Agenda item

New arrangements for commissioned home care

To consider the proposed home care framework and make recommendations as appropriate.


The assistant director all ages commissioning outlined the arrangements for purchasing commissioned home care through an approved list of providers and the purpose of the review that had been undertaken by a project board.  It was noted that an all member briefing had been held on 26 April 2021 and the new arrangements were due to be considered by cabinet on 24 June 2021.


The cabinet member for health and adults wellbeing commented on the statutory duties under the Care Act 2014, the need for alternative arrangements to be in place on the cessation of a notice period of the current arrangements on 31 October 2021, home care helped residents to remain in their own homes and the services were highly valued by clients and their families, and the proposed new arrangements were the result of extensive co-production with service providers and stakeholders.


The chairperson invited questions and comments from committee members, the principal points of the discussion are summarised below.


1.            It was suggested that there was a need for flexibility in home care visit lengths, particularly as some clients might be experiencing mental health issues arising from the Covid pandemic.


2.            Attention was drawn to the difference in the number of hours purchased per week for urban and rural areas (agenda page 28, ‘Market summary’).


3.            It was questioned how the authority monitored the work being delivered by providers. 


The assistant director all ages commissioning outlined the requirement to be registered with the Care Quality Commission, the obligation to use a call monitoring system, and the work of the quality assurance team within the council.  The assistant director for adult social care operations also advised the committee about the reviews undertaken to ensure compliance with the Care Act. 


In response to a further question, the assistant director for adult social care operations outlined how feedback and complaints from clients were managed.  The senior commissioning officer added that the directorate was working with Healthwatch and the Making It Real Board to devise more proactive and innovative ways to reach out to clients and to involve them in the future development of services.


4.            The chairperson commented on the need to consider the market as a whole and the potential for the council to undertake a brokerage role with the self-funding cohort.


The head of care commissioning, referencing the Market Position Statement (MPS), commented on the work that was being undertaken to support the market in its entirety which would be embedded in the service specification, and on discussions around ensuring that people had the right information and advice at the right time.


5.            The chairperson, noting some of the difficulties in delivering services in rural areas, questioned how innovations or technologies might be utilised to address locality challenges, potentially including the home share concept. 


The head of care commissioning commented that: the proposed re-modelled provision was about ensuring sustainability; technologies were being trialled to ascertain how they could support individuals in their homes; the intention was to work with providers under the new framework on the Talk Community agenda to identify needs and to help people to make connections through the hubs, the voluntary sector, and community services; and a review was to be undertaken on the Supported Living Framework.


6.            A committee member said that technologies needed to be updated regularly and suggested that this should be reflected in the service specification. 


The assistant director all ages commissioning advised that technology in the sector was being looked at nationally by the Local Government Association (LGA) and the Association of Directors of Adult Social Services (ADASS), and many providers were part of the United Kingdom Homecare Association (UKHCA) which led on developments within the sector.  He said that all providers would be invited to engage in the technology strategy as it developed and welcomed the suggestion about including related obligations in the service specification.


7.            A committee member, referencing the ‘key risk matrix’ (agenda page 39), noted that all of the risks were in the moderate to significant impact categories, expressed a concern that the proposed reduction in the number of providers would reduce resilience, and questioned emergency provision in the event of provider failure. 


The assistant director all ages commissioning advised that: there had not been a provider failure in Herefordshire for some time, partly due to the way in which services were commissioned; home care fee levels compared favourably with other local authorities in the West Midlands; the council held detailed information about the clients that were supported by providers and the contracts included an obligation to maintain records of employees, providing the option to transfer employees across to other providers to maintain continuity; there were regular provider meetings and the council encouraged providers to discuss sustainability issues; and it was considered that, with the mechanisms in place, provider failure could be dealt with quickly and effectively. 


The senior commissioning officer added that the risk ratings reflected the potential disruption to customers and reiterated that providers had been involved in the co-production of the new arrangements.  It was emphasised that there would be a phased transition, providing the opportunity to providers to diversify into other types of provision.


8.            A committee member, referencing the Queen’s Speech 2021, suggested that a letter should be written to the Secretary of State to seek clarification about the government’s plans for social care reform.


9.            A committee member commented on the need to understand whether strategic collaboration would affect the quality of services and whether provision in rural areas would have parity with urban areas.  It was suggested that an evaluation of how the new arrangements were working should be provided in twelve months’ time.


The assistant director all ages commissioning said that: the Herefordshire market was not considered fragile, particularly given the fee levels; the consolidated position through the new arrangements would help to create a smaller number of stronger providers; the provider forum provided opportunities for collaboration, learning, and innovation; and the benefits of a mixed economy of providers were noted.


Referencing the ‘environmental impact’ section (agenda page 44), the committee member suggested that providers could be encouraged to improve environmental performance.  The assistant director advised that: the direction of travel was indicated in the MPS; around 30% of commissioned home care was currently delivered by people who walk or cycle; consideration was being given to utilising the council’s electric vehicle fleet for the Home First service; the intention was to work with providers to enhance their own environmental performance; and the suggestion that this could form part of future contracts was welcomed.


The senior commissioning officer reported that the top ten providers in terms of volume currently delivered 70% of the commissioned home care but the weakness (in terms of provision, not quality) related to around ten providers that delivered less than 100 hours of commissioned home care; the industry considered 500 hours per week to be a minimum to ensure viability.  He added that building the new arrangements around locality structures would encourage providers to minimise the number of journeys taken.


