Guidance

Local authority market sustainability plans: insights report

Published 2 November 2023

Executive summary

The Market Sustainability and Fair Cost of Care Fund (MSFCCF) 2022 was designed to support local authorities (LAs) to build more sustainable care markets by developing their understanding of the costs of delivering care in their local area. The fund gave LAs £162 million in the 2022 to 2023 financial year to enable them to move towards paying more sustainable fee rates, where they were not already doing so, to providers of residential and nursing care for people aged 65 years and over and domiciliary care for people aged 18 years and over.

As part of the grant conditions for this fund, LAs were required to submit cost of care exercises to the Department of Health and Social Care (DHSC). They were also required to submit and publish cost of care reports in February 2023 and market sustainability plans (MSPs) in March 2023, both on their websites. MSPs included:

• an assessment of current market sustainability
• anticipated impacts on market sustainability
• strategies for improving market sustainability over the next 1 to 3 years
• the cost of care for the local area and an explanation of how the exercise was carried out, including provider engagement

The MSPs reflect the data and positions of LAs between March 2022 and March 2023.

See a central repository of cost of care reports and market sustainability plans by LA.

As part of its grant assurance process, the department conducted an in-depth review of the provisional MSPs submitted by all 152 LAs in October 2022. As of the beginning of the 2023 to 2024 financial year, there are 153 LAs in England.

After follow-up discussions with some individual LAs and further review of final MSPs, published in March 2023, the department has compiled this insights report, which is intended to be a resource for LAs across the country, highlighting some of the many approaches LAs are taking to building sustainable and innovative markets. Wide engagement with and involvement of providers, service users, their friends and family, was a consistent theme.

LAs highlighted a set of shared challenges, which included:

• the ability of their 65 years and over residential nursing care markets and their 18 years and over domiciliary care markets, to deliver enough care and support for their local populations
• the diversity of provision
• provider exits from local markets
• underpayment within the sector and workforce supply

LAs cited a number of approaches they are taking to address these challenges and these are the main focus of this report.

The report is organised thematically. Each section includes a case study, taken from LAs’ provisional MSPs, which demonstrates an approach that has led to encouraging results in the LA’s market.

The department identified the following themes as key to LAs’ strategic approaches to improving market sustainability. At the time of submitting their MSPs, LAs:

• were seeking to expand their domiciliary care markets and secure greater supply

• were seeking to stabilise and adapt their care home markets to the changing needs of local populations by:

  • recognising the need for residential and nursing care that can cater to specialist needs
  • investing in alternatives to standard residential care, to expand provision that supports person-led care and support

• highlighted that market sustainability is dependent on a wide range of factors, including:

  • embracing the growing role of technology in delivering care and support
  • identifying the importance of working in closer partnership with health services, especially on discharge commissioning
  • investing in proactive quality management processes to improve and maintain standards of care and support
  • workforce recruitment and retention in both LA roles and, but most acutely in, frontline social care delivery was highly constrained across all LAs

These themes are explored in detail later in the document with relevant examples.

LAs are the experts in shaping their markets and their approaches to doing so will be determined by their individual circumstances. The examples and case studies in this report reflect individual LA perspectives on activities that can support market sustainability and may not be relevant for all LAs.

Introduction

Background

The MSFCCF was developed because analysis has shown that some LAs are estimated to pay below the sustainable cost of providing care, with resulting higher fees for many self-funders and pressures for local market sustainability.

Under the Care Act 2014, LAs have a duty to promote the efficient and effective operation of the market for adult social care and support as a whole. The Care Act guidance states that they should assure themselves and have evidence that fee levels are appropriate to provide the agreed quality of care, enable providers to effectively support care users, and invest in staff development, innovation and improvement.  

This can be considered a duty to facilitate the market, in the sense of using a wide range of approaches to encourage and shape it. The ambition of the Care Act is for LAs to influence and drive the pace of change for their whole market, leading to a sustainable and diverse range of care and support providers, continuously improving quality and choice - delivering better, innovative and cost-effective outcomes that promote the wellbeing of people who need care and support.

High-quality, personalised care and support can only be achieved where there is a vibrant, responsive market of service providers. The role of the LA is critical to achieving this, both through the actions it takes to commission services directly to meet needs and the broader understanding of, and interactions it undertakes with, the wider market for the benefit of all local people and communities.

The outcome of cost of care exercises was not intended to be a replacement for the fee-setting element of LA commissioning processes or individual contract negotiation. In practice, it’s expected that the actual fee rates paid may differ due to such factors as rurality, personalisation of care, quality of provision and wider market circumstances.

In the Autumn Statement in November 2022, the government announced, having listened to the concerns of local government, the decision to delay planned adult social care charging reforms and to retain the funding in LA budgets to support them to meet existing pressures.

As part of that, the department maintained MSFCCF funding at £162 million per year for 2023 to 2024 and 2024 to 2025, and announced the creation of a new, ringfenced fund of £400 million in 2023 to 2024, and £680 million in 2024 to 2025; the Market Sustainability and Improvement Fund (MSIF). This changed the context for FCC, as anticipated market changes, such as the extension of rights to LA commissioning under Section 18(3) of the Care Act, were delayed.

The government has since announced an additional £600 million package of funding for adult social care for 2023 to 2025. £570 million of this is for the MSIF Workforce Fund, which closely mirrors the existing MSIF to support increased adult social care capacity, improve market sustainability, and enable LAs to make tangible improvements to adult social care services, with a particular focus on workforce pay. Combined, the overall MSIF profile is £927 million in 2023 to 2024, rising to £1.05 billion in 2024 to 2025. 

