Home Care in North Lanarkshire - A Review

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1 best value review of home care housing and social work services July 2009

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3 Contents Chapter 1 Our vision for home care page 1 Chapter 2 Introduction page 2 Chapter 3 Context page 4 Chapter 4 Home care in North Lanarkshire page 7 Chapter 5 Consultation page 13 Chapter 6 Financial analysis and benchmarking page 18 Chapter 7 The way forward page 21 Chapter 8 Summary of recommendations page 28 Appendix 1 Financial modelling for in house home care service page 30 Bibliography page 31

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5 Chapter 1 Our vision for home care Home care in North Lanarkshire plays a key role in meeting the policy objective of supporting people to stay in their own home. A major event for stakeholders - including service users, carers, home support workers and managers, providers and trades unions was held on 8 April to consider the characteristics of a high quality home care service. Participants were invited to first identify, then prioritise through a scoring system, the criteria that make up an excellent service. They decided that, in order to support people well, the service needed to be: - Person centred - recognising that each person s needs are unique to them and require to be met in highly personalised ways. - Communicative - staff must know the person well to support them effectively, be skilled enough to meet their needs and be familiar with their support plan. - Consistent - seeking, wherever possible, to ensure support is provided in a consistent and reliable way. - Flexible - providing support when it is required and being able to respond to changing circumstances and needs. - Enabling - supporting people to maximise their capacity for independence by respecting their dignity and recognising their strengths and abilities. This review assesses the challenges in realising this vision across home care services and makes recommendations that are designed to enhance the prospect of people being well supported in their own homes and communities. Duncan Mackay Head of Social Work Development July 2009

6 Chapter 2 Introduction 2.1 Enabling people to live as independently as possible in their own home is a long standing government policy objective. Good quality home care services play a major part in realising this objective by: - Helping people regain or maintain their independence, through the provision of personal care and support. - Reducing social isolation. - Helping people to be safe and well. - Supporting family members and other unpaid carers. - Helping to prevent unnecessary admissions to hospitals and care homes. - Facilitating early discharge from hospital. 2.2 Home care is aimed primarily, though not exclusively, at meeting the personal care needs of older people and is the largest social work service in North Lanarkshire: over 1,400 home support workers employed by the council provide 1.5 million hours of service a year to over 5,000 service users. In 2008/9 78% of home care was provided in house whilst 22% (over 435,000) hours was purchased from independent sector providers. 2.3 It is important that home care is seen as part of a spectrum of services that support older people in each locality in North Lanarkshire, as described in the council s Living Well - A Quality of Life Strategy for Older People. Driven by people s aspirations to live at home, and reflected in government policy and accompanying resources, the service has grown by more than 300% during the lifetime of North Lanarkshire Council. This is the first full scale review of the service since 1997/ This review is part of the council s programme of Continuous Improvement Service Reviews. The aim of the review is to evaluate the service, examine scope for potential improvements and seek approval for recommendations designed to achieve improvements. 2

7 2.5 A review project team was formed and met on a monthly basis, receiving information and presentations from a range of interested parties. The following processes were implemented: - Stakeholder consultation. - Value for money analysis, including benchmarking with other local authorities. - A formal options appraisal. 2.6 A major report into home care services in England stated: The implication of government policy is that further expansion will be needed in the medium to long term, as well as changes to the way these services are organised and delivered. Time to Care? An overview of home care services for older people in England (2006) Commission for Social Care Inspection. 2.7 In Scotland it is equally evident that home care will continue to play a major role in supporting vulnerable people but it requires to do so in ways that adapt to the changing context set out in chapter three. The recommendations contained in this report reflect that context and propose ways of addressing the issues raised, within available resources. 3

8 Chapter 3 Context 3.1 This review takes place in a changing context, notably: - A restated government commitment to continue to shift the balance of care so that a greater proportion of older people are supported at home. - The impact of demographic change and the requirement to respond to the needs of an ageing population through the provision of personal care and support. - The increasing gap between assessed need and available resources, and the prospect of further constraints within future local government settlements. - More integrated approaches to service planning and delivery across the council, NHS Lanarkshire and other partners. - A widening of the scope of external regulation and inspection, including the establishment of national care standards for care at home. - Implementation of the findings of the national 21 st Century Review of Social Work. - A drive to measure outcomes not just outputs, reflected strategically in Single Outcome Agreements (of which national outcomes for community care form part) and, increasingly, at an individual level. - Rising expectations that people exercise choice and control over the support they receive. 3.2 For home care in North Lanarkshire the context also includes: - The challenge of achieving greater consistency and personalisation in standards of performance in such a high volume service. - Rising local authority employee costs arising from implementation of the single status agreement. - A relatively undeveloped local market in independent sector homecare. 4

