Is Home Care playing its full role?

Home and Community Care Ireland’s Michael Harty outlines the main barriers that are holding back the sector and the potential solutions.

Home Care is a part of our health service that could be playing a much more important role. A role that could have a significant effect on relieving the pressures in other areas such as residential care and the acute sector. The reasons for this under-performance of Home Care are varied but can be classified into two main areas.

The first area is the financial under-performance from poor efficiencies, resulting in the HSE not getting value from existing funding.

These inefficiencies can be traced to:
• Funding silos;
• Poor accountability; and
• Lack of competition.
The second area is Home Care providers not providing the quality and complexity of Home Care needed to get the medical community to refer patients with confidence. These quality issues within the sector can be traced to:
• Lack of regulation;
• Lack of strategic procurement; and
• Poor empowerment of clients.
Both of the above areas are perfectly amenable to being fixed quickly and with a number of simple initiatives, if the motivation is there from the Department of Health and the HSE.

Financial under-performance
Presently the State’s Home Care spend of about €325 million is placed in two distinct funding silos. Approximately €195 million for the Home Help budget and €130 million for the Home Care Package scheme. Both of these budgets fund exactly the same type of Home Care but are placed in separate silos which enables the State to direct funds to favoured providers. In the case of the Home Help budget, this leads to funding not going to the best and most efficient provider but to the provider who has been designated for that area, creating mini-regional monopolies.

In addition, there is a funding silo for residential care of nearly €900 million through the Fair Deal scheme, which creates a false demand for residential care because that is where the bulk of funds are ring fenced.

A large part of the State’s Home Care spend is administered through Section 39 funding from which many providers are arbitrarily excluded. In addition, this Section 39 funding is paid in advance of care being provided to these organisations. Up to very recently, there has been little or no follow-up on how these funds were spent. Several Prime Time exposés have shown as much as 50 per cent of these funds in some cases were not going towards the provision of care as was intended.

Competition and Home Care provision don’t seem to fit together but the provision of healthcare is one of the few areas where people make decisions on providers overwhelmingly on the basis of quality and not price. For this reason, competition and client choice can be a great driver of quality Home Care provision. The knowledge that if service provision isn’t up to scratch, the client can easily change provider is a great incentive for providers to up their game. This is not the case with the Home Help budget which is distributed through regional monopolistic providers with no competition and no client choice.
This is an unacceptable situation, especially when you take into consideration that the type of client we are referring to is often a vulnerable older person whose propensity to complain in the first place is very low.

Low quality and complexity
Regulation with legislative underpinning has been spoken about for the Home Care sector for several years now but the Government’s present position is that it won’t be in place until 2016-2017 at least. This is despite draft proposals having been drawn up several years ago after consultation with all stakeholders. There is also a reluctance on behalf of the Department of Finance to concede any further entitlements such as with residential care. Unfortunately, it is only when a scandal occurs that this type of issue moves up the political priority list.

The most powerful tool that the State has to structure the Home Care sector is the procurement process. First of all by ensuring all funding is allocated through the process and secondly by ensuring that the process promotes quality Home Care in an efficient manner. It also needs to promote a cohort of professional providers willing to invest in their organisations to ensure they are keeping pace with the needs of a rapidly increasing older population as well as being able to generate confidence within the acute sector, that Home Care is a viable option for the discharge of clinically suitable patients.

By having a cohort of professional Home Care providers able to move up the acuity scale, you will drive savings by improving the throughput of patients through hospitals and also shortening their stay. In the absence of regulation, the most powerful force for driving quality Home Care is the client. By empowering the client through giving them choice over what their care plan looks like, who their provider is and when that care is provided, we can take the power away from administrators and allow the wishes of the client shape what our Home Care services look like.

Solutions
So what can be done to address these issues? The key is to use the tools already available to the HSE namely the procurement process, proper consultation with relevant stakeholders and putting into practice the Government’s avowed policy of “money should follow the patient”.

Firstly, all funding for Home Care provision should be allocated through a transparent procurement process with quality being the main determinant. Secondly, the procurement process should encourage the concept of client choice as well as the establishment of a range of professional licensed providers willing to invest in their organisations and overcome the reticence of the acute sector to utilise their expertise.

The recently published Home Care tender has done none of these. In the HCCI, we would call for a procurement process where the HSE sets an internal reference price for the cost of Home Care and uses this as the basis of valuing their Home Care funding. Clients would then be given funding based on this valuation as well as a list of licensed providers. Clients would then contract one of those providers who would in turn be able to cost each client on an individual basis rather than what we have now – where providers are expected to give a catch all price for a four-year period for everything from simple companionship to late stage dementia or palliative care.

This funding would be presented as the State’s contribution towards the client’s care in conjunction with the significant tax relief available where the clients own funds are used.

Thirdly, funding should be directed to where the demand for services really is, rather than the situation that we have now where the vast majority of the elderly care budget is arbitrarily ring-fenced for residential care.

The demand for elderly care services is going to increase rapidly in the coming years and we need to ensure that our existing funding is providing the best quality and most appropriate care to the maximum number of older people.

Home and Community Care Ireland (HCCI)
Carlow Gateway Business Centre
Athy Road, Carlow
Tel: 083 192 4987
Email: michelle@hcci.ie
Web: www.hcci.ie