Purpose of the report

This report is intended to be a supportive tool for LA commissioners, and others with a role in market shaping, who are developing strategies to improve market sustainability and capacity. The report may also serve as a launchpad for conversations between LAs and their providers about approaches to improving local market sustainability.

LAs were not required to provide information on the level of effectiveness of the activities outlined in their MSPs and so the report does not comment on this. More evidence and evaluation would be required to understand the impacts of these activities on LAs, providers, people who draw on care, and their friends, family and carers. It should also be noted that the information presented in provisional and final MSPs represents a specific point in time, and individual LAs’ circumstances may have changed since the time of writing. For these reasons, this document is not intended to be a commentary on, or assessment of, the effectiveness of the adult social care sector. Rather, it aims to synthesise the challenges as reported by LAs, and the solutions they are putting in place.

The department is not endorsing the activities highlighted in the report, nor recommending that LAs adopt them; local market conditions, geography, population need, consultation with care users and providers will all inform local decisions as to action taken and its impact on market sustainability.

The key themes emerging from the department’s review of MSPs are set out below. Additionally, LAs consistently cited underpayment and the differential between LA and self-funder fee rates in their MSPs, reporting variable starting points and levels of ability to move towards paying the full costs of delivering care in their area.

Summary of key insights

The main market sustainability concerns outlined by LAs in their provisional MSPs are summarised in Table 1 below. Our review highlights that LAs are most concerned about the ability of their 65 years and over residential nursing care markets and 18 years and over domiciliary care markets to deliver enough care and support for their local populations. The percentages in this table refer to the proportion of LAs that expressed concerns across these indicators in their provisional MSPs.

Table 1: concerns expressed by LAs in their market sustainability plans

Risk indicators	65 years old and over residential care	65 years old and over residential nursing care	18 years old and over domiciliary care
% expressing concerns over limited capacity	24%	67%	61%
% expressing market exit concerns	28%	29%	26%
% expressing diversity of provision concerns	43%	N/A	26%
% expressing concerns with FCC calculation	56%	55%	54%
% expressing concerns with workforce supply	93%	86%	93%

LAs’ approaches to these concerns and shared challenges are summarised below.

Expanding domiciliary care markets and securing greater supply

Key points

Key points included:

• some LAs raised difficulties with securing enough domiciliary care and noted it’s highly vulnerable to external pressures, including volumes of people awaiting discharge from hospital, workforce supply and the impact of pay conditions, or fuel costs. Hard-to-reach areas were a significant issue in domiciliary care with particular challenges around securing provision in rural areas due to travel costs and a reported non-driving workforce

• 61% of LAs expressed concerns with the ability of their domiciliary care markets to deliver enough care and support. 93% of LAs reported concerns about workforce supply affecting their ability to deliver enough domiciliary care and support

• LAs sought to strengthen their supply of domiciliary care by improvements to contracting and payments for example, via development of neighbourhood-based models, greater intelligence and engagement, and adapting and growing the offer for example, through greater involvement of voluntary, community and social enterprises (VCSEs)

Shared challenges

61% of LAs specifically indicated in their MSP that they were concerned about the ability of their domiciliary care markets to meet local population need. The majority of LAs reported an ambition to expand their provision of domiciliary care to reflect policy ambitions to better support people in their own homes for longer and meet growing demand.

The majority of LAs indicated growing waiting lists and levels of unmet and under-met need, which may be related to domiciliary care supply. Some also reported commissioning domiciliary care in intervals of 15 minutes, with potentially significant negative impacts on sufficiency and quality of support, as well as on staff wellbeing and retention. A clear driver of the challenges in securing sufficient domiciliary care was the availability of the social care workforce, see ‘Factors influencing market sustainability’. 93% of LAs reported being concerned about workforce supply in their domiciliary care market. Other reasons listed include the supply of care providers that LAs can contract with at their fee rates, quality, and increasing market shares focussed on self-funders.

In some areas, provider exits led to a reduction in the number of domiciliary care providers available to the LA to contract, which impacted choice and control for people and overall market stability. Some LAs are looking to address this via focussed efforts on identifying and monitoring at-risk provision using data on occupancy, self-funder numbers and geographical pressures, and the implementation of contingency plans.

Some LAs sought to increase the number of providers they contract with to meet local need. However, several LAs have recognised the efficiency challenges of managing a larger number of providers in their market, with consequences also for providers who are not able to benefit from large or stable market shares, and on the continuity and stability of services for people who draw on care and support.

Many LAs used frameworks to purchase care from domiciliary care providers under which terms and pay rates were set. However, some LAs outlined that providers had exited existing frameworks (citing low fee rates and contract hand backs from providers, provider failure or quality issues). This resulted in growing volumes of placements being purchased individually according to current demand or ‘spot purchased’, including with providers catering for the self-funder market at a higher price and out of area. Care packages that were ‘spot purchased’ were often done so at higher cost and dependent on market availability and rates, leading to high levels of volatility.

LAs noted additional pressures at times of high demand, notably arising from hospital discharge volumes (see more in ‘Factors influencing market sustainability’) and resorted to spot purchasing to meet large volumes of demand. Where LAs were not able to secure enough domiciliary care, it led to wider impacts across the sector, for instance with a greater number of people discharged from hospital going to residential and nursing care.

Activities adopted to increase domiciliary capacity

Our review of the MSPs outlined a wide range of activities highlighted by LAs to seek to strengthen capacity in the domiciliary care sector.

