Reimagine care

Written by Mark Essex, KPMG Strategy on 12 May 2016 in Sponsored Article
Sponsored Article

KPMG explores the use of digital platforms to improve life for service users and carers

Where we are

Government policies on public services emphasise personalisation, empowering service users to choose providers that best meet their needs. But despite an increase in the use of personal budgets, the offer in social care often falls short of these goals. And it isn’t only service users: carers too often operate within a demanding, inflexible system that takes little account of their preferences, requirements and specialisms.

Imagine if, as a service user, you were given a timetable for visits built around your essential needs such as meals, washing and personal care.  Someone did talk to you about managing a personal budget but it seemed quite daunting to plan it all.  And anyway, even if you set the schedule it still wouldn’t be flexible enough.  Some days you don’t need as much help, or you have relatives or friends who can help out.  What if you need the loo but its hours till your next visit?  What if you get hungry between visits?  What if you feel able to feed yourself today, but really need a lightbulb changing?  Even if you made the plan, it still feels a bit too rigid, doesn’t it?

Some of your carers have time to talk, you enjoy their company and you build up a rapport.  Others are professional, but not warm.  On some days, if there is traffic, or your carer is up against the clock, your visits can feel a little bit rushed. You don’t expect to click with everyone but wouldn’t it be nice if you could have more of your visits with the people you like?

Now put yourself in the shoes of a carer: you are on or near minimum wage on a ‘zero-hours’ contract that is difficult or impossible to combine with other work.  You receive rigid timetables with sometimes optimistic travel times.  There are days when you have barely enough time to get everything done before you have to get in your car and dash to the next appointment.  At those times, you’d like to provide a more caring experience, but the service users are not your employer; you work for the care company, whose customer is the local authority.  

And now let’s imagine you are that company that contracts with the local authority to provide the care.  Your performance metrics tend to emphasise efficiency and availability over service users’ views and experiences.   You understand this.  Your customers have seen significant pressure on their budgets, yet have statutory obligations to provide services to an ever-expanding population of people with infirmities, disabilities and long-term conditions. Councils have tried to square this circle by cutting rates, but this only puts more pressure on this narrow-margin industry – paring away at the quality you can offer. 

While so many public services become more citizen-centric, we have a system of visiting social care services which poses challenges to carers, providers, commissioners and service users.  Users, who often struggle to have their views heard through other channels, and who could benefit more than most from a better level of choice and voice.

Let’s Reimagine this…

Let’s ditch the rigid timetables and the staff rosters; the local authority contracting process and the tight-margin care management firms. Could we make service users the clients here, rather than their local authorities – putting them in the driving seat? Could we let people choose the times and types of service they receive, and allow them to select their preferred carer? Could we make caring roles more flexible and attractive, bringing in a new cadre of carers who fit the job around the other things in their life – rather than having to fit their lives around the job? With a change in approach and some relatively straightforward digital technologies, we don’t see why not.  Just imagine if a service user could request a visit as easily as ordering a taxi.

Many local authorities around the country have developed forms of ‘personalisation’, in which service users can choose to spend their ‘budgets’ at a range of local services – but these don’t generally include home care, instead providing a menu of daytime activities provided by approved firms. With digital technologies, though, it would be possible to take this much further – enabling service users receiving home visits to ‘buy’ a much wider range of services, at the time of their choosing, from named individuals. 
 


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Following an assessment of an individual’s care needs, they would be given a ‘budget’ and a mobile device containing real-time information on all the carers in their area: each carer listing would contain details of their skills and services, their availability, and a rating based on feedback from previous clients. Then they could ‘spend’ their budget how they chose, requesting the timeslots, the services and the individuals that met their needs that day. 

After each visit they’d be asked to score the quality of care, influencing the carers’ rating and guiding the choices of other service users. In time they would no doubt come across carers with whom they had a particular bond, and might want to schedule a regular visit; but if their needs changed and they required – for example – someone to unblock the drain or do a bit of shopping for them, then they could always rearrange. And if they had an urgent need for personal care or a meal, they could simply press a button and receive a visit from the first available carer.

