Introduction: Commissioning home care for older people
Home is a powerful symbol of autonomy and independence, whereas institutions are associated symbolically with the loss of autonomy. 
This guide captures the latest research findings on an important and emerging area of social care – that of home care for older people with complex needs. It also provides some practice examples of innovative work in this area.
The number of people aged 65 and over is projected to increase by 23 per cent from 10.3 million in 2010 to 12.7 million in 2018. Growth in this age group is projected to continue for the foreseeable future, with the 65+ population expected to reach 16.9 million by 2035.  More people are living alone in old age and can access less informal care than in the past.  The cost of home care is forecast to rise from one per cent of the UK’s Gross Domestic Product (GDP) now to between 2 and 4 per cent by 2050 (GDP being the total market value of all final goods and services produced in a country in a given year).
As the population grows older and the political and financial drive to keep older people out of hospital increases, the way home care is provided must change.
The home care market will have to respond to the needs of this expanding group of older people who use services (referred to in the rest of this guide as ‘users’). As people are living longer, the number of older people with complex needs who live at home is increasing. A tightening in eligibility criteria for those in receipt of home care means that those receiving care have more complex conditions including long-term, chronic health conditions and multiple conditions. 
What are complex needs?
There is no set definition of ‘complex needs’ in the home care situation. They can include one or more of the following:
- long-term conditions or multiple conditions, such as heart disease, diabetes, osteoporosis, arthritis, epilepsy, needs following stroke or frailty
- mobility and continence difficulties
- mental health issues.
A higher proportion than ever before of older people receiving home care are now considered to have complex needs. Seventy-two per cent of councils only offer home care services to those with substantial or critical needs.  Users typically have an average of three diseases and 10 different complaints. 
The current situation
Home care is sometimes seen as a low-paid, low-expectation service held together by the goodwill of frontline staff – not the professional integrated service capable of substantially improving the health and wellbeing of users that will be needed in the future. 
Home care services are often experienced as impersonal, inflexible, underfunded and poorly integrated with other health and social care services. Services are not designed around the person, but depend on how organisations are structured or who is doing the commissioning.
Sometimes staff are poorly trained and poorly paid, which leads to high turnover of paid carers (32 per cent leave within 12 months; 56 per cent within two years). This can mean a lack of continuity of care for older users and a lack of flexibility in changing care arrangements. Home care users may feel that their care staff are indifferent to their needs. 
Users also have problems accessing the right services for their needs because of:
- organisational barriers such as a lack of information about what is available
- a lack of support from an unpaid carer or advocate
- social isolation
Social isolation can be a real problem for:
- users from black and minority ethnic groups
- users in rural areas
- people who use mental health service users
- older people with high support needs.
Funding cuts continue to have an impact on home care services, with commissioners finding that they are having to drive down costs to meet their own restricted budgets.  This has an effect on the service provider market, with service providers that are dependent on local authority/health and social care trusts in Northern Ireland (HSCs) contracts having to reduce costs to a minimum. This has an impact on staff levels, skills and morale. The ageing care workforce will also start to have an impact as currently 50 per cent are over 45 years old.