Contracting and payment activities included:

• neighbourhood based models, with one (or several) lead providers taking on guaranteed volumes in one geographical patch, and several supporting or contingency providers. Often lead providers are awarded block contracts and/or are required to take on minimum hours to ensure secure provision

• some LAs choosing to increase capacity via dynamic purchasing systems (DPSs). However, some MSPs highlighted the risks of having a DPS based on price, spreading hours across high numbers of providers (making oversight more difficult) and potential impacts on quality. Increased numbers of providers has also been identified as risking destabilising the market, as existing providers may no longer be viable and may not be able to offer staff guaranteed hours, impacting retention

• uplifts targeted towards packages of care in rural areas, cross-borough tendering, re-tendering at higher baseline rates, uplifts for travel times

Intelligence and engagement activities included:

• provider engagement via monthly and/or quarterly forum meetings and webinars, shared partnership boards, ‘responsive commissioning plans’, sharing of best practice

• new market position statements with near-live and interactive data

Adapting and growing offer activities included:

• greater involvement of the VCSE sector and/or micro-enterprises
• increasing the use of direct payments and Individual Service Funds
• in-house provision, especially for rural areas
• piloting with providers with flexibility to arrange care on a timetable driven by providers and those who access care and support

LAs linked the value of neighbourhood-based (or lead provider based) models to better relationships with providers. LAs also reported an improved ability to secure care packages, thereby reducing waiting lists. LAs sought to increase the efficiency of neighbourhood models, for instance by ‘tightening’ the areas in which providers operate or introducing a contractual requirement for providers to pay staff on a rostered basis or for full shifts, to better ensure compliance with the National Living Wage. Several LAs, where such models are not in place, conversely acknowledged that the absence of lead providers or area-based providers has led to under-representation in certain geographical areas.

Some LAs referred to ongoing transformation programmes to take a more radical approach to reforming their domiciliary care markets, often accompanied by an ethos of building strong relationships with people who draw on care and providers. LAs highlighted the strength of taking a holistic and integrated approach to creating sustained change in their domiciliary markets, and the need to maintain flexibility to adapt to changing needs and ambitions of people who draw on care. Examples of additional flexibility included building in regular contract reviews to ensure fees continue to reflect need but are also more reflective of current inflationary pressures. Other activities included funding parking permits to ensure domiciliary care staff were able to park at individual residences at no cost.

Case study: developing hyper local commissioning

An example from Gloucestershire’s market sustainability plan:

We took a decision to focus on commissioning domiciliary care based on smaller statistical neighbourhoods. There are 373 lower-layer super-output areas (LSOAs) in Gloucestershire defined by postcode, each hosting about 1,500 residents. They are coterminous with district and county borders and offer an approach that could ensure provision is both local and familiar. Considering purchasing at this level gives a level of data not apparent at a district level. It allows us to target support and incentives.

We developed a home care search tool which enables brokers to approach providers who have known capacity and are local to the customer. The Office for National Statistics (ONS) and the Department for Work and Pensions (DWP) data showed that there is unemployment in areas with long waiting-times which implied that there was a workforce to be developed. We therefore also applied the new tool to target a Proud to Care local recruitment campaign in the Forest of Dean which is currently being evaluated. We have further local campaigns planned for Gloucester and Cheltenham.

The success of our hyper-local commissioning approach is evident: since April 2022 the balance of care has moved towards home care and there are now  more older people using home care as a result. Our only increase in bed-based care has been in placements supporting dementia, other residential and nursing is unchanged.

Gloucestershire has since reported this figure has risen to 19% by March 2023.

See Gloucestershire County Council - provider information

Adapting care home markets to changing needs of local populations

Key points

Key points included:

• 74% of LAs outlined an oversupply of residential care that caters for more ‘standard’ needs. Only 24% of LAs reported concerns with securing enough residential care (without nursing)

• challenges with residential and/or nursing care are especially felt in highly urbanised areas (for example, almost 50% of London boroughs outline concerns with securing enough residential care with and without nursing), leading to high levels of out-of-area placements. Reasons for this include property prices and lack of available land

• LAs overall reported an increase in complexity among people requiring residential and nursing care, in part due to the greater share of social care delivered by domiciliary care and other community services. 67% of LAs reported concerns with their ability to secure enough nursing care

• LAs sought to engage with providers to increase the available supply of nursing and specialist care, worked collaboratively with NHS partners and created development opportunities for staff to better meet complex need

• a majority of LAs signalled an ambition to develop a greater supply of alternatives to standard residential care that can offer people more choice and control to live independent and fulfilling lives. They were seeking to achieve this through the development of independent living schemes, more community-based activities and more work with micro-providers

LAs were seeking to stabilise their residential care markets

Shared challenges

Most LAs did not express concerns in their MSPs about the supply of more standard residential care. Only 24% of the MSPs submitted to the department explicitly outlined concerns with securing enough residential care (without nursing). In some areas, LAs reported limited spare capacity due to the volume of people being discharged from hospital.

Highly urbanised areas, such as London, experienced greater pressures on standard residential care due to high local property prices. LAs reported a greater reliance on purchasing care out-of-area, and limited opportunities to foster stability and higher costs impacted by fees set by neighbouring authorities.

Despite generally not reporting issues with the quantity of residential care, several LAs highlighted sustainability impacts related to fee rates and contracting mechanisms similar to those in domiciliary care. These included increased spot purchasing, particularly where authorities had not updated framework contracts and/or rates, or where these only apply to a small share of the market. LAs reported that this resulted in some providers increasingly focusing on the self-funder market, and in higher levels of top ups.

