Annex C: Market Sustainability Plan for the London Borough of Hounslow – March 2023

Section 3: Plans for each market to address sustainability issues, including fee rate issues, where identified.

Both market areas (care homes and home care) are generally aligned in their views on risks to market sustainability. NWL has not been surprised by much of what has been expressed by the market through this process. Key themes from this exercise relate to a) the markets’ perception that current rates are not reflecting actual costs; b) the challenges posed in relation to securing a permanent workforce, its relationship with fee rates and how these issues affect quality locally. 

The strong relationships reported between commissioners and providers will enable a partnership approach to addressing this and further strengthen the dynamic. As a sub-region we are, through our collaborative work programmes, focusing on improving quality of our commissioned services. The most significant risks identified by the provider market to sustainability all lead to adversely impacting on delivering a good quality service. Interestingly, the quality of services was not seen as a major risk to market sustainability by providers when asked to rank key strategic risks. We will however, due to the correlation that a permanent workforce and fee rate gap to cost of care has with quality, continue to ensure this focus sub-regionally as well as through individual borough approaches. 

Hounslow’s updated market position statement, published in October 2022, identifies the key challenges for the two markets and how they will be addressed through commissioning intentions. The document can be found online.

Funding 2022/23 and into 2023/24

Hounslow has recorded spend as follows for the Market Sustainability and Fair Cost of Care Fund Grant for 2022/23:

Fair Cost of Care and Market Sustainability Grant 2022-23 allocation £674,556
(1) Spending associated with fee increases for 18+ domicillary care £300,000
(2) Spending associated with fee increases for 65+ care home places without nursing £200,000
(3) Spending associated with fee increases for 65+ care home places with nursing £100,000
(4) Spending associated with internal resourcing for implementation activities £25,926
(5) Spending associated with external resourcing for implementation activities £48,630

Adult Social Care Market Sustainability and Improvement Funding: 2023-24 allocation

£2,340,125

This allocation amounts to 3.75% of Hounslow’s approved budget for Adult Social Care for 2023/24 so there are limitations on how much can be delivered through this funding. However, Hounslow has committed to spend the Market Sustainability and Fair Cost of Care Fund Grant for 2023/24 to sustain the rate uplifts from 2022-23, expand the fee uplifts to other settings and support the local care market in training, development, and sustainability.

a) 65+ Care Homes Market

Funding 2022/23 and into 2023/24

During the 2022/23 financial year the Council has continued its approach of uplifting existing placement fees as well as new placement fees and considering the needs of each client where they are not routine nursing. If individual, client specific changes are discounted, agreed uplifts are between 3% and 6%. Hounslow Council acknowledges that the cost of care rate identified is higher than the rate currently paid. Additional inflationary pressures are being funded through the 2022/23 allocation of the DHSC Market Sustainability Fund (£0.3m).

There are positives that we will use to plan our approach next year. Firstly, the Council has engaged with all nine providers in a local planning exercise to identify costs and agree fees. We will continue to do this in future years. 

Firstly, during financial year 2022/23 the Council, the Executive Director of Children’s and Adults’ and the Director of Commissioning met each of the nine care homes for older people in the borough to discuss placement costs for financial year 2023/24.  

Due to the limitations of the Cost of Care exercise and incompleteness of the data collation, we have concluded that there is insufficient information to rely on the outcome rates, but we will use this information to inform our fee setting process.  

Secondly, funding the demand and supply of adult social care in Hounslow remains challenging, particularly in the current climate of inflationary pressures and cost of living crisis as felt nationally.  Uncertainties remain around the true and full impact of the Covid pandemic on the system and population To support this, we will continue to use the Market Sustainability Fund to address fee uplifts as applicable within the terms of the funding. In this regard, Hounslow’s Strategic Finance Team work closely with the adult Joint Commissioning Service to forecast inflationary pressures for 2023/24 to feed into the fee setting process.

Thirdly, working alongside neighbouring boroughs through the West London Alliance of local authorities we will continue to review care homes fees paid by West London boroughs on a quarterly basis. We will continue to use this data to inform our fees when placements are made in neighbouring boroughs.