9 - The requirement for a regulated workforce with appropriate levels of qualifications. 3.3 Balance of care - Scottish local authorities and their NHS partners are measured on the extent to which they have shifted the balance of care for older people. This calculates the proportion of older people with intensive support needs living at home, against those living in care homes or long stay hospital environments. The national target is that 30% of older people should be supported at home. In North Lanarkshire this proportion is currently 40% due to a range of community based services and approaches, not least sustained additional investment in home care. 3.4 Regulation of workforce - the home care workforce is now subject to registration with the Scottish Social Services Council (SSSC). All home care workers are required to achieve SVQ2 or equivalent recognised qualification by 2012, though the SSSC may defer implementation of this requirement. Managers of home care services are required to achieve SVQ4 to the same timescale. 3.5 Demographic change - in common with the rest of Scotland and the UK, North Lanarkshire has an ageing population. In North Lanarkshire numbers of people over 65 years are projected to rise 65.7% by 2031, with an even more pronounced increase in those aged over 75 years (92.3%). Age has a direct correlation with the incidence of dementia and other cognitive impairments, sensory impairment, mobility problems and difficulty with personal care tasks. 3.6 Applying these population projections to home care provision as currently delivered would represent a 23% increase in hours by 2015, a 44% increase by 2020 and a 68% increase by 2025 with associated impact on required resources. 3.7 Rising costs - implementation of single status has resulted in improved pay for council employed home support workers. Based on the current workforce and volume of support provided, this equates approximately to an additional 0.5m per year up to 2011/ Independent sector home care providers have long argued that levels of local authority funding are unsustainably low. Their representative organisation - Scottish Care at Home - made a submission to the review that assessed the financial requirements of providing home care services on behalf of a local authority. 3.9 Duty of best value - councils must fulfil a duty of best value as set out in the Local Government (Scotland) Act 2003: The duty of best value being to make arrangements to secure continuous improvement in performance (while maintaining an appropriate balance between quality and cost) 5

10 3.10 Councils must also make savings in line with efficient government initiatives, in increasingly difficult economic circumstances. The service has to be affordable as well as desirable and that dimension has been explored rigorously in the course of this review Personalisation - personalising the delivery of public services is an explicit goal of Scottish policy as set out in A Partnership for a Better Scotland (2003). It is central to the government s social inclusion policies and the changing aspirations of people with support needs and their families Changing Lives - the Report of the 21st Century Social Work Review (2006) endorsed this, stating: Increasing personalisation of services is both an unavoidable and desirable direction of travel for social work services Commissioning personalised services is inevitably more complex than procuring stationery or furniture. As everyone s needs are unique, each service should, wherever possible, be planned, designed, funded and provided on an individual basis. This presents particular challenges for a service on the scale of home care. 6

11 Chapter 4 Home care in North Lanarkshire 4.1 Home care in North Lanarkshire expanded rapidly from 1997 onwards. Additional funding in local government settlements to support policy objectives enabled major investment in services. A subsequent recruitment campaign engaged 600 additional staff, raising the total council workforce to the current total of over 1, Each of the six localities employs a home support team leader, a senior home support manager and six to eight home support managers, one of whom is responsible for co-ordinating purchasing from independent sector providers. The number of home support managers in each locality is calculated by a trigger mechanism activated by agreed levels of service, work and resources. 4.3 In 2008/9 expenditure on directly provided home care amounted to 23.03m. Of this, 20.5m went on home support worker wages, including superannuation and national insurance, 1.8m on direct management costs and the remainder was apportioned to office accommodation, finance and personnel support etc. Over 5m of home care was purchased from other providers in 2008/ A small team at headquarters consists of a home care service manager and three other posts. This team is responsible for policy, performance management and quality standards issues in home care as well as providing specialist information and advice. The headquarters team manages out of hours home care services that are located at Merrystone Care Base, Coatbridge, including the community alarm service. 4.5 Services provided at Merrystone are central to supporting people in their own homes. The community alarm service has over 10,000 service users and receives an average of 14,500 calls per month. The out of hours home care team averages 2,900 calls per month. Overnight home care plays an important role in preventing avoidable hospital admissions but is not yet universally available across North Lanarkshire. Merrystone is the base for the evening and night time district nursing service and the ability to refer directly to this service makes a major contribution to preventing hospital admissions e.g. management of issues relating to catheter care. 4.6 Whilst there is no significant overlap on tasks undertaken by home care and those of district nursing or other allied health professionals employed by the NHS, close collaboration is necessary to meet the often complex requirements of people with health and support needs, especially those with one or more long term conditions. Separate work is being undertaken by the Older People s Partnership Board to 7

