Changing lives through changing policy

Harold Bodmer

Director of Community Services

The National Picture Today

380k

1.1m1.8m

5m

Care and support affects a large number of people. In England there are…

People in residential care

People with care at home

People employed in the care workforce

Informal carers

Statistics from “Caring for our future: reforming care and support”, White Paper July 2012

What are our chances?

The Picture in Norfolk• Norfolk has the “oldest” population in the region

• Whilst the overall population of Norfolk is predicted to increase by 25% between 2008 and 2033, the number of people aged 65-74 is likely to increase by 54%, and the number of people aged 75+ should go up by 97%.

• In the same period the North Norfolk district is likely to develop one of the largest proportions of older people aged 65+ in the country

Service Delivery to Commissioning

• History of social care delivery - Great Hospital in Norwich

• 25 years ago - very little social care market• Almost all service in-house, Home Care (helps),

day centres, residential care homes, day centres • NHS Long stay hospitals• Little or no choice

Revolution 1A market for social care

• NHS and Community Care Act - the development of markets

• Social care took on contracting, then gradually the concept of social care commissioning

• The role of social workers as the gatekeeper of eligibility

• Choice starts to be important

Revolution 2People in charge

• The Direct Payment movement, a social movement, adopted by policy makers

• Importance of User Led Organisations• Significant change for local authorities • People in charge, people set the agenda• Followed by Individual then Personal Care

budgets, then Personal Health Budgets• Now hardwired into policy

Age is just a number…

• 50 – 65• 66 – 80• 81 - 100

• ‘Ageing (living) well’• Keeping independent• Care, support and

sharing experiences

A change of response:

•Solutions based on local communities

•Integration of health, social care, housing, voluntary and independent sector

A shifting concept

Revolution 3

• Integration with the NHS• Been with us for years/ different models/ joint

funding/ joint arrangements• Now firmly in policy, Better Care Fund, pooling

of resources• Integration of Commissioning• Integration of Social Care provision• Join up experience for people

Revolution 4 The Care Bill

• Promote well-being, prevent and postpone need for care

• Cap on costs that people have to pay for care• Element of response to Francis inquiry• National eligibility criteria• Equality for carers• Promotes integration

Revolution 4 The Care Bill

• Providing information and advice• Market shaping• Co-operation

The new approach

• Numbers up…. Funding down, the perfect storm?

• The new contract. A public debate about expectations for health and social care

• Positive image for ageing• Beyond personalisation• A new role for councils in this. Whole lives and

whole communities• Role of Health and Wellbeing Boards• Challenge established rules in way operate• Change our joint working culture

Top issues forhomecare providers

Great British Care Show, Norwich

Andrew Heffernan, Membership and Marketing Director

2nd April 2014

Issues for the homecare sector

• Operating environment:o Commissioning of state-funded careo Short visits, “bad news” stories

• Workers’ terms & conditions:o National Minimum Wage, Zero-hours contracts

• Regulation:o New inspection methods, Quality Ratings, market oversight

• Recruitment:o Cavendish Review, recruiting values, supply of workers

• Legislation: o Care Bill

The operating environment

• Council commissioning is getting worse:o Either: Reduction in number of “approved providers”

or: Volume spread thinly through framework agreementso ADASS: 15-min visits account for 16% of all purchaseo Providers’ over-reliance on state-funded business

• Public not aware that social care is means-testedo “Dilnot-style” funding cap in Care Billo Responsibility between individual and the state unclearo Residential care still seen as the default option

Equality & Human Rights CommissionClose to Home Recommendations Review

• Links commissioning, workers’ Ts&Cs, staff turnover & quality

• UKHCA helped EHRC produce questionnaire, which found:o 1 in 5 LAs with rates of £8.96-£11o 1 in 3 LAs setting maximum prices

• EHRC recommends:o CQC to monitor commissioningo NMW compliance clauses

UKHCA’s minimum price of £15.19/hour

• BBC Radio 4 finds:o 97 of 101 councils pay

prices below £15.19o Average minimum rate

£12.26

• Coverage on:o BBC Breakfasto BBC News Channelo BBC Radio 4 & 5-Liveo BBC Local Radio

Assumptions used in our minimum price

Minimum Wage: £6.31

Travel time: 11.4 min

Travel costs: 4 miles£0.35/mile

NI: 9.5%

Holiday Pay: 10.8%

Training: 1.73%

Pensions: 1%

Gross margin: 30%

Based on fee of £15.19 per hour to provider for contact time only

How can you use UKHCA’s Minimum Price?

