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 We found that a wide range of care activities were being curtailed or withdrawn from service users’ care plans, particularly reducing social contact and checks on safety.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. Page 1 of 17 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. Page 2 of 17 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. Page 3 of 17 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. Page 4 of 17 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.) Page 5 of 17 Figure 1. Page 6 of 17 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. Page 7 of 17 Figure 2. Page 8 of 17 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. Page 9 of 17 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. Page 10 of 17 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’. Page 11 of 17 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. Page 12 of 17 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 Page 13 of 17 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. Page 14 of 17 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.) Page 15 of 17 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. Page 16 of 17 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 Page 17 of 17