Will Direct Payments Make Adult Residential Care more Personalized? Views and Experiences of Social Care Staff in the Direct Payments in Residential Care Trailblazers

Direct payments, i.e. cash payments made directly to the individual in lieu of social care services, have become an established option in council‐funded domiciliary care as a means to better personalize care and support. As part of its agenda to modernize social care, the Government tested their use in long‐term residential care in 18 trailblazing councils in England. This article presents findings from the independent evaluation of this initiative, using interviews with project leads seconded to the programme in all participating councils, and with council and care home staff involved in implementing direct payments in residential care in five sites. Interviews were conducted between September 2014 and November 2015. They explored professionals' views and experiences of personalization in residential care and their thoughts on the potential contribution of direct payments to promoting personalization. Whilst there was agreement that good care takes personal preferences into account and that many care homes could provide a more personalized service, doubts were voiced about whether direct payments were an appropriate mechanism to achieve this aim. This was seen as particularly pertinent in relation to residents with very high care needs and limited capacity to exercise choice and control. Interviewees also identified a number of risks and challenges to implementation, including financial risks to care homes. The findings from these interviews suggest that the contribution of direct payments to personalizing residential care may be more modest than expected.     

“A game of two halves?” Understanding the process and outcomes of English care home closures: Qualitative and quantitative perspectives

With care services increasingly delivered via a market there is always a risk that care homes could fail financially or struggle in terms of quality, ultimately having to close. When this happens, the received wisdom is that subsequent relocation can be detrimental to the health and well‐being of older residents (possibly even culminating in increased mortality). However, there is very little formal evidence in the United Kingdom (UK) or beyond to guide policymakers and local leaders when undertaking such sensitive work. Against this background, this article reports findings from an independent evaluation of what is believed to be the largest care home closure program in the UK (and possibly beyond). This consisted of qualitative interviews with older people, families, care staff, and social work assessors during the closure process in one case study care home and one linked day center, as well as self‐reported health and quality of life data for older people from 13 homes/linked day centers at initial assessment, 28 days after moving and at 12‐month follow up. The study is significant in presenting public data about such a contested topic from such a large‐scale closure process, in its focus on both process and outcomes, in its mixed‐methods approach, and in its engagement with older people, families, and care staff alongside the use of more formal outcome measures. Despite significant distress part‐way through the process, the article suggests that outcomes either stayed the same or improved for most of our sample up to a year after moving to new services. Care homes closures may thus be a “tale of two halves”, with inevitable distress during the closure but, if done well, with scope for improved outcomes for some people in the longer term. These findings are crucial for current policy and practice given that the risk of major closures seems to be growing and given that there is virtually no prior research on which to base local or national closure processes. While some of this research is specific to England, the underlying issue of care home closures and lessons learned around good practice will also apply to other countries.     

Managing the Care Home Closure Process: Care Managers' Experiences and Views

This paper reports case study research that set out to identifywhat care managers do during independent care home closures.Little research has focused on the way in which care homes forolder people are closed in England, or what those involved thinkabout the process. This paper reports the activities and viewsof care managers directly involved in helping older people relocatefrom care homes that were closed by their owners. During suchclosures, residents and their families have no choice but tomove, usually to a deadline, and with little control over theprocess. Care managers have a responsibility to help arrangealternative care for those current residents who are publiclyfunded, and to offer information and support to those fundingtheir own care (the ‘self-funded’). Closure relatedactivities could involve considerable staff time. Care managementarrangements, including the organization of teams and provisionof needs assessments, varied across authorities. The care managersdescribed drawing on emotional counselling and inter-personalskills, as well as practitioner knowledge and experience, particularlywhen offering support and advice about finding appropriate newhomes. Tensions between aims, constraints on their actions andviews of good practice are identified.     

Lay Assessors and Care Home Inspections: Is There a Future?

This paper reports on research funded by the Nuffield Foundationexploring the role of lay assessors in the care home inspectionprocess in England and Wales. Lay people have been includedin many care home inspections for the past decade. Similar layinvolvement is included in other public service inspectionssuch as the Office for Standards in Education (OFSTED) inspectionsof schools. The Board of the short-lived National Care StandardsCommission (NCSC) controversially decided to dispense with suchlay involvement in the inspection process. The replacement body,the Commission for Social Care Inspection (CSCI), intends toinclude lay people in the inspections of support services inthe community but is hesitating about reintroducing them intocare home inspections. This research project was able to explorethe role taken by lay assessors in thirteen inspections of carehomes for older people and for adults with learning disabilities.The research concluded that lay assessors had a significantrole in communicating with residents and staff and observingcare home life. Their role was particularly important, as inspectorswere often so involved in paperwork and checking policy compliancewith the national minimum standards that they were often ableto spend little, if any, time talking to residents or staff.It is argued that there is considerable potential for a strengthenedrole of lay people in the care home inspection process.     

