United Kingdom Homecare Association
Commissioning Survey 2011
This briefing is designed to provide top-level information about a survey of
homecare providers’ experience of the recent purchasing arrangements
and tactics used by local authorities who commission homecare services.
1.
Abstract
United Kingdom Homecare Association undertook a study of the
commissioning practices of local authorities to understand the impact of
local authority commissioning decisions in the context of stringent public
spending cuts.
We were provided with examples where the dignity, quality and safety of
elderly and disabled service users could be placed at risk. Regrettably,
the link between the quality and cost of homecare services is not always
reported in the context of commissioning decisions made by local
authorities who are responsible for arranging four-fifths of all homecare in
the UK.
We found that up to 82% of councils were reducing how much care they
would pay for, and reducing the number of homecare visits people
receive. 58% of councils appeared to have cut the price they pay
independent and voluntary sector providers for homecare. The use of
short visits of around 15 minutes or less to undertake personal care
appears to be increasing rapidly.
We found that a wide range of care activities were being curtailed or
withdrawn from service users’ care plans, particularly reducing social
contact and checks on safety. Activities that help people stay at home,
including shopping, help with bill-paying and laundry were most likely to
be stopped all-together.
Employers reported increasing difficulty recruiting and retaining
careworkers to undertake homecare, particularly in rural areas, and that
the wages they could pay their workforce was increasingly threatened by
very low fee levels from councils.
A series of short, anonymised case studies drawn from the survey are
provided in Appendix 1. Information about the survey design and
response rates are provided in Appendix 2. A brief description of the role
of United Kingdom Homecare Association is given in Appendix 3.
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2.
The issues and context
UKHCA has monitored and commented on the homecare sector for over
20 years. With recent public spending cuts, our member organisations
describe increasingly challenging market conditions created by local
authorities, who are the sector’s majority purchaser.1,2
There are clear concerns, borne out in UKHCA’s survey and recent media
coverage, that the quality of homecare services could be adversely
affected by the commissioning practice of councils.
This can be characterised as an attempt to reduce spend adult on social
care services by:

reducing access to state-funded care;

reducing the amount of time allowed to meet people’s needs;

reducing prices paid to independent and voluntary sector providers.3
Although around 6.6 million hours of homecare is delivered safely and
effectively every week, UKHCA believes that these trends in council
commissioning are likely to increase the danger of developing homecare
services that:

do not fully meet the needs of people who use home-based care;

appear to be hurried and lack dignity;

increase the risk of injury to homecare workers and the people to
whom they provide care.
1
In Northern Ireland social care is commissioned by Health and Social Care
Trusts. Throughout this paper references to “councils” and “local authorities”
should be assumed to include Health and Social Care Trusts.
2
UKHCA estimates that the state purchases around 80% of all homecare
services provided in the UK. The majority of state-funded care is delivered by
independent and voluntary sector providers.
3
For brevity references to the “independent sector” should be assumed to
include both private and voluntary sector providers.
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Our survey provided 47 case studies about individual service users from
providers who believed they now receive inadequate care to meet their
needs as a direct result of recent commissioning decisions. For the
purpose of comparison, providers said that 17% of packages had been
insufficient to meet the user’s needs before they were changed by the
council. After changes were implemented, 55% were described as
receiving 'somewhat insufficient' care and 45% 'seriously insufficient'
care.
3.
Most significant trends identified
Our survey provided 206 separate impressions of recent local authority
commissioning practice, covering 111 statutory sector purchasing
authorities across the UK (see Appendix 2 for survey design).
We found evidence of councils engaging to some degree in a wide range
of cost-cutting measures,4 the most common being:

Active reduction in the amount of time allocated for care for at least
some service users (82% of councils);

