5. PRACTICE ISSUE FIVE: The implications of maintaining older people at home
It is predicted that demand for long-term care will continue to grow, reaching a peak around 2040 (Karlsson et al, 2006). The Personal Social Services Research Unit developed a model to predict the future costs of long-term care. They have predicted that services will have to expand by 61 per cent between 1995 and 2031. Homecare will have to increase by around 60 per cent by 2040 (PSSRU, 2007).
In Scotland, the policy commitment to free personal care has raised questions as to whether the current situation is sustainable in the long term. Bowes and Bell (2006) confirmed that expenditure had been greater than expected but highlighted that free personal care added only 10 per cent to expenditure on older people’s services.
Karlsson et al (2010) predict that the number of older people in receipt of unpaid (informal) care will increase from 2.2 million in 2006 to 3 million in 2050. The impact of caring on health and well-being has been well documented. Looking specifically at carers of people with dementia, Schoenmakers and her colleagues (2010) have shown that they are more likely to experience higher levels of burden and depression compared to other groups of carers.
Carer stress and wellbeing is difficult to predict and measure. Contextual factors such as age and ethnicity as well as stressors and strains and resources such as coping and social support must be considered. Interventions to support unpaid carers have not always been successful. Schoenmakers et al (2010) highlight the importance of not assuming that one type of intervention will suit all carers. Interventions to enhance psychosocial resources are likely to be significant and include carer education, behaviour management techniques, problem solving training and personal counseling for emotional distress.
The importance of carers’ assessments cannot be underestimated. However practitioners continue to have concerns and anxieties about undertaking such assessments (Miller, 2007). These anxieties relate particularly to resource implications. Yet, a number of studies have confirmed that requests from carers tend to be fairly modest (Seddon et al, 2007; Miller, 2007).
As can be noted from the policy context described earlier, there have been significant changes, over a relatively short space of time, in the care environment relating to the delivery of services for older people with higher level care needs. First, there is a commitment to a more person-centred style of care service with a greater level of choice for the service user. Second, demographic and social changes have led to an increased demand for care services, thereby requiring an expansion in the social care workforce. Third, there has been a decline in the supply source for this traditionally low skilled work. Fourth, in response to policy requirements, there have been changes in the arrangements for the delivery of social care which mean that a significant number of social care staff are now employed outside the statutory sector. Finally changes in practice brought about by policy drivers such as personalisation have changed both the role and remit of the social care workforce and the relationship between the workforce and those who require support (Chester et al, 2009).
A consistent theme throughout much of this evidence review was the need for effective partnership working and integrated service provision, which takes a whole systems approach. This is a significant challenge as the evidence base for effective partnership working in a range of services/processes which support older people with higher level needs at home is patchy, with many of the challenges appearing difficult to resolve (see for example Glasby and Dickinson, 2008).
In addition spiraling costs of care with decreasing resources, including the availability of appropriately skilled and trained staff, mean that the provision of services which can effectively meet the needs of older people with higher level care needs will continue to be a challenge. However the evidence reviewed here does provide guidance on where the focus of interventions should be to achieve effective outcomes.