Caring for older people with complex needs at home is a long standing international policy goal and the provision of assistance with activities of daily living is an integral part of this (Australian Government, 2018; Welsh Assembly Government, 2010; New Zealand Government, 2016). Older people with complex needs may be unable to achieve outcomes associated with activities and instrumental activities of daily living and as a consequence there is a significant impact on their wellbeing. They are likely to need support at home on a daily basis; with more than one agency contributing to their care plan which would require regular monitoring and review (Applebaum and Austin, 1990; Social Services Inspectorate and Social Work Services Group, 1991; Department of Health and Social Care, 2018).
The United Kingdom has comprised four devolved heath care systems since 1999 when responsibilities for health were devolved to Scotland and Wales as well as Northern Ireland (National Audit Office, 2012; OECD/European Observatory on Health Systems and Policies, 2017). In each country social care, including home care, is arranged and funded by local government: local authorities in England, Scotland and Wales and Health and Social Care Trusts in Northern Ireland (Thorlby et al., 2018). There are also significant differences between the countries in terms of population, geographical size and population density, life expectancy and mortality rates (Ham et al., 2013; Sutherland and Coyle, 2019). However, in all these countries there is an increasing population of older people who form the majority of home care users, increasing demand for social care and significant budgetary pressures (Ham et al., 2013; Timmins, 2013; United Kingdom Home Care Association (UKHCA), 2016; Thorlby et al., 2018). Home care is increasingly provided by the independent sector which provides the majority of home care within all countries of the UK, although local government in Scotland directly provide home care services to a greater extent compared to the other countries (UKHCA, 2016). All face issues relating to the social care workforce in terms of recruitment, retention and skills shortages (Welsh Assembly Government, 2010; UKHCA, 2016; Scottish Care, 2017; NHS Health Scotland, 2018). In policy, all four jurisdictions have demonstrated a commitment to greater integration of health and social care (Welsh Assembly Government, 2010; Ham et al., 2013; Timmins, 2013; OECD/European Observatory on Health Systems and Policies, 2017; NHS Health Scotland, 2018). There has also been an emphasis on the development of personalised care services and an increasing use of direct payments as a means of giving those eligible for social care support greater choice over how they receive support and care at home (Department of Health, Social Services and Public Safety, 2011; Ham et al., 2013; UKHCA, 2016; NHS Health Scotland, 2018).
Home care is broadly defined as a means to enable both adults and older people to remain independent and living in their own homes (Department of Health and Social Care, 2018). Responsibility for their planning and provision was transferred from the public health department to a social services department within local government. Increasingly these services were caring for a more disabled and frail clientele; providing help with activities of daily living rather than domestic assistance; and assistance at weekends and evenings as well as during the day. In short, more intensive personal care provision for people was planned as an alternative to admission to residential or nursing care. It was recommended that the home care service should change to one which was more professional, flexible and targeted. To achieve this required both the revision of the core tasks undertaken and the provision of training for home carers (Department of Health and Social Security/Social Services Inspectorate, 1987). The community care reforms confirmed the commitment to enabling people to remain at home and receive the care they need to maximise their independence if possible and the development of home care services was integral to this (Cm 849, 1989). Increasingly they have focused, but not exclusively, on providing personal care for older people with complex needs through multiple visits throughout the week, thereby providing an alternative to admission to residential or nursing care. Following the implementation of the community care reforms of the 1990s in the UK, local governments (previously providers of social care) became ‘enabling agencies’, focusing on the commissioning of services rather than their provision. It was expected that the range and diversity of home care services would be facilitated by the growth of independent sector provision in localities (Cm 849, 1989). Now home care organisations in all the countries provide support for older people with complex needs living at home which may take the form of help with activities of daily living, instrumental activities of daily living and, more recently community participation.
Across the UK two aspects of strategic commissioning have been identified in policy: planning and delivery. Service planning includes the assessment of local needs, appraisal of options and service redesign to ensure the availability of sufficient services to meet demand. Service delivery includes procurement (matching service objectives to resources available), contracting (the legal agreement between the commissioner and service provider) and contract monitoring/management (ensuring services are delivered to the agreed quality standards) (Department of Health and Social Care, 2018). In essence this addresses the issue of what services are provided and by whom. National policy guidance identifies community representatives and provider organisations as partners in service planning and the latter in arrangements for delivery (Welsh Assembly Government, 2010; Audit Scotland, 2012; Department of Health and Social Care, 2018; Northern Ireland Assembly, 2016). In England, the activities associated with the commissioning process are described as market shaping and emphasise the importance of outcomes to service users (Department of Health and Social Care, 2018). Home care is either paid for by service recipients or, if the older person is assessed as having eligible needs, local government. One English local authority reported that it commissioned nearly five million hours of home care annually, at an estimated cost of £65m (Associate Directors of Adult Social Services, 2017). Nevertheless, nationally there is concern that this service is under resourced (UKHCA, 2016). This provides the context for this literature review.