The head of care commissioning said that the new arrangements would include a contractual obligation in terms of picking up rural packages and this could enhance choice.  The senior commissioning officer commented on the need for viable rounds for providers and said that the new arrangements should give providers confidence to respond proactively going forward.


10.          A committee member commented that problems of isolation and loneliness existed in both rural and urban areas.


A concern was expressed that the reduction in the number of providers could have a disproportionate impact on the resilience of providers that were unsuccessful in the tender process; it was commented that some providers may be more reliant on regularly commissioned packages from the council to sustain their operations through the vagaries of the business, particularly in terms of self-funders.


The head of care commissioning said that, having undertaken significant engagement and consultation, it was clear that the current situation was unsustainable and the new arrangements, co-produced with providers, sought to mitigate against the associated risks.  The assistant director all ages commissioning commented on: the potential for providers to diversify; the unusual position of the self-funding cohort being the dominant purchaser locally and not the council; and some of the implications of consolidation.


11.          In response to a question, the assistant director all ages commissioning advised that Talk Community had been involved in the project from the outset and commented that demand on home care had been reduced by designing services around communities, whilst maintaining satisfaction levels above 85%.


In response to a further question, the head of care commissioning confirmed that the service specification would be in the form of links to live and updated information, rather than static documents.  It was reported that home care providers were very engaged, the provider forum was well attended, weekly communications were circulated, and there was active signposting to other services.  It was recognised that the sector was changing quickly at national, regional and local levels, and it was essential that the providers were kept up to date and treated as key partners.


It was also confirmed that there were positive discussions with system partners in Herefordshire and Worcestershire about working together on mental health and other issues.


12.          A committee member commented on the potential for international and national businesses to acquire and asset strip providers and questioned the measures in place to monitor any such activity. 


The assistant director all ages commissioning said that the local market was strong due to its diversity but it was consolidating, and the new arrangements provided the council with the discretion to assign or not to assign a contract.


13.          A committee member acknowledged other members’ concerns about the potential consequences for some providers but felt that the key issue was whether the service being provided was as good, if not better, than the existing arrangement. 


The senior commissioning officer confirmed that the principal motivation was to ensure that quality of care was available throughout the county at the same standard.


14.          The chairperson suggested that there may be opportunities to work collaboratively on workforce and retention issues, such as: recruiting within communities; upskilling the workforce; and childcare provision and flexible working arrangements. 


The assistant director all ages commissioning reported that: a grant had been received from government recently which, following consultation with providers, would be utilised for a recruitment campaign and the refresh of the care sector website; there were good contacts with Skills for Care, a national body for adult social care workforce development; there was an opportunity to promote working in the care sector to people previously employed in the retail, leisure and hospitality sectors given the relevant transferable skills; the council continued to meet with providers fortnightly as part of the response to the Covid pandemic; Disclosure and Barring Service (DBS) checks had been funded during the pandemic; many care workers worked restricted hours to accommodate their own caring and parental responsibilities; and there were particular challenges and opportunities for Herefordshire as a rural county.


The senior commissioning officer commented on some of the potential benefits of locality based working, ideally with people recruited to deliver care in the areas near to where they lived.


The head of care commissioning reported that, in view of the impact of the pandemic, counselling support had been put in place to support care workers.  The importance of upskilling and career progression was recognised for individuals, with an overview provided of the work of the practice improvement lead within the quality assurance team, and for the integration agenda for health and social care services.


15.          In response to a question from the chairperson, the senior commissioning officer said that there was commitment from the Making It Real Board to continue to work with commissioners and partners to bring about improvements, especially in terms of quality assurance and engaging with service users. 


The assistant director all ages commissioning said that he chaired the Making It Real Board, the board wanted to play an active role in the emerging Integrated Care System, and, in order to enhance diversity and representation from across Herefordshire, encouraged more people to become involved.


16.          A committee member welcomed the references in the report to continuity of care and said that ‘customers having the option to retain their current provider’ (paragraph 25, agenda page 22) should be an immutable commitment.


The assistant director all ages commissioning confirmed that this was a key principle, albeit there was the possibility that, if a provider did not wish to apply or if their application was unsuccessful, a provider may choose not to continue providing services in Herefordshire but the design of the new arrangements should minimise this risk.


The committee considered draft recommendations and agreed the following resolution.




a)         That consideration be given to assisting self-funders pro-actively through the service specification.


b)        That consideration be given to the information, advice and support available to clients, including self-funders, linked to the ongoing work with Healthwatch, Talk Community, the Making It Real Board, and the transformation of community mental health services.


c)         That creative approaches to supported living, including home share, be reviewed as part of the emerging Supported Living Framework.


d)        That commitments be secured from providers to participate in and to support technology enabled living developments, and innovations to improve environmental performance.


e)         That provision in rural areas be explored with providers on both sides of the border to avoid any potential gaps in provision.


f)         That opportunities to work collaboratively on workforce recruitment and retention issues be considered with a view to:


i.              recruiting within communities to deliver services locally, especially to support clients in rural areas and to minimise unnecessary travel;


ii.            encouraging people to take up or restart a career in the sector, including through the refresh of the care sector website; and


iii.           developing the range of health and care functions being delivered to maximise the value from each visit, to make every contact count, and to enhance career pathways through the upskilling of the workforce.


g)        That a briefing note be provided to the committee in twelve months to evaluate progress, including any consequential impacts on market resilience and on the lived experience of service users in terms of the continuity and enhancement of care.


h)        That the executive be invited to write to the Secretary of State to seek clarification about the government’s plans for social care reform.

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