12 maximise the alignment between hospital discharge processes, community based health and social work services and home care. 4.7 The in house home care workforce is overwhelmingly part time (94%) and female (93%). 48% of the workforce have been employed for more than five years. The age profile is striking. 5% are aged under 30 years old; 19% aged years; 32% aged years; 36% aged years; and 8% over 60 years. 4.8 The profile of home care staff indicates significant future challenges for workforce planning. In recent years the numbers of people leaving the service are close to the numbers recruited. Between 2004/5-2007/8 384 new home care staff were recruited whilst 361 staff left. Some potential applicants are deterred by the part time nature of the work and in particular, the need to provide services at evenings and weekends. In % of home support workers worked a standard shift of hours Monday-Friday. Today only 9% of the workforce are employed on that basis. 4.9 The profile contributes substantially to high levels of long term absence in home care. The workforce is drawn from communities with some of the poorest health in Scotland and the UK. Short term absence in home care is routinely amongst the best in the council (1.73% in 2008/9) whilst long term absence is amongst the highest (6.73% in 2008/9). Sustained action has reduced absence in home care but the combined figure of 8.46% in 2008/9 remains a major source of inefficiency Unlike some areas of activity, absence can incur direct additional costs in the form of external purchase or overtime, as the service still has to be provided. There is, therefore, a close relationship between use of overtime and absence; and overtime and ability to recruit. In addition, the adoption of council wide core terms and conditions requires premium payments in defined circumstances. Overtime premiums accrued in 2008/9 amounted to 1.1m Home care staff work to duties set out in a tasks document that is periodically reviewed and updated. Over time, the proportion of home care that is personal care has increased greatly, as increasingly frail people are supported in their own homes Changing economic conditions influence the capacity to recruit to the home care workforce. The expansion of the overall social care sector in the previous decade, together with reducing unemployment rates, meant that recruitment became difficult in some locations, in particular Cumbernauld. The current recession is likely to alter this context Just as the directly provided home care service requires to become more efficient through reducing absence, it also needs to reduce the amount of non-allocated hours to maximise efficiency i.e. the 8

13 proportion of hours not spent providing direct support. This is extremely complex to achieve for a number of reasons Firstly, the nature of home care means that it is characterised by times of peak demand for service i.e. meal times, supporting people to get up, get dressed, go to bed etc Secondly, service scheduling is influenced by numerous variables - 20% of service users, at any one time, do not require the service for various reasons e.g. they are in hospital, respite care, with family, attending medical appointments etc. Some of these changes are unpredictable or less predictable than others. Many calls on the service arise from hospital discharge processes - if these are not well planned it places severe demands on home care. Furthermore home care staff do not specify required support in these circumstances as this is directly prescribed by social work and health assessors Thirdly, workers require time in their contracted hours for structured supervision and personal development (and consultation findings indicate that many feel this is inadequate), training etc. Travel time may not be built into schedules, instead managers strive to ensure visits are made in close proximity. Whilst it is recognised these are real challenges, the review requires to make considered assumptions about reductions in the volume of non-allocated hours As previously stated, the SSSC has determined the minimum recognised qualifications required for home support workers and managers. This represents a substantial undertaking for providers and in particular for the council, given the size of the workforce There are significant challenges both in terms of freeing up and supporting staff to complete the necessary qualification, but also in the logistics and financial impact of backfilling to ensure a service is provided. Plans to meet this requirement form a recommendation of this review The management task in home care is significant. It includes planning rotas; covering absence; negotiating with referrers; supervision of staff; inputting data and reviewing the needs of service users. Some of these tasks may be viewed as management, others as co-ordination. There is considerable variation in how tasks are delineated between managers and admin staff across North Lanarkshire and a requirement to apply best practice more uniformly Considerable improvements in efficiency in home care services have already been made within the council through adoption of a Business Change Programme using the Vanguard method, starting in 2007 and progressively rolled out across all localities. Following discussion with service users, staff and other stakeholders the processes involved in 9

