For families navigating the world of self-directed supports - often for the first time - the promise is powerful: choice, control, flexibility, and the opportunity to shape care around a loved one’s life, not just their needs. But for too many, the reality falls painfully short of that ideal. Why? Because we’re expecting families to lead a transformation while working in silos, with patchy information, inconsistent advice, and unclear communication. And frankly, it’s setting people up to fail.

Michael Harty as Director of Home Care Direct,  on paper, could be considered a competitor to Karen McCormack in inCharge. Yet they found themselves in total agreement: in the current landscape, self-directed supports are hard to reach for too many families - not because the model is flawed, but because the scaffolding to make it work simply isn’t there.

At its heart, self-direction depends on people having the right support to make informed decisions. But what happens when there’s a vacuum where that support should be? What happens when families can’t get a straight answer, when policies differ not just from one region to another, but seemingly from one official to another? When terms are used interchangeably with no clarity, when guidance is buried in inaccessible documents, or delivered in jargon that alienates the very people it’s meant to serve? Or in some cases, entirely absent.

What happens is families retreat into silos. They reinvent the wheel, make mistakes others have already made, and burn out trying to figure out systems that should be designed to help them, not hinder them. And when that happens, the opportunity that self-directed support offers is not just missed - it risks being undermined entirely.

This comes in a month where Karen has spent hours – hours - looking at insurance options, pouring over administration tasks, navigating applications and funding systems, trying to draw down supports. And more often than not, the forms don’t make sense. The language is vague. The rules behind the systems feel disconnected from real life - whether that’s the lives of people planning for their self-directed future or the realities facing small businesses trying to get off the ground to support them. The level of bureaucracy is, quite frankly, out of control.

There are great people working to deliver supports whether that’s self-directed support packages or social care services. But their greatness is dampened by systemic flaws.

Some families manage to push through. They’re often the ones with the time, energy, resilience, or confidence to dig deep, persist, and build their own informal networks. But should access to good support depend on how articulate or assertive you are? Should it depend on who you know, or whether you happen to find a helpful person on the right day?

Michael said, “We need to stop pretending that "choice and control" is enough of a promise on its own. People don’t make good choices in a vacuum. They make good choices when they are well-informed, when they are listened to, when they can ask questions without feeling like a burden, and when the systems they interact with are joined-up and responsive. And before they become battle weary and exasperated”.

Karen added, “If we want self-directed support to work in Ireland - and we are living proof that it works, it works amazingly for my daughter - it must come with clear, consistent, and timely information. It must be communicated in ways that are easy to understand and be consistent. And it must be underpinned by a shared infrastructure of support that brings families out of isolation and into communities of learning, sharing and guidance on how to do it”.

This isn’t about one app, one service, or one agency. It’s about collaboration.

Michael Harty and Karen McCormick agree, both seeing it from different angles. We don’t need more silos - we need connection. We need to build ecosystems, not empires. Because when families are well-supported, well-informed, and not alone, self-direction stops being a buzzword and starts being a reality.

If we don’t act now to fix this vacuum, we risk turning a hopeful model into a broken promise. But if we do, the impact could be profound - not just for those drawing on care and support, but for the families who support them, and the communities where they live.

Karen McCormack and Michael Harty

We are entering into an important phase with regard the setting of standards and regulation of home care. Several months ago, first drafts were published of standards and also a draft bill.

Since then, there have been updates to the standards and also we have also been advised that an Authorisation Scheme for the provision of home care services within the disability sector is to be published along the lines of the scheme we have seen under Older Persons. This authorisation scheme will draw up a list of approved corporate providers for home care provision within the disability sector.

The first published standards and draft bill on home care provision clearly highlighted the fact that personal budgets and personal assistance services were different and would not come under these initiatives in the same way as normal top-down home care provision.

However, since then, there has been a lot of lobbying on the part of large corporate providers to ensure that personal budgets and personal assistance services are regulated in the same way as mainstream top-down services.

With this in mind it is interesting to see that in the latest draft standards circulated on the 6^th March, the definition of home support is broader that in the draft regulations and the specification of “in the home” has been removed and as such could be interpreted to include PA services.

It is imperative that the new Home Support Adults Disability Authorisation Scheme doesn’t unintentionally diminish the independent living model of personal assistant service currently been delivered. The work being carried out, at present, to clearly define the difference between a personal assistant service and a home support service is crucial with regards to protecting current and future personal assistant services.