The move towards outcome-based commissioning is set in the context of the provision of personalised social care support for older people. This is a generic term of international importance. For example, the World Health Organisation proposed a global strategy for a ‘fundamental paradigm shift’ in healthcare service design, to provide care reflecting the needs and preferences of service users (World Health Organisation, 2015, p. 7). The concept of personalised care has been integral to social policy for vulnerable adults and older people in England for over a decade (HM Government, 2007). This placed a requirement on local governments to offer older people and their carers choice and control over how support is delivered at home. It included the option of receiving a payment and taking responsibility for organising care, or for this to be arranged by a local government care manager and for assistance to be provided by either a home care agency or a personal assistant (Department of Health and Social Care, 2018). Personalised care has implications for the manner in which support is provided, emphasising for example, quality of life and a focus on outcomes rather than discrete tasks (Social Care Institute for Excellence, 2014). Commissioners of home care for older people are required to ensure sufficient and appropriate services are available, offering flexible support to meet the needs of vulnerable older people living at home (Department of Health and Social Care, 2018). For the older person the focus of high quality commissioning should be on citizenship, health and wellbeing and achieving good outcomes with people using local health and social care resources to best effect (Health Services Management Centre, 2014).
As noted above, in the UK home care is mainly, but not exclusively, provided by independent agencies. It is defined in policy terms as a means to enable both adults and older people to remain independent and living in their own homes (Department of Health and Social Care, 2018). This definition was employed in the literature review. A scoping methodology was chosen, since it is an approach particularly suited to addressing broad topics rather than narrowly defined research questions (Arksey and O’Malley, 2005; Manthorpe and Stevens, 2010). It permits the inclusion of a wide range of evidence chosen on the basis of relevance rather than focusing on study design or quality. Thus it supports the aim of mapping the literature to identify sources and types of evidence to produce a fuller picture of existing practice (Mays et al., 2001). The review follows the principles outlined by Arksey and O’Malley (2005). There are five stages: identification of research question(s); identification of relevant studies; paper selection through use of inclusion/exclusion criteria; recording and analysing the data; and reporting results. The first four are outlined below followed by the results in the findings sections. The review process started in the autumn of 2016 with searches undertaken between October and December of that year. Data analysis was completed in the winter of 2017/18. During this process additional searches were undertaken to update the review and no new studies found which met the inclusion criteria.
The development of the review was informed by earlier work commissioned by the Department of Health Social Care Workforce Research Initiative (Qureshi and McNay, 2011) which identified the need for greater understanding of the processes underpinning the commissioning of services. A general research question emerged which took into account the available literature and particularly its fragmented and rudimentary state.
What are the lessons from research for commissioners of home care for older people?
This was undertaken as the first stage of a mixed method study and evidence from the literature review informed other components of the research. These were: a survey of English local authorities in 2017 to explore current commissioning arrangements for home care in England and changes in the preceding decade; and interviews with commissioners and home care providers to enhance understanding of emergent trends relating to the range, content and practice of service commissioning. Findings from these will be reported separately.
Although the focus of the wider study was on England, a decision was made for the scoping review to focus on all countries of the UK, reflecting other reviews which have chosen to do this due to the countries’ shared history and similarities (Sutherland and Coyle, 2009; National Audit Office, 2012; Ham et al., 2013; Timmins, 2013). In addition, based on previous research, a dearth of studies in England was anticipated (Quereshi and McNay, 2011). The review included a range of peer reviewed and grey literature, in an effort to determine what is known about this topic in the UK. Literature was located via: systematic searches of seven online databases and hand searching references from three articles (Chester et al., 2010; Hughes et al., 2013; Chester et al., 2014) and one journal, Research, Policy and Planning. This was chosen because of its focus on publishing research relating to social care services provided by local authorities who have responsibility for commissioning home care. Additionally, the researchers identified further relevant literature from publications by scanning bibliographies. Figure 1 provides the search terms used. Studies were only included that reported findings rather than theoretical or conceptual pieces. Thus, as Mays et al. (2001) stated, “the simple test of relevance for inclusion is to specify that each reference must relate to some form of research, inquiry, investigation or study” (p196). Following the search of seven databases, 733 articles were identified after the removal of duplicates (Figure 2).
A three stage screening process was undertaken to assess whether papers matched the inclusion and exclusion criteria shown in Figure 1. First, titles were reviewed for relevance by two researchers (RJ, AR). In the second stage the same researchers reviewed the abstracts. Decisions were made by consensus and through an iterative process, sometimes requiring adjustment of earlier decisions after discussion between researchers in both these stages. One researcher (RJ) reviewed the complete text of articles in the third stage with another (JH) reading those considered to be on the margins of the study. In these circumstances, decisions about the inclusion of articles in the review were also made by consensus. The outcomes of this are recorded in Figure 2. Included literature was required to be related to studies including older people in the UK, focusing on one or more element associated with commissioning home care, and including empirical data. No exclusions were made on the basis of quality issues; therefore the scoping review potentially deals with a greater range of study designs and methodologies than a systematic review (Arksey and O’Malley, 2005). Literature publication dates were limited to between 1993 and 2018.
