Will the public care about care this election?
With a general election to come this year, public sentiment about social care will be a clear issue for election candidates.
Recent reports have raised important questions about the way the sector is funded, but with even more recent increases in council tax fresh in the public minds, how willing are the public to support a message that the sector needs even more funding?
Among those critical of social care funding was the Reforming Adult Social Care in England report, which called for more assurances that funding for social care market sustainability and improvement would not end up in providers’ pockets without making an impact on care services.
Criticising the DHSC’s data collection and transparency, the report states: “We are concerned that the Department’s grasp of what it is getting for the £1.6 billion funding to support hospital discharge, is … vague.”
In addition, Skills for Care’s Pay in the adult social care sector report highlighted that at the end of 2023, two in five independent sector care workers were paid below the Real Living Wage, with a median average rate of £11 per hour.
This followed a British Social Attitudes survey which found that 57 per cent of respondents were dissatisfied with social care services due to inadequate pay, working conditions and training for social care workers.
For the Care Workers’ Charity, which financially supports care workers, the reports are a welcome endorsement of the much-stated need to improve pay and conditions for care workers. In its election effort, the CWC intends to publish a manifesto to highlight the plight of care workers and the causes and impact of poor pay and conditions.
However, Liz Jones, policy director at the National Care Forum, feels it is a “false premise” to say that higher wages were simply within the gift of employers and she has laid some blame at the feet of local authorities which commission services but which are not able to meet the real costs of care. This has an impact on the prices charged to those who fund their own care as well as providers’ ability to maintain the scale/quality of their services, she believes. “The concept of a ‘sustainable care market’ is simply not a reality when we haven’t got enough money coming into the system”, she said.
Council tax rises due to the social care precept do little to warm public sentiment towards further investment in social care and NCF senior policy and external affairs lead Nathan Jones, believes it will be a battle will be to overcome the ingrained view that care home owners make massive profits from the care of older people. He said: “Politicians share that perception as well.”
A community asset
The NCF sees the election as an opportunity to stress the importance of long-term funding for social care and it has prepared a pack for its members to use when speaking to prospective candidates and councillors.
NCF Policy Director Liz Jones said: “We know once the election gets announced, the candidates will be interested in talking to social care providers and be interested in getting their vote and the vote of the people they support. We know there is an opportunity there.”
For Care England a key message will be that the value of social care to local communities and economies cannot be understated. Chief executive Professor Martin Green explains: “Underfunding of care by the Government is a major impediment to the development of new services and the sustainability of current ones.
“We intend to go into the media so that the messages we are delivering about the importance of care to local people and local economies will be heard by the general public as well as by critical decision makers.”
However, CWC CEO Karolina Gerlich is realistic about the challenge this message faces. She said: “Politicians are forever scared of tackling social care around the election: they see social care as a vote loser rather than a winner because as often it comes with a message of ‘it needs more money! And, where is the money going to come from?’”
Care Home Management: April 2024
LPS delay is a “time for reflection”
In spring the Department for Health and Social Care announced that the Liberty Protection Safeguards (LPS) would not be implemented until the next Parliament at the very earliest.
Replacing the Deprivation of Liberty Safeguards (DoLS) process, LPS is intended to streamline the process and bring 16–17-year-olds, who are currently subject to Court of Protection rulings, into the framework.
The delay means that DoLS continue to apply to anyone aged 18 and over who lacks capacity to consent to the arrangements for their care and treatment and who is cared for in circumstances which deprive them of their liberty.
Sheree Green, director of Greenchurch Legal Services, explained: “The intention had been that LPS would provide a more streamlined way of protecting the individual’s rights than the complex, longwinded and bureaucratic DoLS, which requires local authorities to supervise the process for all care homes and hospitals.”
Green added that since the Supreme Court ruled in 2014 ruled that the human rights of disabled people should be protected to the same extent as the population at large, local authorities have been overwhelmed with referrals.
As a result, the average length of time to complete a DoLS standard authorisation was approximately five to six months in 2021-22, said Hannah Taylor, partner, health & care regulatory for law firm Bevan Brittan. She added: “Until recently, a Re X streamline application would be with the Court for between six and 12 months before authorisation.”
While the LPS provisions have been broadly welcomed, many stakeholders see the delay as an opportunity to iron out some potential wrinkles in the new system.
Greenchurch’s Green points out that the LPS provisions need to ensure that they define ‘deprivation of liberty’ in line with the acid test set by the High Court in 2014.
She said: “We would also like to see a time limit on proposed emergency powers to detain people.”
Homecare provider Upward Care also hopes that arrangements can be made to renew capacity assessments every 12 months. This would avoid having to chase up DoLS for each service user.
Andy Dennehy, training and development manager and safeguarding lead at the provider, said: “That would be our biggest hope for a change. The amount of time we spend chasing DoLS is excessive.”
Care Home Management: August 2023
HSE highlights links between staff wellbeing and safety outcomes in new report
There are “strong links” between staff wellbeing in healthcare settings and safety outcomes, a report by the Health and Safety Investigation Branch (HSIB) has found.
HSIB’s third bulletin concerning the harm caused by delays in transferring patients to the right place of care concluded: “While staff are trying their very best to ensure safe care, harm is happening, and this is affecting patient outcomes and staff wellbeing.
“This further impacts the ability of staff to stay well at work.”
Staff told the HSIB that wellbeing is prioritised by healthcare organisations only when there is time to do so. Staff also said that their wellbeing was only considered fully when it had deteriorated beyond the point at which they could be supported by colleagues or their local professional health and wellbeing services.
The investigation heard that the opportunity to speak openly, confidentially and within the safety of a facilitated discussion was incredibly helpful and ‘cathartic’. This could take the form of protected time for staff to come together to talk about the emotional impact of their work.
According to a recent Health and Safety Executive (HSE) survey, of the 1.8 million workers in Great Britain suffering a work-related illness, around a quarter were in human health and social work.
HSE said in its strategy for 2022-2023, that current trends show that work-related ill-health is increasing in Great Britain.
In detail it said that stress, depression, or anxiety were the most common causes of work-related ill health in Great Britain, and it called on wider industry and business to support improvements.
