Avril Craig and Romana Khaoury interviewed older people to gauge their experiences of domiciliary care, and make practical recommendations for how it can improve
Longer life expectancy has meant that the proportion of those requiring more complex social and health services has risen as a consequence
That we live in an ageing society where people live longer is beyond dispute. Longer life expectancy means the proportion of those requiring more complex social and health services has risen as a consequence.
‘The research shed light on the value of person-to-person contact for the older people we interviewed’
By comparison with the rest of the UK, Northern Ireland has the fastest growing population – and it is ageing. Predictions indicate the number of elderly people aged over 85 will almost double from 2010-26. This ageing population in Northern Ireland presents significant implications for the provision of health and social care services, particularly in the area of domiciliary care.
The purpose of our study was to explore the views of older people and carers receiving a domiciliary care service from across the country. A mixed methods approach was used combining qualitative and quantitative methods, with the aim of investigating the older person’s and carer’s perspective and to increase the comprehensiveness of the overall findings.
Importantly, the research provided more than a description of how domiciliary care operates on a daily basis and it shed light on the value of person-to-person contact for the older people who were interviewed.
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Context and policy
The focus of social care in Northern Ireland under principles set out in the 1990 People First community care document is to support people in their own homes for as long as possible. In general, older people favour this approach to their care provision.
Domiciliary care is defined as the range of services put in place to support an individual in their own home. Services may involve routine household tasks in or outside the home; personal care of the client; and other associated domestic services necessary to maintain an individual in an acceptable level of health, hygiene, dignity, safety and ease in their home.
‘Addressing isolation brings new challenges to the social care system and goes wider than health and social care services’
In Northern Ireland there are five health and social care trusts that, as part of an integrated health and social care service, provide domiciliary care. The number benefiting from the policy has increased steadily. The latest figures, for 2011, show that 23,552 people receive domiciliary care. The service is delivered by a mix of statutory and independent providers, though use of the latter is growing.
The purpose of the study was to gain insight into and describe the experiences of older people and their carers, who deliver a range of care services in the context of pressure on services and the potential changing policy context for home care.
The research found domiciliary care provides an essential service for many people living at home, sustaining independent living and assisting families. On the whole, most people interviewed rated the service highly, both for the quality of care provided and the supportive and friendly approach of the care workers.
Nevertheless, there were a number of recurring issues that remain a cause of concern and which reflect the pressure and problems facing the social care system. These are discussed below.
Continuity of care: People did not see the same care workers every day and often the worker was poorly informed about the individual’s needs. This lack of continuity was very unsettling for some vulnerable older people, particularly coping with different people coming into their home on a daily basis and at irregular times.
Time pressure: One of the most frequent issues among respondents was the amount of time care workers spent in their homes. While some recognised care workers struggled under heavy workloads, they felt the time constraints in the service meant essential needs were not being met and therefore workers rushed and did not take time to talk or encourage the older person. Such time pressure has a negative impact on the quality of care providedat a physical and emotional level.
Poor organisation: Problems with care providers at an organisational level were a recurrent theme, specifically the lack of communication between them and the clients. A common complaint was that clients were rarely informed if a care worker was leaving and someone new was starting, so they had no idea who was coming to their home. A few people said that care staff seemed similarly ill informed and often arrived at the house with little or no knowledge of the person they were there to assist.
Inflexible service: Many people said they would like to see more flexibility in domiciliary care services. This was most commonly expressed in relation to inconvenient or irregular visiting times which could result in people not being helped out of bed until lunchtime or being put to bed much too early in the evening when they were not tired enough to sleep.
Some people suggested poor coordination and organisation from above was responsible for this lack of flexibility. Others felt care workers were much too restricted in the tasks they could perform, which made an already inflexible service even more limited.
Social isolation: In addition to the physical strains on the system, there is a need to address the social and emotional issues experienced by older people. For some people the care was valued simply because it brought human contact, otherwise they might not see anyone from one day to the next. For older people on their own or whose family do not live close by, the care workers provide a lifeline. As this study has indicated, domiciliary care means more to older people than just physical help with everyday activities.
Addressing isolation brings new challenges to the social care system and goes wider than health and social care services. If we are serious about prevention, then addressing emotional health and wellbeing is key to the quality of life experienced by older people receiving care.
Practical steps and key recommendations to improve care
The rise in the number of older people in Northern Ireland’s population is a key issue for policymakers, stakeholders and the public as the social care model is encountering a range of demographic, economic and social tensions and will continue to do so.
The following practical steps and recommendations are suggested for domiciliary care services to enable the sector to adapt efficiently in response to an ageing society:
- A multi-agency group should be established, including transport and housing providers as well as health and social care, which is focused on practical outcomes for older people who need support.
- Stakeholders should facilitate opportunities for all to have discussions about how home care is assessed, planned and delivered. This is to ensure that service users, carers and the public have the chance to contribute to the future of domiciliary care.
- Domiciliary care provision should link clearly to wider policy initiatives to ensure older people receive a joined up service.
- There should be an ongoing evaluation of the implementation of reablement schemes. Reablement should be incorporated into the wider strategic framework for supporting the care needs of older people.
- Emotional support should be provided with care packages that include options such as a befriending service to address the social isolation of many older people.
- Older people should be provided with a range of choices which address their needs and are seen by them as desirable options for their future care.
Care providers need to take steps to ensure:
- Staff are aware of the need for maintaining dignity and respect for the person receiving care and relatives caring for them. Furthermore, providers of domiciliary care (trusts and private providers) should ensure their staff receive consistent training so the privacy, dignity and safety of the person receiving care not only meet minimum standards but are maintained at the highest possible level.
- Continuity of care must be ensured in order to make sure that any risk or changes in the needs of vulnerable adults are identified quickly.
- A clear patient pathway should be established which ensures a smooth transition from hospital to care at home.
Older people value the care services they receive, although there are still problems with the way care is delivered. If older people’s health and wellbeing are to be truly addressed, then domiciliary care services need to provide a holistic approach to meet the individual’s needs.
Dr Avril Craig is a research officer and Dr Romana Khaoury was a research assistant at the Patient and Client Council