On the provider side, this model reduces the costs associated with scheduling appointments and rostering staff.   Instead, carers would effectively be self-managed, signalling their skills and availability and letting the technology organise incoming service bids into an efficient route between jobs. So the carer’s working lives would be transformed: given the ability to choose when they work and the freedom to decline jobs, the role would grow in status, flexibility and autonomy. This in turn would attract new kinds of people into the job: parents willing to work during school hours; the active retired, happy to do a few jobs a day; the employed who want to earn a little extra in evening work; even volunteers ready to contribute their earnings to charity and, perhaps, to spend a little extra time having a cuppa with their clients.

Of course, not all services are the same: people’s needs, locations and characters would affect how attractive a particular job is to carers, so the system would even out these variations by altering the price paid. If a service user’s remote location or difficult health condition made it harder for them to attract carers, the price paid for a visit would be raised. If carers with a particular skill proved in short supply, the price for that service would increase until others retrained or entered the market. And if individuals experienced long waiting times on any particular day, a steadily-rising price should encourage carers to squeeze in an extra visit or come on duty.

By passing power from the local authority and the management firm to the service user and the public service worker, this model would return control from institutions to citizens. By providing a real-time picture of service users’ evolving needs and the people available to serve them, it would provide a way to dynamically match supply and demand. And by attaching higher prices to services found to be more scarce, it would ensure that gaps in provision were plugged. 

Currently, many service users feel as if they get what they’re given and carers do what they’re told: our rigid system provides services that aren’t required whilst ignoring people’s changing needs. But under this model, both groups would win back control of their lives in a system that gives each side exactly what it’s looking for.

How it would work

There are four parties under this model: the commissioner; the provider; the carers; and the service users.  All four would have different ‘dashboards’ on a shared app that would gather, process and share data.

The commissioner would typically be the local authority, although people ineligible for state-funded care could also access the system – either performing the commissioner’s scrutiny duties themselves, or passing that task to the council or their Power of Attorney. The commissioner would perform an oversight role on the work of the provider, scrutinising the system’s performance, ensuring that minimum standards are met, and handling any complaints or appeals from service users. It would also receive alerts when the system identified a risk: if, for example, a service user failed to log on or a call for service was left unanswered for too long, then the provider would have to intervene.

The provider would be responsible for conducting care assessments and reviews; recruiting, vetting, training, monitoring and advising carers; providing service users with the right equipment, training and support; adjusting the pricing protocols to ensure that people’s needs are being met; and providing a core service to support users with specialist needs or to fill any gaps which the new approach could not fulfil for any reason.

Service users would be given an app and, if required, a simple smartphone or tablet. This would show all the carers available – both in real-time, and through the shifts that carers have chosen to advertise over coming weeks – and prompt users to rate the quality of care after each visit. They could search for individuals’ names, high ratings or specific services, and either book visits in advance with particular individuals or simply request an urgent visit from the next available carer. Users would all pay the same for a particular service; the price variation would only affect the fees paid to carers, ensuring that people receive a broadly equal service even where it proves harder to attract a carer for a particular job.

Carers would be carefully vetted and trained, then upload a profile setting out their skills and the services they can offer. They’d be encouraged to set out their availability over future days and weeks: whilst it would be possible to simply switch on their ‘taxi cab light’ and pick up any unmet demand, those who allowed service users to book in advance would be likely to get the best jobs and the most efficient travel itineraries. And they’d be able to see the ratings and skills of other local carers, along with the proportion of their available time pre-booked – encouraging them to improve their service quality or undertake training in order to get a bigger share of the market.

Whilst service users would pay a fixed price for a specific service, carers would have to keep a close eye on the fees available: some would vary to reflect the need for a longer journey or visit; a higher rate might be paid for unsociable hours visits; and other fees would gradually rise as the system tried to attract a carer for a complex medical condition or an unpopular individual. 

Those with the best average ratings would receive more bookings and fill their diaries more quickly; but they could also be paid a small premium for each job, ensuring that great service brings rewards even where supply is so tight that most carers can find plenty of work. As with private sector equivalents such as CheckaTrade, the need to build and retain a good rating would be likely to have a strong positive influence on service providers’ behaviour.

Before finalising a booking, carers would be presented with information on relevant travel times – perhaps using local traffic information and data on daily congestion patterns – and the app could suggest diary alterations to make for a more efficient route. Via GPS tracking, the app would monitor carers’ locations and keep service users updated on their estimated arrival times. And before a carer arrived at a property, the app would ensure that service users had the carer’s photograph and supply both sides with a password to verify identity.