Chancellor Jeremy Hunt announced in his Budget last month a £400m plan to increase mental health and musculoskeletal resources and expand the Individual Placement and Support scheme.
He also pledged to bring forward two new consultations on how to improve the availability of occupational health services provided by employers and double the funding for the small company subsidy pilot.
All employers, under section 2 of the Health and Safety at Work Act (1974), have a general duty of care to ensure the health, safety and welfare of all employees, and this includes employees’ mental health.
According to the Health & Safety Executive, there are six main areas that can lead to work-related stress if they are not managed properly. These are: demands, control, support, relationships, role and change. It adds that factors like skills and experience, age, or disability may all affect someone’s ability to cope.
It calls on employers to takes five steps based on risk assessment:
Have conversations
Recognise the signs and causes of stress
Respond to identified risks
Reflect on agreed actions
Make risk assessment routine.
“It needs to become the norm to talk about stress and how people are feeling and coping at work,” says the HSE.
Law firm Hill Dickinson recommends that, as a minimum, employers should ensure access to support is clearly signposted to employees.
However, to be in line with the recommendations of the HSIB report, these services should be accessible within a reasonable amount of time to avoid staff’s mental health and wellbeing deteriorating further due to “significant waiting lists”.
The onus should not be on staff to have to seek support when they feel they really need it. “Due to high workloads and the ongoing pressure on the system, [this] can often be once mental health has deteriorated significantly,” the firm said.
Care Home Management: April 2023
Six months on from the launch of ICS, and…
In July 42 Integrated Care Systems (ICS) launched with the aim of joining up health and social care systems to provide more seamless services.
Almost six months on, however, social care providers are finding it hard to get involved with these new bodies, set up to replace CCGs, which are now responsible for planning and commissioning publicly-funded social care services.
Nathan Jones, senior policy, research and projects officer at the National Care Forum, said: “Our members are finding it incredibly difficult to engage with the ICS at system-level at the top level.
“What our providers find is where they had good relationships with the local authority and health board commissioners before the ICS went live, they got more involvement.’
“We do have a few members who have actively tried to engage at system-level and above and just can’t.”
Jones added that lot of providers were engaged at place level.
Chief executive of Care England Professor Martin Green said the issue was that when the ICS reach out to social care it is “on the basis of what it can do for the NHS”.
He said: “There is very little change going to happen because the ICS culture is totally NHS focused and dominated.
“We have had some good contact but it is very much a patchy picture. When you think about how many there are, the number who have engaged with social care is very few.”
Jones argued that one problem was social care not having a statutory voice on the Integrated Care Board. “That is a real barrier to the collaborative approach”, he said.
He explained that in some areas, commissioners think local authority representation is sufficient to give social care a voice. In others there is a mentality of keeping a distance between the commissioner and provider.
Jones added: “Many of our members would give good insights into how to make discharges work better and how you could prevent admission in the first place, but they don’t get listened to.”
“It is the problem of having a very powerful partner, one institution, versus social care which is very fragmented.”
The commissioning power of the new ICSs is also a concern for some providers. Sanjeev Kanoria, founder and chairman of Advinia Health Care, said: “Integrated health and social care is a very good idea. It prevents bed blocking and allows for faster movement of patients in hospitals into social care settings.”
On the converse side, he wonders what will happen when they have more market power. He says: “If you have one market player, you contravene all principles of market dynamics. That is a big risk.”
Kanoria said measures should be put in place by the Government so that the ICS wield their power in the right way.
Professor Green added that the ICS should have been set up with requirements to include social care in the planning process and the development of services process.
“Social care has been trying to get a voice but, frankly, I can’t believe that a government that is supposed to be focusing on integration would make the same mistakes that have been made with PCTs, CCGs, health and wellbeing boards.”
In addition, many people in the ICS were previously employed in PCTs and CCGs, causing concerns that an NHS mentality will continue to pervade.
The National Care Forum has been working with NHSE and DHSC to start the process of creating routes into the ICS for social care.
They are looking at how to make social care an active part of the system, Jones said. Ideally, this would involve people who have social care knowledge on the Integrated Care Boards as well as in the Integrated Care Partnership.
But, he said: “How do you force the culture change when there is no mandatory representation?”
Care Home Management: February 2023
Navigating the new CQC single assessment framework
The CQC’s new single assessment framework represents a sea change for social care inspection and ratings.
Under the scheme, which is being piloted from this month (August) and is expected to apply to all social care providers from next January, CQC inspections will not be the only source the regulator draws on when deciding ratings.
Instead, CQC will also consider feedback from service users and their families, from social care workers and from other health relevant sources.
Inspections will continue but will be much shorter and more frequent that the current version.
The ratings from Inadequate to Outstanding will remain the same but will now be based around 34 quality standards, which will apply to all services regulated by the CQC.
The care watchdog said it had made the changes to make things simpler and to better reflect how care is delivered by different types of services across a local area. In the new model one framework would connect all its registration activity to its assessments of quality.
Samantha Burges, senior associate solicitor at Ridouts, said: “There will be more transparency in terms of what CQC is looking at and what they are basing their judgements and ratings on.”
Data will be collected through a portal, currently being piloted, which will be accessible to providers.
Partner at Browne Jacobson Carl May-Smith added his belief that ratings will change more regularly.
He said: “[That] they collect different information from different sources at different times means that they might get information about one quality statement and that might change the score up or down, and recalculate your whole score. Your rating might change from that one key question.”
May-Smith said that providers could prepare for the change in the system by gathering as much data and feedback as possible from their homes and carrying out surveys with residents and their families.
He said: “We are advising providers to start more proactively collecting feedback, get surveys out with service users and their families, collecting and collating feedback you get from others in the system.”
May-Smith warned that with a small sample size one negative feedback can significantly affect the ratings.
However, other feedback collected in a meaningful way can put negative statements into perspective.
He said: “That can make a difference now as well as making a difference going forward.”
Burges agreed saying: “It is an opportunity for providers particularly if they are pro-active. In my view it sounds like engagement is key to making the most of this and ensuring your rating is truly reflective of your service, particularly if you think you are better than you currently are rated.”