The start date, 1993, was chosen to mark the implementation of the White Paper ‘Caring for People’ (Cm 849, 1989) in the NHS and Community Care Act 1990 which signaled the development of an enabling role for local governments as commissioners of service rather than providers of home care. This included the development and support of private and not-for-profit providers (known as the independent sector) and the regulation of all provider agencies through the process of service specification and contracting. The decision to focus on the UK reflected the origins of the development of the enabling role for local governments. It was regarded as replicating the introduction of the purchaser/provider split in the NHS and conceived of as a mechanism to promote competition and ‘value for money’ in service provision (Wistow et al., 1992; Cm 849, 1989). As such the development of commissioning arrangements for home care is unique to the UK and differs to that in other countries where it is more likely that an independent organisation will both commission and provide support to enable older people with complex needs to live at home (Australian Government, 2018); New Zealand Government, 2016).
Two approaches to data analysis were undertaken. First, a deductive approach was used to identify the categories and organise and interpret the data (Whittemore and Knafl, 2005). Second, an inductive approach was used which permitted relevant themes to emerge (Ali and Birley 1999; Coffey and Atkinson 1996).
The literature relating to arrangements for commissioning home care for older people is reported in terms of: the nature of the literature; a description of the emergent themes; and an analysis of arrangements for commissioning home care articulated in studies. The latter has four sub-themes highlighting that it is a complex and dynamic process: guiding principles which underpin it; pursuit of the goal of personalised care; influential factors/key determinants; and the process of strategic commissioning. Older people in receipt of home care are referred to as ‘service users’, reflecting the terminology used in the papers included in the review and associated policy documents.
Twenty-two papers, relating to 21 studies were included in the review (Table 1). Varied research designs were used including a single case study, multiple case studies, surveys, a systematic literature review, document analyses, process evaluations and an economic analysis. Four evidence synthesis papers were also included, two of which were prepared for government. One of the latter was prepared by the National Institute for Health and Care Excellence (NICE), a non-departmental public body responsible for developing guidance and standards, and the other commissioned to inform the implementation of the National Dementia Strategy (Department of Health, 2009). The most frequent research paradigm was a mixed methods approach with both qualitative and quantitative data (n = 10). It was notable that five papers did not provide any information about study size. There were 17 papers in England, four in Wales and only one covering the UK as a whole. None were from Scotland or Northern Ireland. Data collection occurred between 1995 and 2016 with eight studies not providing the date that their research was undertaken. Primary data was collected mainly through questionnaires (n = 8) and interviews (n = 4). Five literature reviews were included, two of which were classed as selective literature reviews. The latter were commissioned by the Welsh Government (Bolton, 2016; Mellors and Bolton, 2016) to inform the service development and redesign of home care services.
|Reference (Year)||Research Design||Research paradigm||Location (study size*)||Date(s) of data collection||Method of data collection (sample size)|
|Atkinson et al. (2016)||Systematic literature review||Qualitative and quantitative||Wales (National)||Not stated||Literature review, interviews (n = 93), focus groups (n = 28),|
|Bolton (2016)||Document analysis||Qualitative and quantitative||Wales (Not available)||2016||Selective literature review**|
|Challis et al. (2011)||Evidence synthesis***||Qualitative and quantitative||England (National)||Not stated||Literature and document review, secondary data analysis, discrete choice experiment (n = 28), questionnaire (n = 93) and interviews (n = 21)|
|Chester et al. (2010)||Survey||Quantitative||England (National –122 local authorities)||2008||Questionnaire (n = 122)|
|Chester et al. (2014)||Survey||Quantitative||England (National –122 local authorities)||2008||Questionnaire (n = 122) and secondary data analysis|
|Fernandez et al. (2012)||Survey||Quantitative||England (National –78 local authorities)||November 2011–January 2012||Questionnaire (n = 78) and modelling based on local characteristics|
|Forder et al. (2004)||Survey||Qualitative and quantitative||England (11 local authorities, 155 services)||1999||Questionnaire (n = 155) and interviews (n = 56)|
|Glendinning et al. (2008)||Survey||Qualitative and quantitative||England (6 local authorities)||June and December 2005||Questionnaire (n = 71), interview and focus groups (total n = 82)|
|Goodman et al. (2011)||Survey||Quantitative||England (National)||Not stated||Questionnaire (n = 91) and document review|
|Hughes et al. (2013)||Survey||Quantitative||England (National –122 local authorities)||2008||Questionnaire (n = 122)|
|Manthorpe and Stevens (2008)||Process evaluation||Qualitative||England (Not available)||February and May 2008||Interviews (n = 33) and focus groups (n = not given)|
|Matosevic et al. (2001)||Survey||Qualitative and quantitative||England (11 local authorities, 155 services)||1995||Questionnaire (n = 155) and interviews (n = 56)|
|McGrath et al. (1996)||Survey||Quantitative||Wales (National –8 local authorities)||Spring 1995||Questionnaire (n = 504) and interviews (n = 57)|
|Mellors and Bolton (2016)||Document analysis||Qualitative||Wales (Not available)||2016||Selective literature review**|
|Netten et al. (2007)||Process evaluation||Qualitative and quantitative||England (17 local authorities, 121 services)||Not stated||Secondary data analysis and interviews (n = not given)|