The Effect of Financial Incentives and Access to Services on Self-funded Admissions to Long-term Care

With the growth in the numbers and proportion of older people in the population the funding and incentive structures around long‐term care are of international concern. A study of the circumstances of self‐funded admissions to care homes allowed the comparison of self‐funders with publicly funded admissions to care homes in the UK, the influences on self‐funders in their decision to move into a care home and resources on which they were able to draw. These findings contribute to our understanding of the impact of current policy on self‐funders and our thinking about the way that future policy and practice changes could improve the way we use society's resources in the provision of long‐term care.     

‘Replacement Care’ for Working Carers? A Longitudinal Study in England, 2013–15

In the context of rising need for long‐term care, reconciling unpaid care and carers’ employment is becoming an important social issue. In England, there is increasing policy emphasis on paid services for the person cared for, sometimes known as ‘replacement care’, to support working carers. Previous research has found an association between ‘replacement care’ and carers’ employment. However, more information is needed on potential causal connections between services and carers’ employment. This mixed methods study draws on new longitudinal data to examine service receipt and carers’ employment in England. Data were collected from carers who were employed in the public sector, using self‐completion questionnaires in 2013 and 2015, and qualitative interviews were conducted with a sub‐sample of respondents to the 2015 questionnaire. We find that, where the person cared for did not receive at least one ‘key service’ (home care, personal assistant, day care, meals, short‐term breaks), the carer was subsequently more likely to leave employment because of caring, suggesting that the absence of services contributed to the carer leaving work. In the interviews, carers identified specific ways in which services helped them to remain in employment. We conclude that, if a policy objective is to reduce the number of carers leaving employment because of caring, there needs to be greater access to publicly‐funded services for disabled and older people who are looked after by unpaid carers.     

Family councils in nursing facilities: strategies for effective participation

This article provides an overview of the role of family councils. The contributions of the three groups that play a significant role in the development and support of family councils, relatives and friends of the facility's residents, facility administration and staff, and local advocacy organizations, are discussed. The role of the staff advisor, generally the facility social worker, is a major key to a successful council. Barriers that impede family council success are identified, and strategies that improve effectiveness are presented. Family councils play an important part in improving the quality of lives of long-term care residents.     

Increasing Choice and Control for Older and Disabled People: A Critical Review of New Developments in England

This paper critically examines new policies currently being implemented in England aimed at increasing the choice and control that disabled and older people can exercise over the social care support and services they receive. The development of these policies, and their elaboration in three policy documents published during 2005, are summarized. The paper then discusses two issues underpinning these proposals: the role of quasi‐markets within publicly funded social care services; and the political and policy discourses of consumerism and choice within the welfare state. Despite powerful critiques of welfare consumerism, the paper argues that there are nevertheless very important reasons for taking choice seriously when considering how best to organize and deliver support and other services for disabled and older people. A policy discourse on consumerism, however, combined with the use of market mechanisms for implementing this, may be highly problematic as the means of creating opportunities for increased choice and, on its own, risks introducing new forms of disadvantage and social exclusion.     

Professional Perspectives on Decision Making about the Long-term Care of Older People

With the increasing pressure on social and health care resources,professionals have to be more explicit in their decision makingregarding the long-term care of older people. This groundedtheory study used 19 focus groups and nine semi-structured interviews(99 staff in total) to explore professional perspectives onthis decision making. Focus group participants and intervieweescomprised care managers, social workers, consultant geriatricians,general medical practitioners, community nurses, home care managers,occupational therapists and hospital discharge support staff.The emerging themes spanned context, clients, families and services.Decisions were often prompted by a crisis, hindering professionalsseeking to make a measured assessment. Fear of burglary andassault, and the willingness and availability of family to helpwere major factors in decisions about living at home. Serviceavailability in terms of public funding for community care,the availability of home care workers and workload pressureson primary care services influenced decision ‘thresholds’regarding admission to institutional care. Assessment toolsdesigned to assist decision making about the long-term careof older people need to take into account the critical aspectsof individual fears and motivation, family support and the availabilityof publicly funded services as well as functional and medicalneeds.     

Do hours matter? The relationship between motivation and study intensity in learners of English in Scotland

This paper examines the impact of English language learners’ motivation on their choice of study intensity using data from a national survey of learners in publicly funded English for Speakers of Other Languages (ESOL) courses across Scotland. In particular, the motivation of learners attending only a few hours per week (i.e. very part-time learners) is compared with those attending for more hours. Our study found that there are differences in motivation and aspiration amongst very part-time and part-time or full-time learners but also that employment and child care may have as much influence as motivation in causing learners to enrol on very part-time English classes. The findings relating to these learners in our study present a particular challenge to ESOL providers which offer only very part-time courses.     