14 the service were mapped. This highlighted areas where the service could be made more efficient and effective, in particular: - The need for prompt completion of financial assessments (so that accurate and timely billing could take place). - The need for home support worker schedules to contain up to date and accurate information in relation to times and tasks to be completed. - The need to resolve a backlog of service user reviews, meaning packages of support may no longer be appropriate. - The need for improved communication between managers and home support workers The results of applying better processes were significant. For example one locality had 911 inaccurate schedules at the completion of the process mapping in their area. When measured 14 weeks later this had reduced by 41%. When measured in February 2009 the figure was 1.05% (103 inaccuracies out of 9,382 care episodes per week) More recently, in recognition of the need to further improve communication between managers and a dispersed home care workforce, and to alert staff to changes in schedules, all home support workers have been issued with mobile phones. There is a requirement to examine the prospect of using technology for electronic scheduling in the context of experience elsewhere % of home care service users are adults aged over 65 years of whom 33% are aged years and 29% over 85 years. For the most part it is a service that supports older people in their own homes. For younger adults with disabilities or mental health problems, support is commissioned from specialist providers. A relatively small number of younger adults continue to receive support from home care Services are commissioned from private home care providers in all parts of North Lanarkshire, but on a relatively modest scale compared to in house provision. Six contracted providers provide the bulk of support whilst there are also some small local providers that operate in specific locations The nature of the sector, the scale of public sector services and the way services are commissioned combine to create issues of staff turnover and quality in independent sector providers. Scottish Care At Home s Workforce Development Survey (2008) estimates that 33% of staff in the sector are on zero hours contracts. This was reflected locally by the survey of providers undertaken as part of this review. 10

15 4.26 Whilst some providers achieve greater consistency through a stable workforce, it is a mixed picture. The council can contribute to improving the quality of commissioned services by stabilising its purchasing so that providers have a more predictable flow of business, so enabling them to deploy staff on contracts that reflect those circumstances. The age, health and circumstances of home care service users does mean significant turnover is inevitable - there are an average of 48 new service users every week - but providers are disadvantaged when support packages are placed with them for reasons that suit the council (e.g. short term problems with recruitment or absence) then withdrawn when those problems are resolved. This is a challenge for managers in the context in minimising non-allocated hours, but it is necessary if the choice of alternative providers is one that service users can exercise with confidence. Performance 4.27 As previously stated, home care plays a major role in securing the balance of care for older people in North Lanarkshire, which is amongst the very best in Scotland. It also plays a major role in the management of delayed discharge, whereby the North Lanarkshire partnership achieved the position of having zero delayed discharges throughout 2008/9. NHS Lanarkshire is the only health board area in Scotland to have sustained this position since reporting began in The contribution made by home care has helped reduce the average length of hospital stay to 4.4 days against a Scottish average of 5.5 days The service has adapted significantly to the changing requirements of service users since the last major review of home care in 1997/8. Then the average hours received was 1.3 per person per week, now it is 8.9; 5% of service users received support at weekends, today it is 71%; 2% received support in the evening, today it is 37%. The majority of support provided is now personal care (85%) whereas originally it was primarily a domestic service The only mandatory national performance indicators retained for independent audit from 2009/10 relate to home care service for older people, and this allows some benchmarking with other local authorities. North Lanarkshire performs generally better than the national average as the table below shows. National information for 2008/9 is not yet available for purposes of comparison. 11

16 Indicator NLC 07/8 Scotland 07/8 NLC 08/9 Older people receiving personal care per 1,000 pop Older people receiving evening and/or overnight service per 1,000 pop Older people receiving weekend service per 1,000 pop Older people receiving service per 1,000 pop Total hours of service per 1,000 pop The increased sophistication and application of assistive technology has diminished the need for certain aspects of support e.g. sleepovers, and is an important tool in managing the challenge of demographic change. Services for people with higher level of needs are often complemented by a range of other supports such as day care, respite, community alarms and other assistive technologies. The key indicator is the proportion of people being supported at home as opposed to long stay care, the so called balance of care North Lanarkshire Council was one of a number of councils who interpreted (conflicting) legislation and guidance to determine that meal preparation (as opposed to support to eat meals) was not personal care. New government regulations from April 2009 have determined that it shall now be classed as personal care. 12

17 Chapter 5 Consultation 5.1 Consultation took place with independent sector providers; service users; carers; staff of all grades working in home care; and staff from elsewhere in the social work service and from other agencies. A detailed report of the consultation is available on request. Views expressed during the consultation informed the options appraisal stakeholder event referred to earlier. 5.2 Service user consultation - questionnaires were sent to 2,361 service users of council and independent sector provided home care. 628 were returned (26.6%) - not untypical for this type of survey. The survey looked at overall satisfaction and outcomes; the core attributes of empathy, assurance, responsiveness and reliability; and tangibles such as information. Key findings were: Satisfaction Outcomes Empathy - 76% of service users were satisfied or very satisfied with their experience of home care; 8% were dissatisfied or very dissatisfied. - Highest levels of satisfaction were reported by older people. - Highest levels of dissatisfaction were reported by younger adults supported by private providers (21% said they were dissatisfied or very dissatisfied), though it should be acknowledged this was the smallest sample (19 people). - In respect of outcomes, 69% of respondents agreed the service helped them cope better and 68% agreed it made them feel more confident. The positive response was significantly higher for people receiving service from the council (10-20% higher than for the independent sector). - 79% agreed that the home support worker always has time to listen to me. - 88% agreed that the home support worker always treats me with dignity and respect. - 71% agreed that the home support worker visits at times that suit me. 13

