Homecare has come a long way since the days of home helps, when support at home was largely domestic and increasing personal care needs often resulted in admission to residential care. Now people with relatively complex needs can be supported to live independently, without the need to leave their own home or community.
But as homecare has become more sophisticated, so have demands on providers. A common dilemma for homecare managers is how far their careworkers are allowed to go in carrying out medical and quasi-medical tasks .
The dwindling workforce of community nurses and rising number of people with complex health needs supported at home, mean homecare services are being asked to carry out tasks formerly the preserve of medically-trained staff.
Applying dressings, peg-feeding, administering injections, and changing catheters all now figure in homecare packages. District nurses and families also ask careworkers informally to fill the gaps in healthcare provision by carrying out medical or quasi-medical tasks.
This rings alarm bells for homecare providers, concerned about the extra responsibility they are being asked to take on, often without formal recognition.
Typically, UKHCA members ask us “Is our careworker allowed to…?”, when they call our member helpline, describing the medical procedure they have been asked to carry out. In this instance, let’s say it’s administering insulin to a diabetic service user.
The regulatory guidance for providers does not usually provide specific advice. So it is down to the provider to make a considered decision. To reach this decision, we suggest the provider answers the following questions:
- Do you want to carry out this task or service?
- Is it part of your business plan and strategy, or would it be mission creep?
- Do your policies and procedures cover the task?
- Do you have sufficient staff who are qualified and experienced to supervise the task?
- Do you have a sufficient number of careworkers who are trained and competent to carry out the task, by a trainer who in turn is trained, competent and experienced?
- Can you cover staff sickness and holidays?
- Do you have the expertise to carry out clinical governance reviews?
- What if something goes wrong, would your supervisors and workers know how to respond correctly?
- Is your business insured to carry out the task?
- Does the task appear in the care package and contract documents?
- Are you being paid in a way that recognises the complexity of the task?
In most cases, members reach the conclusion that either the service is ready and able to carry out more complex health tasks, or it is not.
But that doesn’t stop homecare managers from feeling under pressure from council or Clinical Commissioning Group commissioners, or being concerned that they may be viewed as un-co-operative, if they turn down a package.
No homecare service wants to turn down a care package and this can lead to a provider trying to find a way to carry out the task concerned, even if they are initially unsure.
This is where a clear-headed risk assessment is needed to make sure that no excessive risks are taken with the safety and well-being of the person who needs care.
A lack of investment in community healthcare services can never justify providers being forced into taking risks with service users’ safety, to meet commissioners’ demands.
But with the direction of homecare pointing to more medical tasks being carried out at home, as healthcare budgets tighten, perhaps the time is right for strategic thinking on just how to make sure there is a suitably trained workforce in the future.
The enhanced careworker role may provide a solution, or we could borrow the nursing associate idea from the NHS. It all comes down to money. It wouldn’t harm to reverse the decline in number of community nurses, which has nearly halved since 2010 , and promote a system of integration that really works at the frontline.
 For a discussion of the legal implications, see article by Anthony Collins Solicitors in May 2015 Homecarer which explores the increasing shift of health responsibilities to providers and the risks and problems this involves, available to UKHCA members at: www.ukhca.co.uk/downloads.aspx?ID=465
 Queen’s Nursing Institute and Royal College of Nursing, Outstanding Models of District Nursing report, 2019: https://www.qni.org.uk/resources/outstanding-models-of-district-nursing-report/