Questions Raised for Local Authorities when Old People are Evicted from their Care Homes

Correspondence to Peter Scourfield, School of Community, Health and Social Studies, Anglia Polytechnic University, Cambridge CB1 1PT, UK. E-mail: p.scourfield{at}apu.ac.uk Summary Successive government policies have created a situation wheremost residential and nursing care is provided by the independentsector. It is in the nature of a marketized and privatized caresystem that homes will periodically close or change ownership.The physical and mental well-being of elderly residents experiencingeviction and relocation can be seriously damaged by the experience.No policy and practice guidelines have been issued from centralgovernment to cover how care home closures should be managed.Local authorities are therefore dealing with such events onan ad hoc basis. Understandably, the main emphasis is oftenput on actually finding appropriate alternative placements.Practices vary across different local authorities. This articleasks whether the necessary work required to minimize the harmfuleffects caused by the stress of relocation is actually beingcarried out properly. It also raises the questions of what exactlyshould be offered to older people when they are given noticeto quit, who is best qualified to do the work and whether caremanagement as it has developed within the ‘purchaser/providerframework’, is adequate to the task. In short, where cansocial work for older people be found when it is needed?     

Regulating child care: from the Children Act 1948 to the present day

This article reflects selectively on the development of the legal regulation of child care practice in England and Wales since the Children Act 1948. Two main themes are identified: the burgeoning burden of the statutory responsibilities of local authorities throughout the period, and the controls more recently imposed on the discretionary exercise of statutory powers. The impact of the latter on particular areas of practice is discussed within the context of the growing influence of international treaty obligations, the concept of children's rights, and the outcomes of research on the legal framework of child care practice.     

Organization and Supply of Long‐term Care Services for the Elderly: A Bird's‐eye View of Old and New EU Member States

This article provides an overview of the organization of formal long‐term care (LTC) systems for the elderly in ten old and 11 new EU member states (MS). Generally, we find that the main responsibility for regulating LTC services is centralized in half of these countries, whereas in the remaining countries, this responsibility is typically shared between authorities at the central level and those at the regional or local levels in both institutional and home‐based care. Responsibilities for planning LTC capacities are jointly met by central and non‐central authorities in most countries. Access to publicly financed services is rarely means tested, and most countries have implemented legal entitlements conditional on needs. In virtually all countries, access to institutional care is subject to cost sharing, which also applies to home‐based care in most countries. The relative importance of institutional LTC relative to home‐based LTC services differs significantly across Europe. Although old MS appear to be experiencing some degree of convergence, institutional capacity levels still span a wide range. Considerable diversity may also be observed in the national public–private mix in the provision of LTC services. Lastly, free choice between public and private providers exists in the vast majority of these countries. This overview provides vital insights into the differences and similarities in the organization of LTC systems across Europe, especially between old and new MS, while also contributing valuable insight into previously neglected topics, thus broadening the knowledge base of international experience for mutual learning.     

Breakdown of teenage placements in Swedish foster and residential care

This article deals with the problem of breakdown in different types of out‐of‐home care (foster care/residential care) for Swedish teenagers. How often are such placements prematurely terminated against the wishes and intentions of child welfare authorities? Which factors appear to increase or decrease the risk of placement breakdown? The sample consists of a national cohort of 776 youths who started 922 placements during 1991. Every placement was followed in municipal case files for a maximum period of five years. Between 30 and 37% of all placements were prematurely terminated, the exact figure depending on whether a narrow or wide definition of breakdown was applied. The lowest rates of breakdown were found in kinship care and secure units, the highest in non‐kinship foster homes. Teenagers who display antisocial behaviour and/or have mental health problems constitute a high‐risk category for most types of out‐of‐home care, but especially in non‐kinship foster homes. Risk factors in relation to breakdown were analysed in the four main forms of Swedish out‐of‐home care separately (foster homes, privately/publicly run residential care and secure units). The analysis pointed out that risk factors are not the same in all types of care, but antisocial behaviour at time of placement increased the risk in most forms of care. Prior research indicates that placement breakdown is a major problem of child welfare in other countries, and this study found that Sweden is no exception.     

Promoting Personalization in Social Care Services for Older People

This article presents findings on 4 themes associated with the personalization of social care for older people: integration of health and social care services; initiatives that prevent the need for more costly interventions; services to maintain people at home; and systems that promote choice, control, and flexibility. The quantitative study utilized data from a national postal survey conducted in England. Findings suggest variable progress regarding the range and style of support available to older people. These are discussed in the context of service integration, community-based services, and consumer-directed care. Implications for service development and future research are highlighted.     