Activities adopted by LAs to seek to strengthen their residential and nursing care markets

Contracting and payment activities included:

• block contracting with providers to enable them to replace older properties through the building of new homes

• new residential framework contracts which set out terms and conditions, opportunities for transitional beds at enhanced rates, and lower rates for shared rooms

• regular cost of care exercises to support budget setting, in some places with open-book accounting from providers. However, it was noted that it will be important that providers are not disproportionately burdened by such approaches

• social worker-driven commissioning

• more reactive purchasing of care, for instance via the introduction of DPSs. However, some MSPs highlighted the risks of having a DPS based on price that can lead to high numbers of providers and impacts on quality

• reducing investment, in line with anticipated demand, in some forms of residential care (without nursing and non-specialist), with increased investment into alternative models of care (this is explored further in section ‘LAs investing in alternative models of care and to expand provision which supports person-led care’).

Diversity of provision activities included:

• working with a chosen provider to address capacity issues around nursing provision and to build new nursing homes

• strengthened in-house provision or contracting with providers that have acquired homes previously owned by the LA in order to improve stability

• ‘peppercorn’ rent leases to minimise barriers to entry to the market, with maintenance and repairs fully funded

Integrated commissioning activities included:

• integrated care boards (ICBs) and integrated care systems (ICSs) entirely purchasing residential and nursing care beds to create consistent funding and commissioning arrangements. This also reduced the burden on providers by reducing the number of organisations involved

• joint strategies between the LA and ICS to improve quality of care, and co-produce future services

Engagement with providers activities included:

• one contract manager allocated to each provider to develop closer understanding and relationships with providers

• a collaborative approach to contract monitoring through consistent contract meetings and joint agreement on arrangements such as key performance indicators and contractual clauses

Block contracts were reported to be well received due to providing stable levels of funding. However, it is also important to consider the trajectory towards greater support at home, and some LAs reported the potential to reduce residential block contracts over time. LAs noted that providers have welcomed updated tenders.

Case study: block booking to strengthen the stability of the residential care market

An example from Staffordshire’s market sustainability plan:

The council is continuing to expand our block booked bed capacity across all 65 years and over care homes. Providers report this is welcome and is attractive to the sector as they are able to bid at a price that meets their costs and have guaranteed income for the period the contract is in place. The most recent tender has secured an additional 125 beds.

The council will be redesigning our commissioning process during 2023 to consider whether the current DPS arrangements are fit for the future. This will be undertaken with ongoing communication and engagement with the sector and with the voice of people with lived experience and their families and carers shaping the vision and outcomes.

See Staffordshire County Council provisional market sustainability plan.

Recognising the need for residential care and nursing care that can cater to specialist needs

Key points included:

• a growing number of LAs recognised the need for more specialist and/or nursing care to cater to specialist needs (such as dementia or mental health), and that these services were essential to ensuring people’s needs are well met
• specialist and nursing services often required more intensive resources
• specialist care also included services supporting specific cultural or linguistic needs

Shared challenges

With a greater share of social care delivered by community care providers, many LAs noted a significant increase in complexity among people seeking care in residential and nursing settings. Providers were increasingly requesting additional one-to-one hours to cater to growing need.

Almost all LAs discussed challenges in sourcing more specialist and nursing care to meet local changing needs. 67% of LAs reported concerns with their ability to secure enough nursing care. Reasons for capacity challenges included:

• fee rates for specialist or nursing care that providers were not willing to accept
• existing residential or nursing care stock not well set up to meet need
• a lack of alternative capacity to standard residential care
• limited collaborative working with ICBs to address shared issues

Workforce supply issues also impacted LAs’ ability to secure sufficient capacity for specialist and nursing care. In many areas, nursing and complex settings were de-registering with the Care Quality Commission (CQC) due to challenges in funding and sourcing nursing staff.

LAs reported engaging with providers to transform existing provision to better suit more complex needs; spot purchasing to secure suitable provision; or increasing in-house provision.

Activities adopted by LAs to develop more specialist and nursing care

Increasing supply of available care via purchasing and contracting, including:

• increased in-house provision by LAs for more complex care, for example, dementia care

• certainty of volume of activity via block booking of specific services (for example, block booking 100% of specialist services)

• new contract types for flexible provision or new bandings within existing frameworks, following provider engagement

• specific and/or targeted fee uplifts, including using MSIF and FCC funding in specific areas, such as residential dementia, nursing, and nursing dementia; adaptations; or towards providers catering to the highest needs

• targeted fee increases for providers wishing to upskill and diversify to meet more complex needs

Upskilling and developing workforce activities, including:

• development of dementia support teams and multi-disciplinary team working within care homes to better support residents

• training for new home care providers on reablement, via the local reablement team

• introduction of a specialism focus in home care support to support providers in upskilling staff, and focusing on a specific client group. For example, the Homecare Association’s ‘Train a Trainer on Dementia’ programme

Engagement with providers activities, including:

• working with existing providers to upskill and cater for more complex needs, in some cases as a pilot with bespoke support packages in place to help providers shift towards enhanced level of needs

• an agreed set of definitions on levels of complexity in care and number of hours typically required at each level to ensure individual packages are commissioned at more appropriate levels

Adapting the offer and integrating commissioning activities, including:

• new bedded dementia nursing care home co-owned by the LA and the NHS with a local organisation commissioned to provide the care and support

• enhanced ‘Health in Care Homes’ programme

• block booking of dementia beds by NHS partners

• development of more virtual wards, short-term reablement, step-up and/or step-down beds, respite, and dual registered homes

LAs reported benefits to working with existing providers and strengthening these relationships to take a collaborative approach to developing specialist and nursing care that is more catered to local need. LAs whose MSPs put forward the development of new specialist care provision as successful in their area referred to significant engagement with providers, through mediums such as provider forums and specific pre-procurement market engagement events, to better understand what could give providers most certainty, such as long-term block booked contracts.

