Scope
The Health and Social Care Delivery Research (HSDR) Programme is inviting applications to address key evidence gaps to improve the organisation, delivery and quality of home care services across the UK including evaluation of new models of organising and delivering home care services. This topic emerged as a top area of research need for the programme in a recent, priority-setting exercise involving a wide range of stakeholders.
Social care delivered in people’s own homes by professional carers is known as home care or domiciliary care services and might include help with activities such as getting out of bed, washing and dressing, using the toilet, preparing meals and remembering to take medicines (as well as some clinical areas such as PEG feeding, catheter management and end-of-life care). Home care services may be required, either on a temporary basis or longer-term, to help people to stay living as independently as possible in their own homes. Home care can also be provided as “live-in” care, “extra-care” housing or supported living. What is understood as home care can be broad, and researchers are requested to define and justify their scope in relation to their particular research question. Arrangements for home care services differ across the countries of the UK and the programme welcomes cross-UK studies and those which feature comparative elements. Evaluations solely focused on time-limited, reablement care are out of scope for this commissioned call.
People who use home care services include older people and disabled people. Eligibility guidelines, based on needs assessments under the Care Act 2014, mean that in England household tasks alone would not usually entitle people to help from a local authority and, therefore, are often paid for privately. These types of support services are slightly different, usually referring to domestic tasks like gardening and cleaning, and are not usually delivered through local authorities. They are therefore not within the scope of this call.
Background
Demand for home care services is growing due to an increasing population of older and disabled people, and also in terms of its position as an alternative to residential care. Older people (over 65 years) are the largest group of users of home care services, but they are also used by younger adults with support needs. It is estimated that over 600,000 adults across the UK used home care services, commissioned by local authorities or health and social care trusts in 2019-2020. This data does not include people who may need home care but are unable to access it, nor the growing number of adults who are also privately arranging and paying for home care.
A financial assessment, or means test, determines whether local authorities will contribute to the cost of home care services. Users of self-funded home care services are projected to rise by 65% (between 2015 and 2040) and by 130% (between 2015 and 2070) while, over the same periods, disabled adults using home care services are also predicted to rise significantly. There are limited data currently available to understand the number of people self-funding home care services across the UK but, in England, it is estimated that around 27% of funding for home care services comes from those paying privately.
Supporting people in their own homes is a key strategic aim for health and social care, providing integrated pathways of care and enabling people to age well in the place they want to live. Lack of provision of home care services can impact the quality of life of adults and older people, as well as provide challenges for health and care services, particularly if it leads to hospital admission, delayed hospital discharge or unnecessary admission for long-term care.
There is considerable diversity in the home care provider market from micro-enterprises to large businesses, both registered and regulated, with over 10,000 such providers in the UK. Home care service providers are facing challenges as a result of funding pressures, changing population demographics, market fragility, workforce pressures and commissioning models in the public sector. Recent reports provide an overview of what is happening across the UK in terms of market provision and alternative approaches to service organisation and delivery and commissioning. Most home care services, including services paid for by the local authority, are provided by the independent sector. The Association of Directors of Social Services has expressed concern about the sustainability of the home care market (ADASS, 2017), so it may be useful to consider the concept of many home care services providers in the market, rather than just one (King’s Fund, 2018). Across all health and social care services, providers are struggling to recruit and retain staff. A CQC survey found that 41% of home care services providers indicated that workforce challenges have had a negative impact on the sector and the services they deliver.
Identified research need
NICE Guideline NG21 highlights uncertainties in the evidence around home care service packages, as well as what safeguarding practices are most effective in improving outcomes for people using these services. Evidence is also required about what is the most effective and cost effective models to support people with dementia living at home.
A 2018 King’s Fund report looks at innovations and models of home care services that include examples of neighbourhood care like the Buurtzorg model in the Netherlands, Shared Lives schemes, Wellbeing Teams, place-based schemes and relationship-centred care models, as well as models that aim to provide more integration of health and social care. The report finds that there is little evidence about implementation at scale, whether particular models of home care services reduce usage of other formal services, or whether models of care developed for younger adults with disabilities can be easily transferred as services for older people. The report highlights how home care services, and its workforce, could play a more integral part of the wider health and social care system, noting that traditional models of commissioning were often cited as a barrier to spreading innovation in services and care.
A recent stakeholder consultation identified research priorities for home care for older people. Stakeholder groups varied in the topics they prioritised for research. Out of 20 research topics that were identified, only one topic area (joint working between home care and health services) was a top 5 research priority across all stakeholder groups. This consultation also identified ‘workforce recruitment and retention’ as a high priority across three of the participating stakeholder groups.
Workforce pressures are a key challenge for the delivery of home care services. Staff turnover in the care sector highlights that employers are struggling to recruit and retain staff, however turnover is not uniformly high. Just under half (45%) of the domiciliary care workforce are employed on zero-hours contracts and home care services have the highest vacancy and turnover rates (estimates) in the adult social care system. Evidence is needed on models of commissioning and their impact on recruitment and retention and home care workers’ engagement and role within the wider health and social care system. There is very little evidence about home care services provided by personal assistants – individuals who are paid directly either by self-funders or through direct payments.
