Why Bristol City Council's Homecare Service Must Be Saved

If you care to look through the older posts on this site, they tell the tale of our campaign to save Bristol's Homecare Service from privatisation 4 years ago.  By campaigning effectively, the decision was sucessfully overturned by Homecare workers, service users and the electorate.  In the local election, the Lib Dems paid the price for treating Homecare with contempt.  They lost many seats and consequently lost the confidence of the Council Chamber.  A new minority Labour administration, supported by the Conservatives, worked with the trade unions to agree a viable way forward for Council Homecare.  The service was too expensive because staff time was under-utilised.  Managers argued it was a consequence of high sickness levels and inflexible hours of work.  Homecare workers quickly agreed to change their hours and supported plans to reduce sickness.  In return, the Council would commissioned work from its own Homecare Service in such a way that labour efficiencies would be radically improved.   

Fast forward to 2011: The homecare workers did everything required of them and the response from the Council was one that can only be described as betrayal.  Workers moved to flexible contracts and sickness absence was halved: close to target by mid 2010.  The Council failed abysmally to deliver on their side of the bargain and did not effectively commission work from their own Homecare Service.  As a result, labour efficiencies are now breathtakingly bad.  Back under Lib Dem control, Bristol City Council again plans to privatise all of its Homecare service. Perhaps the Lib Dems have decided to exact revenge for their defeat in 2007.  Perhaps the management and supervising politicians are so astonishingly incompetent that they don’t understand that paying Homecares for doing nothing for 40% of their time dramatically increases unit costs.  Whatever the cause, we are faced with the nauseating spectacle of Homecare workers, service users and the Bristol electorate being punished for having the collective courage to challenge care privatisation back in 2007.

Since 80% of the homecare currently provided for older people in Bristol is commissioned by the Council from private sector outfits, what we are faced with in 2011 is not a case of in-house versus market-led services.  The arguments against wholesale privatisation are two-fold: both concern the protection of vulnerable people.  Firstly, the homecare workers themselves and secondly, the older and disabled people they care for.

Women (because it is an almost exclusively female workforce) working for private sector homecare agencies have some of the very worst terms and conditions of employment of any workers in the UK.  Hence it is difficult to recruit women to work in homecare and staff shortages are endemic.  In terms of traditional economic theory, one might think that labour shortages would push up wages.  However, the homecare market is 'monopsistic' - this means that in the local market for homecare services, there are many providers but only one customer.  The single customer, in this case Bristol City Council, prevents effective competition by exerting monopoly control over how much it is willing to pay. 

Instead of producing an improvement in wages, the labour shortage in homecare makes the working conditions worse. Workers are cajoled or bullied into working long or unexpected hours to cover for staff shortages.  Corners are cut.  Care companies go bust, workers get into serious personal debt.  The vast majority of women working for private sector homecare companies are employed on contracts that deny them the employment rights which many other workers take for granted - like the right to take unpaid time off work in a family emergency, or maternity pay, sick pay or the confidence that accompanies a regular income and stable hours of work.  The very basic rights they do have, like entitlement to the national minimum wage or basic holiday leave, are routinely violated.  Official statistics show that 10% of all homecare workers are paid below the National Minimum Wage, and these are only the reported cases.  However, Council employed care workers, although not highly paid (in Bristol they get a basic wage of £7.11 per hour), do have employment rights, do have a trade union to represent them, enjoy sick pay and have much greater economic security than their private sector counterparts. 

Homecare markets are localised: the controlling customer for the entire local market is Bristol City Council and the women who work as homecares live near to the service users they care for.  The most significant element in competition for labour supply is the existence of work opportunities both with the Council and with private agencies.  If the better paid and more secure jobs provided directly by Bristol City Council disappear, terms and conditions will deteriorate even further in the jobs that remain in the private sector.

This impacts on the second group of vulnerable people in the homecare market: the older and disabled people who receive services.  Labour shortages in the private sector mean that staff turnover is so high that older people often don't know who their carer is, who the next person knocking on the door will be.  If a carer does not show up, older people can find themselves left sat in their own urine or faeces, or unable to take the medicine they need, or left without a drink all day.  They get frightened. 

