Home care provision can be broken down into two broad segments. Care that is funded by people themselves or family members and care that is funded by the state. They are two very different animals.

Self-funded care is generally characterised by personalised care arrangements put in place with the full involvement of the person being cared for, as well as the carer. It generally costs less than state care and delivers value for money with all unnecessary overheads removed and the majority of funds going directly to the carer. Its usually very strong on continuity with the same carer or carers coming in week after week. It’s not overly prescriptive on what can and can’t be done, rather concentrating on what works for the person being cared for. It often encourages the involvement of others and can foster neighbourly engagement.

Importantly, the State is hardly involved in controlling, verifying or managing this care in any way.

On the other hand, state funded care is expensive with huge amounts of funds spent on managing, controlling and verifying. Only a small percentage of funds go to carers the most important link in the chain. Continuity is a massive problem with carers changing every few months. Its very prescriptive on what care and by whom it can be delivered. Standardisation and measurability are prioritised.

Yes, I know I am generalising to a certain extent but by and large I think the assertions are correct. Does abuse happen in self-funded care? Yes, without a doubt but is it any more than in state funded care? I know also that a lot of people can’t fund their own care but the point here is to highlight the different outcomes under the two scenarios and ask should state funded care look more like self funded care?

What are the differences between the two segments? For me there are three principle differences, Choice, Trust and Autonomy.

In the case of self-funded care, families have wider choices on what care looks like and who delivers that care. They are trusted to be able to make those decisions and subsequently manage that care. Lastly, they and their carers have autonomy without any need to adhere to KPI’s or reporting processes.

Life is incredibly complex and so is the delivery of home care. Is trying to simplify the commissioning of home care into a tender with specifications, KPI’s and reporting requirements doing an injustice to the people involved and the work they are carrying out?

Having specifications through a tender, immediately assumes a standardised service delivery. The problem is people aren’t uniform. They are incredibly varied and different. A rule based homogenous response, can’t cope with the variety of people’s needs. What a tender with a list of approved corporate providers adhering to a set of standardised rules and processes does, is take away the opportunity for a more personalised and nuanced response that stems from say a carers experience or knowledge of someone’s needs.

It also imposes a set of overheads on all care situations whether they are needed or not.

What specifications do, is allow for measurement and a subsequent focus on price. In order for providers to be compared on price the service has to be standardised. This suits the accountants and, in many cases, those corporate providers but not necessarily the people receiving the care.

By carrying out tenders in their existing form, we are holding providers and families to account for outcomes that they don’t have full control over. Are KPI’s and reports just giving us the illusion that we are controlling an incredibly complex system, we don’t and can’t? Does the present tendering system just encourage gaming in the production of information whether that be in the tendering process itself or in the subsequent delivery of care? Does it disadvantage smaller more direct forms of provision who don’t have the specialised departments to fill in forms and regurgitate reports?

I think this crisis has helped to highlight the inherent capabilities of people and communities and also that the world won’t fall apart if we relax the rules somewhat and do things in a different way.

Commissioning of home care needs to change to foster the positives we see with self-funded care. Commissioning needs to foster the intrinsic motivation to deliver great care not just the meeting of externally set targets which are rarely checked anyway.

Sometimes I think we forget, that it is not systems and organisations that produce great outcomes. Its people.