18 Responsiveness and Reliability - 70% said they were always informed of when my support worker will visit. - 63% agreed that no changes are made to the service I receive without me being involved. - 63% agreed that if my home support worker cannot make my appointment I am always informed. - 63% agreed that meetings arranged to review my needs are convenient for me. 5.3 It can be seen from the above findings that, whilst levels of overall satisfaction are reasonably high and that people largely considered themselves to be treated with dignity and respect, services found it more difficult to be as responsive and reliable as people expect. 5.4 Carer consultation was carried out in focus groups organised in conjunction with North Lanarkshire Carers Together. These were not very well attended and generated a very wide range of views, from which it is difficult to draw clear conclusions. Carers were asked to identify good points about services received; areas in need of improvement and suggested ways of improvement. 5.5 Good points included: there is a bigger range of services available ; teams of dedicated workers ; it allows carers to go out to work ; it can allow people to live at home longer ; and workers are interested in doing the job. 5.6 Areas in need of improvement included: you do not always get your full allocation of hours ; home care workers change too regularly ; there is a lack of flexibility about the service, you must take the hours given to you ; the service is variable ; and some workers have no knowledge of the conditions affecting service users. 5.7 Suggestions on improvements to service included: care plan should be available in service users homes so that all home support workers have access to it ; workers should have more information about the service user before they go into the home ; there should be targeted groups of workers to deal with specific care groups ; consistency of workers ; and more training and better pay. 14

19 5.8 Staff consultation took the form of a postal survey of home support workers; and focus groups of managers and administrative staff. 258 home support workers responded to the survey (17.3%). The main points to emerge were: % felt the time they had with service users was too little ; 40.5% said it was about right. - Though 74.9% said they felt very well/adequately supported by their line manager, only 20.1% of workers said they had regular supervision sessions with their line manager. - Most home support workers said they had attended a wide range of training and were able to specify what it was % said they had a high or very high level of job satisfaction, whilst 30.5% said average and 22% low. - Workers felt that the best features of the service were the personal care and other services that supported people to remain in their own home. 46.2% felt the service met the needs of service users very well/well, 33.6% said average and 17.4% poor. - Improvements identified included spending more time with service users and improved communication with managers. 5.9 Separate focus groups were carried out with home support managers and senior home support managers and team leaders. Many of the issues raised were similar. The main findings were: - Issues associated with the time consuming nature of scheduling and the numerous alterations caused by changes to a service user s circumstances, absence etc. - Quality of assessments received and perceived lack of capacity to undertake reviews. - Capacity to undertake effective supervision of staff. - Time taken up on absence management. - Specialist training for home support workers. - Issue relating to debt recovery. - Issues relating to information technology. - Time spent monitoring private sector providers. 15

20 - Improvements identified included equipping home support workers with mobile phones (since implemented) Administrative arrangements are organised differently in different localities and the level of responsibility for duties assumed seemed to vary. The main issues raised concerned: - Time to carry out duties. - For some, a perception that tasks allocated exceeded their remit. - Issues relating to recruitment and retention of admin staff. - The need for appropriate induction and training in what is a demanding job Trades unions were invited to make a presentation to the Best Value Review Group. Whilst no written submission was received, the following issues were raised: - The difficulties in achieving a balance between contracts that reflected the needs and circumstances of employees and the demands of the service e.g. for service at evenings and weekends and peak times. - The need for staff to be suitably trained so that they can respond flexibly to a wide range of different situations. - The need for better communication between managers and home support workers. - Problems created by scheduling such as travel time and overlaps. - Levels of long term absence caused by poor health Other staff in North Lanarkshire and partner agencies, through locality planning groups, were invited to identify positive aspects of home care and areas for improvement Positive aspects included: improvements in the joint working relationships with health service staff; no waiting lists; a good service that responds well and quickly; use of recording diaries in service user s homes; good communication between home support managers and other managers Suggested areas for improvement included: the need for more frequent reviews; more time for completion of tasks; issue relating to written records; need for more specialist knowledge and training; need for greater continuity of staff. 16