The overall concern is that individuals who should be offered a personal assistant service will be provided with a Home Support Adults Disability service because there is no clear guidance for those who are commissioning the service, particularly if they don’t have a clear understanding of personal assistant services. There is a significant risk of this happening if the new Home Support Adults Disability Authorisation Scheme commences before there is a clear definition and assessing criteria distinguishing the difference between home support and personal assistant services.

A potential unintended consequence of the new Home Support Adults Disability Authorisation Scheme, is that if providers don’t sign up to the authorisation scheme, they will not be offered any new work so therefore it will be providers who primarily deliver home support services that will be offered all new services. It may also prevent people from contracting with or employing PA’s directly.

The WRC pay alignment ruling could further complicate this issue as well.

It is vital that in any move to bring in regulation and standards for home care services especially in the disability sector, that people retain the right to go down the independent living road with personal budgets and personal assistance services and can have control over what their support looks like and who provides that support.

It is imperative to retain real choice within our home care arrangements.

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.

With the recent publication of the draft bill for the Licensing of Professional Home Care Providers, it got me thinking about how the home care sector is changing and how it needs to change into the future.

Up to recently with most of our existing provision, home care was and is, very much characterised by a top-down approach, with corporate providers offering services on their own terms and in ways that suit them. It’s a case of fitting the person needing support into ready-made processes and structures rather than the other way around and having services adapt to the individual’s needs.

The approach by corporate providers and indeed the HSE, is very much we know what’s best for you and we can’t entertain or trust that in fact you might be the expert in your own needs.

This dictatorial approach is finding more and more resistance amongst a Boomer generation of older and disabled people, who are healthier, more educated, more sophisticated and more demanding. A cohort who are demanding change. This is a generation who have redefined many issues throughout their lives and who are used to getting their way.

In addition, in Ireland we recently commenced the Assisted Decision Making Act and put in place the Decision Support Service and the Taoiseach also committed to ratifying the UNCRPD all of which are all about tearing down this top down approach and making sure that people have control over what their support looks like and who delivers that support.

One of the most important pillars in maintaining this top-down approach has been an excessive deference at the altar of safeguarding causing extreme risk avoidance and the squeezing out of any control by people needing support.

The assumption is always that someone needing support is vulnerable and can’t be trusted to make decisions by themselves. There is a certain amount of scaremongering on this issue which suits corporate providers as it helps them maintain their market share and profits.

Change is coming though, through the magical excelsior of choice. Personal budgets, direct payments and technology are the agents that will create and drive choice, bringing a home care sector that is more dynamic, more innovative and more in tune with what the needs of it’s users are.

The unfortunate fact is that home care is a service that people generally dread receiving, I think mainly due to their lack of control in shaping that service. Wouldn’t it be so much better if we could move home care to being a service people want and desire, rather than a service to be avoided.

The demand for personal budgets and direct payments is high within the disability sector, where many people want control over the lives they live. However, despite this demand, their roll out has been relatively slow due to various reasons we addressed in a previous blog ( https://blog.homecaredirect.ie/whats-holding-back-the-roll-out-of-personal-budgets/)

Here I want to concentrate on one of those reasons, namely the unbundling of funds from traditional providers.

Where people with disabilities are receiving services from a traditional provider and they want to move to a personal budget or direct payment, their funding has to be transferred over to them. When that provider is a normal for-profit provider, the transfer of funding is relatively straight forward as that provider sends in monthly invoices for the service, they are providing to the person concerned and so the amount is easily identified.

The only issue here is if your provider is a low-cost provider to the HSE you will get less funds than if they were charging a higher price. So, you could be discriminated against depending on whether your provider before the move over to a personal budget, is cheap or expensive for the HSE.

However, when the provider is a Section 39 funded organisation it is more complicated. Their funding is bundled up into block grants that these organisations receive from the HSE. So, when people want to move down the personal budget route or a direct payment route, these funds have to be unbundled and this is where the problems start.

In many cases especially where Section 39 providers are concerned, there is initial resistance to funds being unbundled as this means the organisation are losing a client and funding. In some cases, the organisation refuses to unbundle funds unless the HSE replace the person leaving with another case or unless the HSE pays compensation for loss of a client. These compensation payments can be of the order of €6-€10,000.

If this barrier is overcome, the next issue the person has to face is at what rate his hours are unbundled. When someone is receiving a service from a traditional provider, they get a specific number of hours of support. Now to unbundle those hours, an hourly rate has to be applied to get an overall annual monetary budget.