Given the integral role of home care services as part of the health and social care system, this topic emerged as a top area of research need for the HSDR programme in a recent, priority-setting exercise involving a wide range of stakeholders. Any research proposals should complement ongoing work funded by the NIHR HSDR Programme or other funders, for example, the NIHR HSDR funded study “Supporting, enabling and sustaining home care workers to deliver end-of-life care: a multiple-methods community-based case study”. Research proposals should build on, and complement, these and other relevant, ongoing NIHR research studies in this area, such as ‘The benefits and costs of domiciliary care’ and ‘Promoting Values-Based Recruitment in community dementia support through Situational Judgement Tests’.
Areas of interest
The HSDR Programme is interested in receiving rigorous, well-designed research studies that should generate national learning – so small-scale or single-site service evaluations will not be supported. The Programme is not prescriptive about methods, but we would expect significant engagement with all relevant stakeholders, including people using home care services and their families and people providing home care services and their staff. Any proposal meeting both the scope of the brief and the remit of the HSDR Programme will be considered, but some specific areas of interest have been identified:
- Workforce – given the high level of vacancies and turnover of home care staff, evidence is required on recruitment, and particularly retention, as a key area of research interest. Other areas of interest are: comparing different models of employment on recruitment and retention; professional development; effects of different approaches to staff training on outcomes for people who use home care services. Research is also needed to understand expanding workforce roles and the increasingly complex skills required to support people with more complex needs, and to maximise effective workforce contribution to, and interface with, the wider health and care system.
- Evaluation of different models of home care services and the barriers and enablers to their implementation; models of integration of home care services within the wider health and care system; evaluation of commissioning models that maximise the harnessing of effective use of home care workers’ skills, data and insight at the interface of health and social care.
- Given the size, range and value of the home care services sector, and the importance of these services in supporting people to live in their own homes, this call is interested more broadly in increasing the evidence base and the research readiness of the sector. This may include research exploring the quality (completeness, validity and reliability) of existing data and exploring and testing the linkage of relevant data, the development and evaluation of taxonomies (for example, home care activities – types, intensity and delivery model), core outcomes, frameworks and innovative methods to support high-quality research and reporting, as well as research to develop capacity within the home care services provider and researcher communities.
- Innovative approaches to, and models for, commissioning and delivering home care services for adults and older people with a range of care and support needs, including people living with dementia.
- Experience of receiving home care from the perspective of people using these services for a range of care and support needs and from their families and supporters. Research studies should include exploring the needs of diverse population groups including tailored services, access, health inequalities, safety and safeguarding.
- Evaluation of the use of technology in the organisation and delivery of home care services, as well as in home care environments and on the direct provision of home care services.
Additional information
The Doing Research in Home care research study is exploring the experiences of home care services providers and research teams working in this field. The study is developing a 'research toolkit for home care' for both providers and researchers, and it is anticipated that this will be available online in June 2023.
Applicants should consider contacting their local NIHR Research Support Service (RSS) for early advice and support to ensure proposals are appropriately costed (this was previously supported by the Research Design Service).
Research Inclusion
The NIHR is committed to creating a diverse and inclusive culture, as outlined in our Equality, Diversity and Inclusion strategy 2022-2027. We therefore encourage applications from people from all backgrounds and communities. We are committed to having leadership and teams that contain diverse skills and experiences.
All NIHR research proposals need to demonstrate that they have met the requirements of the Equality Act (2010). Researchers should consider being diverse and inclusive in the design, planning, conduct, impact, and dissemination of their research study.
NIHR also welcomes partnerships between research active and other less active institutions and those located in geographical areas of deprivation. Applicants are also expected to pay attention to populations that have been underserved and to conduct research in locations where the need is greatest.
General guidance
The HSDR Programme supports applied research with the aim of improving both health and social care services across the nation, and is open to any appropriate methodological approaches to answer the proposed research question(s). The approach must be fully explained and justified.
To enhance the success of a research proposal, a clear theory of change and pathway to impact, with links into the NHS and social care services delivery, is suggested. It is useful to consider in the research study design how outcomes could be scaled up to maximise impact and value for money across the NHS and social care services – the focus is on applied research with tangible impacts that improve the quality and organisation of health and social care services. This includes stakeholder engagement and the development of processes, tools, and guidelines to strengthen workforce capacity. Please see the HSDR Programme for further information.
Research proposals should be co-produced with national organisations, professional bodies, health and social care service professionals, and service users. Links with health and social care planners and professional bodies are required to ensure impact and scaling up of research findings to benefit the wider health and social care system.
The COVID-19 pandemic is having a significant impact across the health and social care system. As this research may be conducted during the COVID-19 response and recovery period, applicants should consider how the impact of the COVID-19 response and recovery may affect the deliverability of their research.