Reducing the number of visits that people receive by careworkers
(76% of councils).
From the case studies submitted to the survey, we estimated that not only
were fewer visits being made, but the average visit length was reduced by
around 10 minutes (22%), from 48 to 38 minutes.5 However, we saw
many examples of care where very short periods were allocated for
assistance with hygiene and mobility needs or meal preparation was
constrained to very short periods of around 15 minutes.
4
Quantifying the extent to which these activities are being undertaken was
outside the scope of this survey.
5
The case studies in our survey were selected from those where, in the
providers’ opinion, the council had changed the package of care to a level that
was “somewhat insufficient” or “seriously insufficient” to meet the user’s
needs. We should emphasise that these figures are not intended to represent
the national picture for all people receiving homecare in the UK, however, they
provide an impression of the experience of those who may be particularly
disadvantaged by their council’s commissioning practices.
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These actions carry considerable implications for homecare services:
Reducing the time permitted for personal care to be completed can create
undignified, hurried and impersonal care; or make it difficult to meet a
person’s care needs. In extreme cases it increases the risk of unsafe
working conditions and injury to service user or careworker.
Reducing the number of visits to the service user’s home can increase
social isolation for many older, frail or incapacitated individuals who live
alone, and place additional strain on care provided by family members
and unpaid carers.
Case study: A gentleman in his 90s had his care reduced by 92% after
his council in the Yorkshire and Humber region cut his original 28 visits
per week (each lasting 45 minutes) down to just 7 visits per week (each
lasting only 15 minutes). The council saved around £230 per week, and
now spends just £20 a week on 1.8 hours of care, which is
understandably described as 'seriously insufficient' by the provider.
Most councils calculate payment for services based on “contact time”, the
time actually spent inside the service user’s home. Shorter visit times
generate lower fees which must still accommodate the costs of travel to
and from service the service user’s home, and makes it harder to offer a
pay rate sufficiently attractive for workers to undertake very short
episodes of work.
Short visit times are a particular problem in rural areas, where travel time
often far exceeds time spent delivering care. Providers repeatedly
reported difficulties recruiting and retaining careworkers with the right
skills and experience because of these issues.
10% of providers told us that councils’ cost-saving measures had led to
them turning-down work in rural areas, or where visit times were
inadequate for the care required, or had become unprofitable. We believe
that this will increase over the next few years and may threaten the
availability of services, particularly in rural areas.
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We heard repeatedly about careworkers leaving the sector and a difficulty
recruiting because of the pay rates providers could offer. Providers cited
short visits with long travel time as causing difficulties in staff retention.
We heard from at least 4 providers (3%), who had already cut wages in
order to remain in business, and 12 providers (8%) considering ceasing
trading with councils or stopping provision in the local area.
From our case studies we analysed the different types of care that were
most likely to be restricted or withdrawn as councils reduce the care
people receive (see Figure 1.)
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Figure 1.
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Our impression is that people are most likely to receive less assistance
with:

maintaining social activity or social contact;

checks on safety;

prompts and reminders to self-care;

washing, bathing or showering;

assistance with healthcare needs.
However, it was also noticeable that services most likely to be stopped
completely also included activities which actually help people remain in
their own homes:

shopping;

managing their finances and bill-paying;

help with laundry.
Case study: A lady in her 90s no longer receives the seven evening-time
visits to help with personal care and check-up on her safety. Since the
council in the South West of England reduced her care by 41% in January
2011, she has been scalded attempting to make a cup of tea; has spent a
night lying on the floor undetected after a fall; and a skin condition has
deteriorated as she is unable to apply the lotion she needs. She now
regularly telephones her daughter in the evenings in a state of distress.
This has saved the council £62 a week.
We saw a range of other cost-cutting measures undertaken by councils
(see Figure 2.), including:

58% of councils were attempting to push down prices previously
agreed in established contracts with providers;

50% of councils removing enhanced rates to incentivise work in the
evenings, weekends and public holidays (when workers reasonably
expect enhanced pay rates);

41% of councils were reducing the use of pairs of careworkers in a
single visit. These double-ups are generally used for safety reasons
during manual handling procedures.