|NICE (2015)||Evidence synthesis***||Qualitative and quantitative||UK (Not available)||Not stated||Literature and document review|
|O’Rouke (2016)||Multiple case study||Qualitative||England (2 local authorities)||December 2013–January 2014||Interviews (n = 8)|
|Rodrigues and Glendinning (2015)||Evidence synthesis***||Qualitative||England (6 local authorities)||Study 1: August 2011 and October
Study 2: March and May 2013
|Interviews (n = not given) and focus groups (n = not given)|
|Scourfield (2007)||Case study||Qualitative||England (1 local authority)||Not stated||Interviews and focus groups (total n = 16)|
|Wanless et al. (2006)||Economic analysis||Quantitative||England (Not available)||Not stated||Secondary data analysis and modelling of costs|
|Ware et al. (2003)||Multiple case study||Qualitative and quantitative||England (7 local authorities)||August 2000–May 2001||Interviews (n = 120), case file audit, document review|
|Wistow and Hardy (1999)||Evidence synthesis***||Qualitative and quantitative||England (Not available)||Not stated||Document review, case file audit and secondary data analysis|
Table 2 presents an analysis of home care commissioning arrangements described in the studies. Thirteen addressed the purpose of commissioning from a strategic perspective. The remainder explored it in the context of assessment and support planning for individual service users (Ware et al., 2003; Scourfield, 2007). Several documents articulated the purpose of strategic commissioning as an aspirational goal. Three of these related to the provision of quality services within the home care sector (Wistow and Hardy, 1999; NICE, 2015; O’Rourke, 2016). Goals relating to service delivery were also identified: matching service availability to local need (Wanless, 2006; Hughes et al., 2013); flexibility in service delivery (Glendinning et al., 2008); and cost effectiveness (Mellors and Bolton, 2016). Other documents described how these goals might be achieved. For example, Goodman et al. (2011) noted the importance of partnership working between health and social care commissioners at a strategic level. Five documents highlighted particular aspects of commissioning: the identification of the needs of the local population and their implications for service provision (Challis et al., 2011; Bolton, 2016); the importance of workforce requirements and associated service costs (Netten et al., 2007); and the procurement and monitoring of contracts (Chester et al., 2010; Atkinson et al., 2016).
|Reference (Year)||Purpose||Key actors*||Sources of information||Components|
|Atkinson et al. (2016)||Procure and contract services to ensure availability for those eligible for local authority support and self-funders||Providers||–||Contract type
|Bolton (2016)||Understand and assess population needs and design outcome-based services||LA
Stakeholders Representatives of service users
|Goal of commissioning strategy||Performance measures|
|Challis et al. (2011)||Determine the balance between generic and specialist domiciliary care for older people with dementia||–||Record of service
Specialist training in dementia care
|Specialist home care, specifically for people with dementia|
|Chester et al. (2010)||Compliance with contracting and employment legislation in partnership with health||Providers
|Strategic needs assessment||–|
|Chester et al. (2014)||–||LA staff
|Fernandez et al. (2012)||–||Providers (independent sector)||–||Contract type
|Forder et al. (2004)||–||–||–||Contract type|
|Glendinning et al. (2008)||Provide flexible services responsive to service user needs||LA staff
Representatives of service users
|Service user views||Performance measures|
|Goodman et al. (2011)||Partnership working at a strategic level||LA staff
NHS staff (joint commissioning)
|Hughes et al. (2013)||Promote home care provision in a locality for those eligible for local authority support and self-funders||LA staff
|Manthorpe and Stevens (2008)||–||Representatives of service users||–||Contract type
|Matosevic et al. (2001)||–||–||–||Contract type|
|McGrath et al. (1996)||–||Care managers||Care manager views||–|
|Mellors and Bolton (2016)||Provision of cost effective services through identification of populations needs, development of policy and service models and market management||–||Strategic needs assessment||Contract type|
|Netten et al. (2007)||Focus on workforce requirements and service costs||LA staff
|NICE (2015)||Promote high-quality home care services through multidisciplinary working and protocols||LA staff
Stakeholders Representatives of service users
Representatives of carers
|Provider views||Contract type
|O’Rouke (2016)||Promote quality service through focus on workforce requirements, market management and costs||–||–||Performance measures|
|Rodrigues and Glendinning (2015)||–||–||–||Contract type
|Scourfield (2007)||Promotion of personalised care**||–||Size of budget|
|Wanless et al. (2006)||Provide sufficient services to meet community needs by developing and managing local care markets||LA staff
Size of budget
|Ware et al. (2003)||Match service user and carer needs with provider capabilities**||Care managers||Care manager views
|Wistow and Hardy (1999)||Promote relationships with home care providers to ensure quality consistent with user-defined standards||LA staff||–||Contract type
Key stakeholders involved in commissioning included a range of staff from different disciplines, both health and social care. Six papers mentioned providers and five identified both NHS and local authority staff. Representatives of service users were mentioned less  with seven papers having missing data. Sources of information used in commissioning were only reported in 10 papers. These included: strategic needs assessments (e.g. Chester et al., 2010); size of budgets (Wanless et al., 2006); service standards (e.g. Ware et al., 2003); and service user (e.g. Glendinning et al., 2008), provider (NICE, 2015) and care manager views (e.g. McGrath et al., 1996). Finally, the most commonly reported components of commissioning were contract type (12) and performance measures (8).