Case study: developing dementia specialist provision

An example from Isle of Wight’s market sustainability plan

We will be working with our ICB colleagues to jointly develop dementia specialist provision. We will also aim to establish a joint funding arrangement for those residents who are being discharged into social care with higher acuity and complexity. This will enable additional funding for residents whose needs are beyond adult social care and thereby support providers with their increased costs on staffing and training.

We are supporting our providers to skill-up staff in supporting people with dementia - through funding a structured highly specialist dementia training programme in the calendar year of 2023.

See Adult social care reform on the Isle of Wight

Investing in alternative models of care and expanding provision to support person-led care

Shared challenges

Many MSPs described the increasing demand for new models of care which can adapt to reflect the wide spectrum of needs and aspirations of local populations and individuals. While MSPs identified different models according to their geographies and demographics, they outlined the overall need to diversify existing provision in co-production with people who access services, their carers and relatives, and providers and commissioners.

Increasingly, the provision of alternative models of care was identified by LAs as enabling greater choice and control for people who access care and support, which promoted independence and wellbeing.

While LAs were expanding on innovative market shaping and commissioning practices, MSPs also describe work still to be done to embed alternative models and make the shift away from traditional care.

LAs identified the importance of consulting, engaging and co-producing with people who need support. Some LAs cited that the physical estates in their residential market limited opportunities to diversify provision. Others noted the need to support and train the workforce to embrace new ways of working. Moreover, innovation often required a significant cultural shift, driven by ambitious leadership. New and alternative models were more challenging to implement and sometimes required significant system and structure reform, particularly to the scale required for mass change.

For these reasons, new models of care took time to embed, and LAs reported concerns that they could not do this quickly enough to meet growing need. LAs noted that new models in place were generally small-scale and not yet widespread.

Activities adopted by LAs to seek to expand alternatives to residential care

Investing in independent living accommodation to diversify housing options, including:

• prioritising reviews of care and accommodation strategies to identify areas of need, which are often settings which offer a step-up option from living at home

• investing in the development of ‘extra care’ schemes to develop independence-driven care. Frequently cited as an essential component of joint commissioning by health and social care, and used as an option for intermediate care and rehabilitation, as well as longer-term housing

• increasing provision of ‘supported living’ settings, to provide a combination of suitable accommodation with some forms of personal care

Community-based activities, including:

• Shared Lives schemes, offering greater flexibility and more community-based care

• provision which maximised the voluntary care sector and drew on community assets to ensure that services are integrated and embedded within communities. Some areas were investing in enterprises and investment programmes focused on building communities that facilitated people having full and independent lives. These typically operated by giving volunteers capability to pick up lower-level needs and deliver preventive care

Micro-provider initiatives, including:

• some areas were investing in the development of a range of community micro-providers to complement the existing offers from their market

• social enterprises were cited as helping areas to launch programmes which help people start and run small, independent enterprises offering care and support. These providers typically supported people with personal care, managing their home and usual routine, or to help facilitate social contact

Empowering recipients of care to take more control over their own care, including:

• use of apps and databases that enabled self-funders and direct payment holders to arrange their own care services more easily. These often made the use of direct payments simpler for LAs

• the development of personal assistant databases by some LAs, to support people to advertise and recruit local personal assistants

Case study: strategies to develop extra care provision

An example from Bracknell Forest’s market sustainability plan:

Current strategies identify the continued development of alternative provisions to avoid hospital admissions and over-reliance on residential placements, sustaining the ‘home first’ ethos for individuals to remain at home and as independent, for as long as possible. Over the coming years there is the identified need for the further development of extra care provision as a ‘step-up’ from living at home, including models which can support people with more complex needs.

The care and accommodation strategy explains findings from recent assessments and identifies the need for an additional 260 units of extra care accommodation by 2037. These plans will be worked through in more detail during 2023 to 2024 and 2024 to 2025.

See Bracknell Forest Council health and social care strategies and policies.

Factors influencing market sustainability

Key points

Key points included:

• LAs were beginning to embrace assistive technologies to support people to live independently and safely at home, reduce isolation, and to build on workforce capacity

• many LAs sought to work collaboratively across the sector and with NHS partners to ensure system-wide approaches to supporting staff, to support discharge and to better understand the needs of local populations

• while most LAs reported their supply of residential care is sufficient to meet need arising from discharge, they reported having an insufficient supply of domiciliary care services to support more timely discharge from hospital, where pathway 3 of the discharge to assess (D2A) model has seen increased demand

• LAs reported issues with quality and lower quality CQC ratings which were being driven by a range of issues including fees, the availability and turnover of staff, training investment in staff, and the quality of local housing stock (and investment in this). Many LAs referred to the use of internal monitoring and quality assurance teams, bespoke training and support and the setting of clear quality guidelines to proactively work with providers to improve

• across a range of service types, an average of 90% of LAs identified workforce supply as an area of particular concern. This was identified most acutely in 65 years and over standard residential (93% of LAs) and 18 years and over domiciliary care (93% of LAs)

• 86% of LAs recognised workforce supply in nursing care as a significant challenge. Many LAs emphasised that investment in upskilling the workforce was needed to cater to growing acuity and complexity of needs

Embracing the growing role that technology has in the care sector

Assistive technologies were identified as helpful for people to manage complex health conditions and live with dignity at home for longer, while staying connected to others.

Used effectively, MSPs expressed a hope that technology-enabled care would support both outcomes and efficiency of care and support, but also stated that clarity was needed on how these new technologies would be funded and how LAs, ICBs and providers could work together to embed these.

