The Governance of Home Support Services in Ireland

This thesis explores the governance of home support services for older people in Ireland, focusing on the case of services provided in one HSE Community Healthcare Organisation area, in order to make a clinical judgement on the knowledge of workers who provide care to older people in their homes. It compares service delivery methods – HSE, not for profit and private providers – in order to ascertain if those methods have any impact on the quality of the services being delivered. Home support services provide care in the home, assisting people with functional activities of daily living. Home support has the potential to keep people well at home by focusing on providing preventative care, such as ensuring older people receive optimum nutrition and hydration, are protected from infection, and maintain skin integrity. To achieve this, however, workers providing home support must have the skills, knowledge and autonomy to deliver appropriate and timely care interventions based on a holistic, evidence-based assessment of their clients. Publicly funded home support services in Ireland are currently provided in two ways, directly by healthcare assistants employed by the Health Service Executive (HSE), and indirectly by voluntary and for-profit agencies who have a contract to deliver care on behalf of the HSE. Approximately 67% of home support services are outsourced to these agencies. This study will show that there is little oversight and monitoring of outsourced services by the HSE, and where monitoring does take place there are no penalties imposed on agencies who do not comply with contracts. International evidence has shown that home support work is precarious in nature, in the main provided by women and migrants who work in unsupportive working environments with poor pay and conditions, poor access to ongoing education, no career pathways, with the constant threat of losing paid hours of work. Due to the nature of the work demand for services vary through the day, with workers often working split shifts over a twelve-hour period to meet demand. All of these precarious working conditions were found in this study, and conditions were especially poor for those working on outsourced HSE contracts. The home support workers role evolved from nursing, and originally was conceived as a supportive role to a qualified nurse. The vision of the role was as a delegated function, with the qualified nurse overseeing the work of the assistant but retaining accountability for the tasks undertaken. However, this study will show that this role has been completely eroded, and no consideration has been given to the importance of replacing that clinical oversight. The study will also demonstrate that workers have not been provided with adequate training to deliver evidence-based care and are overly reliant on life experience to guide them in the provision of the care they deliver. It will show how there is no discernible difference between workers in each sector in terms of their clinical knowledge and the ongoing professional development and support they receive. Finally, the study will show a deeply committed workforce, across all sectors, who despite how they are treated go over and beyond to provide the best care they can to older people. It will show a workforce who want to learn and improved their knowledge and skills. Finally, the study will provide some recommendations which could improve both the service delivered and the lived experience of the workers who deliver care in the home setting. The study makes a unique and important contribution to the literature. There has been very little research conducted from a healthcare perspective on home support services in Ireland or internationally. Industrial relations scholars have studied the working conditions but not the standards of care provided by the workforce. This study fills this gap by examining the regulatory framework (strategic governance), the competences, training, supervision and clinical oversight of the workforce (clinical governance) and the working conditions, vulnerability, empowerment and supportive working environment (workforce governance).