However, Burges said that this might be harder for smaller providers who don’t have the teams to focus on the task. “I think there could end up being a disparity between providers who are more savvy, and those who aren’t.”
It won’t just be social care workers who will need to adapt to the new assessment framework.
Banks and insurers often base their proposals on a care home’s rating and more regular changes can have an impact on their operations.
It is also unclear how providers will be able to challenge ratings under the new system.
Care Home Management: August 2022
Image: National Cancer Institute/Unsplash
SPEED IS OF THE ESSENCE
It is no secret that the UK has some of the worst cancer survival rates among OECD countries.
Add to that the impact of Covid-19, and it’s clear that the NHS is struggling to manage waiting lists and to direct patients along its cancer pathway as fast as other high-income nations.
The government’s Elective Recovery Plan highlighted the role that the independent sector can play in taking away some of this burden.
But is this actually going to happen on the ground or is a different approach needed?
It is not just the pandemic that is responsible for the current situation, according to Independent Health Provider Network chief executive David Hare, but long-term structural issues.
He said: ‘We have known for quite some time the UK has lagged behind comparable nations when it comes to cancer survival rates. The numbers are pretty stark.’
He said that breast cancer survival rates lag well behind and for colon cancer survival it is the lowest in the OECD.
Hare added: ‘There is a huge amount to do and that is not just a pandemic effect, it is a long-term structural issue with regards to cancer treatment in the UK driven in many cases by slower than average detection rates.’
The problem was a lot of cancers were only diagnosed after referral for something else which slows down accessing the right treatment.
Check4Cancer chief executive Professor Gordon Wishart said poor outcomes were due to inadequate early cancer detection, a lack of access to optimal treatment and a shortage of cancer treatment specialists.
Wishart also found in his own breast cancer research that after 65 treatment ‘fell off a cliff’ as well as ‘massive region- al differences’ in access to surgery for older patients.
He said that this just shows that ‘cancer services in the UK need to be reviewed and completely reorganised’.
‘I think until we have ringfenced resources and treatment, especially treatment, we are always going to be under pressure from whatever pandemic comes along next’, he said.
Furthermore, the UK’s diagnostics ca- pacity lags behind comparable nations.
Genesis Care chief medical officer Dr Eliot Sims said that, in some cases, ‘a reticence to adopt ‘novel’ diagnostic techniques and treatments has delayed realising improvements in treatment and perpetuated cost and efficiency challenges.
He said: ‘The UK has pioneered treatment in some areas, yet in others it continues to rely on well-established but increasingly outdated models of care that are unable to meet the growing demand.’
Hare argued that the development of Community Diagnostic Centres will help increase capacity, but it is currently unclear the extent to which that is adding additional capacity rather than redesignating existing diagnostic services.
It is expected that the majority of these centres will be NHS-led. ‘The capital that the independent sector could deploy into those centres is sitting on the shelf’, he added.
Professor Karol Sikora, one of the world’s leading authorities on cancer, agreed that the slow progress in diagnostics was ‘the key problem’.
He said there was a lot of private cancer equipment and private diagnostic equipment that could be deployed to support the NHS. ‘They are not over- used’, he said.
Sikora added that the independent sector could offer appointments outside of traditional hours. For example, for something like endoscopy, there is the capacity there to change ways of working.
‘In cancers there is huge spare capacity in the private sector. It is diagnostics that has the bottleneck,’ he said.
Wishart said that the private sector was already helping in areas like breast cancer diagnosis, particularly in London. Independent providers of radiotherapy
and chemotherapy will also have a key role to play when large numbers of people whose diagnosis has been delayed come through the system, he added.
Sims added: ‘We see some green shoots. The pandemic forced the health- care system to innovate and operate differently. We saw a willingness to collaborate across the public and private sectors. Clinicians were encouraged and liberated to design and accelerate the adoption of new protocols and ways of working.
‘We therefore believe we have a “moment-in-time” opportunity to reset and transform how cancer care is planned and delivered in the UK, based on the best of both current and emerging global practices.’
Despite the role of the private sector outlined in the elective recovery plan, Sikora said the issue is implementing the plan at a local level and ‘there isn’t much interest in that’.
Implementing the elective recovery plan on the ground is going to be key agreed Hare.
He said: ‘We have been very clear for 18 months now that there is capacity for a whole host of specialties, including the cancer pathway, that is not being picked up by the NHS and we are not really seeing that trend shift.
‘The overall policy environment for working with the independent sector is as positive as I can remember it.
‘The problem is it breaks at local level where protection of Trust balance sheets, focus on very long waiters, the move towards integrated care systems, seems to be stopping translated intent into measurable reality.’
However, IHPN is seeing more people accessing private oncology services and seeing growth in that market.
One of the routes they are using to do this is PMI.
For example, AXA Health has given all its members access to a remote GP service so they can speak to a doctor without placing additional volume and strain on the public services.
Director of medical policy John Burke said: ‘It also encourages our members to be proactive in engaging with us if they have a concern about a sign or symptom which may be cancer.
‘In addition, we have developed an easy route through to diagnostics by developing pathways with private facilities to connect individuals quickly – and without the need for them to engage with their NHS GP first.
‘This approach also helps ensure that, upon diagnosis, there’s a seamless transition for the member to onward care, if required.
‘By way of example, in the first quarter of 2022, 99% of our members with a breast concern accessed a diagnostic appointment within ten days of contacting AXA Health.’
Wishart added that if another 5‒10% of the population were to have PMI, that ‘would take a huge pressure off the NHS’. It would also protect the core services, he said.
More urgently, however, he said a dedicated cancer recovery plan, with a minister responsible for cancer treatment to produce a new strategy, was essential if targets were to be achieved.
Hare argued that a dedicated cancer plan with clear commitments around how the independent sector can be brought in at the point of diagnosis and the point of treatment would be appropriate.
He added: ‘The elastic has rather snapped back despite the recovery phase, arguably for cancer patients, is more daunting than the pandemic response.’
‘A fully formed long-term partnership, leveraging investment, improving co-ordination between providers and focusing in on early diagnosis could over the medium to long term make a real impact’, he said.
Hare, however, cautioned that the independent sector is not a silver bullet, and its inclusion needs to be accompanied by wider reforms.
