Thinking about…

The True Cost of Cheap Homecare

I have always been a glass half full person and it drives my family mad from time to time. If I’m being completely honest I tend to go around thinking my glass is full rather than just half full which makes me wonder about all the issues we hear around capacity and homecare. Is the capacity for homecare really the glass half empty that it is often implied to be.

Are there capacity issues amongst our home care colleagues, or is it more a case that those commissioning our home care services from their local providers have an expectation around capacity based on how much they are prepared to pay?  Do they hide behind capacity as the challenge because they are not prepared to pay more?

In fact capacity is a bit of an odd word to use in this context because the thing that drives capacity is the  price of homecare rather than how much supply of homecare is available.

In my mind this is a false economy, as the cost of good homecare is still much less expensive than the cost to the NHS of keeping someone in hospital longterm when they don’t need to be there or the cost of somebody going into residential care. On average the cost of good homecare at a fair price will be around £30 – £50 an hour (depending on the complexity of someones needs).

I recently facilitated a workshop for senior managers in a local health service system looking at how they could improve their relationships with colleagues in social care, the voluntary sector and the independent sector. The things that stuck in my mind about that workshop were the joy that my health colleagues saw in the value of free services from the voluntary sector or how much cheaper the independent sector was than anything the NHS could provide. When I pointed out to them that free and cheap is not a great way to think about their colleagues in social care, the voluntary sector or the independent sector and that a saving to the NHS remains a cost to their partners, they began to think differently.

In my mind many of my colleagues in health tend to look at the initial price, rather than looking at the cost benefit of paying a good rate for homecare services.

It’s a little bit like making a decision about whether you’re going to pay out more in the long run for the washing machine that will last you 20 years, or the washing machine that’s going to last you five years but has a much smaller initial cost. 

From a homecare perspective, paying more for a quality service is going to cost you less in the long-term than paying for a cheaper service that is more likely to result in people being re-admitted to hospital. Either you’re paying a rate that means the homecare agency can’t hold onto staff, or a rate that enables the home care agency to flex someone’s home support depending upon their particular needs. 

Which ever way we frame it, cost cutting can lead to unsafe care and more safeguarding referrals. This is a moral and and humanitarian issue for people with care and support needs and the home care workers supporting them.

Is it acceptable for a health care commissioner to purchase the cheapest care which results in homecare workers travelling 20 miles each way on public transport to support someone for two hours in the morning and an hour in the evening and them having to hang out in a nearby park most of a cold winter day (unpaid) as it’s easier and cheaper to do that than travel back and forth from their home to the home of the person that they are supporting?

Is is acceptable for a health care commissioner to purchase the cheapest care that they can from a provider rated ‘requires improvement on 3 out of 4 categories’, one of which is tissue viability,  when the person they are purchasing the care for already has grade three pressure sores?

Is is acceptable for a health care commissioner to purchase the cheapest care they can from a provider employing workers who have poor understanding of English, have had no training and have no understanding of fluids, continence, how to use equipment or how to administer medication (and in particular morphine) safely?

At what point do some of our healthcare commissioners become complicit in creating safeguarding issues? Or are they already complicit each time they choose the cheapest homecare over the most appropriate care (which isn’t always the most expensive)?

Many homecare organisations have amazing and brilliant workers that are proud to work in social care. As one homecare owner said to me recently: “I have had one of my team in tears witnessing this kind of poor care at the end of someone’s life. I can not believe it’s not more of a scandal.”

When commissioning the homecare workforce we seem to adopt a tayloristic approach to all things homecare. What I mean by this is that we’re more interested in what we get for each minute we are paying for in terms of activity, rather than whether or not what we are paying for is delivering care  that means people can remain independent, stay out of hospital and be well supported by happy, fairly paid homecare workers. Workers who stay in the job they do not only because they love their job but because they know that it pays them enough to support and feed their families well.

A couple of years ago the Health Foundation published a report looking at poverty amongst residential care workers in social care. What it found was that one in four residential care workers were living in poverty. I don’t have an exact figure for the home care workforce but I wouldn’t be surprised if a similar number of home care workers are living in poverty too.

Is it acceptable for our colleagues in The NHS to be driving poor quality care and support and poverty amongst social care workers in order to save a few pounds here and there? if we want to see capacity in homecare work well, we need to pay and train people properly and we also need to trust and value their knowledge and skills because without them we will never be able to meet demand.

Jim Thomas

January 2025