How to provide humane homecare

One of the most amazing people I met during the Barriers to Choice Review, which is where I have been for the past seven months, was an extraordinary and articulate lady in Dorset - who deserves to be listened to for her stories about Atos assessments and other inhuman treatment by the social care system.

She is an a wheelchair, and I especially remember her description of her morning visit by a care worker arriving to get her out of bed and into the shower.  It is nearly always somebody new as she buzzes them in through the front door.  “I say hello to my carer when they put their head round the door and introduce themselves," she says. "Within seven minutes, I am naked with them in the shower. It’s a strange relationship.”

That really brought it home to me the poverty of so much home care, and it was confirmed by the reports this morning that a quarter of social care organisations are failing at least one of the Care Quality Commission's standards.

The CQC's scrutiny is pretty inadequate, and still based on the discredited tickbox system of regulation, so we won't really learn much from that.  Many local authorities are reducing the number of care contracts they have dramatically, so that they can monitor them better.

This makes a lot of sense, but in the short term it certainly reduces choice and diversity - and also probably encourages the kind of pile-it-high-sell-it-cheap style of homecare that we all know about: never seeing the same person twice, rushed care, being put to bed at teatime and all the other indignities of care without any kind of relationship.

Conventional wisdom suggests that this is the only way that the burgeoning costs of social care can be controlled - and social care and children's services alone are due to take up the whole of our local government budgets by the early 2020s (see the famous Graph of Doom).  But I am not so sure that the economics of scale apply here (I'm not sure they apply anywhere much).

The trouble with economies of scale is that, usually, the diseconomies of scale rapidly overwhelm them - and poor, relationship-less care, by massive agencies which would prefer their clients to be more dependent than less, is almost certainly no exception.

I was enormously impressed by some of the micro-providers I met, and by the work Nottinghamshire County Council has led to encourage their emergence (nearly 50 new micro-providers over two years).   They are able to provide proper homecare, by familiar people, with attention to detail and relationship, in a cost effective way.  Yes, it is small scale - that is why it works - but, as they say in the USA: small + small + small = big.  Choice in homecare, via personal budgets, really matters.

Humane homecare doesn't have to be provided by micro-providers.  The big agency Home Instead is one of the more enlightened providers here and manages the same thing.  In both cases, though, there is a minimum price below which it is impossible to go.  The big issue is now how to provide effective care, at scale - but without pretending there are economies in scale - at an affordable price.

I believe it can be done, but not without unleashing the huge resources of neighbours and community at the same time - and this is only in its infancy.  Once again, I am indebted to the systems thinker John Seddon for the basic rule - if you try and control costs directly, they tend to rise; if you look at where the demand is and provide a flexible system to meet it, then costs will fall.

This matters very much indeed, and for selfish reasons - it is our own futures we are planning for.