Around 18-21% of councils were removing one or more of the
payments they had previously made towards careworkers’ travel time
or travel costs, or premium payments to incentivise work in rural
areas, where travel time can be considerable.
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Figure 2.
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We were particularly disturbed by the number of providers who felt that
commissioners had ignored provider’s knowledge about the service users'
needs and condition. Providers appeared to have no involvement in
commissioning changes in almost two-thirds (62%) of the case studies
they supplied. Indeed, even when involved in reviews of service users’
care, providers felt that their recommendations were either wholly or
partly accepted in just 6 of the 19 cases.
4.
Conclusion
The Association is sympathetic to the complex challenges faced by
directors of adult social services and their commissioning teams in
balancing competing demands on constrained budgets. The solutions to
these challenges lie not only with commissioners and providers, but
society and government re-thinking its priorities.
The frequency and severity of issues identified in our survey suggest that
councils themselves and government in all four administrations must ask
serious questions about whether commissioning practices are running
contrary to the needs and wellbeing of service users and their carers.
While not assessed in this survey, the cost implications for the NHS should
also be included in the equation.
Politicians and local communities must question whether councils are
alotting sufficient resources for effective homecare services that can be
delivered to a sufficiently high standard, and keep people at home, rather
than in hospital and residential care.
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Appendix 1.
Case studies
The following descriptions are a selection of the 50 case studies submitted
in the second part of the on-line survey.
1.
A provider's request for an additional 15 minutes of care each
evening to check on the wellbeing of a lady in her 80s was denied by
a council in the South West of England funding her care. She had
developed an infection, but wanted to stay at home rather than go
into hospital. We estimate that these visits would have increased the
cost of this lady's care by £26 per week, in addition to the £103 the
council already paid. The cost to the NHS would have been
significantly higher.
2.
A gentleman in his 90s had his care reduced by 92% after his council
in the Yorkshire and Humber region cut his original 28 visits per
week (each lasting 45 minutes) down to just 7 visits per week (each
lasting only 15 minutes). The council saved around £230 per week,
and now spends just £20 a week on 1.8 hours of care, which is
described as 'seriously insufficient' by the provider.
3.
A lady in her 80s in the North West of England lost much of the
assistance she needed to remain at home, including shopping;
paying her bills and help with her laundry. The 7.5 hours of care she
received each week was cut by 67%, leaving careworkers little time
to fit these activities around help with her personal hygiene needs in
the three visits she receives each week.
4.
A daily half-hour visit to help a lady prepare a meal and attend to her
personal hygiene in the South East of England was discontinued
without discussion with the agency about her needs. The provider
believes that the council responsible is undertaking a policy of
cancelling packages of care that only require a single visit per day.
5.
A gentleman in his 40s in the South East of England receives a
specialist homecare service for people with mental health needs. He
no longer receives sufficient one-to-one care to monitor and support
his psychological state, leaving his provider describing his care as
'seriously insufficient'. The 23 hours of care he received each week
has been reduced by 83% by reducing 14 visits a week down to just
four.
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6.
A council in the South West of England reduced the amount of care
for an older lady by declining to pay for a second careworker to help
use a mechanical hoist to use the toilet safely. This measure saved
the council £61 a week, but increases the risk of injury to the service
user or the careworker.
7.
A lady in her 80s in East Anglia has Parkinson's disease. The 14
hours of care she received was halved in May, by halving each of her
half-hour homecare visits, despite her needs remaining the same.
Parkinson's is associated with variable exacerbation where people
may require more assistance than usual. The provider said 'on bad
days we have to rush. All four calls per day have been reduced to 15
minute visits, which includes delivery of personal care'.
8.
A lady in her 90s no longer receives the seven evening-time visits to
help with personal care and check-up on her safety. Since the
council in the South West of England reduced her care by 41% in
January 2011, she has been scalded attempting to make a cup of
tea; has spent a night lying on the floor undetected after a fall; and a
skin condition has deteriorated as she is unable to apply the lotion
she needs. She now regularly telephones her daughter in the
evenings in a state of distress. This has saved the council £62 a
week.
9.
A younger disabled adult in her 30s received the equivalent of over
76 hours of intensive care a week at her home in West Scotland. Her
care was reduced by 26%, after the introduction of a direct payment,
which now only covers two of the four visits where careworkers were
needed in pairs. On the other visits one careworker has to cope
alone. The provider believes the care is now 'seriously insufficient'.
10. A lady in her 70s has had 5 minutes shaved from each of her 20minute visits, despite care being necessary to help with physical
activities, including getting in and out of bed and using the
bathroom. The provider said that 20-minute visits were 'somewhat
insufficient', but rates the shorter 15-minute calls as ‘seriously
insufficient’.
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11. The condition of a frail gentleman in his 90's in Northern Ireland
began to deteriorate. His needs were being met with four half-hour
visits a day from two careworkers, working together. This cost the
local Health and Social Care Trust £305 per week. The Trust
declined to provide any additional time to help the gentleman use the
toilet, wash and dress, leaving the provider describing the care they
were paid to deliver as 'seriously insufficient'.
12. A provider in the East Midlands felt compelled to accept a 20% fee
reduction to enable a younger disabled gentleman to remain with the
agency that he's used for the last 17 years. The social worker
commissioning the care wished to introduce care at a rate below the
£12.73 per hour charged. The provider has foregone £423 a week to
help this gentleman remain with the service he knows and trusts.
However, each time councils push down the price they pay for care,
less money is available to support workers' training, wages and the
agency's other running costs.
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Appendix 2.
About this survey
This survey was an online exercise completed by member organisations of
the United Kingdom Homecare Association, the professional
representative association for domiciliary care providers.
The motivation to undertake this survey was the increasing concerns of
independent and voluntary sector homecare providers on the impact of
public spending cuts on the commissioning of homecare services; the
possible risks to the quality, dignity and safety of services; and the threat
to the financial viability of the independent and voluntary sector, who
provide the majority of state-funded care in the United Kingdom.
The survey was undertaken in August 2011. It covers all four
administrations of the United Kingdom and the online questionnaire was
made available to UKHCA's member organisations who currently trade
with local councils (or Health and Social Care Trusts in Northern Ireland).
The survey was divided in two parts, and organisations could select one or
both sections.
Part one
This section looked at providers' general experience of local authority
commissioning:

