Summary of NESF Report: Implementation of the HomeCare Package Scheme

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Introduction

The National Economic and Social Forum (NESF) is a social partnership organisation which advises the Government on policies to achieve greater equality and social inclusion. It also studies the most effective ways to implement policies. This leaflet summarises the findings and recommendations of its 38th report, Implementation of the Home Care Package Scheme.

What is the Home Care Package Scheme?

The Home Care Package Scheme is a scheme operated by the HSE which provides care in the home, mainly for older people who are at risk of admission to long-term care. A HCP can include  nursing care, home help and/or various therapies such as physiotherapy and occupational therapy. Each HCP is tailored to the needs of an individual, based on their medical condition and the level of care they need. So in some packages there might be more home care while other packages might include more therapy and nursing, depending on what is needed.

The scheme was set up in early 2006, and in 2008 was allocated €120m. This allowed approximately 8,000 people to benefit from a HCP at any one time.

Report findings – design of the HCP policy

The need for HCP’s , and a policy around them, was outlined in the comprehensive Report of the Working Group on Long-Term Care in 2005. National guideline to put the HCP policy into effect were then written in 2006. Significant funding was made available and HCP’s began to be provided in HSE Local Health Offices (LHO’s) across the country.

Older people receiving HCP’s, and their families, are very positive about them. They allow older people to remain in their homes for longer; and their families to continue caring for them. This reduces stress and increases quality of life. Good practice in the management and implementation of HCP’s were strongly committed to this scheme working well.

However, the exact outcomes of the HCP policy were not agreed, and the national guidelines drawn up on how the HCP scheme should operate were not put into action. The result is the different LHO’s now implement the scheme in different ways around country. These differences include:

  • Different means tests for a HCP,
  • Different medical assessments of the need for a HCP,
  • Different amounts of funding per HCP,
  • Variations in how HCP’s are monitored, and
  • A variety of organisations delivering HCP’s.

While some of this flexibility is useful, it can also result in inequalities and inconsistencies between different areas.

Some other problems were identified in the management of HCP’s. These include:

  • Duplication of work – older people can undergo a number of means tests and assessments of need,
  • Little collection and use of data on HCP implementation and management, and
  • Little ‘coming together’ of all those working on HCP’s, to learn from each others’ approaches.

This leads to ineffective use of time by staff at local level, who are duplicating work and ‘re-inventing the wheel’.

The Report also found:

  • Poor links between the budget allocated and the outcomes aimed for, and
  • Weak accountability structures – it was not always cleat who was responsible for delivering what, or what would happen when actions were not completed within a set timeframe.

Reasons for variation in, and problems with, HCP implementation

Overall, the Report shows that HCP policy was well designed, but that implementation of the scheme does not follow all of the proposals made by the Report of the Working Group on Long-Term Care. This contributes to local variations in implementation. In fact, working practices do not provide strong motivation for those delivering the policy to implement the HCP scheme as planned in the Working Group’s national strategy. Current working practices are structured around local, annual budgets; local work practices; a lack of consequences when national targets are not met; a lack of connection between policy maker and policy implementers, and between different policy implementers; and unclear eligibility for HCP’s.

What reasons are there for these problems in HCP policy implementation?

Some of these problems occur with HCP schemes in other countries too – for example, poor co-ordination in delivery, a variety of needs assessment and eligibility procedures, inadequate monitoring, and little data collection.

However a number of organisational culture issues were identified which underpin this situation in Ireland in particular. These are:

  1. Decisions are not being taken at national level on how to target limited funding in a policy area with high costs. A result is that eligibility criteria for accessing a HCP are very unclear.
  2. There is a lot of dialogue about decisions, but decision-making following on from this is slow.
  3. The dialogue has too many layers of policy makers, with too few policy deliverers and service users involved.
  4. There is more emphasis on spending annual local budgets than on meeting goals of long-term national strategies.
  5. This emphasis on the local is a reason for little data collection, and little use of data to improve management of HCP implementation at national level.
  6. This emphasis is also linked to the lack of consequences when national strategy targets are not met within set timelines.
  7. And the emphasis on the local links to the poor delivery plans for reaching goals of national strategy.
  8. A loyalty to local organisations, rather then to national strategy, is evident.

It seems that the connection between national strategy, decision-making and local working practices is poor.

Recommendations

The case study of HCP implementation underlined how important it is for policy design and implementation to take into account the six key issues identified in Table 1. The recommendations for better HCP implementation are grouped around these six key issues, as outlined in Table 2.

 

Table 2 Recommendation  to support more effective implementation of the HCP scheme

Strategy with agreed outcomes

  • Agree the number of HCP's to be supplied
  • Agree standard eligibility criteria

Accountability

  • Clarify the responsibility of different organisations and individuals, and incentivise it

A focus on delivery

  • Devise detailed delivery plans
  • Co-ordinate delivery more effective
  • Set standards for delivery, and monitor them
  • Innovate in delivery – use IT, non-traditional providers, etc

Links between outcomes and budgets

  • Link budget and staff for HCP’s to the needs of older people
  • Understanding of organisational culture
  • Take organizational culture into account, so that there is a coherent link between policy design and policy implementation

Measurement

  • Collect data on the likely need for HCP’s
  • Collect data on the inputs, outputs and outcomes of the HCP scheme
  • Use this data to manage the scheme’s performance

 

A Steering Committee should also be set up, chaired by the Minister of State at the Department of Health and Children with Responsibility for Older People. This Committee would be responsible for implementing the recommendation in Table 2.

Overall, the Report stresses that Irish policy needs to focus more on understanding organisational culture, so that organizational issues which might prevent good policy implementation are recognised and engaged with. It is also clear that more work in needed designing how policies will be delivered. These two issues in particular need attention to ensure more effective policy design and implementation in Ireland.

Source: National Economic & Social Forum Report No 38, September 2009

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