Sims agreed: ‘A focus only on NHS-funded care risks ignoring those who choose to access privately-funded healthcare.
‘There is undoubtedly a role that the independent sector can play but a focus on traditional “outsourcing” models is unlikely in our view to fundamentally change the dial.’
HEALTHCARE MARKETS UK: JULY 2022
Image: Georg Arthur Pfluger/Unsplash
Playing second fiddle
The impact on UK care homes has been the main focus when it comes to the effects of Covid-19 on the sector. However, while there were not the same high number of deaths from the virus, the homecare sector has also been severely affected by the pandemic.
So much so that Baroness Hallett chair of the UK Covid Inquiry has recommended the scope be expanded to include ‘other care services’.
At the time of writing, the government has yet to confirm the extension of the scope which the Homecare Association helped push for. Its chief executive Dr Jane Townson told CMUK: ‘If care homes played second fiddle to the NHS, we played second fiddle to the care homes.’
She said while there were not as many deaths of homecare users from Covid as they are not in ‘congregate settings’, homecare workers had to make their own PPE and be very careful not to put their clients, themselves, and their families at risk. ‘Homecare workers had to carry on going out and often they were the only professionals that were,’ Townson said.
While death rates from Covid were lower than residential social care, with only around 3% of service users passing away because of the virus, mortality rates among homecare users were substantially higher than the five-year average during the pandemic.
This was due to messaging around staying at home and protecting the NHS and fear of infection in hospital, Townson said. She added: ‘That is something that needs to be investigated because people were not accessing healthcare as much as they probably could have done.’
Lucy Campbell, chief executive of homecare franchisor Right at Home UK, said ‘the pandemic saw our business be- ing met with challenge like never before’ due to ‘additional infection control risks and navigating the ever-changing policy decisions, to unpredictable staff absences due to isolation’.
She added: ‘There was some in- creased difficulty in accessing acute treatment in hospitals although thankfully this did not result in any major negative health outcomes for our clients.
‘Primary care support from GPs was largely unaffected by the pandemic, with only some relatively minor delays experienced, although there was increased difficulty in franchises gaining proactive support from district nurses to train our caregivers in basic clinical tasks.
‘This sometimes delayed Right at Home being able to support more complex care needs, until we could at least access a district nurse to train senior staff who then disseminated this training throughout the franchise caregiver team.’
Another issue highlighted by the Homecare Association is it took a year for asymptomatic testing to be made available for domiciliary care workers.
While the risk of infection was lower in homecare than care homes, the people being supported were in higher risk categories, Townson argued, making them just as vulnerable to severe or even life-threatening symptoms.
Campbell said: ‘As there was no effective means of testing in the early stages of the first lockdown, this will have un- doubtedly led to unnecessary isolation, which consequently resulted in additional pressure on the workforce.’
Homecare providers did innovate with some agencies putting together teams with better PPE who would visit Covid-positive patients. Those workers who were more concerned about contracting the virus were redirected to service users testing negative.
Campbell said, in the face of adversity, there were also opportunities. The pandemic ‘saw our network coming together like never before, which in turn allowed us to positively raise the profile of our sector, whilst attracting talent from other pressurised sectors.’
She added: ‘For a period, this actually saw our recruitment boom, with our network bolstering itself for the gradually increasing levels of demand.’
This boom, however, is reversing as the retail and hospitality sectors are no longer subject to restrictions, attracting burnt out homecare workers with less stressful jobs. Skills for Care data shows the vacancy rate in domiciliary care now stands at 13.4%.
Homecare also saw a big reduction in its workforce when the government announced vaccination would be a condition of employment. Between 20,000 to 40,000 workers left the sector according to the Homecare Association.
Campbell said: ‘For Right at Home the true impact of the workforce challenges hit us around October 2021, when the onset of the Omicron variant put further pressure on our workforce.
‘This coupled with the cost-of-living challenges, have seen an increase in staff fatigue.’
Homecare Association research, published in April, found homecare workers were concerned over the rising cost of living, with fuel and energy bills being main worries. A survey, which attracted more than 625 responses of association members, resulted in more than four-fifths (82%) saying the primary concern was either the cost of fuel or energy bills.
In addition, more demand for home- care services is also stretching the remaining workforce even thinner.
May’s ADASS Waiting for Care 2022 report found there has been a 16% increase in the number of homecare hours delivered since spring 2021. This number has dropped from a high of more than 41 million hours in autumn 2021 in the first quarter of 2022 as staff vacancies and sickness impacted.
ADASS said almost 170,000 hours a week of homecare could not be delivered during this period due to this shortage, a seven-fold increase since spring 2021. One of the reasons for this, Townson explained, was staff are still having to test and isolate with absence rates of up to 30%.
She said: ‘You have got to do the best you can with the people who you have got left. So, you are trying to get them to do more calls, reducing the time that you are spending with people you are supporting.’
Furthermore, the infection control and testing fund, which allowed employers to pay workers when isolating, ended in April.
With almost half of homecare workers on zero hours contract, there is an increased risk they would need to work despite having Covid. ‘That is a really big problem, especially with the cost of living going through the roof,’ Townson said. ‘On top of that we have got fuel prices going through the roof.’
She said workers were leaving for jobs where they do not have to drive, that they cannot afford to work for no pay, and are tired.
However, the rising demand for homecare services, means investor confidence in the sector remains strong.
Townson said: ‘We are seeing more of the larger companies buying companies that are a bit smaller. We are seeing a number of small providers selling up and being bought by providers the next size up. Overall, the numbers don’t seem to be changing that much at the moment.’
Operationally, several key lessons will be taken forward from the pandemic. These include being prepared for future pandemics by creating robust supply lines for PPE, expecting frequent changes in government policy and how to communicate these simply to the workforce.
‘The importance of clear and effective communication both internally in our net- work and externally with CCG’s and local authorities. We ensure there are very regular opportunities for mutual support and discussion,’ Campbell said. ‘At the height of the pandemic we were holding twice weekly network-wide communications calls with around 70 franchise owners and registered managers attending.
‘This allowed everyone to feel safe and confident and was truly valued by everyone involved.’
