptations or, if necessary, suitable alternative housing to give these people more independence. The teams should work closely with the home care service and housing providers, and should concentrate on people who have difficult needs for up to six weeks after leaving hospital.

Equipment and adaptations

Reducing waiting times

3.14 Studies have shown that by providing suitable equipment at the right time we can help people to live at home longer and reduce their need for personal help. Delays in being assessed are, however, often very long - sometimes as much as a year. We must reduce waiting times.

3.15 Agencies can adopt several strategies to achieve this. These include:

self assessment;
community occupational therapists accepting assessments by health service occupational therapists;
occupational therapy assistants carrying out some assessments and fitting basic equipment;
professionals in one agency using the resources of another agency, for example, in joint equipment stores; and
re-allocating resources.

Community alarms

3.16 Community alarms can help us to provide effective community care by:

giving people confidence, a feeling of security, and peace of mind at home;
allowing frail older people to return home from hospital earlier;
offering an effective way of communicating with emergency health, social care and housing services; and
providing peace of mind for carers.

Respite care

3.17 Many people who go into a residential or nursing home do so because their carers can no longer cope without more support.

Effective respite services

3.18 Positive changes are already taking place, but respite care services do not generally have a strategic focus. They tend to follow existing patterns and may be driven by crisis. Respite care needs to be seen as a standard part of the home care package. It must be flexible so as to meet the needs and wishes of the person cared for, and available both at home and elsewhere. Developing an effective respite service which meets users' and carers' needs is a priority for local agencies.

Making change happen

3.19 We expect to see five changes in support to people at home across the social work, health and housing sectors. These are:

a shift towards home care services;
better and more flexible home care services, supported by suitable housing;
more flexible respite services and training to support carers;
community-based health services to support the shift to home or community-based care; and
more cost-effective services.