Read the full evidence outline that looks at new models of care at home and the evidence supporting their use (including references).
While care at home appeals as a way of supporting people to live independently the evidence suggests it is on the whole not doing this well. Despite the promotion of choice, control and independence, the lived experience is often short, care-assistant visits, focused on basic tasks like eating, medication and getting dressed. This time-and-task commissioning remains the dominant approach. But the growing number of people with complex health and social care needs, together with continuing tight finances, means this current model of care could be seen as neither sustainable nor meeting people's needs.
Evidence
Finding evidence on the impact of non-traditional social care and support approaches is challenging generally, and this search revealed little in the way of strong empirical research from Scotland and comparable countries, around new (and existing) models of care at home. There are a number of alternative approaches to independent, inclusive living, but few examples being widely implemented in practice, little evidence of consistent efforts to share learning, and the extent to which they can be scaled up is questionable. Many are new or still being piloted and require the collection and monitoring of outcomes data. There is arguably a lack of sufficient skills, time and resources to properly support this.
The current system seems to support local innovation rather than widespread improvement, and is often dependent on local leadership, a willingness to change, and the availability of additional funding.
It should also be noted the focus in the published literature is very much on support for older people. There are considerable gaps when it comes to other groups.
There is agreement though that provision of care in the home has to be seen in a wider context, including community assets, wellbeing and prevention, the role of unpaid carers, and other services such as healthcare and housing.
Commissioning
Alternative approaches to commissioning are widely supported in principle, but rarely fully achieved. Traditional approaches are frequently cited as a barrier to spreading innovative models of care. Those looking to change the way care is organised and experienced by service users can find inflexible and risk-averse commissioning and an unwillingness to move away from a time-and-task approach. The need to broaden the commissioner role, focussed on outcomes and as part of a collaborative partnership model with providers and other stakeholders, is recognised. Despite this, progress towards outcomes-based commissioning has been slow and inconsistent, with little evidence of a shared understanding of the concept or how to fully measure it.
Autonomous team working / neighbourhood care
The evidence base from the Netherlands shows lower costs, reduced demand, lower staff turnover, and high satisfaction rates for people supported by the Buurtzorg model. Cultural and regulatory differences in the UK have presented difficulties in adapting it. Where the neighbourhood care approach has been adopted, it has provided good quality of care with positive feedback from staff and clients, but has required additional investment and more flexible commissioning.
Collaboration / multi-disciplinary teams
The evidence suggests that MDT approaches are associated with improved experiences and outcomes for people who use services, including a reduction in service use, increased self-management and preventative care, engagement and activation through social prescribing and shared decision-making, and greater continuity of care across different care settings.
Workforce
A general need to elevate the professional status of domiciliary care is identified across the literature. Those delivering it are essential to quality of care, and improving their status, pay and conditions, and opportunities for progression is seen as vital, particularly with ongoing high rates of turnover. Greater self-management, autonomy, and collaboration are seen as likely developments in a future social care workforce, with increased blurring of job roles and a wider range of health and care responsibilities. Better engagement between commissioners and providers to identify suitable support needed for future service demand is key to understanding and securing capacity.
Housing
Closer working between social care, health and housing services is needed. The right home environment can maintain or improve people’s physical and mental health, wellbeing and social connections, enable them to carry out day-to-day activities safely and comfortably, and help them to do the things that are personally important.
There are new models of care recognising this, offering the ability to remain at home or in a more homely setting for longer. These range from developing existing models such as home adaptations to communal living arrangements with shared home care provision and live in care. However, the majority of older people live in mainstream housing that often does not meet people’s needs as they get older - small room sizes, internal stairs and outside steps, baths rather than showers. Installing aids and adaptations such as rails and level access showers, can improve a home's accessibility and usability.
Community / social connections / networks
Connecting people to wider community support and resources and cultivating partnerships with local voluntary services, housing associations and other community organisations creates the capacity for self-care and social prescribing, enhances health and wellbeing, and promotes resilience and independence. Approaches like Community Circles, Circles of Support, asset-based community development, and local area coordination, aim to harness these resources. The use of micro-enterprises, underpinned by personalisation and personal budgets, can be a central part of this.
Involving people and families
Service users, carers and families are the voices missing from most of the discussions around new models of care. Individuals, carers and families should have a much greater say in their care and be more involved in the relationships between providers and commissioners. The need to involve people who use services, their families and carers better and earlier in discussions about social care supports is a consistent theme in the recent Scottish Government Independent Review of Adult Social Care.
The potential benefits of models based around family are clear, but are not appropriate or feasible for all those who need care.
Self-directed support / personalisation
Progress here has been slow and inconsistent. Personal budgets, offering individual rather than commissioner choice and control, have not had the transforming effect on services they should have. Many home care providers feel it can support more flexible, innovative and person-centred care delivery in principal, but the reality is system barriers, lack of understanding and poor communication.
Telecare / tech / digital
Social care at home has seen little benefit from advances in technology. Current use of technology is mainly home-based adaptations such as handrail fittings, lighting improvements, and stair lifts. Technology Enabled Care in people’s homes can support and promote independence, manage risk, and provide assurance, but there are concerns around its use to reduce costs and face to face support, and whether there is any real demand from commissioners and service users. Technologies might be best seen as an enabling or preventative tool for care workers, service users and carers to support new ways of working, not as a replacement for the social care workforce.
This literature search was limited from 2015-present using a variety of sources and databases, including NHS National Education for Scotland's Knowledge Network, Social Care Institute for Excellence, Google Scholar, ASSIA, Emerald, and Ovid.
Suggested reference: Sanders, R (2020) ESSS Outline: New models of care at home. Iriss. https://doi.org/10.31583/esss.20211124