She said another lesson was being open to discussing mental health, with Right at Home launching a ‘full suite of mental health support resources’ at the peak of the pandemic. ‘This programme is something we will continue to run annually with the network to further support retention,’ Campbell added.
The Department for Health and Social Care was contacted for a comment.
Care Markets: July 2022
Image: Elena Mozhvilo/Unsplash
Stabilising the system
The health and social care levy came into force last month (April) to bolster the state-funded system. The Department of Health and Social Care (DHSC) has said that of the £39bn raised by the increase in national insurance over the next three years, £5.4bn would be allocated to social care.
‘It will end spiralling social care costs, provide a limit to the cost of care for everyone in the adult social care system for the first time, and significantly increase state support,’ according to DHSC.
Buffeted by the impact of Covid-19, the financial threshold for state support shrinking in real teams and a drop in the number of care home places available, publicly funded social care needs all the support it can get.
Care England chief executive Professor Martin Green told CMUK: ‘Publicly funded social care is in a critical condition and unless there is some serious and remedial action taken by the government, at both a local and national level, we will see many providers exiting the market, or going bankrupt.’
He said this was down to decades of underfunding in the social care sector, which had been managed through a degree of subsidy from people who are paying the true cost of care.
While this is set to change with the introduction of the social care reform agenda, Prof Green pointed out that providers in the last year have had enormous extra costs from increases in the living wage, and huge rises in energy costs.
He added: ‘Throughout the economy we are seeing the inflation rate increasing to levels we have not seen for many years, and we are also facing serious staff shortages, which are taking the cost of labour beyond the minimum wage.
‘Unless this underfunding is halted there will be many casualties in the care sector and many people who will not get the vital services they need.’
LaingBuisson estimates 47% of care home residents are funded by social services, with or without third party top- up, with a further 9% financed by NHS clinical commissioning groups under continuing healthcare arrangements.
However, due to the substantial price premium charged to privately-funded residents, only 46% of revenues come from state payors, according to the latest edition of LaingBuisson’s Care Homes for Older People.
The Covid-19 pandemic has had a major impact on state-funded care home services. In the first two phases of the pandemic, more than 32,000 care home residents died.
Furthermore, stops on new admissions in homes that had experienced Covid-19 outbreaks led to the creation of an ‘occupancy gap’.
These, coupled with a public fear of admission to care homes due to the risk of infection led to a fifth fewer people in UK care homes, according to the King’s Fund Social Care 360 report, published in March 2022.
This report stated: ‘The fall in new re- quests among older people in 2020/21 is likely to reflect a reluctance to come forward for services during the Covid-19 pandemic.’
This finding cited Institute for Fiscal Studies research, which found almost three-quarters of over-50s needing com- munity or social care services in the first stage of the pandemic said they had not accessed them, with almost half of this number reporting that they had not even tried to contact them.
The pandemic also caused a back- log in the number people waiting to be assessed for social care services.
An ADASS survey last November reported more than 200,000 people were waiting to be assessed for social care services. According to the research: ‘There has been a 271% increase in people waiting for more than six months for an assessment compared to the previous survey.
‘There has also been a 20% increase in people who have had an assessment and are waiting for care and support or a direct payment and there are 166,136 overdue reviews of care plans.’
This led to around one in 10 people being offered care options that were not their choice or did not meet their needs.
Prof Green said this reduction in occupancy was because ‘the system was not working in the way it used to, so the number of assessments and people going into care services was significantly reduced’.
He went on: ‘The occupancy levels, which are lower than they have been for many years, also have a serious impact on the income levels of care services.
‘The reduction in the numbers of people who use care services is not based on the need for them, it is based in the reality that the system is in backlog and people who should be in receipt of sup- port are not getting access to services.’
Chief executive of the National Care Forum Vic Rayner added: ‘There are two things going on. One is a short-term trend about people staying away from care. And the second which is a longer-term trend which is about local authorities making the eligibility so high that people can’t access care.’
However, eligibility criteria are set to remain as stringent as ever, limiting those who qualify for state-funded help.
Rayner said the levy will not impact this. ‘It won’t be brought down. I think what is going to be shocking for the public is they will suddenly understand that it isn’t all care that’s being paid for.’
Furthermore, the means-testing upper threshold for social care services has remained at £23,250 of assets, so not keeping up with rising inflation. The King’s Fund calculated if it had, the upper threshold would be £5,781 higher than it currently is.
The upper threshold is due to rise to £100,000 and the lower threshold will increase to £20,000 of assets in October 2023.
LaingBuisson said this will mean an immediate shift in the proportion of existing residents and new admissions from private pay to council support, usually at lower fee rates.
It predicts payor shift will be highest in areas where the value of personal assets (owner-occupied property) is close to the new asset threshold of £100,000. The threshold change will be less of an issue in affluent areas where property values are substantially higher than £100,000.
According to the Care Homes for Older People report: ‘Providers in non-affluent areas who are focused exclusively on public pay will be winners, financially, by virtue of expected increases in councils’ usual fee rates as part of the policy package,
‘However, neighbouring providers with a focus on private pay are at risk of being net financial losers, depending on the share of their private payers who are below the new asset threshold and become eligible for council support – usually at lower fee rates.
‘All depends on the level at which council fees are set in any given council areas. The fear is that the central government funding available for its ‘fair price for care’ (FPC) policy will be insufficient to set council fees at adequate levels.’
Responding to the King’s Fund report chair of the LGA’s community wellbeing board Cllr David Fothergill said: ‘While the government’s plans for reform are good, there is currently a financial and staffing crisis in social care that have not been considered.
‘Councils could find themselves unable to balance their budgets this year, which is why we need to see urgent investment in adult social care that will ensure the best possible care for those that need it.’
Prof Green added: ‘The government must prioritise social care and they must stop giving the vast majority of the money that has been raised by the social care levy to the NHS.
‘Social care is in crisis, and we need at least 40% of the levy money immediately in order to stabilise the system and make it sustainable for the future.’
Care Markets: May 2022
PREPARE YOURSELF FOR THE NEW LIBERTY PROTECTION SAFEGUARDS
The new Liberty Protection Safeguards (LPS) are due to come into force next April, replacing existing Deprivation of Liberty Safeguards (DoLS), to protect people receiving care’s human rights.
