Promoting independence in old age

The National Institute for Health and Care Excellence (NICE) has published its first guideline for the social care sector to promote high-quality home care services for older people at a time when demand for such services is set to grow.

Home care refers to practical support for people who need help to continue living in their own homes. During 2013-14, 470,000 people used home care funded by local authorities in England and almost 80 percent of them were at least 65 years old.

With more people living longer – it’s predicted that the number of people in England aged 65 or older will rise from 1 in 6 (16.3%) to almost 1 in 4 (23%) by 2035 – effective services will become increasingly important.

Professor Gillian Leng, deputy chief executive and director for health and social care at NICE, said: “The need for support at home is something that is likely to affect many of us. As we age, most of us will want to continue living in our own homes, surrounded by a lifetime of memories, for as long as we can.

“Helping a person remain as independent as possible is an important component to maintaining their wellbeing. Without good support, older people can suffer from social isolation, malnutrition or neglect. They may also be at risk of injuring themselves, perhaps from a fall or other accident, if they do not receive adequate help and could end up in hospital.”

Since the Care Quality Commission introduced its new inspection regime in October 2014, more than two thirds (68%) of home care services inspected so far have been rated Good or Outstanding. However, a report published last year by the Local Government Information Unit (LGiU) highlighted concerns that some working practices could affect the quality of a person’s care.

Sandra Duggan from North Yorkshire used home care services to help look after her late mother. She helped to develop the NICE guideline and said good care is vital for families: “When arranging home care for my mother I saw good care workers and some not-so-good workers so I know what a difference good care can make. My mother was able to stay in her own home for 5 years until she died, supported by her family and the home care workers. I will always be grateful to the home care service for that. Home care workers are definitely undervalued.

“These recommendations use evidence to define a quality home care service which can give families peace of mind. The guidelines will help local authorities, home care services and families to know what best practice looks like.”

The NICE guideline for home care says that a ‘one size fits all’ service is not the best way to provide good home care. Instead, it advocates a ‘person-centred’ approach where the needs and wishes of the individual are heard and respected.

Bridget Warr, chief executive of the United Kingdom Homecare Association (UKHCA), chaired the group of experts which developed the guideline on behalf of NICE. She said: “As people age, many will need some support to achieve their wish to remain at home, near to friends and family. The help each person needs will differ and it is important that the homecare delivered is tailored specifically to the individual; his or her needs, wishes and aspirations.

“The guideline emphasises the importance of people receiving support from trained and competent staff with whom they are familiar. For this to happen, those commissioning and delivering home care must work together with the person wanting support to plan the right co-ordinated care in the way the person wants. They should be sure that there is adequate time allowed for the home care worker to provide good, sensitive support in a way that protects and enhances the person’s dignity, wellbeing and independence.

“The guideline spells out how this can be achieved and will, I hope, help to provide focus for those many providers and commissioners who want to ensure high quality, responsive, sustainable support at home is available to those who want it.”

The NICE guideline recommends that home care providers:

Ensure services support the aspirations, goals and priorities of each person, and that they and their carers are treated with empathy, courtesy and respect.
Make sure support focuses on what people can or would like to do, not just what they can’t do.
Prioritise continuity of care by ensuring the person has the same home care worker or workers so that they can become familiar and build a relationship.
The guideline also includes recommendations to support home care workers, from training and development to highlighting the need for services to give them enough time – not generally less than half an hour with each person – to do their job properly.

Miranda Okon, a home care worker in London and a guideline committee member, said that supporting staff is a vital part of improving the quality of home care: “The role of a home care worker is a valuable one to many older people and their families. I see 3 or 4 people a day and help them with things such as doing their laundry or shopping, cooking meals, or helping them to wash. I also make sure I have time to chat to them as I might be the only person they see that day.”

“Visits of less than half an hour are not allowed in the area where I work and this makes sure I am able to do everything I need to for each person without rushing. But this isn’t happening everywhere and if workers are in a situation where they have to choose which task to do before they have to rush out of the door this isn’t acceptable. Home care workers deserve proper recognition and support to do their jobs well and giving them enough time is vital to this.

“Regular training and development is also important: not only will it lead to a more skilled workforce, but may even help to retain staff by giving them a better defined career path.”

The NICE guideline also includes recommendations relevant to local authorities, Clinical Commissioning Groups (CCGs) and others who commission home care services. It says they should check that support is delivered through a coordinated team to promote integrated working and foster good communication. The team may include health and social care practitioners, advocates for the person using home care services and other individuals or groups who may provide support.

It also recommends that home care support is considered for older people with low to moderate needs to avoid, delay or reduce future dependency on health and social care services. Home care packages should also address the person’s wellbeing as well as practical support.

Max Wurr, Head of Policy and HR for the home care provider, City & County Healthcare Group, was also part of the NICE home care committee. He said: “No one is under any illusions that these are tough times for social care. Local authorities are spending less money in real terms on home care and providing such support to fewer people. However, we are confident that local authorities, along with everyone else in our sector, will welcome and support this guideline, which is based on the best available evidence and is intended to be aspirational but achievable.

“We want to set a standard for home care that achieves better outcomes for older people. This means including them in the design, planning and delivery of every aspect of their service and working together effectively with family carers, health professionals and other partners.”

Other issues addressed in the guideline include how to manage and address late or missed home visits, delivering telecare and putting a safeguarding process in place to help home care workers report signs of abuse or neglect.

Minister for Community and Social Care, Alistair Burt said: “Most of us envisage spending our old age in our own home and we want to provide the great care that can make that a reality. We asked NICE to develop this guideline so that everyone involved in providing home care has clear standards that we will expect them to follow. This will not only provide reassurance for countless families who rely on this care but for the thousands of workers who want the time and support to be able to give people the care they deserve.”

NICE has also begun a public engagement exercise to inform the development of a quality standard for home care. This will be different to the new NICE guidance as it will focus on roughly 6-8 specific key areas of care most in need of improvement. Organisations and groups who have registered an interest in this standard are being asked for their views on which key areas should be addressed. The quality standard will be developed using existing NICE guidelines and other sources of information accredited by NICE. When it is published next year it will complement the NICE home care guideline.