Summary findings from individual papers are detailed in Table 3. The emergent themes drawn from them are described below.
|Reference (Type of publication)||Focus||Findings|
|Atkinson et al. (2016)
(Report for government)
|Guidance to inform service commissioning||A well-trained, well-paid workforce with appropriate working patterns is required to recruit and retain domiciliary care workers and deliver high quality care (not defined). This requires changes in commissioning processes and terms of employment together with increased funding.|
(Report for government)
|Explores the concept of outcome-based commissioning||An outcome-based approach to home care requires commissioners and providers to work together to design new approaches at both the service and individual level, which reflect differing levels of need.|
|Challis et al. (2011)
(Report for government)
|Guidance for commissioners on generic and specialist services for people with dementia||Decisions about commissioning specialist home care, specifically for people with dementia, and the extent to which their needs can be met by these or generic domiciliary care should be guided by issues of quality, intensity of service, mix of services, links between services, and costs and effectiveness.|
|Chester et al. (2010)
|Description of variations in commissioning and contracting arrangements||Commissioning and contracting arrangements vary across England. Different approaches are likely to influence arrangements for the delivery of front-line care.|
|Chester et al. (2014)
|Influence of commissioning and contracting arrangements on staff recruitment||Factors particular to a local area (e.g. the percentage of female working age population economically inactive who want a job and rurality) influence commissioning and contracting arrangements.|
|Fernandez et al. (2012)
(Report for government)
|Commissioning arrangements consequent on the on-going personalisation agenda||Most services provided by the independent sector under a spot contract. Client needs and type of contract were the main drivers of price for home care.|
|Forder et al. (2004)
|Explores the effects of different contracting arrangements on price, output and profit for providers||Local authorities as purchasers of home care have the power to affect both the level and flexibility of pricing. Contract type affects the price of home care.|
|Glendinning et al. (2008)
|“Investigation of emergent outcome-focused services from multiple perspectives||An emphasis on developing outcomes-focused social care services is likely to extend beyond typical home care tasks and the future scope of adult social care services.|
|Goodman et al. (2011)
|Influence of interprofessional working amongst front-line practitioners||Staff from health and social care organisations require a shared identification of outcomes for older people and their carers living at home.|
|Hughes et al. (2013)
|Description of commissioning and contracting arrangements||Key issues in commissioning home care are: regular dialogue with service providers; partnership with health; contracting arrangements which reflect service outcomes; specification of training; and contract monitoring.|
|Manthorpe and Stevens (2008)
(Report for government)
|Implications for home care in rural areas from the introduction of personal budgets||Development of personalised care at home requires account is taken on service user views and in rural areas the contribution of the voluntary sector, particularly local community groups.|
|Matosevic et al. (2001)
|Description of providers and their contribution to the development of a mixed economy of care||Describes the home care market as being at an early stage of development and suggests it will evolve over time.|
|McGrath et al. (1996)
|Implications for strategic commissioning from the experience of front-line practitioners||Care coordination undertaken by front-line staff is likely to place increasing demands on the provision and management of resources.|
|Mellors and Bolton (2016)
(Report for government)
|Explores options for the procurement of services for commissioners||Service user and carer involvement in commissioning and procurement is important.|
|Netten et al. (2007)
|Describes different contracting arrangements and their implications for service quality||Analysis suggests areas that have a more long established policy of purchasing care from the independent sector may have providers with a more established and experienced workforce.|
|Describes different contracting arrangements and their implications for service delivery||Home care should promote independence and support people to do the things that are important to them through person-centred care by delivering personal care and practical support to older people living at home.|
|Explores the link between commissioning arrangements and service quality||Personalisation permits the relational nature of caring to be included in commissioning and service delivery arrangements. Identifies the importance of choice in service delivery from a service user perspective.|
|Rodrigues and Glendinning (2015)
|Implications of integrated services for commissioning||Commissioners and providers will need to take account of the increased choice and risks associated with personal budgets taken as a cash payment which give service users more control and choice over the care they receive.|
|Implications of personalised care for commissioning||Home care services are fragmented and of variable quality and with the exception of intermediate care do not provide integrated health and social care.|
|Wanless et al. (2006)
(Report for government)
|Exploration of funding options for social care in the context of demographic projection||Advocates improving the articulation of wellbeing outcomes in addressing care needs. Acknowledges that social care for the elderly will continue to have multiple sources of funding.|
|Ware et al. (2003)
|Description of the consequences of strategic commissioning decisions for front-line practitioners||Care managers require information including service capacity to match service user and care needs to match with resources available within provider organisations.|
|Wistow and Hardy (1999)
|Both strategic and front-line practitioners plus service users||The development of relationships between purchasers and providers is key to the provision of quality services.|
Two guiding principles emerged from the analysis: the role of the concept of outcomes in framing response to need within the strategic commissioning process and the manner in which services are delivered by providers. Two papers and two reports for government address the roles of outcomes in commissioning home care. Wanless (2006) advocated the inclusion of wellbeing outcomes in addressing care needs. To achieve this Bolton (2016) suggested that commissioners and providers should work together to achieve an outcome-based approach to home care. An earlier publication suggested that developing outcomes-focused social care services was likely to extend beyond typical home care tasks related to activities of daily living, for example, to meeting needs associated with wider activities such as social engagement (Glendenning et al., 2008). Another paper highlighted that an outcomes-based approach must be shared by staff from both health and social care organisations providing care for older people at home (Goodman et al., 2011).