• Support discussion with local commissioners

• Send to local councillors asking why council paying below UKHCA’s rate

• Use UKHCA’s Costing Model to calculate actual costs:o www.ukhca.co.uk/CostingModel

• Challenge council to open-book costing exercise

Quality and flexibility:15-minute visits

• Debate about short visits is helpful for highlighting commissioning issues

• Media now understand that inadequate care is part of a wider problem

• Prepares argument for why keeping head of NMW is challenging

• Guardian/EHRC etc alsoidentify inflexibility of visitsand choice of worker

National Minimum Wage

• Increased investigations by HMRC triggered by:o Workers contacting the Pay and Work Rights Helplineo Intelligence about non-compliance from 3rd partieso Risk-based assessment of providers by HMRC

• Increasing media attention:o Alleged non-payment of careworkers’ travel timeo HMRC report – November 2013o Recent publicity on zero-hours contracts

HMRC investigations of 224 social care providers

45% non-compliance Average under-payment of £139

HMRC (2013) National Minimum Wage Compliance in the Social Care Sector

Reason(s) for NMW non-compliance in the homecare sector

HMRC (2013) National Minimum Wage Compliance in the Social Care Sector

Why’s this importantfor you?

• Reputation of entire homecare sector at risk

• Workers’ rosters make compliance hard to check

• Commercial damage for non-compliant employerso Repayment of arrears to workers at current rates o Fine of 50% of arrears (minimum £100, maximum £5k)o New rules to “name and shame” in public

HMRC may come knocking

• HMRC likely to ask for:o Pay recordso Weekly/monthly rosterso Schedules of pay rateso Workers’ contractso Evidence of you checking

compliance

• Be confident and cooperative!

+

Minimum Wage compliance(Highly simplified)

Basic rate(s) of pay are used.Do not rely on unsocial hours premiums

or enhancements for short visitsto achieve compliance with NMW

Average pay over reference period of

up to1 month

Total pay before enhancements

Total contact time Travel time + Training>=£6.31

Time spent providing care in the service user’s home

Includes: Travel between visits and time spent on training approved by the employer

Excludes: Journeys to and from worker’s home and other ‘non-working’ time

Minimum Wage non-compliance:The risk factors

• Low rates:o Basic rates around £6.31/houro Relying on enhancements for short visits/unsocial hourso Not changing rates for younger workers on their birthday

• Payment for “contact time” only:o Large amount of travel time, relative to “contact time”o Use of very short visits and/or long gaps between them

• Other issues:o Having insufficient records (eg. travel time)o Deductions for uniforms or accommodation provided

UKHCA’s NMW ToolkitFree resource for UKHCA members

• Based on HMRC documents, obtained under FOI

• 3 main sections:o How NMW works in complexity of

homecare serviceso How to audit compliance (individuals &

samples of workers)o Suggested actions to achieve/improve

compliance

www.ukhca.co.uk/downloads.aspx?ID=422

Forthcoming changes in CQC regulation & inspection

• New “Fundamental Standards” & regs

• Specialist inspectors

• Tougher registration and action against non-compliance, including vacant manager posts

• On-line “Provider Information Return” to be completed in advance

• “Market oversight” for largest providers

Inspection themes for each service:

1. Is it safe?

2. Is it effective?

3. Is it caring?

4. Is it responsive to people’s needs?

5. Is it well-led?

CQC’s Quality Ratings

• All services to be rated by March 2016:o Wave 1 Pilot (ratings won’t be published)o Wave 2 Pilot (ratings may be published)o All other services (ratings will be published as awarded)

• Ratings will be:o Awarded at location levelo Provided as an aggregated score & for each of 5 themeso Determined by a set of ‘rules’, however…o Inspectors have some discretion to deviate from rules

Worker recruitment and training

• A Certificate of Fundamental Careo Proposed by Cavendish Reviewo Possible duplication with Common Induction Standards

• Emphasis on recruiting for “values”o Materials from the National Skills Academyo Increasing interest in profiling workers

• Councils attempting to limit zero-hours contractso If your councils do this, can you afford the Ts&Cs?