Uses of technologies that LAs have identified

To support people to live well and independently at home, and reduce the reliance on care home provision, LAs identified:

• technologies to help providers design better environments through adaptations, from simple aids to more complex adaptations such as wet rooms and domestic lifts

• technology to deliver more personalised care to individuals through smart home devices such as voice-controlled intelligent personal assistants. Capabilities include setting reminders, providing news updates, playing audiobooks, all of which give individuals a greater sense of independence

To keep people safe, LAs identified:

• technologies to support preventive care and signal early warnings of health deterioration

• a ‘safe steps’ multi-disciplinary team programme, a digital falls risk assessment tool to reduce falls in care homes

• technology tailored specifically for dementia care provision to improve overall outcomes. For example, the automated hydration tracking systems and GPS wearables

To support social contact and reduce isolation and loneliness, LAs identified:

• use of Reminiscence Interactive Therapy Activities (RITA) in care homes, a digital therapy system which offers an interactive touch-screen system and allows users to use apps, games and other leisure activities

To build on workforce capacity, LAs identified the following:

• telecare, digital health and telemedicine are all examples of technologies which can support and assist care workers with their routine work

• electronic medication management systems offer electronic medication administration records (eMAR) and allow care workers to document medication administration along with observations in an auditable manner, to improve workflows, enhance data and help care workers manage stock

• care management software, particularly for homecare provision, is facilitating providers’ visibility over their care and support

MSPs set out opportunities and challenges to the growing use of technologies in social care. Of the LAs who provided a measure of the impact of these technologies, most described that outcomes appeared to have improved. Some LAs also reported on the important steps to ensuring technologies can be implemented in compliance with information governance and data protection legislation. This included ensuring consistent connectivity and the implementation of appropriate cyber security for certain digital technologies.

LAs also shared that to harness these technologies to reduce pressures on the workforce, there remained a need for training among professional staff responsible for installing, using, and maintaining telecare systems and other technologies, and resourcing challenges in the health service to respond.

Case study: deploying remote monitoring technology

An example from London Borough of Bexley’s market sustainability plan:

The London Borough of Bexley has deployed [a] remote monitoring technology across many of its care homes. [This remote monitoring technology] enables care home staff to take vital signs and baseline reports. The remote monitoring data is shared with GP practices in real time enabling them to make informed decisions from the practice and to prioritise their patients appropriately.

Using remote monitoring in our care homes supports the health and wellbeing of residents by enabling staff to pick up on the ‘soft signs’ of deterioration and acting on them more quickly.

As well as enhancing contact with GPs and supporting care home staff in their caring role, the technology is helping to prevent emergency hospital admissions.

See London Borough of Bexley market sustainability and cost of care report.

Identifying the importance of working in closer partnership with health services, especially on discharge commissioning

Shared challenges

Some LAs expressed concerns about the ability of their residential care market to meet need at times of high demand through pathway 3 (temporary or permanent placements requiring 24 hour bedded care) of the D2A model. In some areas, LAs reported that up to 53% of packages initially commissioned as D2A placements became long-term residential packages for individuals requiring more intensive support. LAs identified the importance of additional training to ensure staff are well equipped to meet this changing need.

Some LAs reported that an insufficient supply of domiciliary care contributed to a discharge backlog, especially for people on pathway 1 (requiring care and support at home). In some cases, MSPs demonstrated that domiciliary care waiting lists have increased by as much as 6 times from 2021 to 2022. Some areas reported that their dedicated support for discharge, such as reablement services, is having to pick up ‘uncovered’ domiciliary care packages due to lack of available staff in wider domiciliary care services.

Activities adopted by LAs to improve joint working and discharge

To improve joint working on discharge, LAs adopted activities including:

• a joined-up approach to commissioning discharge to assess beds between LAs, clinical commissioning groups (in place at the time of publication of provisional MSPs), and ICSs

• joint working with ICBs on nursing recruitment and market development for discharges, working together to improve community-based provision to support home-first strategies and reduce the use of residential beds for discharge

• targeting improved GP support to care homes with high hospital discharge

• aligning home care procurement with district nursing neighbourhood teams to improve joint approach

• using local care networks and/or organisations to deliver, manage and commission adult social care. This enables care and health teams to work together to provide a holistic approach to coordinating care around a person’s aspirations and needs

Wider joint approaches included:

• working with the ICS to understand changing needs of older populations and manage the wider markets

• commissioning all bed-based care through local integrated care organisation

• all care home and domiciliary care services jointly commissioned with ICB

• promoting links to local resources and community assets via localised neighbourhood working

• closer joint working on funded nursing care, continuing healthcare and one-to-one support hours to address gaps in fees

Discharge-specific support included:

• investment in reablement and home-related support

• use of LA-commissioned extra care to provide complex rehabilitation

• jointly commissioned step-up and/or step-down reablement between LAs and the NHS

• targeted support for complex pathways (for example, dementia complex needs step-up and/or step-down)

• hospital discharge rapid response services that are attached to each acute hospital and distinct from domiciliary care contract

• use of assistive technology embedded within hospital discharge teams to track support needs of people in their own homes to promote independence

Prevention activities included:

• investment in preventative community services and enabling community to offer early advice, guidance, and support to prevent deterioration

• investment into digital solutions to support the early identification of illness and health deterioration (for more on assistive technologies see section ‘Embracing the growing role that technology has in the care sector’ within ‘Factors influencing market sustainability’)

• introduction of specialist teams, for example specialist dementia support teams, who can provide training and support to care providers to ensure they are better equipped to meet individual needs

Some LAs emphasised prevention and early intervention in their pathways, with strategies and plans to continue to support people in their own homes and help to avoid health deterioration and admissions into hospital. Some LAs sought to increase their investment in preventative services and measures using virtual wards, anticipatory care, social prescribers, and the voluntary sector to offer advice, guidance and support.