Only a couple of days ago a very elderly, incontinent and immobile service user had his care package taken away from Bristol's own homecare service and handed over to a private agency.  He was distraught at losing his trusted Council homecare worker and cried for many hours because his new agency carer had forgotten to give him a hot drink and had not changed his sheath catheter.  He was left at risk of dehydration, urinary tract infection and skin ulcers.   Older people who need care know how vulnerable their lives are. 
They have little faith in a system in which their only point of social contact or their only source of personal assistance is based upon an unstable commissioning arrangement between faceless bean-counters at the local authority and the local franchise of a multi-million pound care company. 

Sometimes these companies fail.  In high profile cases, take for example Bristol's Winterbourne View as exposed by Panorama, owners decide to shut up shop because appalling, institutionalised abuse is uncovered.  Not infrequently, business failure means going bust - look at the precarious state of Southern Cross care homes.  Most often though, homecare agencies fail their service users by cutting corners, employing untrained staff, failing to complete Criminal Records Bureau checks, mixing up service user's medication, not putting in the time they are supposed to, or simply failing to turn up at all. 

This market instability is the price we inevitably pay when we (as a society) collectively concur that markets can run things more efficiently than centralised, highly bureaucratic, publicly-owned services.  True, the care market is regulated, but the Gordon Brown inspired 'era of light-touch regulation' did not only impact goings-on in the City of London, it also shaped the regulation of care markets.  The regulation of private sector care has been progressively watered down at every opportunity.  The Care Quality Commission, the current regulator of care services, now has such a poor reputation for quality control that in June of this year it even lost the confidence of the very private sector companies it was designed to oversee at the National Care Homes Association annual conference.

It's too late to turn the clock back on the privatisation of care services.  Not all private sector care is bad.  However, we must deal with the reality that, in fact, all these companies operate within a care market which is based on weak regulation, routine abuse of employment rights and a desperate clamour for cheapness from a monopoly customer.  In such a system, the retention of (some) Council run, secure, reliable and democratically accountable homecare services becomes an absolute necessity.  When the market fails, as it inevitably does, the Council's homecare service picks up the pieces.

When two private homecare companies in Bristol ceased trading earlier this year, it was the Council's homecare service that stepped in to take on the abandoned service users.  The Council's emergency homecare team provides round-the-clock cover, intervenes in case of missed appointments and at times of critical need.  Bristol City Council's homecare workers are, without doubt, the most experienced and capable carers in the City.  Despite being low paid, homecare is a highly skilled job.  These workers apply a wealth of knowledge about medication, medical equipment, physical disabilities and older people's health needs.  They pay attention to the signals that warn of a person becoming weaker, take preventative action and build proactive relationships with their service users.  There are huge outstanding care needs within our City: take for example the 50% of dementia sufferers who live in their own homes or the 20% who live totally alone - as yet there are no specialist homecare services for them.  Consider the needs of the terminally ill who do not wish to die in hospital - their expectations of a dignified death in the comfort of their own home are only just beginning to be taken seriously.  Think of your own Dad or your Grandma, what do you wish for them?  Surely, at a minimum, you want a care market that does not dump its inherent failures on people who are too weary, too frightened and too dependent to do anything about it?

Bristol City Council, as the architect of the care market in the City, has the power to make or break care providers.  Its approach to its own Homecare Service has been to try and break it.  Despite the best efforts of the workforce, they have been betrayed.  The Council has failed to use the time and expertise of its own staff in a determined effort to claim the service is too costly.  A Council employed Homecare earns £7.11 an hour, each hour of care bought from the private sector costs at least £16.  Homecare is not a technical enterprise, it's a business based on organising skilled women in such as way as to make sure that as much of their time as possible is spent with an older person in need of care at home.  Bristol City Council have been doing that task so badly of late that they calculate their own service now costs £34 for each hour of care delivered.  This is simply not good enough.

The solution needed in Bristol is not to de-regulate homecare even further, putting every last pound of public money into private hands, but to retain the service and manage it properly.  For the sake of vulnerable people in the City, both those who work in homecare and those in need of care, Bristol's City Council's own Homecare service must be retained.