However, following a change in ministerial personnel and with a new COVID variant to contend with, many in the sector now believe the implementation of LPS will be put back until at least the autumn.
With no sign of a public consultation or a code of practice outlining the details of the changes, it is difficult for care home providers to know what the changes could mean for them.
However, there are still a number of measures that care home providers can put in place now to prepare for the new regulations.
The biggest change is that LPS will apply to people who lack capacity aged 16 and above in all settings. The outgoing DoLS only apply to registered care homes and hospitals and people aged 18 and over.
Care England consultant Rachel Griffiths, who is a member of one of the working groups focusing on LPS, said: “Hospitals and care homes will not find it too difficult at the moment to make the changes that will come in with LPS.”
Griffiths said that “detailed training” as well as a new code of practice will be coming out when LPS is implemented so providers are ready for the change.
Care home managers were initially earmarked to take the brunt of administration work under the new regime but, following feedback from the sector, those plans have been dropped for now.
However, the legislation remains in place to implement this further down the line to switch some of the workload from local authorities.
Griffiths said: “I think it might be left to wither on the vine, but it is there if the Government decide to bring it in later.”
There are, however, changes that will affect care homes.
Under LPS, assessments will still be carried out by doctors and social workers but instead of there being nominally six assessments there are three.
Whether the person lacks mental capacity to consent to the care plan will remain the same.
Furthermore, a doctor probably still has to confirm that the person has a mental disorder as defined in the Mental Health Act.
Under DoLS the best interest assessor does three assessments which LPS will see bunched into one and renamed the “Necessary and Proportionate Assessment”.
The LPS process should also be frontloaded so that statements are already in place before new residents enter a care setting, further reducing bureaucracy.
Questions remain around how this will work in practice. In some situations, authorisation could be portable between settings or when someone is admitted from the hospital. However, the necessary and proportionate assessment would need specify in advance what restrictions there would be on the person’s freedoms in the new setting.
Lucy Bowker, solicitor at Gordon’s Partnership, said: “It will be important for providers to stay up to date with the implementation of the LPS and make sure their voice is heard during the public consultation when it does take place. We certainly would be very interested to see the draft regulations and code of practice to understand how the LPS will work in practice.”
While waiting for more details on LPS, providers can ensure that their current paperwork is up to date and any DoLS applications awaited are followed up. Bowker added: “This will not only aid the transition to the new system once it is implemented but assist with regulatory compliance.”
Under the new system, assessments can be reused if there have been no major changes, including the capacity assessment if the care provided, and the person’s capacity as described in the assessment is staying the same.
Professional assessments can also be reused, as well as a DoLS one.
Griffiths said: “The mental health assessment is the one that is going to ease the process hugely if you can hang on to it and make sure it’s at the forefront of the file.”
She explained: “The timescales for DoLS are loosened: since the Cheshire West case in 2014 nobody has been able to meet the timescales.
“It is going to be less bureaucratic. It is going to feel more intuitive. Somebody who is never going to regain capacity can be deprived of their liberty under an authorisation for much longer instead of always having to re-do it every year for DoLS.
“There are still timescales, but they are more in tune with the individual, so the bureaucratic burden is lessened.”
CARE HOME MANAGEMENT: DECEMBER 2021
CARE HOMES SQUARE UP TO COVID VACCINATION CURVE-BALL
Care home operators were thrown a curveball by the Government when it ruled that all members of staff must have received both Covid-19 vaccines by November 11.
As the September 16 deadline for having the first vaccine approaches, the move has had different impacts among care home operators.
For sole providers, which make up the majority of the care home market, losing even one member of staff can have a huge effect.
Red Rocks Nursing Home on the Wirral has already lost an RGN who refused to have the vaccination and subsequently resigned.
Owner Mike Vaughan said he has been running an advert for a new RGN for four weeks without interest.
He said: “There is just not the pool of people there.”
Vaughan added that if they weren’t able to recruit enough nurses, he would have to look at the home just providing residential care.
He said that there has been a 96.2 per cent take up of the vaccine within the home but he believes a take up rate of 80 per cent was reasonable in his view.
“I would like 100 per cent but I’m not going to get that”, he said. “I think we all need a bit of slack.”
The residents and their families have a strong relationship with the home, which is primarily private-pay – and its staff. There have not been any safety concerns raised, Vaughan added.
At Orchard Care Homes it has been a priority to keep existing and potential residents and their families up to date with the vaccination status of staff across its estate of 24 facilities.
It has used the same approach with councils placing residents with them.
Orchard’s director of people and talent Rebecca Dobson said: “We have been open and transparent with our partners regarding staff’s vaccination status and COVID-19 safety processes within our homes. This will have instilled confidence in our ability to safely welcome and care for new residents.”
Orchard has yet to lose any staff members and has been providing regular, independent, medical information in regard to the virus and safety of the vaccination in order to encourage employees to take the jab.
This includes hosting webinars with an associate professor and viral oncologist from a leading University.
Dobson added: “Should we have any staff losses this would be incredibly sad, as we would lose highly experienced and skilled people as a result of the Government’s new policy.”
Following April’s mandatory vaccination policy consultation, the policy was extended to all care homes, including those for younger adults.
The Lisieux Trust, which has two care homes for people with learning disabilities and autism, has also adopted a policy of transparency about the number of staff who have been vaccinated.
It has done this by publishing the figures in several editions of its monthly newsletter, so residents, families and staff teams were aware of the numbers.
Furthermore, it has not been asked to provide evidence of vaccinations by councils before a new placement so far.
Chief executive Jess Alsop-Greenacre said: “We are due to start consulting with staff members about the mandatory vaccines in the next few weeks; following this process we’ll know how many staff members may face dismissal if they refuse to have the vaccination.
“Currently 11 out of 85 staff in the entire organisation have refused to have the vaccination and only two of these work in our care homes; the remaining nine work in our supported living services.”
Alsop-Greenacre added that, if staff members leave or are dismissed as a result of the rule, they will need to use more agency staff while they recruit to fill the vacancies.