With regard to service delivery, Scourfield (2007) advocated that home care services providing both short term (intermediate) care and long term support to older people at home required an integrated health and social care approach. This issue has also been addressed in two government reports. Guidance from NICE (2015) stated that home care should promote both independence and support through person-centred care. In a report prepared for the Welsh government (Atkinson et al., 2016) improvement in the recruitment and retention of home care workers was identified as a requirement for high quality care.
Home care services have been described as fragmented and of variable quality adversely affecting the service user experience of personalised care (Scourfield, 2007). However, the literature also identified three approaches which may contribute to the provision of a quality service: sufficient capacity to meet need, services responsive to user needs and dialogue between purchasers and providers. First, commissioners should seek to facilitate the development of the local market in home care to ensure the supply is sufficient to meet demand. From a care manager perspective the compilation of a care plan to meet the needs of service users requires the availability of services to deliver it (Ware et al., 2003). Another paper noted that this can only be achieved through the development of a market in social care and the emergence of multiple providers in a locality (McGrath et al., 1996). Second, in providing services responsive to user need, O’Rourke (2016) highlighted the importance of service users exercising choice in their selection of a provider service. Third, the relationship between purchasers and providers has also been identified as an important determinant of service quality (Wistow and Hardy, 1999). More recently, it has been recommended that commissioners and providers work together to design new approaches for home care at both the strategic and service delivery level to achieve more personalised care as experienced by the service user (Bolton, 2016).
Factors which may influence commissioning were identified as: service objectives; service user needs; their views about the uptake of personal budgets; local area characteristics; and contract type (Chester et al., 2010). For example, it has been suggested that service objectives for home care should include recognition of the importance of interprofessional working by front-line staff and take account of service user needs and preferences (Goodman et al., 2011). In terms of strategic objectives, decisions about the balance between specialist and generic home care services for people with dementia should be guided by determinants of quality, integrated services and cost parameters (Challis et al., 2011). More broadly service user needs were identified as an important determinant of price (Fernandez et al., 2012). Type of contract was also identified as influencing the price of home care (Forder et al., 2004; Fernandez et al., 2012) with spot contracts (a price per case arrangement) associated with a higher price of services provided by the independent sector (Fernandez et al., 2012). Changes in the commissioning process were signaled by the introduction of personal budgets and the suggestion that service user preferences for service receipt were taken into account (Manthorpe and Stevens, 2008; Rodrigues and Glendinning, 2015). Regarding local area characteristics the influence of rurality, the contribution of the voluntary sector and the local employment market in service delivery, have been highlighted as factors to be considered in the process of commissioning home care for older people (Manthorpe and Stevens, 2008; Chester et al., 2014).
Shortly after the introduction of the community care reforms the home care market was described as being at an early stage of development (Matosevic et al., 2001). Three sub-themes have subsequently emerged as important in the process of strategic commissioning: stakeholder involvement; the contracting process; and the influence of the latter on service delivery. In terms of stakeholder involvement in commissioning, early work by Wistow and Hardy (1999) identified the development of relationships between purchasers and providers as key to the provision of quality services and this was confirmed subsequently (Hughes et al., 2013). More recently the importance of service user involvement and engaging health colleagues in the commissioning and procurement of home care has been noted (Hughes et al., 2013; Mellors and Bolton, 2016). The importance of service outcomes and the balance between provision of home care services specifically for people with dementia and the extent to which their special needs are met within generic home care services were also identified as factors to be considered in the contracting process (Challis et al., 2011; Hughes et al., 2013). It has been suggested that features of this influence service delivery. Forder and colleagues (2004) reported that the level and flexibility of home care was related to the price determined within the contracting process. Additionally, a long established policy of contracting care from the independent sector may help providers retain a more established and experienced workforce, thereby promoting continuity of care for service users (Netten et al., 2007).
