After several reports and numerous promises, it seems as if the political powers that be are serious this time about bringing in regulation for the homecare sector, under pinned by a statutory right to the service, similar to what we have with nursing home care.
The introduction of regulation and statutory rights is a complicated policy change with many moving parts that the Department of Health will have to manage. They will have to determine the strategy for addressing these issues so as to ensure that regulation does what it’s meant do, improve provision and make homecare more widespread, while making sure that there are no unintended consequences.
The main policy challenges with bringing in regulation and a statutory right to homecare are;
- Deciding who is eligible and to what are they entitled?
- Deciding on a funding model
- Deciding on the right mix of types of provision
- Ensuring regulation is effective and suitable
- Ensuring adequate workforce to supply the demand for services
- Ensuring informal family care continues
At Home Care Direct we are supporters of these policy changes and we see them as a real opportunity to ensure homecare plays a much fuller role in the health care continuum than to heretofore. We feel our platform model has much to contribute in meeting these challenges.
Eligibility and Entitlement
Presently about 50,000 people get some form of homecare funded by the State. If it becomes a statutory right, these numbers will presumably increase significantly with the attendant cost increase. The State will have to look closely at what level they want to set eligibility and entitlement so as to control the cost implications.
By fostering lower cost options like the Home Care Direct platform, the State can help themselves ensure as wide an eligibility criteria as possible while limiting the cost implications. It would also help to address the estimated 10% of unmet need for people who presently are in receipt of HSE funded hours.
Presently home care is not means tested and is free but this means that the amount of care that can be delivered is severely restricted as evidenced by increasing waiting lists for home care. Approximately €408M was spent on HSE funded home care in 2018 but if a statutory right comes in this funding will have to increase and the likelihood is that there will have to be some form of co-payment from service users.
Shoe horning everyone irrespective of individual situations and needs, into using an expensive full agency service is likely to increase resistance to any form of co-payment. By giving service users more choice such as the ability to contract directly with locally qualified carers and therefore get better use of their allocated funds, it will make the case for co funding much more acceptable.
In fact models like Home Care Direct where more control is placed in the hands of families, will encourage increased private funding of care because of significant cost savings and better continuity of care.
Service Provision Mix
With publically funded home care, who delivers the service has always been a contentious issue. The ideal split between state, not for profit and private provision will depend on your ideological stance. Currently about 80% of the home help budget is delivered directly by the HSE while about 60% of the home care package budget is delivered by private providers.
In Home Care Direct we would make the case that increased choice for families is a great driver of quality and efficiencies. Not just choice from a limited list of approved corporate providers, but choice that includes the possibility of contracting directly with local qualified carers where appropriate. With this type of choice, you create competition which keeps corporate providers “honest” in their dealings with families but more importantly with carers or risk losing business to people working directly. It also ensures that corporate providers concentrate on where they are genuinely adding value.
The two principle pillars of great home care that a platform model delivers are, happy well rewarded carers and continuity of care.
Effective and Suitable Regulation
The challenge with introducing regulation into the home care sector is to ensure the benefits of regulation such as improved quality are attained but at the same time we do not limit choice, innovation, supply or inadvertently increase costs.
We must be careful that regulation takes into account the various models of provision that are out there or indeed will appear in the coming years. Regulation cannot just indiscriminately regulate out, models or practices that are working successfully and it must be flexible enough to allow for future innovation.
Regulation can easily become a method of maintaining a cosy corporate Status Quo to the detriment of smaller, more personal or more innovative models of care.
Regulation also needs to be careful it doesn’t stimulate the “black market” for care by placing high administrative burdens on providers and increasing costs or pushing smaller organisations or individual carers into the shadows. The administrative burden needs to be proportionate to the type and model of provision.
The “black market” for care can be effectively combatted with the generous tax reliefs available which can be used to encourage cash practices out into the sunlight. Personal budgets can also play a role by avoiding excessive State handholding and putting more trust in families to make correct decisions around what care is suitable for loved ones. Real personal budgets which don’t limit families to a limited list of approved corporate providers but rather for example enable direct contracting with individual carers in a tax compliant manner, are growing extensively in other jurisdictions and need to be fostered much more here.
Live in Care is a particular prevalent part of this “black market” which could be successfully addressed by the above measures.
The advantages of successfully combatting black market care are significant in safer care and increased revenue for the State.
The bottom line is, for regulation to be effective and suitable, it must be measuring the right things. Rather than measuring inputs as is done presently through HSE tenders, we need to be measuring outcomes such as patient’s quality of life.
Ensuring Adequate Numbers of Carers for Future Demand
The home care sector is presently struggling to meet existing demand let alone the increased demand coming down the tracks. In addition carers are leaving the sector in increasing numbers, looking for better paying jobs in other sectors.
The main reason for this exodus is simply that caring is not an attractive career. Poor wages, little guarantee of work and precious little career pathway pushes carers to look for employment opportunities elsewhere.
The policy conundrum is how we make caring a more attractive career without significantly increasing the cost of care so that it is unaffordable.
At Home Care Direct we feel this can be best achieved by having a wider ecosystem of care models families and carers can choose from.
Home care is a very personal service and yet we insist on shoehorning everyone into a costly full corporate agency type service whether they need it or not. A corporate service which doesn’t even guarantee continuity of care for families, a basic tenant of quality home care. By doing this we are adding on extra unnecessary costs to the system. Where there are family members and local proactive carers available to manage a care relationship directly why not just let them get on with it rather than foisting on the home care budget, the significant overhead costs of a corporate provider?
We know there is a significant amount of private direct care in the market already. Why not support that through having a carer register so families have more comfort over who they are dealing with.
This way, increased funds flow directly to carers making the career more attractive while still bringing significant savings to the home care budget. Corporate providers have a role to play but where they are genuinely adding value, not as a matter of course.
Interestingly, we also seem to be perfectly happy with the significant amount of family carer’s provision, estimated at a value of nearly €4B, to carry on without any burdensome regulatory or administrative obstacles.
Sustaining Informal Care
The vast bulk of home care delivered in Ireland is by informal carers, generally unpaid family or friends. It would be impossible for the State to replace this care, in addition to what it already funds and provides.
Therefore any regulation that is brought in must be mindful of this and ensure that this informal care is supported and fostered.
Paid home care can act as an important support to family carers through respite care and help with heavy physical tasks in the home. Paid home care can also allow family carers to take up some employment work outside the home.
Once again Home Care Direct feels that the ability of families to plug into a network of qualified local carers directly to support the work they do, can go a long way to ensuring the work family carers carry out is sustainable. It would be cheaper and more personal, than having to go through corporate providers.
In summary the introduction of a statutory right to home care together with appropriate regulation, can have a transforming effect on the home care sector and the role it plays in our health system. The policy challenges highlighted above can partly be addressed by a simple movement towards trusting families and people needing care more and providing them with a wider range of choices that they can exercise.
If we are to meet these challenges successfully, we are going to have to move away from the Status Quo and embrace new initiatives, new ways of thinking and become less risk averse. The potential prize is a vibrant social care sector making Ireland a great place to grow old in.