Legislation: The Care Bill

How to contact us

Website:

www.ukhca.co.uk

E-mail:

andrew.heffernan@ukhca.co.uk

Telephone:

020 8661 8152

Twitter:

@ukhca

Principles behind our minimum price

• Fees calculated solely for “contact time”

• Workers receive flat-rate NMW for “working time”:o Contact timeo Supervision and trainingo Applicable travel time (and reasonable travel costs)

• Provider can cover:o NI, pensions, training and holiday payo Reasonable operating costso Acceptable profit / surplus

NHS Choices and Transparency

• NHS Choices (www.nhs.uk)o All CQC registered social care providers listedo Likely to become main info source for self-funderso Free advertising for your business

• Government appetite for transparencyo Possible introduction of “Friends and Family Test”o DH want providers to publish “transparency measures”o Third party “Trip Advisor” style comments are included

5 “transparency measures” for homecare services

• Staff stability (Low turnover)

• Staff qualifications

• Resolving complaints within agreed timescale

• Scheduled visits successfully undertaken

• Scheduled visits taking place on time

Minimum Wage:What you need to know

• NMW is averaged over a reference periodo Your payment period or 1 month (whichever is shorter)

• “Working time” includes:o Contact time and applicable travel timeo Training and supervision

• It is lawful (but risky) to pay “contact time” onlyo But you must achieve NMW over the reference period

• Deductions from pay and non-reimbursement of costs (eg. mileage/fares) are taken into account

Impact of short visits

Short

homecare

visits

bought by

local

authorities

Short

homecare

visits

bought by

local

authorities

Rushed, undignified care for highly dependent people

Rushed, undignified care for highly dependent people

Travel time increasesas a proportion of total cost

Travel time increasesas a proportion of total cost

Workers dissatisfiedwith their ability to provide care

Workers dissatisfiedwith their ability to provide care

High staff turnoverdrains skills & experience and increases costs

High staff turnoverdrains skills & experience and increases costs

Potential non-compliance withNational Minimum Wage

Potential non-compliance withNational Minimum Wage

Dissatisfactionwith homecare services andadverse publicity

Dissatisfactionwith homecare services andadverse publicity

INTEGRATION – PARTNERSHIPS FOR SUCCESS

Terry Cotton, Executive Board MemberNorfolk Independent Care

NORFOLK INDEPENDENT CARE

Umbrella group representing hundreds of care providers

Residential and Nursing Care Homes, Home Care and Day Opportunity Organisations

Vision to enhance quality, develop sustainable services, share challenges and solutions

Challenges for Norfolk

County Council budget cuts 2014 – 2017 Highest proportion of people aged 65 – 84

across Eastern Region Second highest proportion of people aged over

85 By 2033 people aged 65 – 74 expected to

increase by 54% By 2033 people aged over 75 expected to

increase by 97%

INTEGRATION

Range from relative autonomy – co ordination, joint appointments, enhanced partnerships and structural integration

Integration between service sectors, professions, settings, organisations and types of care (Reed 2005)

Macro, meso and micro leve ( Ham and Curry 2010)

CURRENT PIONEERS

14 Across Country Barnsley – centralised monitoring centre Cornwall and Isles of Scilly – 15 Organisations

working together Islington – CCG and Local Authority Integrated

Care Organisation at Whittingdon Health South Devon and Torbay, already well

integrated and working to 7 day provision

INTEGRATION

Local Government Association Value Case for Integrated Health and Social Care

Has to be person centred, actively supporting individual in co delivery of their care, removing defined boundaries between professionals and recipients to develop partnerships working towards shared goals

Increased efficiency and relieve pressure on acute providers

Integration Critical Success Factors

Friendly relationships Leadership Commitment from the top Joint Vision Joint Strategy

(Petch 2011, Lesson from early adopters)

INTEGRATION

Role of Health and Wellbeing Board Better Care Funding to drive integration –

pooled budget for commissioning of integrated health and social service

2014/2015 – transfer of some £1.1 Billion in total to Local Authorities

2015/2016 - £3.8 Billion linked to achieving outcomes, including plan that meets national standards

BETTER CARE FUND

NATIONAL INDICATORS ADMISSIONS TO RESIDENTIAL AND CARE

HOMES EFFECTIVENESS OF REABLEMENT DELAYED TRANSFERS OF CARE AVIODABLE EMERGENCY ADMISSIONS PATIENT/SERVICE USER EXPERIENCE 7 DAY SERVICE LOCAL MEASURES

BETTER CARE FUND “ Essential for CCGs and Local Authorities to

engage with providers from the outset to scope increased capacity requirements and idenify mechanisms to best address these. Work with providers will be crucial to manage the transition to new patterns of provision.”

Norfolk Health and Wellbeing Board February 2014

SO?

Norfolk HWB Board has Voluntary Sector representation none from the private Sector

West Norfolk was going to be a Pioneer, but special Measures at the Queen Elizabeth Hospital was precluded, but Minister stated would still be able to engage

West Norfolk has a Executive Forum, the Forum has voluntary sector representation none from Private Sector

Partnership Working

Is there still mistrust of the Private Sector at different levels in the Public Sector?

Is there a need for an open debate on this issue?

Values and culture?

“The dark side”

Missing a big trick?

People who use our service