Alignment with public policy objectives

There are many ways in which this idea sits neatly alongside existing government policies, service reform agendas, public sector goals and popular opinion, including:

  • •    Personalisation and choice in public services
  • •    Government as a facilitator rather than a provider of public services
  • •    The digital by default agenda, and the aim of rebuilding services to make full use of the potential of data and digital technologies
  • •    The need to drive up the standards of care, focusing on patient needs, safety, and really high-quality service provision
  • •    The public disapproval of ‘zero-hours’ contracts, and the desire to give people more satisfying, empowering and engaging working lives
  • •    The aim of strengthening the role of competition in public services in order to drive up quality
  • •    The austerity agenda and ‘more for less’: this system would do away with much of the administrative work involved in scheduling and managing carers, cutting the costs of delivery. By closely matching demand to supply on a daily basis, it should also improve outcomes and efficiency in service delivery. These are particularly crucial goals in social care: demographic changes and falling council budgets are already weakening services and forcing the government to permit rises in local taxation. The forthcoming rise in the minimum/living wage is set to exacerbate these problems
  • •    The goal of increasing voluntary work and building community cohesion. With the role of carer made much more flexible and autonomous, new kinds of people should be attracted into the field – including volunteers, and others able to spend more time with service users than they’re being paid for.


Going further

Whilst this app could work at a borough or district level, the market would function more effectively if the system was applied on a larger scale – enabling carers to serve a bigger market, and minimising inefficiencies and perverse outcomes around council boundaries. The city-regional devolution agenda could be helpful here.

Extending the system to a national or regional level would open up further possibilities: perhaps people with relatives receiving care in other parts of the country could provide services to people in their local neighbourhood, gifting the credits earned to their relatives for them to spend.

With the system in place, it could also be extended to cover other forms of work – allowing service users to buy, for example, home repair or decoration services from providers. These providers could pay a charge on work won through the system, helping to fund the care service whilst enabling vulnerable people to buy services from providers who’ve been vetted, tracked and monitored through the app. This facility could help tackle incidences of fraud, aggressive door-to-door sales, distraction thefts and poor service – major risks for vulnerable people living in their own homes.

Summary 

Our current care system offers an inflexible, inefficient service that can deprive users of choice and is unable to flex around people’s changing needs and preferences. Just as importantly, it disempowers carers, who have little control over their working lives and are tasked with meeting the needs of their employer rather than their clients. This system has grown up over time as government has tried to meet the ever-growing needs of an ageing population in the face of weakening family support systems, creating a big, low-margin industry built around the interests of local authorities and private providers.

Our suggested system would strip out some of the administrative deadweight and focus on three key goals: providing the right care services for individuals; facilitating councils’ responsibilities to meet their statutory obligations; and improving the working lives, morale and performance of carers. Digital technologies enable us to rethink our system of care visits from first principles, building a replacement that prioritises the rights, choices and wellbeing of individuals rather than the interests and budgets of organisations.

To discuss this piece in more detail, feel free to contact the author at mark.essex@kpmg.co.uk or email us at reimaginegovernment@kpmg.co.uk​ 

About the author

Mark Essex works in KPMG’s Government Strategy practice where he specialises in critical thinking, analysis and solving problems that don’t have a defined methodology. Mark can be reached at mark.essex@kpmg.co.uk

This article is one of a series of thought experiments in which KPMG staff imagine new ways for government to achieve public policy objectives. This might mean building services around the user rather than the provider, or drawing on the huge potential of data and digital technologies, or tapping into the power of markets, new incentives, transparency, or the wisdom of crowds. 

In every case, it involves fresh ideas.To channel our thinking, we imposed three rules: 1) Ideas must be designed to produce better public outcomes without increasing the burden on the taxpayer; 2) they must align with the government’s philosophy and headline policies; and 3) they must be realistic and deliverable.But within these rules we want to step outside conventional thinking, and test out new ideas on how public policy goals can be achieved. We want to stretch ourselves, applying new technologies and techniques to solve old problems. We are not calling for a specific future – but we are reimagining it. 

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