Fourthly, we will continue to implement a package of quality related support for care homes and care home residents in borough, noting that this is likely to change as we receive feedback from care homes at the care home forums held monthly.

 

b) 18+ domiciliary care market

Funding 2022/23

The feedback from provider events highlighted rates of pay and workforce challenges as the two most significant issues facing them.  Workforce challenges described predominately relate to the supply (for example competition from other employers, low rates of pay) and retention of the workforce (pressures of the role, complex patients, travel time etc).  Hounslow believe these two issues to be intrinsically linked and that a stable, fairly rewarded and valued workforce is key to meeting the care needs of the borough and residents.  

The cost of care exercise has given some degree of confidence that the current year home care rates and approach to setting them with contracted providers is reasonable.  

Due to a low confidence in the data and sample size provided, more work is required to achieve a cost of care which accurately reflects the market requirements. More work is also required to understand and prepare for an increasing self-funder market. 

The recent significant increase in LLW has raised concerns moving forward regarding affordability within current budget and funding constraints.  There is concern that the increase in demand and LLW rates will leave a significant funding gap in home care with no assurance as to future levels of funding available to meet the gap.  The LA wishes to maintain payment of LLW but with its increasing rates and insufficient funding this will need to remain under review.  It is strongly felt that payment of the LLW is required to support a sustainable market.

To begin to address the issues raised by providers Hounslow is using £0.3m of the funding awarded this year to uplift contracted provider rates to bring forward the LLW uplift to January 2023.  It is felt that this will support providers and carers and work towards improving retention and recruitment rates, addressing in part both of the key issues raised and provide support towards the issues caused by the cost-of-living crisis.

Hounslow intends to grow the current quality and assurance capacity within the placements and brokerage team by utilising funding to secure a further quality and assurance officer.  This will expand the capacity to support providers in improving quality and ensure quicker responses and support to early signs of declining quality.  

Hounslow continues to support training in the care market (in care homes and in home care) and development of staff, through the use of free on-line training with an external training partner (Virtual College).  This is available to CQC registered providers in the borough and all employees of such providers.  The aim is to provide training to support areas where providers or carers feel they are lacking in skills, for example dealing with challenging behaviours.  This is in addition to any statutory training required for their roles and provided by their employers.

To support recruitment Hounslow partnered with Care Friends to offer a free app to incentivise carers to recommend friends or relatives to care roles with their employer to Hounslow registered providers through the Workforce Capacity Grant funding.    This allowed providers to run current referral schemes or commence new schemes through a modern app allowing staff to track and claim cash rewards.  This was a trial scheme put in place based on feedback and research recognising that personal recommendation delivers better quality and better retention levels in new recruits. Hounslow continues to listen to feedback from providers on new ways to address challenges and support initiatives and trials where possible.

Future Actions to Support Market Sustainability 2023/24 and 2024/25

The Council continues a wider package of support for the older people care home market. The care home forum continues to be well attended monthly and will address issues identified by care homes. Topics of significant concern to care homes in 2022/23 have been patient transport to hospital and referrals for mental health support. 

Sustainable Rates

Hounslow is a LLW paying borough and will continue to invest in the LLW to promote fair wages for staff, particularly for those in the care sector.  Hounslow will continue to work closely with all providers and understand the market needs and pressures and ensure that rates are sustainable. 

The level of funding made available through the Market Sustainability and Improvement Fund over the next two years (2023/24-2024/25) will dictate where and how resources are allocated. The funding will be used to prioritise increasing fee rates where possible and appropriate to help sustain the market particularly given the inflationary pressures, as well as address improvement needs as required by the conditions of the grant funding.  

Investment in Extra Care

The term 'extra care' housing is used to describe developments that comprise self-contained homes with design features and care and support services available to enable self-care and independent living. In Hounslow there are currently four extra care schemes, with the most recent opening in 2019. 

All schemes will accept people with a learning disability or dementia as well as general needs.

The successful delivery of the 2015 Hounslow Prevention Strategy and the Hounslow Extra Care Housing plan 2015-2019 increased the extra care capacity in Hounslow from 38 flats to 201 flats. This has delivered client choice and reduced demand on home care and care homes. Currently schemes are near capacity with waiting lists developing. Work is underway to project demand accurately, but it is anticipated that at least one new scheme of approximately 40 units will be needed by 2025/26, which will further help reduce pressure on home care and care homes. 