21 5.15 Provider consultation - was undertaken in the form of a questionnaire to contracted providers and an invitation from the representative body, Scottish Care at Home, to present to the Best Value Review Group. Contracted providers are organised in different ways but general themes identified included: - Purchasing of services by the council was patchy and inconsistent, resulting in a lack of certainty and assurance for providers that did not allow them to plan effectively. - Providers had, like the council s in house service, low levels of staff who met future qualification requirements identified by the care commission. - Providers expressed significant difficulty in the recruitment and retention of staff Scottish Care at Home submitted a written response that they presented to the review group, also drawing on their national report More for Less designed to inform decision makers about the future of care at home services. That report estimated that the minimum true cost of care to be per hour. Scottish Care at Home subsequently uprated this figure to per hour, or to include travel time. (North Lanarkshire Council s in house hourly rate was for 2008/9). The organisation are seeking to reach agreement with national and local government on the minimum true cost of care, national contracting arrangements, and quality benchmark for care at home services Their submission to the North Lanarkshire Council Best Value Review recognised the context of the review and future challenges faced, including upward cost pressures in both in-house and external provision The organisation explored the perceived positive and negative outcomes of a series of options relating to how services are provided including outsourcing all or some services; public private partnership models; restructuring in-house services; and employee ownership. It also considered issues relating to the procurement of external services. 17

22 Chapter 6 Financial analysis and benchmarking 6.1 A benchmarking exercise was undertaken with four councils (Aberdeenshire; Fife; North Ayrshire and South Lanarkshire). Areas covered included structure and organisation; prioritisation framework or eligibility criteria; performance; resources; and services. 6.2 All councils had a mixture of directly provided and purchased services, though the proportion of external services against overall provision varied from 3.7% to 29.9%. There was a mix of arrangements across the role of assessor and provider. All bar one operated some form of formal eligibility criteria for allocated work. 6.3 The ratio of home care managers to home support workers varied from 1:24 to 1:46 with an average of 1:33. In North Lanarkshire the average is 1:36. The ratio of home support workers to service users varied from 1:1.5 to 1:4.4 with an average of 1:3.6, though this was skewed by the authority at the lowest end of the range. The reason given for this was that the service is targeted at a high proportion of intensive packages. In North Lanarkshire, where most intensive packages are commissioned from supported living providers, the ratio is 1:4, the same as for three of the four partners. No other services had dedicated administrative support for each manager, as is the case of North Lanarkshire. 6.4 The following table shows hourly unit cost information by benchmarked partners. North Lanarkshire Authority A Authority B Authority C Authority D (see below) 6.5 The benchmarking exercise in relation to finance was of limited value. authority D had not revised their published unit cost since 1996 so the figure cited did not reflect the contemporary unit cost. During a recent Scottish Parliament Local Government and Communities Committee enquiry into tendering Glasgow indicated that their in house unit cost was 16.30p. 6.6 Worthy of more detailed consideration is the analysis of costs between in house and externally provided services. In 2008/9 the unit cost of directly provided home care in North Lanarkshire was per hour. 78% of home care was provided by the council, whilst 22% was purchased externally. The unit cost of purchased services was per hour. 18

23 6.7 It is important to understand what drives these respective costs. In house service costs are characterised by more favourable pay scales, pensionable employment, entitlement to sick pay, permanent contracts and guaranteed hours, underpinned by a management infrastructure deigned to meet the council s statutory responsibilities. 6.8 Desirable - many would argue essential - as these attributes are, it is important to weigh them against an increased unit cost of approximately 3 per hour in a service that provides 1.5m hours a year. In doing so it is necessary to ask two key questions: - Can the cost of in house services be reduced by greater efficiency? - Is the cost of externally purchased services realistic and sustainable at current levels? 6.9 Addressing the question of the cost of in-house services, reasons for time spent by home support workers in non direct support have been considered in chapter four. The main components are holidays, absence, requirements for training, staff supervision, travel etc There is no doubt that, despite improvements, levels of absence are unsustainably high, that there is an associated cost with overtime and that there can be improvements in efficiency by further reducing the overall total of non allocated hours. This has been the subject of modelling and consultation on achievability with home care managers It is therefore projected, using 2008/9 prices, that the unit cost of directly provided services can be reduced from to per hour by 2012/13. Appendix 1 illustrates the financial modelling for these assumptions The second question relates to the cost of purchasing independent sector home care. Scottish Care at Home, the umbrella body, argue that current levels of funding are unsustainably low, particularly in the context of the need for a suitably qualified workforce. Their submission to the review estimated that the minimum true cost of care was per hour, or to include travel time The review considered various options: - Maintaining 80% of service in house but improving efficiency in the ways described. - Expand the proportion of purchased services. - Externalise in house provision to a provider trust or social enterprise. - Externalise in house service to the independent sector. 19

