Regulation is a funny old thing. It’s held up as the be all and end all to improve performance, outputs and customer safety and at the moment we are looking at bringing in regulation into the home care sector in Ireland to supposedly do just that.
Private providers of home care are very vocal in calling for regulation to reduce risks and improve outcomes for people needing home care.
Regulation of home care exists in other countries and it would be interesting to know how regulation improved quality and outcomes in those countries. Has there been a significant reduction in safeguarding issues, has there been a significant increase in customer satisfaction and has there been a significant increase in carer well-being? The fact is, there is very mixed research on how regulation directly and practically improves outcomes for people receiving and providing the service.
The impression I have is that regulation is more to do with the protection of policy and decision-makers than with the fostering of great home care.
I would also have a worry that private providers of home care services see regulation not primarily as a means to improve safeguarding and outcomes but rather as a means to protect their market share and profit margins by erecting barriers to entry to new providers and also new models of home care.
When we ask families who use our services what are the most important issues for them in receiving quality home care, the main things they come back with in no particular order are
A. Having the same carer/PA all the time
B. Being able to choose their carer/PA
C. Having a carer/PA who is competent in what they do
D. Being able to decide when care is delivered
E. Being able to decide what the carer/PA does during their visit
F. Having a carer/PA who is happy and in good form
G. Having a carer/PA who spends their full allotted time with them
H. Having a carer/PA who is properly recruited and vetted
Now if we look at what the present HSE tender and proposed regulation will cover and measure, none of those issues apart from “C” and “H” are addressed or tracked.
Take issue “A” continuity, which I think most people would agree is one of the main pillars of quality home care. Nowhere in the tender or proposed regulation are providers obliged to send in the same carer all the time. It is only at best recommended and certainly not tracked.
Let’s look at issue “F” which while maybe not very technical, gets to the heart of what home care is about, personal connections. The way private providers treat their carers with poor wages and employment conditions, results in very high turnover rates which means that understandably many carers aren’t very happy in their jobs and which necessarily will reflect in their attitude and approaches while on the job. Nowhere is this tracked or overseen in the tender or proposed regulation. Yes it is something that is difficult to measure but why not insist on minimum satisfaction levels through anonymous carer surveys or indeed minimum pay rates.
How about issues “D” and “E” which are all about person centred care and ensuring people can have a say over what their care looks like. The reality is completely the opposite with people needing support having to fit into pre set processes and structures of agencies with very little flexibility or respect for people's wishes.
My feeling is that many of these issues which are obviously important to families aren’t tracked and measured in tenders and regulation because it wouldn’t suit the providers.
I suspect that corporate providers are all for regulation not so much to ensure quality home care but rather as a means to protect their market share and maintain their very profitable profit margins by reducing competition.
The effectiveness of any regulation is also highly dependent on enforcement and oversight. Presently this is virtually non-existent with the HSE’s tender because of a direct lack of resources to do so. When I owned a traditional care provider during 9 years, not once were we inspected.
In my experience the best home care has always been delivered when people needing support are in control whether that is through them paying for care privately or through them having a say through a personal budget.
Let’s hope future regulation puts control firmly in those people’s hands and is not just a smokescreen for private providers to protect their market share.