Lisieux Trust has already set up agreements with some agencies in anticipation that they will have to use their staff in coming months.
At Anchor Hanover the “vast majority” of staff have already received the vaccine voluntarily.
A spokesperson added: “We have contributed to the government consultation on mandatory vaccinations and would welcome a consistent approach across the care and NHS workforce.
“It is also crucial for government to help social care to enhance professionalism through investment and reform to drive parity of esteem.”
CARE HOME MANAGMENT: AUGUST 2021
FOSTERING A BEST FIT
Finding the right framework when delivering foster care is complex. Can successful models be easily replicated?
This summer the government set out its vision for foster care. One of its five over-arching ambitions was that ‘placements are driven by the needs of the child, not availability of a bed, location, provider type or cost’.
This would involve local authorities spending their budgets on the highest quality and most suitable placements to meet the child’s needs and having a strategic approach to sufficiency planning, which drives commissioning and procurement decisions, based on needs.
Furthermore, councils should use their knowledge of sufficiency and local demand to work with other local authorities and independent fostering agencies (IFAs) to ensure resources are used in the most effective ways to meet the needs of their children.
These recommendations came in response to an independent report by Sir Martin Narey and Martin Owers, which found commissioning processes were not being driven by the needs of children. The National Fostering Stocktake stated: ‘We believe that strategic commissioning of IFAs would lower the cost of fostering and improve its quality. But at the moment there is too much buying of placements - in what amounts to large scale spot purchasing - and too little commissioning.’
IFA’s also argued that many councils ‘in-house first policy’ contributes to children unnecessarily experiencing multiple placements because ‘first available’ is not always ‘best fit’.
The government believes the key to improving commissioning is more effective partnerships, and there are a number of projects to test collective commissioning and service delivery. The Department for Education is also supporting new commissioning models, one of which is TACT Peterborough.
Peterborough City Council outsourced its fostering and adoption services to not-for-profit fostering agency TACT (The Adolescent and Children’s Trust), which has more than 500 foster carers looking after 600 children, in April 2017. Under the deal, TACT delivers fostering and adoption services on behalf of the council, with the expectation that it would deliver savings of £1m a year once fully established.
It also boasted that the agreement would ‘reduce the council’s reliance on higher cost independent fostering and residential placements, as well as providing improved training and 24/7 support to all carers, adopters and relatives looking after children who come into care in Peterborough’.
This would be done by recruiting and retaining more local foster carers through an improved support network that TACT would deliver, cabinet member for Peterborough’s children’s services councillor Sam Smith said at the time, leading to more local longer-term foster placements.
And this partnership is proving fruitful with Peterborough’s children’s social care services being rated at Good by Ofsted this summer for the first time since becoming a unitary authority in 1998. Ofsted said: ‘Statutory functions in relation to fostering and adoption are delegated to a national charity which provides a seamless service model.
‘Children live in placements that meet their needs, and overall placement stability is good. The majority of children in care live with foster families. Children are matched appropriately to carers, including, where possible, carers willing to commit to the option of Staying Put in the future.
A small number of children were still privately fostered, however.
But could this model be replicated in other areas?
Attempts to create commissioning consortia or a unified framework for commissioning fostering services have not been met with great success. The complex nature of providing services usually sees social workers or their team leader placing children in foster care, using an existing list of families they use. Furthermore, creating a unified framework for remuneration would be difficult given the personalised nature of each fostering package.
To complicate things further, social workers have a duty of care to children and the foster parents as well, and to minimise placement breakdown. Principle at consultancy Candesic, Dr Joe Taylor explained that personalisation was not just about the children. It was about creating a temporary family so having a unified framework is partially at odds with this.
He said: ‘It is a bit of a red herring this talk of unified commissioning. It is more about finding the right framework.
‘The responsibility of care devolves to the social worker. If they do not find the right placement, they will keep on looking. Social workers are very cautious in making sure they are making the right decision.
‘At the higher end of the market we are going to see more case referrals that can be facilitated by larger groups.’
‘It is older children with complex behaviour who will need a lot of help but people willing to do that are few and far between and sometimes they need to be placed out of area.’
In these cases, social workers would contact their colleagues in other local authority areas, but large independent fostering agencies might be more able to facilitate an appropriate placement. Taylor added: ‘Fundamentally there is a growing role for independent fostering agencies to do more. At the moment the system is very old fashioned and inefficient.’
David Leatherbarrow, National Fostering Agency chief executive, said that it was right that councils should explore different mechanisms and structures for children’s services, provided there is no compromise or dilution to their corporate parenting responsibilities and statutory obligations.
He said: ‘I am very open minded and my team will always consider the right opportunities where we believe we, as an organisation, can add value and make a real difference to the service through our management expertise, our emphasis
on quality and, more importantly, to the children and young people reliant on that service.
‘I would always be supportive of the following three key points: delivery of best value, best quality and child-centric outcomes as the core tenets of
any future consortia or commissioning arrangements being considered for children’s services.’
Charlotte Ramsden, chair of the Association of Directors of Children’s Services’ Health, Care and Additional Needs Policy Committee, pointed out that the National Fostering Stocktake conclud-
ed that it was ‘entirely legitimate’ for councils to either provide most of their own foster care or work with independent providers.
She said: ‘There is no one-size fits all model of delivering foster care, where working in partnership to provide services makes sense and improves outcomes for children and young people in care local authorities will be considering this.
‘A broad range of high quality provision is necessary to meet the diverse needs of the children and young people in our care to enable us to find the right placement at the right time for every child and young person. As with any partnership arrangement there will be opportunities and challenges - some independent providers specialise in recruiting placements for children with very complex needs which are not always available locally. However, the variability of quality in the system is a challenge as is the cost of some types of placements at a time when local authority budgets have been reduced by half since 2010 and demand is rising.
‘It is for each council to decide on local arrangements in line with local needs. Ultimately, the biggest concern for local authorities is that the arrangements in place achieve better outcomes for children and young people. If this also helps with reducing costs, so that any savings can be reinvested in services, it’s a bonus as budgets reduce and need increases.’