This scoping review has explored the lessons from research for commissioners of home care for older people through a systematic scoping review. The literature review followed the methodology outlined in work by Arksey and O’Malley (2005). A variety of research methods and designs were found in the identified literature, with the most frequent being mixed methods. Most papers were from England, with only a few from Wales and none from Scotland and Northern Ireland and primary data collection included mainly questionnaires and interviews. The review has mapped developments in commissioning since the implementation of the community care reforms for which the introduction of the enabling role for local governments was a cornerstone. This has included the more recent emphasis on the development of outcome-based commissioning and the provision of more personalised care.
The use of a scoping method in this review allowed for the inclusion of a number of papers relevant to the research aim, without exclusion on the basis of design or quality of evidence. This provided a rigorous and transparent method for mapping areas of research and made it possible to identify gaps in the evidence base (Arksey and O’Malley, 2005). Included studies were identified via systematic database searches and hand searching of grey literature. Twice as many included papers were identified through the latter than the former.
However, the literature review had several limitations, some of which relate to the scoping literature review approach itself and others reflect the published literature. In terms of the approach, the scoping review methodology does not include an assessment of quality, so recommendations for practice cannot be guaranteed and findings should be treated with caution (Arksey and O’Malley, 2005; Manthorpe and Stevens, 2010). This review focused on empirical studies, and therefore a critical assessment of conceptual and theoretical pieces could not be undertaken as this was outside the scope of this review. The focus on research evidence meant that potentially interesting insights to inform future commissioning strategies from conceptual articles were omitted. The inclusion of a diverse range of research designs created difficulties in synthesising the evidence, thereby potentially reducing the usefulness of the results. In terms of generalisability of findings, only literature from England and Wales were included with no papers from Scotland and Northern Ireland meeting the inclusion criteria.
Furthermore, this literature review has presented certain additional challenges. One of these related to the fact that it focussed on a process and not a service. In the absence of a blueprint for the process of commissioning home care, the review sought to gain a greater understanding of the elements intrinsic to commissioning home care This had the advantage of providing a framework to capture the diverse descriptions of the term in the absence of a common definition. Another challenge related to the fact that within the UK the processes of strategic commissioning of services and micro commissioning for individuals were also provided largely within the same agency, an arrangement not always replicated in other countries. Hence both aspects are represented in this review. Moreover, concepts relevant to commissioning, for example ‘quality’ and ‘outcomes based commissioning’ were not generally defined in the included studies. Nevertheless, the focus on elements of commissioning home care for older people is likely to have an international resonance since irrespective of the source of funding the provision of home care for older people is recognised as a potentially cost-effective alternative to admission to long-term care. In the remainder of the discussion lessons from the literature review will be explored using the following headings: marketisation of home care; care at home; promoting integration with local partners in commissioning home care; and areas for future research.
Market management has been defined as the “planning, implementation, and control of programs designed to create, build, and maintain beneficial exchange relationships with target audiences” (Kotler and Andreasen, 2007: 38). In this literature review on commissioning arrangements for home care for older people, the term is synonymous with the terms marketisation and market shaping, including the concept of market segmentation (for example, providing home care specifically for people with dementia or older adults with multiple chronic diseases). Policy guidance requires local governments to have a market position statement to inform providers of the supply and demand in their area and signal opportunities for development. As such it is the basis for the strategic commissioning of home care. Local governments are also required to have contingency arrangements in case of market failure in home care services (Department of Health and Social Care, 2018). Little evidence of factors which may influence market management was identified in this review. However that which was available can be categorised into two groups. First, those which were exogenous to the commissioning process. For example, the recruitment and retention of the home care workforce is likely to be related to the challenge of providing assistance to service users in rural areas as well as local employment conditions (Manthorpe and Stevens, 2008; Chester et al., 2014). Second, those which were endogenous and more likely to be within the control of commissioners. These included: contractual arrangements (Atkinson, 2016); and the provision of specialist home care to meet the needs of discrete groups, such as people with dementia (Challis et al., 2011). Additionally, the literature review notes the importance in the commissioning of home care, of considering the needs of people who do not receive financial assistance from the local authority (Rodrigues and Glendinning, 2015), subsequently reflected in policy (Department of Health and Social Care, 2018).
A mature market offers the opportunity to exploit the benefits of market segmentation (Normann, 2000). It maybe that with regard to the provision of home care this point is almost approaching, thirty years after the introduction of the enabling role for local governments (Hughes et al., 2013). One possibility is the further development of home care specifically for older people with dementia. It has for example, recently been estimated that there are likely to be over 200,000 new dementia cases per year in the UK. This coupled with increased longevity means that people with dementia in the oldest age groups are likely also to exhibit physical frailty and as a consequence have complex care needs spanning health and social care (Matthews et al., 2016). Another potential segmentation of the home care market could be in relation to meeting the needs of older people living in supported accommodation (Challis et al., 2016). In the future market segmentation may become a key feature of arrangements for commissioning arrangements for older people, particularly in the context of operationalisation of the goals of outcome-based care and more personalised care.