158 homecare providers responded to this section, supplying:

206 individual reports…

about 111 different councils or trusts
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Figure 3.
Part two
This section was designed to highlight examples of how the general
practice of councils impacted on individual service users. To qualify for
this section, providers were asked to select service users whose care
package had been changed by the commissioner in the 6 months to
August 2011 and where, in the provider's opinion, the care package (or
the fees paid by the council) was insufficient to meet the service users’s
needs. We refer to do these as "case studies" in this report.
50 case studies were submitted, 78% of which were from England. All
eight government regions in England and each of the other three UK
administrations were represented in the results by between one and seven
case studies. The survey therefore presents an impression of
commissioning across the whole of the UK.
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Figure 4.
The survey asked providers for a consistent set of data relating to each
user’s care, both before and after the care package was changed, as
follows:

the number of hours of care councils purchased for individuals (or the
amount the individual could purchase with the cash equivalent, a
"direct payment");

how often service users received their homecare service during a
typical week;

whether care packages commissioned were sufficient for the service
user’s needs;

how much involvement, if any, the provider had in the decision to
change the package of care commissioned.
The survey covers care services to adults of all ages, with around 68% of
them older people aged 65 or above (see Figure 5.)
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Figure 5.
Confidentiality
No personal information about individual service users was collected
during the survey. While providers were asked to disclose the
commissioning bodies concerned, this was with the assurance that this
information would not be reported in the published findings.
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Appendix 3.
About UKHCA
UKHCA’s mission, as a member-led professional association, is to promote
high quality, sustainable care services so that people can continue to live
at home and in their local community. We will do this by campaigning,
through leadership and support to social care providers.
Our Vision is of a United Kingdom where a choice of high quality,
sustainable community-based care is available to all.
UKHCA represents 33% of independent and voluntary sector providers in
the UK, and estimates that its member organisations employ over
119,000 homecare workers, who deliver over 2.79 million hours of care
per week to around 166,000 service users, valued at £1.62 billion per
annum.
Colin Angel
Policy and Campaigns Director
United Kingdom Homecare Association
Group House
52 Sutton Court Road
Sutton
SM1 4SL
020 8288 5291
media@ukhca.co.uk
www.ukhca.co.uk
31st August 2011
Registered in England No. 3083104
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