This is where it gets tricky, as the interests of the Section 39 organisation that were providing those hours is to apply the lowest possible rate so they retain the maximum amount of funds, while the objective of the person needing support, is to have the highest possible rate applied so they are allocated the largest budget possible.

To date this process has been extremely opaque with the person involved having no input and getting no information with regard how the hourly rate is calculated and what costs are included. What happens in reality is that Section 39 organisations when applying for funding include every cost possible but when unbundling funds, they are much more selective with regard what costs are included.

We have seen a situation where one particular organisation unbundles funds at a specific rate but when you look at the figures in their Annual Report with regard the funding they received and the hours they delivered, the unbundling rate should be significantly higher.

In another situation we are aware of, a person was offered funding of €37,000 for their 56 hours but unbeknownst to the organisation involved, the person had previously received a detailed calculation showing the cost of their service was actually €86,000!

This creative accounting on the part of section 39 organisations can have a huge effect on the successful take up by people of personal budgets and direct payments. These organisations have all the cards in their hands while the person needing support finds themselves being denied information on what after all are their personal funds and with very little ability to negotiate or push back.

It must be remembered that these are not just abstract economic calculations but rather there is a human being behind these numbers, whose ability to live the life they want and deserve, could be severely affected by this number crunching.

So, what is the solution to bring these calculations and discussions out into the open, in a way that is fair and practical to all involved?

In the absence of a tender process for disability services, I would suggest that the Older Persons home care tender is used to set prices. The fact is that many of the organisations that are involved in the Older Persons tender are the same organisations that provide disability services and the reality is that the prices received for older persons services do act as a baseline for what these same organisations charge for disability work. If they have a set price for older persons work and we accept the fact that there are waiting lists for older persons work, it stands to reasons that companies will not allocate their scarce resources to take on disability work at lesser rates.

There will be a new Older Persons tender in place from July of this year and the expectation is that there will be a standard price set of €31/hr for all providers. Why not use this standard price for personal budgets and direct payments in the disability sector as well. This removes the opaque nature of what we have at the moment and brings much needed clarity and transparency to people who are looking to go down the personal budget or direct payment route while at the same time ensuring the HSE aren’t paying over the odds.

We have a problem in our home care sector. Corporate home care providers despite having the margins to do so, don’t pay their carers enough which means they have problems when recruiting and retaining carers which in turn leads to rising waiting lists for home care. It means Minister Mary Butler had about €200M of unspent funds available for home care.

Corporate providers proposed solutions to these issues mainly revolve them being paid more money and the protection of their eye wateringly high profit margins. Let’s look at some of those proposed solutions.

Firstly, they propose that social welfare rules are relaxed so that carers can work more hours without their take home income being affected. This is basically them asking the government to subsidise the insufficient wages they pay carers. It’s them looking to continue paying low wages so they can maintain their already generous profits and for the State to pick up the tab so that they can better recruit and retain carers.

Secondly, they propose that the HSE pay them higher rates so that can introduce tiered pay rates for carers and pay carers with more experience and qualifications, higher rates. At first look this seems reasonable but the question arises would they use increased rates to introduce tiered pay rates or would they just pocket the difference? It’s instructive to look at what happens in practice in situations when corporate providers do receive higher rates. Presently corporate providers get about €27/hr for HSE funded older persons work and they pay carers around €12/hr. However corporate providers receive significantly more around €35/hr when they do privately funded home care and also when they do HSE funded disability work. Do they pay carers increased wages when they are carrying out that type of work? The simple answer is NO. Carers still get the same €12/hr but the corporate providers profits are much healthier. Why would they suddenly start to act differently if they got increased rates for older persons work?

A third solution they proposed and which they have gotten, is to allow them bring in carers from outside the EU. These carers have to be paid a minimum of €27,000 and work 39hr week. Of course, the question here is, why don’t they just offer these conditions to the existing cohort of carers?

A fourth solution was for the HSE to pay them extra which would allow them to pay carer’s travel expenses. On this point they conveniently ignore the fact that in the existing tender, all providers had to put in a cost for travel. Unfortunately these funds never found their way to carers and are instead dropping to the bottom lines of corporate providers.

The principal lesson from the above, is that corporate providers can’t be trusted to put carer’s interests at the heart of their businesses. Instead carers are a cost which have to be kept to a minimum, in order to maximise profits and independent of the effect this might have on quality. Until this is understood by the HSE we will continue to have rising home care waiting lists.

The best way to encourage corporate providers to treat carers better, is to provide more choice. To open up other options for families and carers outside a limited approved corporate providers list as they do in other countries. Real choice will drive a better deal for carers and in turn improve the quality-of-care families receive.

