What is the objective?
The objective of domiciliary care is to deliver quality home care services that are flexible, responsible and responsive which reflect individual needs. Keeping people independent and healthy as well as providing support to families and carers. An effective service should enable people to regain control of their lives and allow people to shape their own care service. Which is about supporting people to make informed choices about their care. So, Domiciliary Care is about fostering independence and ensuring people remain included in society. Many champion and encourage preventative approaches but sadly, few can evidence that they’re actually doing it effectively.
Why are those objectives a challenge to achieve?
Many point towards underfunding as the biggest hurdle to delivering on those objectives. The reality is that underfunding doesn’t reflect the whole picture, it has simply become the easiest thing to blame. Of course, funding is part of the challenge but to continuously hold it solely responsibly without questioning the existing make-up of service delivery is becoming increasingly negligent.
The incessant pleas for increased funding are born out of rising demand and dropping capacity across Domiciliary Care, which has compounded the challenge in recent years. Not to mention the augmented pressure coming from the Care Act to evidence quality, choice and personalisation on a stretched workforce and fragmented market.
On top of this, individual needs are becoming ever more complex and requiring more and more specialised providers to meet each individual need.
How has this impacted the market?
Nearly 1 in 8 older people now live with some level of unmet need. This year Age UK’s analysis shows there are now nearly 1.2 million people aged 65+ who don’t receive the help they need with essential daily living activities. Sadly, this represents a 17.9% increase on last year and a 48% increase since 2010.
In terms of home care; half a million people receive personal care in the community, of which the majority is provided in people’s homes through Domiciliary Care services.
Each quarter, 500 home care providers register with the CQC, however 400 also deregister in that same time frame. These providers deregister before they have had the chance to deliver their services.
The CQC also highlight that home care providers have withdrawn from local authority contracts where they felt there was too little funding to enable them to be responsive to people’s needs. In the Association of Directors of Adult Social Services survey, 43 councils reported that Domiciliary Care contracts had been handed back in 2016/17, which was predicted to affect 3,135 people.
In Age UK’s February 2017 report, they highlight that 59 councils have reported at least one home provider ‘handing back’ a contract. Two of the largest national home care providers also left the local authority market in 2017. In the same report, Age UK drew attention to A United Kingdom Care Association report which indicated that 11% of UK providers thought they were likely to cease trading in the next year and 74% are planning to reduce the amount of local authority funded care they provide. The survey also indicated that 93% of providers said they saw real term reductions in local authority fees in 2015/16 with 20% reporting a cut.
In 2016/17 the overall staff vacancy rate across the whole of the adult social care sector was 6.6%, rising to 10.4% for Domiciliary Care staff. The staff turnover rate in 2016/17 was 27.8%, rising by 4.7% since 2012/13.
The number of days that people were delayed in hospital waiting for Domiciliary Care more than tripled from March 2014, peaking in December 2016 at more than 42,000 days (although since then these have dropped to 37,000 in June 2017). However, the majority of delays remain attributed to the NHS (acute and non-acute services). In March 2017, 55% of all days delayed at hospital were attributed to the NHS, compared with 37% to adult social care, and 8% to both.
What is happening in commissioning now?
This landscape is a derelict one in its current state. For commissioners of home care services, it would appear that costs are increasing out of balance with available funding, commissioning teams are overstretched trying to fulfil requirements and manage the back office, whilst providers are disengaged and quality is diminishing or is simply un-trackable.
In an attempt to ease the pressure, Commissioning teams have decided to limit the number of providers they work with on framework agreements. At the same time, they’re fixing costs and reducing head count.
Instead of this becoming a more manageable, efficient approach to commissioning services, it has created a broken system. Due to rising demand, the framework agreements in place don’t have the capacity to deal with the growing need. Due to the nature of relationships with the market, providers don’t fully understand requirements and therefore can’t meet people’s needs. The intensity and pressure of the job is pushing carers to question their return for what they put into their roles, as seen with those leaving the sector in pursuit of other career paths.
As highlighted in Improving Market Capacity in Domiciliary Care, many commissioning teams are working around the formal commissioning process in place. In order to fulfil requirements, they are emailing and calling the providers they know and have some form of relationship with to see if they have capacity. Over decades of these arrangements being in place, providers understandably can be left frustrated with the approach as it doesn’t nurture a collaborative relationship, but instead a reactive and fragmented one.
Commissioners are also frustrated at the reactive nature of their commissioning process. They would much rather spend their time engaging the individuals, families and providers to ensure needs are met and the market is collaborative. Instead they spend their time manually processing documents, working around existing processes and generally firefighting.
What are the underlying causes? Understandably the causes go far and wide. Public Sector commissioning is an extremely complex area, so it would also be negligent to over simplify the cause of these challenges. However, the evidence of the current landscape, in part, does point towards the commissioning process, which has been engrained over decades, being exposed by rising demand and complex needs.
The excuse may be underfunding, but the reality and cause is that no one properly planned for this.
Part of the cause then, in terms of commissioning, is the need to spot purchase around the framework agreements. Spot purchasing is untimely, potentially non-compliant and often doesn’t fully cater for the needs of the individual. Instead the provider with available capacity is selected, rather than the one best able to support the individual requiring home care.
The time it takes to commission a package is eating away at the proactive approach many commissioners want to take. This means teams don’t have oversite over the entire available market, their specialities or their capacity. In turn, providers don’t have oversight over the (predicted and actual) level and fluctuations in demand meaning they can’t form a robust strategy to run their business.
This leaves everyone frustrated and reactive to market conditions instead of working collaboratively. Ultimately the individual requiring a home care service, that meets their needs, suffers the most.
Thankfully a number of organisations have decided to move on from spot purchasing and improve their approach. These improvements are changing the outlook for commissioners, providers and most importantly, those in need of care.
How can you solve it too?
Despite the complexities, several local authorities have now moved on from spot purchasing and instead use Digital Commissioning technology to improve entire home care commissioning process.
This means they have complete oversight over their market in one place. They can commission the right service, from the most appropriate provider, at the right time, for the best value (for all parties), in order to support the needs of the individual needing home care.
They can then manage their market in the same technology. This means they can reward quality whilst evidencing outcomes and compliance. The payment process is streamlined and allows teams to spend their time focussing on individual needs and supporting their market, especially SME providers (evidencing Social Value).
This creates and nurtures a collaborative relationship which is open, fair and transparent to all parties.
Where is the evidence?
The likes of Birmingham City Council, both the London Boroughs of Haringey and Waltham Forest, The City of Cardiff Council and a group of CCG’s across the Midlands and Lancashire have removed spot purchasing in favour of Digital Commissioning for Domiciliary Care placement.
The approach is supporting multiple placement categories to deliver on average
The City of Cardiff Council alone, have increased their care provider supply base by 51%. The same council are commissioning Domiciliary Care packages based on 60% quality, with an average of 4 offers per requirement.