A blog entry by Patrick Hall

In December, The King’s Fund published a study of publicly funded home care in England. Home care or ‘domiciliary care’ is social care delivered in the home, mainly by small, private agencies. This includes help with getting dressed, washing, preparing and eating food and sometimes with housework or getting out of the house to see friends and family. This type of care is central to the stated goal of helping people ‘age in place’: avoiding institutionalisation, but also isolation and loneliness. Yet, as the report shows, England’s publicly funded home care markets are unfit for this purpose.

Part of the Fund’s report drew on work I did with the University of York in 2017: Understanding Domiciliary Care in England. We conducted an analysis of nationally available data on home care in order to establish a contextual background to our research and used qualitative interviews to gather data on what is happening in different parts of the country from the perspective of providers and commissioners. The report has had relatively little media interest (apparently there is something else going on) so I thought I’d take the time to reflect on our findings and summarise my thoughts on publically-funded markets for home care in England: those markets that compete for local authority contracts to provide home care for the shrinking population of eligible people with care needs.

There are relatively low barriers to entry into the home care market. Apart from administrative, management and registration costs, travel is the biggest expense for the new home care agency. An agency is its people, so the local labour market plays a huge role in the shape of home care markets. In my opinion, England’s publicly funded markets operate on a spectrum between a rock and hard place: between poor care and scarce care.

A rock: worse care, more of it

Here is what an inner-city commissioner said to me about their home care market:

“Agencies are in the market. So when people say ‘we can’t afford to provide it’; you’re in the market though… and actually our neighbours pay 50 quid a week less and you’re in the market there as well, so you can afford to provide it. It is market management; you are in the market or you are not in the market. If you can’t afford it, then exit the market.”

Where labour supply is plentiful, particularly around cities, commissioners can keep their fees low, pleasing hard-up directors of finance and delivering ‘savings’. The additional cost of travel is kept low because of population density and better infrastructure. An extreme version of this type of market sees intense market entry and exit, extremely low fees and possibly illegal exploitation of workers. Frameworks and contracts often fail, but the next bargain basement offer will always elicit responses from new, speculative agency owners. This is laissez-faire commissioning.

Source: Hall et al 2017

A hard place: some good care, less of it

Here is a typical quote from a commissioner in a large rural county:

“We have come under huge amounts of pressure from providers this year to increase rates. We don’t have the luxury, necessarily, of playing hard ball, ‘no, we’re not going to negotiate with you at all’, and risk them handing back hundreds of packages to us, which we just simply would not have the capacity to replace.”

In places where the supply of labour is low, often in more rural and deprived areas, commissioners have been forced to increase fees to attract workers and account for higher travel costs. Local authorities often step in, expanding in-house re-ablement teams to fill demand. At this extreme of the spectrum, workers are likely to spend large amounts of time travelling, and recipients are likely to receive less care. The workforce is likely to be better suited to the tasks when they can reach their clients, but the work of agencies is stretched. This means the also NHS absorbs some care demand , in the form of community nursing carrying out care tasks and delays in getting people out of hospital. This shows up in the counterintuitively positive relationship between delayed transfers of care and fee rates.

Source: Hall et al 2017

A growing number of people are now ineligible because of what Toby Watt at the Health Foundation calls ‘fiscal lag’: where means test thresholds stay constant during a period of inflation, then the number of people who are eligible decreases. This has resulting in 26% fewer people in England being eligible for publicly funded social care by the policy impotence of successive governments. This means a growing ‘self-pay’ market: where interesting new forms of home care are emerging to meet demand for flexibility, more coordinated care planning and less transactional forms of home-care, often facilitated by digital technology. We are investigating these new models, alongside innovations in the publicly funded sector, in our ‘Delivering Care at Home’ package led by Dr Diane Burns, Dr Kate Hamblin and Dr Cate Goodlad. These models give us a glimpse into what social care in the home could be like. Sadly, for those who cannot afford to pay their own care, they are stuck between a rock and a hard place.

Patrick Hall

Patrick Hall is a Research Associate, working in the Sustainable Care programme. Read more about his work by clicking the link below

Comparing UK Care Systems


Prospects, development and differentiation in the four UK nations