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Home care sector in ‘extremely fragile state’, report warns

Funding squeeze and staff shortages driving providers to desert market

Caroline White

Tuesday, 11 December 2018

The home care sector is in an “extremely fragile state,” in some parts of England with a squeeze on funding and persistent staff shortages driving providers to desert the market, finds a new report* published today by heath think tank The King’s Fund and the University of York.

In 2017 providers handed back home care contracts in more than one in three local authorities, and some of the largest providers have withdrawn from the publicly funded home care market altogether, says the report.

Care is provided at home to more than 350,000 older people and 76,300 young people with disabilities each year. An estimated 249 million hours of home care are delivered annually, most of which is personal care but it also covers reablement services for those leaving hospital and broader support, such as helping someone with learning disabilities live independently.

Between 2016 and 2018, The King’s Fund carried out three pieces of research exploring: the factors driving commissioning adult social care; the mechanisms of purchasing and delivery of home care; alternatives to traditional models of delivering care at home.

The report draws together the findings of those research projects, which record the stated opinions of commissioners, providers, and other stakeholders.

The analysis found that staff shortages are a “relentless challenge” for home care providers in many places, but the extent of the challenge varies greatly depending on geographical location, with those in rural and affluent areas finding it particularly difficult.

The analysis found that fees paid by some local authorities were too low to maintain quality services, leading to high turnover of providers and staff. But commissioners and providers disagreed about whether the quality of home care had declined in recent years and, if it had, the role of fees in that process.

Faced with reductions in their central government grant, councils spent 3% less on social care in 2017-18 than in 2009/10. But some local authority commissioners are sceptical that increasing fees will boost quality or staff wages, fearing the extra cash will go into the care provider's profits.

Four in 10 home care workers leave their role every year and more than half of home care workers are on zero hours contracts, the analysis found.

In 2016-17 around 500 new home care agencies registered each quarter and 400 left the market. In a 2017 survey, many council directors of adult social services had experienced home care providers ceasing to trade in the previous six months (39%) or contracts being handed back (37%).

The report found that home care continues to be commissioned on a “time and task” basis under which providers are paid per hour to provide care but with no measurement of the health and care outcomes achieved. Nor is there much evidence that health and care providers are joining up commissioning of home care.

This needs to change, recommends the report.

Alternative approaches to home care provision have yet to show that they can be scaled up effectively, while approaches using new technology have not yet had time to be properly evaluated.

The findings come as one major home care provider, Allied Healthcare, is sold and transfers many of its contracts to other providers.

Simon Bottery, senior fellow, social care, The King’s Fund, commented: “Squeezed funding and a shortage of workers have left the home care sector in a fragile state. Home care providers are competing for staff with other sectors paying higher wages, offering more stable employment and better working conditions.

“The system needs a fundamental overhaul, beginning with the upcoming Green Paper, but the prize of a better, more effective home care service is worth having.”

Counsellor Ian Hudspeth, chairman of the Local Government Association’s Community Wellbeing Board, said the report was “worrying” and “further evidence of the funding crisis in adult social care and its consequences.”

He continued: “The squeeze on local government funding overall, coupled with rising demand and increasing cost pressures in adult social care, mean many councils are having to make significant savings and reductions within adult social care, which is impacting on an ever more fragile provider market.

“Government needs to plug the £3.5 billion funding gap facing adult social care by 2025 to ensure that quality home care provision is available and continues to play its vital role in supporting people to remain independent and well at home, rather than in costlier settings such as care homes or hospitals. With the right investment and profile, the care profession should be made to be a more attractive, rewarding and fulfilling career."

He added: “While one-off funding injections may help curb the severity of immediate pressures, they are only short-term.”

The government needed to be bold in its forthcoming Green Paper by setting out options to secure the stability and sustainability of social care for the long-term, he insisted.


*Home care in England: Views from commissioners and providers. A report prepared by The King's Fund, December 2018.

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