Centralisation is a concept in management that is all about delivering efficiencies, control and standardisation. McDonalds is a good example of centralisation at work, allowing you to go into any McDonalds in the world and know in advance exactly what you are going to get. Centralisation is the opposite of localisation.

Centralisation works well for many sectors especially where human preferences and personal outcomes are secondary to cost cutting and profit maximising.

The social care sector is a people dominated sector which is all about the human touch, looking after and encouraging those who need help, to live the lives they want to live in the place they call home. Unfortunately, and counterintuitively, it is a sector in Ireland that is dominated by centralisation and top-down dictums.

This means that the care and support provided is very much from a standardised template, irrespective of the personal circumstanced or needs of the people involved. This lack of personalisation is bad for the people involved but it’s also bad for the state, as it commits resources where they are not always needed. This standardised approach often throws common sense out the window and reduces the person involved to a client or service user, rather than treating them as a citizen with capacity and rights.

This centralised approach is propagated by our tendering system which promotes the large corporate provision of home care, as it is large corporates who can  dedicate large departments to submitting intricate tenders and then managing the complex reporting and administration which follows. To make matters worse the system then pits corporates against corporates, encouraging them to find ways to reduce costs rather than deliver great services. It reduces everything to a financial transaction and a strict contractual oversight where anything outside the contract is invalid and of no use.

The results of this system are plain to see.

· Rising home care waiting lists because of a severe shortage of carers due to the fact that caring is not an attractive career. The easiest way to compete for these tenders is to keep carers pay rates low. Perversely though and as can be seen by publicly available accounts, the profitability of these corporate providers is very healthy.

· Increased box ticking and reporting but less practical and personalised support for people receiving care.

· Increased bureaucracy but less relationships and the human touch. The starting point for care is one of mistrust and the assumption that capacity doesn’t exist in the person needing care. Problems are solved by more rules, regulations and penalties.

If our home care system is to become fit for purpose, we need to bring back in trust, choice and a more human approach. The best way to do this is to move away from centralisation and start to delegate.

Delegate to communities, to families and to people themselves. The starting point should be the assumption that a person needing support has capacity and in many cases are experts in their own care and needs.

On the carer side we need to recognise that the two principal pillars of great care are one, happy well paid motivated carers and two, continuity.

We need to recognise that many of these great carers will come from local communities and so we need to ensure that local communities have the structures, knowledge and resources to enable and empower these carers and develop local solutions.

We need to get rid of our present commissioning system that basically sells off older and disabled people to the most efficient corporate provider at the lowest possible cost. We need to start treating people who need care and support as citizens with rights, personal needs and who are capable of making decisions about their lives. If we can trust people and families to fill out tax returns surely we can trust them to make decisions about their care and support?

The introduction of real personal budgets is the best way to start this movement away from centralisation and towards delegation and the transfer of decision making to the local.

It’s difficult to pick up a paper now a days without reading some headline about a shortage of carers and rising waiting lists for home care.

As well as highlighting the problem, there are many suggestions about how to tackle the problem such as increasing carers pay, upskilling carers, providing a career pathway and bringing in carers from abroad.

We certainly need to look at all of those initiatives but with demand for home care only going in one direction, in the long term, the only way we will address capacity issues in home care and bring new people into the sector, is by enabling local communities to help themselves.

What I am talking about is activating local people to become self-employed carers in their own communities. In a way it’s professionalising our neighbours. At Home Care Direct we are convinced there is an army of people out there that would be open to this concept.

I have often spoke about a fictional Mary in Tullamore. Mary loves her community and is involved in the local GAA club, contributes in the parish and also helps out in the local community centre. Mary wants to make her community a better place by helping those who need support. She has no real interest in working for barely above the minimum wage for a corporate provider of home care but she would be very interested in being empowered to work for herself, setting her own rates and availability and having control over her career.

We are convinced all communities are full of people like Mary, who want to contribute and also have the time to do so. While they might not have the skills to take on all aspects of care work, many of them do have the life and social skills to be able to contribute in a meaningful way to make someone’s life better and perhaps be a welcome addition to a stretched professional care service.

This is one of the things we are trying to do in Home Care Direct by making it easy, transparent and safe to incorporate these types of people into the home care sector. Unfortunately, by enforcing a one size fits all system in home care commissioning and provision as we do presently, we are excluding so many people that could make a contribution in a practical way and help make significant inroads into the over 6,000 people waiting on a home care package.