Promoting personalization in social care services for older people

This article presents findings on 4 themes associated with the personalization of social care for older people: integration of health and social care services; initiatives that prevent the need for more costly interventions; services to maintain people at home; and systems that promote choice, control, and flexibility. The quantitative study utilized data from a national postal survey conducted in England. Findings suggest variable progress regarding the range and style of support available to older people. These are discussed in the context of service integration, community-based services, and consumer-directed care. Implications for service development and future research are highlighted.     

Foster children as young adults: many motherless, fatherless or orphaned: a Swedish national cohort study

We examined prevalence of parental deaths among former out‐of‐home care youths at age 18 and 25, and odds of parental loss compared with peers from similar socio‐economic childhood backgrounds. The study utilized Swedish national register data for 12 entire birth cohorts (1972–1983), 35 550 former out‐of‐home care youths and 1 138 726 cohort peers without out‐of‐home care experiences. Logistic regression models were used to compute odds ratios for parental loss through death. It was especially common among former residents of long‐term out‐of‐home care to be motherless (11%), fatherless (11–13%) or orphaned (3–4%) at age 18, compared with non‐foster care peers (1%, 3% and 0.03%). Twenty‐six per cent had lost at least one parent (4% among non‐foster care peers). At age 25, the figures had increased considerably; 36% had lost at least one parent, compared with 7% in the majority population. Adjusted odds ratios for parental loss among long‐term care youth were strikingly high, particularly for having a deceased mother. In short‐term and intermediate care, most youths with deceased parents had suffered parental loss before entering foster care. For youth from long‐term care, parental death after start of placement was most common.     

The 'Consumer Principle' in the Care of Elderly People: Free Choice and Actual Choice in the German Welfare State

In the mid-1990s, together with new long-term care legislation, the German welfare state introduced care markets and consumer choice between family care and different types of formal care. However, instead of using the new option to choose publicly funded care by long-term care agencies, the majority of elderly people in need of care continued to decide in favour of care exclusively provided by family members. The article examines how the persistence of family care in spite of the new options of consumer choice can be explained, using data from representative surveys on the care of elderly people in Germany and the results of guided interviews by the authors with family members involved in care. The findings indicate that there are two main reasons. The first is that elderly people and their families orient their behaviour towards traditional care values in which the first priority is given to mutual support between spouses and generations. The second reason is that elderly people on the one hand and care agencies on the other have substantially different definitions of a good quality of care.     

Nursing Homes in England and their Capacity to Provide Rehabilitation and Intermediate Care Services

The numbers of older people living in residential and nursing home care in the UK have risen exponentially since the early 1980s when the closure of long–stay geriatric wards and changes in social security funding of care home places led to a rapid expansion of the care home industry. While the implementation of the 1990 National Health Service (NHS) and Community Care Act shifted the responsibility for the commissioning and funding of these services to local authority social services departments, the provision of most health services (such as general practitioner care, physiotherapy and specialist nursing services) to nursing home residents remains the responsibility of community–based NHS practitioners. Recently, the attention of policy–makers in the UK has been focused on the need to improve the throughput of the acute sector. Older people who have received treatment but are not yet able to return to their own homes are to be transferred into intermediate care facilities, often by using nursing home beds, with the aim of supporting short–term rehabilitation outside of the acute sector. This paper presents evidence from a study of health service provision to older people living in nursing homes in England. It examines whether nursing homes have the capacity to fulfil the rehabilitation and intermediate care function envisaged by policy–makers. It concludes that shortfalls in the provision of NHS services to nursing homes and difficulties faced by nursing homes in paying for health services themselves may hinder the rehabilitation potential of intermediate care placements in nursing homes.     

"Never right, never wrong": child welfare and social work in England and Sweden

When are parents “unfit” to care for their own children? As in many other countries, social workers in England and Sweden have the unenviable task of forming such judgments. On behalf of society at large, social workers must balance the rights of parents to provide continuing care with the responsibilities of the state in ensuring adequate care of children. They are involved in professional judgments which are also inherently political. In both England and Sweden social workers are able to seek legal orders which, if granted, permit compulsory removal of children against the wishes of parents. In such cases social workers are centrally involved in processes which remove ordinary rights of citizenship from their fellow members of society. The rights of parents and children, together with the responsibilities of the state to each class of citizen, are clearly in focus: intervention in family life requires both grounds and legitimation. But what is the basis of intervention in the two societies? Social work practices in Sweden and England suggest very different answers to this question. In explaining these differences it is necessary to address much broader variations of social and political culture in the two societies. In so doing, variations in social work practice can be located in different cultural values and systems of legitimation. Instabilities and pathologies of professional practices can also be identified within both England and Sweden. These too are quite different in the two societies.