CARE MARKETS: DECEMBER 2018/JANUARY 2019
CHARGING AFTER DEATH: THE CMA SETS OUT ITS PROPOSALS
Following publication of the findings from it’s inquiry into UK care homes at the end of last year, the Competition and Markets Authority (CMA) published guidance last month on charging ‘after death fees’.
After it found that some care home operators were still charging relatives up to a month after the death of a resident, CMA suggests that payments should end within three days or the point the room is cleared of deceased’s possessions and reoccupied (if earlier). Care home operators should not pass on the costs of preparing the room for the next resident or the loss in income caused by a void in occupancy, and should not be still charging the deceased’s estate once the room has been reoccupied.
As care home fees are usually paid in advance, CMA states care homes should refund any advance payments covering the remainder of the period beyond the three days covering the residents death. ‘Such refunds should be timely’, it adds.
However, CMA acknowledges there will be circumstances where relatives may need access to the room for longer than three days.
The consultation document states: ‘It may therefore be appropriate for contracts to make provision for these circumstances, by setting out a longer stop date beyond the initial three days, during which payment must be made if the room remains uncleared. After this longer period, it would be appropriate for the care home to reserve the right to take reasonable steps to mitigate their loss, such as by removing the deceased’s possessions themselves from the room, storing them safely and charging a reasonable storage fee. This would allow the home to get on with the process of preparing the room for the next resident.’
Furthermore, CMA says that operators should not ask for top-up payment to continue after local authority funding is no longer available. In order to be fair under consumer law, top-up payments must be paid for the same period as local authority fees.
Following cases of relatives not just being charged extended top-up fees, but the shortfall in local authority fees once they have stopped, CMA states this is not fair under consumer law, along with charging for the shortfall in FNC payments once NHS funding have ceased.
The consultation document states: ‘The CMA is already taking forward action against certain care home providers that it considers are unfairly charging fees for extended periods after a resident has died, asking them not to enforce their terms. It may also decide to open further investigations against other providers before the publication of its final advice, if it identifies serious concerns about potential breaches of consumer law. In relation to the issues covered in the draft advice, once it is finalised we will expect all other care home providers to review immediately and, where necessary, change their contract terms and practices or risk action.’
Clare Auty, partner in the commercial health team at Browne Jacobson said the guidance was based upon the Consumer Rights Act 2015 (CRA) and Consumer Protection for Unfair Trading Regulations 2008 (CPRs).
She explained: ‘Prior to the CMA investigation, few operators considered the applicability of consumer laws to residents and patients rarely viewing them as ‘consumers’.
‘Furthermore, many advisors who were aware of the CRA would have relied on the CRA exemption that the fairness test does not apply to the main subject matter of the agreement which they believed included price/fees. The CMA believes this exemption cannot be relied upon as fees after death are not the main subject matter and are contingent on the death of the resident. They are therefore not concerned with the level of fees, which is outside the advice, but the period of time for fees to continue to be paid.
‘The CRA applies a test of fairness to terms in a consumer contract, even where those terms are negotiated. A term is unfair if contrary to the requirement of good faith it causes a significant imbalance in the parties’ right and obligations to the detriment of the consumer. Unfair terms or notices are not legally binding and enforcement action can be taken. Where a consumer has paid money, this money is recoverable and orders can be made to refund such sums. The CRA also requires contract terms to be “transparent”.’
‘The CRA also contains a Grey List of terms which may be unfair and therefore are not subject to the exemption. Terms requiring a consumer to pay fees for services not provided are fully subject to the fairness test – for this reason the CMA believe that top up and FNC payments should not be payable post death as they represent fees for clinical services which are not being provided.’
Executive director of the National Care Forum Vic Rayner added that, while the report acknowledges the existing anomaly between local authority contractual practice in this area and that applied to self-funded contracts, it does nothing to address it going forward, instead suggesting that the local authority contractual practice is based on ‘local authorities being well informed, and with equal bargaining power to the care provider’.
She said: ‘This is not only far removed from many of the NCF members’ experience, but is in contrast to the CMA’s own report, which recognised very starkly the underfunding of care provision by local authorities. This does not sound to me like a contractual relationship based on an equal footing, and we hope that the CMA will be looking at challenging local authority contractual practice to bring it in line with it’s proposed consumer law advice to be applied to care home contracts with individual residents.’
Responses to the consultation should be submitted by post or email by no later than 5pm on 16 February 2018.
The CMA’s investigation found that out of 32 of the largest UK care home providers, 15 charged no fee, or charged no fee once the room is cleared of possessions, or only charge fees for three days and 10 charged for periods ranging from five to seven days.
In addition 69 out of 120 care home providers who responded to a CMA online survey said that they do not charge fees following the death of a self-funded resident, only charge for a period of up to three days, or only charge fees until the room is cleared of possessions.
As a result of CMA intervention Maria Mallaband Care Group (MMCG) and its sister company Countrywide Care Homes voluntarily amended its contract terms in December for self-funded residents so that fees will only be charged up to the date of death. Up till then it had a clause in its contracts charging this type of resident up to a month of fees.
MMCG said: ‘The clause upon which they have focussed was, in any event, frequently not applied by us. The CMA are looking into many issues in our sector and we believe their findings will help towards a much needed common understanding of fairness, whether that be in relation to specific terms of business or the chronic underfunding by local authorities of much needed care services.’
Barchester Healthcare told CM: ‘We are actively participating in the CMA consultation. Supported by regulatory guidelines we feel it is appropriate to charge for a period of one week after death for those in long-term residential care. This period allows family members to say goodbye to their loved one in their place of passing, and the dignity and respect to remove personal items during what is a very sad and difficult time.’
A spokesman for Four Seasons said, around 85% of its clients are local authority-funded and council contracts usually terminate within three days or less. Its self-paying residents would be usually be aligned with this policy but it is reviewing the terms and conditions for all its homes with new contracts coming into effect this month.
HC-One added: ‘HC-One’s standard notice period is up to seven days for self-funding residents. This helps to ensure families have enough time to make any arrangements. We always seek to be flexible and will consider individual circumstances and each family’s needs where possible.’
Bupa’s standard approach is 14 days for long term residents and three days for short term residents (who have been at the home for 31 days or less). A spokeswoman added that they do look at the issue ‘case by case’.