One solution outlined by LAs for improving discharge outcomes for individuals was integrated commissioning with close collaboration with health partners in the NHS, such as providers, clinical commissioning groups (in place at the time provisional MSPs were written), ICBs and ICSs. Examples of collaborative working at both micro and macro commissioning levels include collective fee setting (although commissioners reported needing to take care to ensure that commissioning aligns with the provision of individual personal budgets), a joined-up approach to commissioning discharge to assess beds or the development of a joint, co-produced, strategy and market-wide view of system needs.

Case study: integrated commissioning and effective discharge commissioning

An example from Royal Borough of Kingston-Upon-Thames’ MSP:

Over the winter months the council has worked within the wider system ambitions of the ICB and worked closely with its health place partners and utilised the grant funds made available by the government to purchase short term block contracts to help secure guaranteed supply.

There is positive learning, for example the commissioned block beds and home care hours has helped to improve hospital waiting times and to improve patient experience by facilitating efficient and timely hospital discharges. There is also positive feedback from providers in which they said the clarity on demand and guaranteed business commitments has helped them with their planning on recruitment and capacity building. To enable this, the council has commissioned:

• 65 years and over care home short term D2A block beds for standard and complex care for both with and without nursing categories
• 65 years and over care home standard residential care block contract support for medium to longer term demands
• under 65 years old care home short term D2A block beds for complex residential care
• 7-day assessment and discharge to care homes via incentive payments to care home management teams
• 7-day brokerage capacity over Christmas and New Year period
• increase in occupational therapy and assessment capacity within social work teams to support timely assessments of D2A placements

See Kingston-upon-Thames market sustainability and fair cost of care fund reports.

Investing in proactive quality management processes to improve and maintain standards of care and support

Shared challenges

LAs reported challenges arising from workforce supply on quality management. MSPs highlighted the intrinsic links between quality of provision within the health and social care sector, workforce and the availability and ability of those delivering care and support.

LAs reported that insecure and temporary staffing arrangements, for instance with increased usage of agency staff, had detrimentally affected the quality of service provision through, for example, documentation and auditing of care plans becoming less robust.

LAs also stated that many longstanding and skilled members of staff had left the care sector following the COVID-19 pandemic and this had exacerbated quality concerns.

The condition of the buildings and premises for longstanding residential care services were also reported by some LAs as a quality concern. Many areas described properties becoming outdated and in need of investment to modernise and improve.

LAs demonstrated that fee rates paid to providers were a key driver and determinant of care quality. MSPs reported that low fee rates impacted providers’ ability to retain staff, and to invest in infrastructure to create modernised, safe and homely environments.   

Market structure and diversification was shown to have an impact on the ability of LAs to manage the quality of services they commissioned. Areas with a reliance on one particular specialist provider or a dependence on a small number of large organisations reported concerns in offering choice and control, as well as lacking alternatives if the quality of these services started to decline.

Activities LAs have adopted to improve quality management

Internal quality assurance processes and data activities included:

• internal LA monitoring and quality assurance teams completing inspections to complement work done by CQC and using them as a stakeholder in the improvement process

• implementation of monitoring tools such as the provider market management system (PAMMS) to set out tangible action plans for improvement

• use of PAMMS data and data from electronic call monitoring systems to understand and track market pressures

• joint work and continuous engagement between LAs, NHS Providers, CQC and care associations to agree standards and assure quality, maintaining that quality improvement and safety are ‘everyone’s business’

Training and support for providers, activities included:

• bespoke training and support for providers in regard to quality improvement, including workshops, mock inspections, best practice events and management training. It will be important to ensure that each package of support is tailored to the needs and choices of individual providers

• networking, webinars and resources to promote best practice

• regular communication including provider forums, weekly quality check-ins and a dedicated duty number. However, it will be important to ensure providers are also benefitting from these approaches and that feedback is obtained to ensure these remain helpful

• engagement around specific thematic issues in a market with targeted webinars and training sessions on key topics and on particular issues when crises arise

• targeted and specific support for providers who are struggling to improve and maintain quality. It would be important that the cause of any struggles is identified in order to offer the appropriate support

In setting clear expectations, many areas have stated they now have quality agreements, specifications and frameworks in place to give provider organisations clear guidelines on what is expected in terms of quality. However, it is important that any quality guidelines are aligned with CQC, so as to not over-burden providers.

The use of the PAMMS monitoring tools and annual inspections also gives clear guidelines as to what is expected of providers. However, it will be important to manage the burden of additional reporting on providers.

Regular communication and engagement are essential.

Many LAs highlighted the value and advantages of proactively monitoring their commissioned providers to manage and maintain higher quality services. This was mainly achieved through dedicated and embedded quality assurance teams who were able to use their own data, developed relationships and resources to be more proactive in monitoring, assuring, and supporting their partners’ quality.

One way in which LAs proactively addressed quality management was by undertaking ‘unannounced visits’, or mock inspections, combined with an ongoing package of support and training for their providers in order to proactively monitor and improve quality (although the impact on provider relationships needs to be measured). Some LAs provided targeted and bespoke support to services with low ratings or specific issues.  

One particular tool that was commonly reported by LAs is the PAMMS monitoring assessment tool. The PAMMS assessment is designed to be a supportive process to help providers prepare and complement CQC inspections. The PAMMS assessment also provides a report on various quality metrics highlighting areas of success for providers as well as identifying areas that were not achieving such high standards. In the latter case an action plan and support were put in place to promote improvement and realise positive outcomes.

However, LAs highlighted that it would be important to manage the burden of additional reporting on providers as many have their own ‘in-house’ quality assurance processes.