By empowering local people in this manner, we would also be helping to stimulate the local community in an economic sense with less funds leaking outside the community to corporate overheads and profits, but also importantly, stimulating local communities in a social sense. It is well documented that communities that are enabled to help themselves are strong vibrant communities that wean themselves off dependency on costly outside intervention.

Our present home care provision system prioritises this outside intervention at the expense of the assets that are already existent locally.

In Ireland, we have one of the best examples of local communities helping themselves in a sporting sense, in the GAA. Mervyn Taylor of Sage Advocacy, this week in a letter to the Irish Times advocated for a GAA of home care.

What a wonderful idea. An idea that is held back only by the HSE refusing to accept that people are often experts in their own needs, that communities can help themselves and insisting that the shackles of safeguarding must be implemented and if not, better to leave people without any care and support.

People’s needs and situations are incredibly varied, why can’t they have an equally varied suite of options open to them to choose from, for their care and support?

The recent publication of the Report of the Strategic Workforce Advisory Group on Home Carers and Nursing Home Healthcare Assistants, was welcome but at the same time leaves a lot of questions to be answered. The focus of my subsequent comments are mainly with regard to home care rather than nursing homes

The first and most striking point to be made, is that while the report is basically about how to make caring a more attractive career, views directly from carers themselves were not sought at all, only the views of their employers who obviously would have their own agenda, not necessarily in tune with carer’s wishes.

An employer’s aim will naturally be to increase the supply of cheap labour without effecting their margins. A case in point from the report, is the recommendation to remove carers from the visa ineligibility list. I think there would be very few carers who would like to see cheap labour coming in from outside the EU, before providers significantly increase their rate of pay.

In addition to ignoring direct input from carers, the report didn’t consider any input from outside traditional providers and stakeholders. The fact is, it is the status quo that has brought us to this state of play where caring is an unattractive career. Would it not have been useful to consult with a wider spectrum of viewpoints and models, to try and get a different perspective on the issues?

There seems to be a lack of immediacy in the report, with many of the recommendations medium term solutions rather than something to address the significant issues now.

Many of the recommendations also have a feel of tinkering around the edges when possibly what is needed, is a wholesale restructuring of our social care sector. The level of resources certainly within home care would seem to be sufficient, so should we be looking at a complete redistribution of these resources?

For example, presently in home care the demand side is treated as homogenous with everyone needing the same governance and hand holding when this is patently not true. This leads to a huge amount of resources going towards corporate overheads and governance when this isn’t always needed. We all know that the primary reason for the shortage of carers is poor pay. Could some of these lost resources not be redirected to carers through cutting out the middleman and not providing governance to the same levels where capacity exists with people needing support and their families?

There is nothing in the report about fostering more choice for families and carers and opening up the existing commissioning system which bestows a malignant monopoly on corporate providers, so that a wider ecosystem of provision models exists.

Looking at some of the specific recommendations in the report, recommendation 5 is about having providers pay for travel costs and travel time. This would be a positive move so long as the HSE could be certain that funding for this got fully to carers. In the existing tender, providers put in costs for travel in their pricing but virtually none of these funds have been paid over to carers.

Recommendation 6 seems to be a complete cop out, talking about inviting providers to give a commitment to pay as a minimum, the living wage. Surely that should be a red line and obligatory for any provider receiving state funds for home care?

Recommendation 15 concerning personal budgets has the potential to be the most effective recommendation in the report and also have the most immediate impact. However, this is only so if we are talking about true personal budgets, where the person receiving support has real control over what their care and support look like and not a watered-down version where there is a token transfer of control. Personal budgets where people have to use their funds with specified corporate providers and align with pre-set rules and governance, are not personal budgets. True personal budgets allow people decide by whom, when and how support is delivered. Real personal budgets allow people to take the risks they see as reasonable. Real personal budgets allow people live the lives they want not what the system wants. Real personal budgets fit in with people’s desires not the other way around forcing people to fit into a pre-ordained system.

It's a pity the report didn’t look at Minister Rodheric O’Gorman’s recent initiative to mandate the setting up of a child minders registry which would then allow families to contract directly with childminders using state funds rather than having to use a crèche. Something similar could work very well for older persons facilitating the roll out of personal budgets

The real impact of personal budgets as far as the report is concerned, is that they have the potential to get more funds to carer’s pockets and give carers more involvement in their work, thereby making caring a more attractive career.

Demand for home care is only going in one direction and if we are to meet that demand in the future, we are going to have to look beyond the existing status quo of them and us and one size fits all. The future of home care is local, community based and personal.