The Care Act (Department of Health and Social Care, 2018) has challenged home care services to continue their quest to deliver care tailored to the needs of individuals. To date, their development has been characterised by evolutionary change in response to national policy initiatives, local circumstances, funding and existing service arrangements. The findings from this literature review suggested that commissioners and providers of home care should work together so that participation in social activities becomes a core activity alongside that of providing assistance with activities of daily living and instrumental activities of daily living. In terms of Maslow’s hierarchy of needs this incorporates both basic physiological needs and higher order social needs (Maslow, 1943). The term home care might in the future be replaced by the phrase ‘care at home’ to incorporate the goal of more tailored and individualised care reflected in the personalisation agenda. By implication this will challenge home care providers to work in partnership with local voluntary organisations to facilitate the social elements of a support plan.
More generally within the literature there was reference to outcome-based commissioning for home care (Bolton, 2016; Glendinning et al., 2008) but this was not explored in detail. There was little evidence of a shared understanding of the term, reflecting current policy (Department of Health and Social Care, 2018) and the means of measuring it. Previous research has shown that there are measures of intermediate and final outcomes, with the former often measured when examining agency performance because final outcomes [for example the impact of services on individual welfare] are harder to capture (Chester et al., 2015). In this context, intermediate outcomes could arguably be reflected in the process of contract monitoring. Final outcomes relate to the service user experience and they are more appropriately measured at an individual level.
There is evidence from this literature review of some joint commissioning of home care with National Health Service (NHS) commissioners (Goodman et al., 2011; Hughes et al., 2013; Chester et al., 2014). This has been noted in recent research relating to home care and other services (Cameron et al., 2017). The local government and the NHS are partners in commissioning intermediate care services which include home care for older people provided on a short term basis on discharge from hospital (Department of Health and Social Care, 2018). However, this review did not reveal evidence of similar involvement in the planning of home care for older people who required more long term care and assistance.
Such an approach would offer the opportunity to design a service around the health and social care needs of older people with complex needs, reflecting both in a single service, placing a greater focus on ‘care at home’ rather than home care (Challis et al., 1995). Elsewhere it has been argued that the development of integrated services provides an opportunity to respond to the personal preferences of service users (Local Government Association, 2018). Implementing such an approach in localities would, however, present considerable challenges for health and social care commissioners.
In addition to the NHS, the literature review identified providers of home care and consumers [representatives of service users and care coordinators] as partners in the commissioning process (e.g. Glendenning et al., 2008; NICE, 2015; Bolton, 2016). Recent policy guidance has also identified housing providers as partners in the commissioning process (Department of Health and Social Care, 2018). In the context of home care for older people providers of supported or sheltered housing too should be important contributors to the commissioning process. Voluntary organisations providing befriending and social support to older people at home are also potential partners supporting the broadening of the commissioning role to focus on ‘care at home’ rather than its existing narrower remit of home care.
Findings from this literature review have identified several gaps in the evidence base surrounding arrangements for commissioning home care for older people. First, there was little empirical research, especially from Scotland and Northern Ireland, reducing the evidence available to national policy makers and local service commissioners. Given the availability of non-empirical literature, future research could potentially take a more narrative approach to reviewing the literature, tracking the discourses and theories present within this over time. Second, systematic evaluation of new approaches focusing on outcome-based commissioning to inform future practice in different localities could be undertaken. Third, further research into home care for older people with particular needs such as those with dementia or other long-term conditions, or those that are setting specific, such as supported accommodation or rural localities, would inform the development of personalised care. Fourthly, research might also address the process of commissioning home care focusing on key partners and their contributions within the process. An emergent area of research might be an examination of roles along a continuum from consultees to partner to enhance public engagement in the process. Importantly in this context where there is a distinct lack of empirical research, this scoping review formed part of a wider mixed-method national study exploring commissioning arrangements for home care for older people in England, including how these have evolved since 2007, and in-depth exploration of the views of commissioners and providers on the commissioning process. Finally, there is a need for more national research studies in the different countries of the UK exploring the relative influence and interaction of endogenous variables (commissioning and contracting approaches) and exogenous factors (such as rurality and socioeconomic composition) on outcomes for older people receiving home care support in different localities.
A number of lessons for commissioners have emerged from this review. Whilst initially designed to promote competition and ‘value for money’ in service provision, the enabling role for commissioners of home care for older people in the future is likely to be increasingly characterised by collaboration with providers and other stakeholders. Moreover, this review casts doubt on the effectiveness of the market in the delivery of home care particularly for older people with complex needs for whom inter-agency working at both strategic and operational levels are required to allow them to live at home, suggesting that relationships between commissioners and providers characterised by longevity and collaboration are more appropriate. Furthermore, in pursuit of personalised care in the UK there may be lessons from an international context to be learnt with regard to exploring an enhanced role for home care providers in the assessment of need and support planning.
The authors thank the funders for making it possible to conduct this review. We thank the Public Engagement Group which provided material for the development of the discussion and particularly Jude Wells.
This article presents independent research funded by the National Institute for Health Research (NIHR), School for Social Care Research (SSCR). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.
The authors have no competing interests to declare.
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