Case study: PAMMS monitoring

An example from Wirral Council’s MSP:

PAMMS supports a consistent approach to monitoring commissioned providers. It:

• enables providers and quality improvement teams to work together to achieve better outcomes for residents
• gives providers the opportunity to sense-check their internal quality audits against a council’s independent audit
• enables an objective quality audit to be undertaken that supports providers in establishing what is working well and what areas may require improvement
• helps to identify where the council should provide additional support, signposting, or referral to expert teams, for example, infection control, medicine management
• leads to improved CQC ratings for providers

See Wirral Council fair cost of care report.

Workforce recruitment and retention in frontline social care delivery highly constrained across LAs

Shared challenges

LAs highlighted that staff shortages among their contracted providers are very widespread. The vast proportion of LAs noted consistently high turnover rates and fewer individuals replacing them.

Many LAs cited workforce supply issues as a critical driver for system-wide capacity challenges. Increasing complexity of residents’ needs was associated with high expectations of staff skillsets, particularly in residential homes without nursing provision, where there is no permanent clinical backup support (the shift towards more specialist residential care due to increased preferences for domiciliary care is discussed in the section ‘LAs investing in alternative models of care and to expand provision which supports person-led care’).

LAs all reported ambitions to work with providers to develop their existing workforce to cater to the growing acuity and complexity of demands for residents. LAs raised concerns that without enough workforce availability, they were observing an increase in the number of contracts handed-back and difficulties in securing new care packages.

LAs reported a number of factors and challenges that cause these supply problems, including:

• uncompetitive pay or fewer benefits, relative to alternative local employers and/or other sectors, was frequently described as the most salient issue
• some reported careers in social care being perceived as having poor working conditions and lack of opportunities for progression as a critical driver for recruitment challenges
• frequent use of zero-hours contracts, particularly in domiciliary care, was referenced in respect of supply challenges. For example, some LAs emphasised in their reports that guaranteed hours are the exception rather than the rule in home care. The latest Skills for Care data suggests that 24% of the adult social care workforce were employed on zero-hours contracts across 2021 to 2022.  Zero-hours contracting appeared to be employed as a strategy to cater to the huge variation of demand across the working day (with higher demands in the mornings, for instance)

MSPs described a resulting costly reliance on agency staff.

Activities LAs are adopting to recruit and retain staff working in social care

Close, collaborative working across the entire sector, including:

• dedicated workforce roundtables, joint with health partners, to ensure sector-wide values-based recruitment

• development of a trusted assessor role to empower staff to assess and work in partnership with families to safely reduce care packages

• joint workforce plans with ICSs, including integrated career pathways, system-wide approaches to low pay and upskilling

Refreshing current commissioning arrangements towards strategic commissioning, including:

• Ethical Care Charters aimed at improving practices. Examples of charters which encourage ethical, asset-based care and support. Including commitments to the voluntary living wage or London living wage (important to manage fee levels to ensure this is achievable) and improving terms and conditions. For example, some initiatives emphasised the importance of re-allocating workers hourly rates, so they are proportionate towards costs for 30 and 45 minute calls in domiciliary care

• re-design of domiciliary care frameworks to be neighbourhood-based or patch-based, to reduce travel time

• moving to locality working to maximise VCSEs

• procurement of a framework agreement for agency staff to leverage the combined purchasing power of care homes, in order to help manage the cost of agency staff

Targeted, local recruitment campaigns, including:

• targeted work at local schools, colleges and universities

• overseas recruitment grant funding to support providers with recruitment, settlement and integration of overseas workers

• endorsement of an employee referral app launched in partnership with Skills for Care to support finding and retaining high quality care staff in a local area

Training opportunities to improve capacity within the existing workforce, including:

• local and regional training academies

• developing a progressive skill base in complex need care, to upskill existing staff

• development courses for registered managers, covering leadership, staff wellbeing, system resilience, quality and so on

• ‘care accolades’ programmes which focus on sharing and championing examples of excellent in the local care workforce, to ensure talent is recognised and the workforce feels valued

One of the more frequently cited solutions for strengthening the workforce was international recruitment, which was described as a significant driver for the current growth in workforce. Recognising the positive impacts that international recruitment has had in some localities, LAs described their efforts to facilitate forums between providers where practice can be shared and discussed, such as how to successfully recruit internationally.

Where international recruitment was highlighted, these schemes were typically created in partnership with colleagues in health, to secure the continuing supply of international staff.

Case study: neighbourhood design of domiciliary care to support workforce retention

An example from Wigan Council’s MSP:

The Wigan ‘Deal’ entailed a radical reshaping of Wigan’s model of commissioning and care delivery to champion a relationship-centred approach to commissioning. It champions a more collaborative, asset-based relationship between council staff and citizens. The ethical framework they have adopted, which they describe as a:

unique partnership of providers rooted in local communities… making a wider contribution to the place through a shared commitment to community wealth building.

Their ethical framework and neighbourhood model of commissioning which has successfully supported recruitment and retention challenges, including attracting a new profile of workforce, is also expected to continue to positively benefit workforce challenges in homecare.

The neighbourhood design has benefited localised recruitment while reducing travel time and the impact of fuel price increases, helping to attract new local people into working in the sector.

Local data shows that over half of homecare visits are currently being delivered via walking routes and that 86% of carers currently provide support in the area in which they live. Over a quarter of carers are also aged 25 and under.

There are around 750 carers employed in the borough across the 8 ethical homecare partners, with less than 10% of positions currently vacant. While Wigan are not immune to workforce challenges, the local market intelligence shows that the place-based commissioning model in home care through Wigan’s ethical framework has positively impacted on the profile and future sustainability of the workforce.

Wigan Council fair cost of care reports.