24 6.14 What was clear from evidence gathered was that doing nothing was not an option. The council has some experience of the trust option, having previously externalised services to a leisure trust and achieved substantial VAT savings (which would not apply to home care). Social enterprises (employee owned organisations) that provide home care exist in only three English cities and, whilst an attractive model, are of a very small scale. Presentations were received by the review on the pros and cons of both models Externalisation, whether to a trust or private sector, requires staff to transfer on existing terms and conditions, so would not present immediate opportunities for savings in that regard, if that is the primary motive. Increasing the proportion of externalised services would cause in house unit costs to increase as there are fixed costs that could not be released Assuming that the unit cost will narrow between directly provided services and purchased services, it is necessary to consider whether there is added value from a large in house service.this is considered further in the following chapter. 20

25 Chapter 7 The way forward 7.1 The stakeholder event, having facilitated participants to identify then prioritise the criteria for a high quality home care service, invited consideration of three main questions: - What should home care provide? - How should home care be provided? - Who should provide home care? What should home care provide? 7.2 The review studied models of service delivery elsewhere in the UK and paid particular attention to the reablement model in home care. Reablement seeks to assist people to do rather than doing to or for people. It is outcomes focused with a defined maximum duration, by which time a judgement is made about the need for continuing support. It is intended to maximise long term independence, choice and quality of life and minimise the need for ongoing support (and in so doing, impacting on costs of care). 7.3 Reablement has been supported by the Department of Health in England and has been the subject of a longitudinal study by the Care Services Efficiency Delivery Programme (November 2007). This study assessed the impact of re-ablement in four local authorities. Its main findings were: - In three of the four schemes 53% to 68% left reablement requiring no immediate home care package, of whom 36% to 46% continued to require no care package after two years. - Of those who required a home care package within two years after reablement, 34% to 54% had maintained or reduced their package. 7.4 The study recognises that there was no control group to make comparisons but considers there to be a compelling case for local authorities to adopt reablement schemes. 60 local authorities in England had, by the time of the study, developed such a scheme. Some were intake schemes whereby all people eligible for home care are screened and only taken onto reablement where they are considered likely to benefit; others have discharge support schemes aimed at people leaving hospital and are usually highly selective about access to reablement. 21

26 7.5 The study raises questions about the balance of care in participating authorities and their thresholds for publicly funded long term care, answers to which it is not possible to elicit. The prevalent approach was for reablement schemes to be provided in house with commissioned providers identified to meet the needs of people requiring longer term home care. 7.6 It is considered that there is now sufficient research to suggest reablement offers potential for achieving good outcomes at potentially lower costs for some people, at least by deferring their need for support, thereby assisting to cope with projected future need arising from demographic change in constrained economic circumstances. As such one of the recommendations of this review is that it should be developed in North Lanarkshire. 7.7 Locally it is already the case that the MIDAS (Monklands Integrated Discharge and Assessment Service) and Early Supported Discharge teams seek to focus on rehabilitative approaches. Furthermore the model sits well with the partnership s adoption of intermediate care using local authority residential care to maximise peoples independence. Services commissioned from Alzheimer s Scotland for people with dementia also connect well to this approach. It would not, therefore, be a case of developing reablement without some key building blocks already being in place. 7.8 It should be stressed many people will continue to require longer term home care and there is no suggestion that the council will not strive to meet their needs through provided or purchased services. 7.9 Despite the scale of supported living in North Lanarkshire (over 600 people, mostly younger adults with complex, long-term needs), there are still some younger adults who remain supported by directly provided or purchased home care services. There may be good reasons for this e.g. where people are happy with support provided but the nature and conflicting demands of home care means that, generally, this work should be undertaken by specialist, commissioned supported living providers. The Best Value Review of Supported Living, approved by North Lanarkshire Council in October 2007, provides a detailed analysis Home care also plays an often important role in child protection and child welfare that is valued and should be retained, but the service often finds it difficult to support children and young people with significant disabilities and long term support needs in the consistent and flexible ways required. The council has commissioned specialist providers for this purpose and this is the preferred option. There will continue to be, for children and younger adults, circumstances where short term support from home care is necessary and appropriate. 22

