Homecare workers speak directly to DHSC about how homecare is commissioned
Last week, 26 current and former homecare workers came together with the government Department of Health and Social Care (DHSC) for three online roundtables about the future of homecare.
The roundtables are part of a project looking at how homecare is commissioned by local authorities in England. DHSC wished to hear directly from people with experience of employment in homecare about what their roles look and feels like on the ground.
This was a significant opportunity to bring the experiences of people working in homecare directly into government policy discussions. The online sessions offered safe spaces for people to talk openly about their experiences and to suggest practical changes which could make a difference to all those involved in caring relationships.
Here are some of the key themes that emerged:
"People are not tasks"
One of the clearest messages was about the impact of time-and-task commissioning.
People described a system in which homecare visits are often organised around fixed blocks of time, with a set list tasks expected to be completed within these. Yet people's needs don't always fit neatly into a pre-defined timeslot. Examples included 10-minute medication calls where someone also needs help washing or preparing food, 30-minute calls routinely taking 45 minutes or more, and the additional time that is often required when supporting people with dementia.
These discussions highlighted the human relationships at the heart of care. People spoke about supporting individuals who rarely leave their homes, receive few visitors and may rely on their carers as one of their main sources of social contact. Several people felt that five minutes spent talking to someone could sometimes be as valuable as completing a practical task. They argued that companionship and social connection should not be treated as an optional extra.
One person's message to commissioners was that care plans must allow room for conversation, companionship and opportunities for people to engage in social activities outside of their home. Participants felt that commissioning should focus more on outcomes and what matters to the person receiving care, rather than simply buying units of time. They also highlighted the need for care packages to be reassessed as people's needs change.
Pay issues will not be resolved by simply raising the hourly wage
Pay was another major theme, but not quite in the way those with no personal experience of employment in homecare might expect. Rather than talking about the need for a higher hourly wage, people spoke about being paid at all for the work they already do. Travel and waiting between visits, training, meetings and calls that overrun were among the examples of working time that workers said often go unpaid.
Some described being "at work" for much of the day while being paid for only a fraction of that time. The concern was that once all working time is taken into account, the true hourly rate can be substantially lower than the rate stated on a contract.
This is particularly relevant to our ongoing campaign to Fix the FoundationsĀ of pay in homecare. Our campaign calls for a move towards shift-based pay, with homecare workers paid from the start of their first care visit to the end of their last. This is essential to address the high risk of National Minimum Wage underpayment in homecare.
Time is also being lost between visits
The way care is organised geographically was another recurring issue. People described long gaps between care visits, spending hours sitting in cars, travelling between far-apart locations, daily rota changes and unrealistic travel times. This was particularly challenging in rural areas, where rounds can cover large distances.
Several people felt that they could design more efficient routes themselves. Their point was not simply about making workers' lives easier. Time spent travelling, waiting or dealing with inefficient rotas is time that cannot be spent supporting people. People suggested that commissioning geographically coherent, neighbourhood-based services, reducing fragmentation and involving frontline workers in route and care planning would help.
Strangers should not be entering peoples' homes
When asked to think about homecare from the perspective of someone receiving it, one point came up repeatedly:
"I'd want the same carers."
People described continuity as fundamental to dignity, trust and good communication. Having the same carers also means that workers get to know someone's preferences, routines and personality. This allows the relationships that underpin high quality support to develop.
By contrast, people described those receiving care having to repeatedly explain themselves to new faces and having strangers regularly enter their homes to provide intimate care. People emphasised that continuity should be treated as a core outcome of homecare commissioning, rather than something that happens by chance.
Homecare is increasingly complex work
People also talked about how much their roles have changed. They described supporting people with stoma and catheter care, PEG feeding, medication management, complex dementia care, delegated healthcare tasks and safeguarding responsibilities.
Despite this, many felt that the public and professional understanding of homecare work has not kept pace with its increasing complexity. The discussions highlighted a need for homecare to be recognised as a skilled profession, with commissioning and pricing models reflecting that complexity and with appropriate opportunities for training and progression.
The emotional side of care is often invisible
Some of the most moving contributions concerned the emotional labour involved in homecare. People talked about walking into care visits to find the person they support had died, caring for people at the end of their lives and building relationships with people over many years, only to have to leave and immediately move on to the next visit.
People felt that wellbeing support, reflective supervision and bereavement support should form an essential part of the support available to those working in homecare.
Employment conditions affect care quality
People also raised concerns about their experience of basic employment rights, including rest breaks, working-time regulations, payslip transparency, holiday pay, pensions, sickness policies, training payments and what happens when workers raise concerns.
Migrant workers described immense struggles to meet the minimum salary threshold attached to their visa when so much of their working time is unpaid, and their fear of speaking up about this.
While the roundtables were not designed to establish how widespread every individual experience is, the consistency of these concerns across the sessions was significant.
The broader message was clear: employment conditions cannot be separated from the quality of care. When homecare workers are rushed, the people they support feel rushed. When they are stressed, that stress can be very easily passed on. When workers have time and basic income security, there is more opportunity for good relationships and good care.
Bringing frontline experience into policy
These roundtables were an important opportunity to demonstrate what a grassroots network like Homecare Voices is able to do. We bring the experiences and expertise of current and former homecare workers into conversations where national decisions about homecare are being made.
We were pleased to receive thie following feedback from DHSC:
āHomecare Voices responded with remarkable speed, bringing together homecare workers from across the country for workshops at a point where I needed to understand their experiences first-hand. The sessions were skilfully facilitated by Rachel, creating a space where workers spoke openly about the realities of working in the homecare sector. What I heard has given our policy thinking a depth and credibility that data alone could not provide. I would recommend Homecare Voices to anyone who wants to hear directly from the frontline to inform their future plans.ā
Homecare workers have a great deal to say about how social care can be improved. The challenge is making sure these voices are heard. To this end, Homecare Voices welcomes ethical partnerships and media enquiries.
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