Whose responsibility? Boundaries of roles and responsibilities in housing with care

Key points

• Most residents in the study reported very positive experiences of HWC, but a third described problems linked to roles and responsibilities, from building maintenance to increasing care needs.
• Ambiguity around the boundaries between job roles can lead to confusion, gaps or duplication.
• Gaps are often filled by staff members over-stretching their roles but such a discretionary approach can be inconsistent, inequitable and unsustainable.
• Some residents (especially those with cognitive impairments who do not have local, involved family) may need a 'ringmaster': someone who can identify gaps and coordinate the input of health professionals and others.
• Complexity in HWC arises from commissioning, funding, regulation and differences in the local and national policy context - this creates the potential for tensions around role boundaries.
• Despite national variations in terms of HWC provision, housing support funding and care charging, similar boundaries issues arise at scheme level across the UK.
• Residents with high support needs particularly value continuity and good relationships with scheme managers and staff, who work hard to deliver a seamless service, in spite of funding cuts.
• No single model of HWC emerged as being the best for residents: roles and responsibilities can be managed effectively in both multiple and single provider models of HWC, if commissioners, providers and staff have a shared vision, communicate well and involve residents meaningfully.

Background

This qualitative study looks at how different services, providers and other key players work together in HWC schemes and the impact this has on residents' quality of life.

HWC offers older people the privacy of their own self-contained home and the security of tenancy or ownership rights, within a community setting. They can choose to access care and support (usually with staff on site 24/7), company and social activities, and other facilities, such as a restaurant. However, there is an enormous variety of models on offer from not-for-profit, public and private sector providers, sometimes delivering different services in the same scheme. Some are run independently by private companies or charities, but many schemes are commissioned by local authorities. Sometimes commissioning decisions or other circumstances result in a change in who is providing what at scheme level.

Our study focused on the impact of this complexity on older people's quality of life, and the boundary contests which can arise from it. Our fieldwork covered all four nations of the UK and included tenants and leaseholders, and private sector as well as not-for-profit providers.

Rights and quality of life

Most of the residents with high support needs interviewed described huge gains for their quality of life from moving to HWC. Although they did not describe it in these terms, HWC promoted their human and other rights, especially in comparison to other care home residents and people receiving domiciliary care in the community. However, confusion about roles can get in the way of older people’s rights, for example, where confusion about who is responsible for what makes it difficult to complain, or where different views about ‘safeguarding’ and a lack of understanding of housing rights by other professionals mean that someone is pressured into giving up their tenancy or lease as their needs increase.

Grey areas and gaps

In HWC, grey areas occur where it is not clear which frontline worker should do a task or how far responsibilities should stretch. This ambiguity can lead to confusion, gaps or duplication in a number of aspects of HWC provision, including: buildings and maintenance; supporting move-in and participation; responding to increasing needs and end-of-life. Just under a third of residents described problems which seemed to link to roles and responsibilities. Gaps seemed most likely to occur in certain situations, e.g. where tasks are small (in terms of time it takes to do them); when circumstances suddenly or temporarily change; or when tasks are difficult or resources limited. Gaps are often filled by staff members over-stretching their roles but such a discretionary approach can be inconsistent, inequitable and unsustainable. Other workers, relatives or neighbours sometimes fill the gaps.

The 'ringmaster'

Many HWC residents are very capable of organising their own affairs. However, some (especially those with cognitive impairment) may need a ‘ringmaster’: someone to coordinate ad hoc input, chase various agencies and make sure things happen. The study found examples where this role was effectively played by relatives, the scheme manager, another member of staff, or an external professional.

Why is HWC so complex?

The study identified a number of factors driving complexity in HWC, including:

• local authority policies, or an absence of them, in relation to planning, commissioning, procurement and contracting;
• the availability of - and arrangements for - funding available for housing, care and support, within HWC;
• the regulation and monitoring of housing, care and support services;
• the emerging thinking and application of 'personalisation' to HWC;
• the 'models' of HWC in the social, charitable and private sectors;
• the different expectations between residents, family, staff, providers, commissioners, and regulators of what HWC is and does; and
• differences between the four nations of the UK in terms of the provision of HWC and the extent to which this is influenced by government, the funding of housing-related support and charging for care.

This complexity creates the potential for tensions around the boundaries between roles. This has been exacerbated by cuts in public funding - for example, there was some evidence of authorities and providers shunting costs from support to service charges, which can alter the way in which services are provided.

How can this impact on residents?

Roles and responsibilities can be managed effectively and with little evidence of negative impact for residents in both multiple and single provider models of HWC. However, a recurring theme across nations and models was that this was because residents were being shielded from the complexity of the organisational arrangements by the scheme manager and frontline staff who were working hard to deliver a seamless service.

HWC residents put high value on their relationships with scheme staff and on continuity of people and place. Sometimes complexity threatened this, for example when staff had less time to spend with them because they were recording tasks against different funding streams; or when a housing provider was unable to influence the care provider’s use of agency staff. Many local authorities appeared to pay little attention to the impact of their commissioning and procurement decisions on residents, especially where block tendering resulted in uncertainty and sometimes changes to service providers and/or staff. Where this had been managed well, it required time and other resources to involve residents and families.

Practical implications

The study identified a number of practical ways in which organisations can improve the way they work across boundaries to produce good outcomes for HWC residents.

Workforce and management

Frontline staff need to be carefully selected, trained, monitored and supported with good management and pay and conditions if they are to provide the stable, high quality and seamless service that older residents value.

Clarity between the key players

To minimise roles and responsibilities issues, there needs to be clarity from the outset about: expectations of HWC, residents' rights, a shared vision, respective job roles, mechanisms for communication with relatives and between professionals, and user feedback.

Commissioning

Commissioners need to be flexible, rather than prescriptive; focusing on what works best for older people and minimising the impact of organisational change within HWC schemes. They need to look at ways of implementing personalisation so it increases self-determination, not complexity, and think strategically about the role of the private sector in developing and delivering HWC.

Resident involvement

Finding meaningful ways to involve residents in each of these three areas focuses joint working on the things that really matter to older people and empowers them to understand and exercise their rights and responsibilities.

Conclusions

Despite identifying important differences in the policy context and provision of HWC in each of the four nations, the study found similar boundaries issues arising at a scheme level across the UK. Despite many unhelpful layers of complexity in the sector, a fundamental strength of the HWC model is that it brings together housing, support and care professionals and their different values – and perhaps also the varied perspectives of different sectors. However, this makes a clear shared vision essential. Many participants describe their move to HWC as one of managing risk, yet HWC is independent living and expectations about what can and cannot be provided must be made clear to residents and their families. However tight the protocols and however clear the boundaries, there will perhaps always be the risk of gaps: what matters is that all the key players understand this from the outset.