27 7.11 What is universally important is that home care is provided in ways that focus on clearly identified outcomes for people who use it. The social work service s expectation, through its assessment and planning approach, is that the anticipated outcomes of any support plan are explicitly recorded. When it comes to the review stage, what should be considered is the extent to which those outcomes have been achieved. Any changes in service provision should then be made in that context This is not straightforward to accomplish. Home care services in North Lanarkshire do not assess need, they receive requests for service based on completed assessments from staff in social work or other agencies. If those assessments do not reflect clearly identified outcomes, there is a risk that a lack of clarity as to the focus of intervention exists from the outset. Most home care service users are not care managed by any other staff. So if home care managers do not carry out reviews of peoples needs and circumstances, the original shortcomings are perpetuated Being outcome-focused is, therefore, an aspiration that needs to be rooted in the partnership approach to assessment and planning. It applies regardless of whether home care is provided or externally purchased. Existing contracts for externally purchased home care expire later this year, presenting an opportunity to develop a greater outcomes focus in commissioned services The most comprehensive research into the factors that enable home care services to be person-centred and flexible was produced by the Social Policy Research Unit at the University of York - Caring for the Whole Person? Home care for the older person which promotes Wellbeing and Choice (2005, updated in 2007). This major study sought to understand how flexible, person centred home care services could be provided in ways that enhanced the wellbeing of recipients. It studied a mix of local authority in house services and independent sector provision. Key findings were: - A common pre condition for flexible, person centred help was relationships between home care customers and regular workers who got to know them well. - Such relationships require that customers are served systematically by a small number of familiar staff. - Another pre requisite was the extent to which home care workers adopted a caring, customer friendly attitude ; customer centred values were more of a factor than methods or systems. - The extent to which person centred support was provided was shaped by the policies of provider managers and purchasers concerning what practices were encouraged or discouraged. 23

28 - Better outcomes were likely to be achieved by services that focussed on caring for the whole person instead of adopting narrow task driven approaches. - If introduced according to In Control s principles, individual budgets promise to be the best route to flexible, person-centred home care. How should home care be provided? 7.15 The review considered whether home care should continue to be provided in a generic way, albeit targeted largely at older people, or whether there was scope for increased specialisation e.g. for people with dementia, mental ill health etc Whilst the review was attracted to ideas of specialisation, and could see the potential for increased quality this offered, it considered that fragmentation of the service was likely to diminish many of the benefits that currently exist (see below, e.g. capacity, flexibility and economies of scale) Furthermore, the need for specialisation to provide greater expertise (and so achieve better outcomes and enhance service user and carer confidence) has long been recognised and acted upon across the social work service as a whole. A wide range of specialist providers are now commissioned for people with learning disabilities, people with mental health problems, people with dementia, people with addictions, children and young people with disabilities etc The above notwithstanding, there is current practice within home care that seeks to maximise skills and interests of workers in certain areas of work e.g. child welfare. There is further scope to develop creative approaches to workforce deployment in ways that enable staff to develop greater expertise. However in the current financial and demographic context, this has to be achieved on a cost neutral basis The review, therefore, makes no specific recommendation about specialisation but is receptive to any proposals that are achievable, desirable and affordable Increasingly personalised approaches enhance the likelihood of people maximising choice and control over how their needs may best be met through the use of individual budgets There is a growing body of research into the implementation of individual budgets, recently summarised by the Social Care Institute for Excellence (March 2009). Their key findings are that international evidence to date is based on many relatively small examples, but given 24

29 the right level of support, user views are very positive and report improvements In the context of most home care service users being older people, they suggest that older people and people with complex needs may need greater time and support to help them get the most from individual budget schemes, particularly the cash direct payment option This perception is largely confirmed by research into the individual budgets pilot programme (IBSEN), which reported on findings from 13 English local authorities, involving 959 participants, 28% of whom were older people From the perspective of the Best Value Review of Home Care, it is important that people who wish to are able to access individual budgets and that the way home care services are managed, structured and delivered are not seen as an impediment to this. North Lanarkshire has been testing this approach through an In Control Demonstration Project that includes older people. The evaluation of this project, which is currently being undertaken by the University of Lancaster, will inform the next phase of implementation. Who should provide home care? 7.25 Whilst consultation findings suggested that satisfaction rates were consistently higher in directly provided services, the review has identified some of the factors that contributed to this and acknowledges that service users should be able to select from a range of providers There are, though persuasive other reasons to sustain an in house service of the current scale, including: - The capacity to respond to unpredictable demand across child and adult protection, and a wide range of other needs. - The scale of the service, which enables flexible deployment of staff in response to the multiple demands that arise on a day to day basis. - The integrated nature of partnership working with other in house services such as community alarms, day services for older people etc. - The integrated nature of partnership working with NHS Lanarkshire services such as district nursing including out of hours provision. - Control over quality in directly provided services. - Control over workforce planning issues such as recruitment and retention. 25