Home care provision is a lucrative business in Ireland. Not so much for carers but most definitely for their employers.

A major franchise operator in the UK advises prospective franchisees that with a typical turnover of about €2,000,000, owners can expect profit margins of up to 20% or in money terms €400,000.

In addition, franchisees pay a fee to the master franchisor of 6.5% or €260,000.

So out of an amount of €2,000,000, 33% or €660,000 leaks away from directly funding care delivery.

It is well known that the Irish home care market is significantly more profitable than their counterparts in the UK which means that in a similar Irish scenario, could it be 40% or 45%, between €800,000 and €900,000, leaking away from carers to non-core care activities?

As an example, recently published accounts of a for profit provider shows profits of €2.5M on an estimated turnover of about €6M. That doesn’t take into account directors’ salaries or pension payments!

Disingenuously, with the recent launch of a new home care tender, corporate providers of late have being calling on the HSE and government to ensure higher prices for them so that they can increase wages to carers. Existing accounts for these corporate providers show no new price increases are needed as home care provision presently, is a hugely lucrative business and existing margins give them the ability to already significantly increase wages if they wanted. Indeed, the HSE would do well to remember that around 40-50% of any price increase intended to address the sector’s capacity issues, won’t find its way to frontline carers.

The reason for these corporate providers being able to make such profits in Ireland is that they have a monopoly on home care package funding which means families have to use them whether they want to or not or whether they deliver a good service or not.

What’s needed is a new commissioning system that encourages more choice and in turn more funding to get to carer’s pockets rather than owner’s pockets.

We have to start trusting people and realising that in many cases, they are experts in their own care and are well capable of managing their own care budget. It is a huge waste of resources for the HSE to insist on excessive hand holding around governance even where people have the capacity to self-manage their own care and budget.

The present status quo is causing a huge capacity crisis, driving down the quality of care and holding the home care sector back from playing a much more influential role in our health sector. It’s time for change. True personal budgets are that change.

Change is coming slowly to the home care sector in Ireland. With an entrenched one size fits all system in place and a status quo that is looking to protect it’s market share often at the expense of the needs of families and carers, that change will come about when capacity and quality issues become too much to ignore.

Our platform Home Care Direct is new to the Irish home care market and in our efforts to improve home care provision for families and make caring a more attractive career, that pace of change can be frustrating but feedback from people who are using our service is vital in those moments, to remind us that the service we are offering does in fact serve a purpose and has a role to play in improving the sector we are involved in.

It’s not that we are reinventing the wheel, as platforms in home care like ours, empowering carers and people needing support, to work directly without a middleman in-between, aren’t new. They exist successfully in other countries and are playing an important role in addressing capacity and quality issues within the sector.

This knowledge together with the feedback we get from families using our service and carer’s working on the platform confirm that we are on the right path. Examples of some of this user feedback includes

Client A – We switched from using a traditional agency provider because of the problems we faced having constantly changing carers. With Home Care Direct we get real continuity because carers are earning significantly more but it in fact costs us less.

Client B – We have both agency carers and platform carers coming into us but we have noticed a huge difference in the attitude and motivation of the carers from the platform who are working for themselves. I suppose a lot of it is they are setting their own rates and view us as their clients so they take more ownership of their work. The agency carers change all the time and there seems to be little or no oversight which is supposed to be their differentiation.

Client C – We have a home care package for my parents from the HSE but they haven’t been able to find us a carer for over 3 months so we are paying privately for a carer from the platform which we found within a week. Her attitude is amazing. The HSE seemed to be happy to leave us without support being more concerned about tender arrangements.

Carer A – I had left the care sector after not being able to make ends meet working for €11/hr. I didn’t want to change but the retail job I found paid much better and was easier. Thankfully I came across Home Care Direct and after a little bit of hesitancy about working for myself, I am back in the home care sector I love and earning significantly more than I did even in retail. I actually love the increased responsibility I have and the fact I am in control, not a line manager. I think my clients are getting a really personal service and they have even recommended me to friends. I see myself not just as a carer but a mini entrepreneur.

As we build our book of evidence through testimonials like this and as our army of advocates grows for the advantages of our model, we are beginning to see the first changes that are needed in our home care sector to bring down waiting lists and allow home care play a much fuller role in our health sector. These local ripples will spread and hopefully in time, we will get a home care sector swamped with the waves of real choice, where families are trusted that they are often the experts in their own care and where caring is a truly valued career.

