Key White Paper Issues on Developing Diverse Markets. Notes from the East Midlands Strategic Market Development Event – 2nd November 2011

Delegate Information– 67 delegates from;East Midlands Local Authorities, Strategic Commissioning teams, procurement/legal leads, local user led organisations, local provider forum leads, alsoElected Members, Deputy Directors of Public Health, Independent, voluntary third sector providers and provider network organisations in East Midlands and Skills for Care.

Following an overview by Andrew Kerslake on the ‘Caring for our Futures’ engagement process, commissioners, providers and regional agencies attending the conference split into groups to consider the following issues. The summary of each discussion is included underneath each heading.

Inreal markets organisations grow or fail.How do we manage this when service users are dependent on their suppliers?

  • Going to happen more often
  • Suppliers have some concern e.g.are 43% dependent on LA – What happens if that funding goes – what about their clients?
  • Short notice often to come up with alternatives for clients i.e. 24 hour notice of home closure.
  • Need to understand early warning signs.
  • What controls can you build into the system to gain intelligence?
  • Monitoring processes to look at supplier sustainability.

- Can only do this if have a contract, more of a risk as move forward with personalisation.

  • Need ‘redundancy’ in system to cope with such issues – would mean higher charges.
  • Need contingency plans in place working with a wide range of providers.
  • Dependent on having large financially sound providers- penalises smaller ‘locally grown’ organisations.
  • Need good relationships between commissioners and providers.
  • In house services may be able to move in a carer in the short term – further moves to outsourcing will not enable this.
  • Question role of CQC in this, should they be including viability/sustainability in their processes (not just at point in time when visit occurs)?
  • Does Department of Health need contingency plans for this?
  • Liability insurance for providers – what does that cover?
  • How do we support users and carers?
  • Need to respond quickly
  • Need to keep them informed
  • Letting service users know they will be supported.
  • DerbysCounty have developed a plan with NHS about what to do when something ‘big’ happens’.
  • Even if no contractual arrangement need to build good relationships with providers
  • They may use quality tools
  • Are there any ‘characteristics’ which would indicate an organisation is more likely to fail?
  • Most current work is very reactive rather than pro-actively identifying those providers who may be at risk of failing.
  • Could ‘competition laws’ be used to limit provider markets share locally or is this just nationally?
  • Registration of providers.
  • Do providers have a role to deliver ‘contingency advice’ to individual purchasers and should individuals think about this when choosing a provider.
  • Home care providers give little thought to business’s continuity.

- Business continuity plan to be required.

  • Mandatory requirement for user/carer representation on Boards/partnership groups of every provider organisation?

Can we deliver quality at the price we currently pay?

  • How do we define quality?
  • Does care cost calculator work?

-works for some areas

-different for elderly and LD

  • Which market? LD, elderly, MH
  • Is it about how we use money rather than whether there is enough money?
  • Training, how do you pay the wages whilst on training?
  • Conflict of quality against minimum wage.
  • How do you define quality?
  • Is the question really that a minimum wage doesnot necessarily employ workers with the desire to do the work that is required?

How do we grow consumerism?

  • Accept this may take 20 years
  • Need to change the culture in the LA/NHS,away from assumption that people who are ill need to be in a care home.
  • Providers need to do more market research to respond/understand what self-funders /state fundered people want as alternatives to help prevent long-term care.
  • Create informed Customers rather than ‘clients.’
  • More information about what ‘good quality’ looks like.
  • More accessible understanding of cost of care.
  • Board members include service users as customers.
  • LA role in awareness raising in

- Public of cost of care

- Research into what works best for outcomes.

Is there real choice in the market and if now how do we stimulate this?

  • Is this the right question? What is choice?Is there real choice in enabling people to live independently?
  • Market is incredibly raw at this stage
  • Is ‘choice’ stifled by bureaucracy?
  • Needs systematic and accessible methods of capturing needs and demands.
  • Needs co- production methods and techniques, with more collaboration between commissioners, provider market and ‘customer’ forums.
  • Requires shift in expectations and practice for service users, practitioners and commissioners.
  • Need to make better use of the information collected systematically so it can be collated when needed.
  • Market position statementscan be a good a place to start dialogue between commissioners and providers
  • Needs to engagement with customer complaints/comments and business forums e.g. for social enterprises etc.
  • Potential ‘innovation’ funding for use as one off seed funding.

To have choice in the market you must have vacancies to have vacancies you must have higher charges. Discuss?

The discussion covered ways in which to maximise the flexibility of the vacancies that currently exist and how to get more into the system.

The context, from a home owner’s perspective, is that the forecasting of vacancies is impossible. And when vacancies arise, they are not automatically suitable for the people waiting the longest. Accessing extra staff could not make a bed free where there was no bed free. Home owners have a 3% load on the previous staff costs next year because of the pensions obligations.

The broader context would be that the demographically driven likely increase in private beds demand would mean that homes would no longer want to contract with councils or PCTs due to their lower rates. Conversely, however, the ability to get a higher price out of the private market might mean that there was less pressure to charge a proper rate to the public sector, which in effect would be subsidised.

The group believed that it was the same in relation to capacity, within a domiciliary care service. The engagement of bank staff on zero hours contracts was not easy to manage as the competition from e.g. supermarkets for staff on the same pay level was strong.

Ideas recorded

  • Purchase of access to respite and re-ablement beds in Extra Care unregistered settings – some in the group believed that this would have registration implications because of the structure fundamentally boiling down to one purchaser – the council, say, organising (and thus providing) the care together with the accommodation. The licence to occupy the accommodation would either need to be in the name of the client, albeit paid for by the purchaser of the care, in order to separate it from the care provision, and the risk would be that this would be seen to be a device to avoid registration obligations.
  • Re-designation of client groups served in any particular care setting, via amendment of one’s Statement of Purpose and notification to the CQC, as opposed to anything more long-winded.
  • Registration flexibility for beds within a particular curtilage – this is done within Care Villages, so it could be feasible to support managers to re-designate nursing beds as residential care beds and vice versa in a care home so long as it is managed by a registered nurse.
  • Services from Care Settings being dually registered to do care outside that setting e.g. in the local community – with councils’ contracts giving them the right to direct spare capacity out to other council clients.
  • Support, encouragement and expectation of all providers, as business people, to advertise vacancies, not as a mark of shame but of capacity.
  • Better awareness of vacancy levels, fee rates and trends. Use on online market places may assist this?
  • Expectation that the market will continue to attract self-funders and thus subsidise beds for the public sector.
  • Loans or timebanking of one agency’s excess capacity to other agencies? What would the incentive be? The ability to maximise the revenue producing power of having the extra capacity.
  • A transparency obligation on the part of all councils purchasing care home beds to disclose its evidence basis for the identification of its usual rate, so that it can be seen that the council is paying as a full rate for standard care, regardless of top-ups, a non-arbitrary and rational fee in order to procure enough beds to meet the anticipated annual throughput of residential care clients.
  • A culture in which wants could be separately paid for by the individual from disregarded capital or income, or by the relatives, as opposed to the needs, which must be met by the council in its contract, so that top-up and extras can be clearly distinguished from the core cost of a bed.
  • A culture where the council provides something of genuine benefit to providers to the public sector in return for a lower fee e.g. training, advertising.
  • A realistic national financial settlement to underpin the longer term funding of social care, as per Dilnott recommendations.
  • A genuine political confrontation of the issue that we maybe need to pay higher taxes so that care is properly paid for before poorer women or women with relatives with insufficient funds to create capital for payment of private fees are forced back into their relatives’ homes to care for them in the face of nil capacity at the price councils want to pay.

1