Personal budgets, where people needing care and support are trusted to self-manage their allotted budget and support, are a vital and much in demand form of home care in numerous countries throughout the world. They play an important role in providing increased choice and also in making care and support much more personalised.

The principles of the European Pillar of Social Rights and the UN Convention on the Rights of persons with disabilities both encourage the transition towards quality person-centred, inclusive and community-based services, as well as more person-centred funding models such as personal budgets.

Unfortunately in Ireland, this transition has been slow and disorganised. Yes, we have a National Personalised Budget Pilot Programme for the disability sector but it’s roll out has been slow, terribly underfunded and as far as we can see, set up to fail. For older people there is no such pilot programme, only a very watered-down scheme under the existing home care tender called the Consumer Directed Home Support Pilot. This basically gives families the right to select a provider from an approved list of companies that all offer the exact same service. A bit like Henry Ford’s idea of choice when he said “you can have any colour Model T so long as it’s black”. It also allows them to have a say over when support is delivered. This is a far cry from what real personal budgets look like.

The three major problems with the roll out of personal budgets in Ireland as we see are;

Unbundling of Funds

In general, at least within the disability sector, if someone wants to go down the personal budget route, there is no new funding for that. What they have to do is get access to or unbundle, the funds being used for their existing traditional service provision, so that they can use them as their personal budget. The problem here is, that firstly the traditional provider is very often reluctant to give up that funding and secondly when they do, it is nearly always a minimum amount of funding related directly to actual hours of service provision and not the actual amount that these service providers invoice the HSE for delivering the service. For example, the company might be invoicing the HSE say the equivalent of €40/hr to provide a traditional service for person A but when person A wants to go down the personal budget route, they are only offered maybe €18/hr to recruit and manage their own team of personal assistants while the company pocket the difference. Patently unfair.

Lack of an Appropriate Service Level Agreement

Where a person gets does access to a proper level of funding for a personal budget, the next problem is that the HSE have only one type of service level agreement, which is only suitable for a full agency type of service where control and responsibility sits with the corporate provider and not with the person themselves. They do not presently have a service level agreement that reflects what a real personal budget is. A service level agreement that sets out clearly the extra responsibility that the person needing support is taking on as well as the fact that they are in control and the responsibilities of the HSE and where applicable the responsibilities of a broker or intermediate.

This seems incredible considering there is a national pilot programme in place for personal budgets and harks back to my point of the pilot having been set up to fail.

HSE Reluctance to Cede Control

The third reason for the slow roll out of personal budgets is the HSE’s reluctance to cede control and accept that in many cases it is the people needing support who are experts in their own care and that they are capable of self-managing their own support. This goes to the excessive hand holding that is inherent in much of the HSE’s provision of support and results in huge wastage, top down rather than personalised care and a huge amount of frustration for many.

We are not talking about financial oversight of public funds, that has to be present. We are talking about the need to have the appearance of control over the quality of provision and what is best for people. I say appearance, because in reality the control the HSE like to think they have is in practice not there, due to a lack of resources for supervision and checking.

Personal budgets have a huge roll to play in delivering better and more personalised care and support for people. They can also play an important role in getting better value for money with less funds being lost to corporate overheads and profits and more getting to the people needing support and the carers and PAs delivering it.

Importantly, by getting more funds into carer and PAs hands they can also directly affect the present capacity crisis in home care by making caring a kore attractive career.

However, if personal budgets are to play these roles, the HSE need to address the issues holding back their use and make a decision to really foster their availability and growth rather than stymie it.

The home care sector in Ireland is experiencing huge capacity issues because of a lack of carers. The main reason for this is that low pay and poor employment conditions from corporate providers, means that caring isn’t an attractive career.

At Home Care Direct we have as one of our missions, the aim to make caring an attractive career and in doing so, directly address the capacity issue the sector is facing.

We do this by putting carers at the centre of what we are doing. We empower them and put them in control. Because of this, we are attracting new people into caring and also keeping existing carers who otherwise would be leaving the sector.

In fact, a recent survey we carried out amongst carers on our platform, found that 29% were new entrants to caring and a further 24% were carers who were on the point of leaving the sector. That means that over 50% of the capacity that the Home Care Direct platform is bringing to the sector, is NEW capacity.

Take the case of attracting new entrants. Mary is from Tullamore. Mary is keen on contributing towards her local community and does so by being involved in the local GAA club, the parish and the local community centre. Mary knows most people in the town and most people know and trust Mary.

Mary would be very open to doing care work as well locally, but she has no interest in working for a corporate provider earning barely above the minimum wage. However, she is very interested in being enabled to work for herself in a safe and tax compliant manner, setting her own rates and availability and in addition having all her administration and tax returns managed for her.

At Home Care Direct we are making it easy to work for yourself and in doing so, enabling an army of Marys across the country.

Now take Siobhan living in Navan who has being working for the last 5 years with a corporate provider for €11.50/hr. She finds her roster changing on a regular basis building up little continuity with her clients and she is constantly asked to do last minute fill ins which don’t suit her. Siobhan is an experienced carer with her QQI major award but she feels undervalued and in these times of increasing costs just unable to cover her bills. She loves caring and knows she is capable of delivering great person-centred care but is prevented from doing so because of the system she works under. With a heavy heart she recently applied to the local Lidl for a job that pays significantly more.

At Home Care Direct we help the Siobhan’s of this world to turn her love for caring into an attractive career, enabling her to earn rates of €23/hr and to set her own availability. She also loves the feeling that her families are HER clients not an agency’s and because of this she is motivated to deliver an excellent person-centred service. She also loves taking on the role of sales and marketing for her micro enterprise. Most of all, she is delighted she never took up that Lidl job offer and is continuing to do what she loves best.

Having other options for both families and carers in how care is delivered is one way of addressing the capacity crisis in caring. Our existing one size fits all corporate model will never attract or hold the Mary’s and Siobhan’s of this world which is a serous problem taking into account the ever-increasing demand for home care.

Our commissioning system and upcoming regulation, needs to embrace new ways of working as well as fostering a wider ecosystem of providers, in order to offer both carers and families REAL CHOICE.

We have a real capacity crisis in home care at the moment. Demand for services is soaring, funding is in place but there is a lack of carers to meet that demand mainly because wages are so poor for such an important role.

No problem I hear you say. Let providers just increase carer wages, problem solved. Unfortunately, it’s not quite that simple.

The way the home care sector works in Ireland is that roughly 60% of provision is outsourced to a limited list of approved corporate providers. This means they have a monopoly on funding and this together with the dispersed nature of the business, means they have huge power when it comes to setting carer wages and in turn their own profits.

The first issue is, do these providers have sufficient margin to increase wages? A recent blog we published demonstrates that they do (https://homecaredirect.ie/blog/how-can-we-ensure-a-better-use-of-funding-within-homecare/ ) without any need for price increases from the HSE.

The second issue is, do they have the will to do so? The question to ask is what’s in it for them? Their present situation is that they are making very generous margins even though they might not be growing that much. Taking into account home care is an extremely pressurised business because of its highly people orientated nature, is it worth corporate providers to reduce margins to increase turnover but maybe only end up with the same bottom line?

Remember a large number of these providers are husband and wife type operators with turnovers between €2M and €5M making a lucrative return with unlimited demand. Do they want to run faster just to stand still?

If the will isn’t there from existing providers to increase capacity significantly surely the sensible thing is to allow those idle funds be used in other ways to help meet the demand there is for home care?

One simple and obvious way to do this would be to allow families use those funds to contract directly with carers in their locality where appropriate. If it costs the HSE say €27/hr to provide care through outsourcing, where they can’t provide care, why not allow families use those funds to contract and manage their own care directly? At €27/hr families would most definitely find local people that suit their needs. This kind of option is available in most other countries.

An option like this would bring new people into caring but also ensure those funds are spent locally rather than being lost to corporate overheads and profits, generating a huge economic benefit that would be really welcomed in these challenging times.

With waiting lists for home care rising, surely it is better to give families other options rather than leave them waiting for care and leaving funds idle in Government coffers?

Louise one of the carers on our Home Care Direct platform was on Ireland AM last week, giving the view from the frontline on why there is a shortage of carers but also offering a practical solution.

Louise is a great example of how capable many carers are but how their passion for caring and contributing to their communities, is being destroyed by the poor employment conditions offered by corporate home care providers.

So many care situations don't need a full agency type service, so why can't families use the funds it would have cost the HSE, to contract directly with local carers? Surely that's better than leaving them on growing waiting lists?

If we want more carers like Louise, and we are convinced there is an army of mini entrepreneurs like Louise out there waiting to be activated, we need to move away from our present one size fits all system and give carer's like Louise other options in how they work and contribute to their communities and in doing so, give families who are waiting on care more choice and control over what their care looks like.

https://www.virginmediatelevision.ie/player/show/809/196632/0/