Hospital Discharge

The discharge to assess pathway has changed rapidly during the course of the pandemic.  Hounslow works closely with the hospital and ICB to ensure better joint working.  Recent changes have seen the secondment of a placements officer in the hospital team based at the hospital, to assist in the smooth transition of discharge packages.  The hospital team are working to ensure market capacity is protected through the thorough assessment of needs on discharge.  This is helping reduce the over reliance on larger packages of care as seen at the height of the pandemic and reducing pressure on providers.  In addition, the hospital team are intending to commission training for homecare providers to better support single handed packages of care with the use of assistive equipment.

Social Care- Training Academy

Hounslow is building a social care Academy initially offering apprenticeships to social workers but in this time period will be expanding to include care apprenticeships.  This is being developed in conjunction with London ADASS ‘Proud To Care’ framework (in development).  The vision is to provide a consistent approach to training and development of care staff, ensuring core standards of care that ensure fair and consistent level of care for Hounslow residents and support the ongoing recruitment and retention pressures currently faced across the sector.  The academy will work closely with external partnerships such as local colleges, university and training providers to deliver a first-class apprenticeship designed to support and develop our carers and local people wishing to join the care sector.  Further to this, leadership qualifications will be offered to care staff wishing to progress to registered managers, providing a pathway and career.‚Äč

Specialist Provision - Learning Disabilities and Autism

Hounslow aim to develop more specialist care provision in the area learning disabilities jointly with the NWL Integrated Care System (ICS).

In line with the national transformation agenda for people with learning disabilities, we will work with the market to develop supported living placements for people who currently are unable to access service provision within Hounslow. Working in partnership with the ICB we will scope the need and demand for the development of a local learning disabilities forensic service which will be able to provide a multi-disciplinary model of support to enable people with complex needs and forensic behaviours to be safely supported within a community setting.

In line with the local authority’s procurement plan we will be seeking to re commissioning our existing adult shared lives provision in 2023. Shared Lives provision offers an alternative to supported living and residential placements, by matching vulnerable residents with carers who can offer support in their own family home. We will be looking to enhance the number of carers and homes currently available to cater for increased numbers of people supported and widening the scope to include a range of client groups.

Following the conclusion of the pilot supported living scheme, which became operational in May 2022, we plan to procure and commission a service that can cater for vulnerable people who display complex behaviours due to their learning disabilities and/or autism that have not been successfully placed in more conventional provision. The service will be fully developed following the conclusions of the pilot scheme and will likely follow a positive behaviour model of support provided across health and social care professionals. 

Support to Maintain and Improve Quality

Hounslow is investing in further roles (as described above) to support providers in understanding areas in which they can improve, using tools and technology to pick up on early indicators of potential provider failures or reductions in quality and providing support and assistance in co-producing plans that will support providers and address identified issues.  These roles will be supported by the continued use of PAMMS and where applicable, the mandated ECM. Hounslow will share audit information with neighbouring boroughs under a new initiative led by the West London Alliance of local authorities.

Hounslow reviews homecare KPIs on an annual basis to ensure they are fit for purpose and are driving the desired outcomes, namely improvement in quality.  These reviews will continue with provider input.

LBH will continue to progress towards achieving the cost of care using the existing strategies, engagement, and continued relationships with providers, planned procurement activity and support detailed in this report.

Travel

A new patient transport contract has been introduced and access to transport is available to all care homes to hospital and community health sites for outpatient appointments. 

Other Commissioning Intentions 

  • The Council will complete an Outline Business Case for the expansion of capacity for the Council operated residential care homes.
  • We will engage with Care Homes over the Discharge to Assess process and seek to learn lessons from the operation of Discharge to Assess during the past two years.
  • The NHS NWL ICB will continue to make placements using their block contracts and seek to make non AQP placements at AQP rates

Conclusion

Hounslow Council has acknowledged the findings of the exercise and will use the information it has confidence in to inform its existing fee setting processes. However, it is important to reiterate the limitations of the processes, as well as the quality of the data collated not allowing for total reliance on the output. 

Whilst we will be working within our sub-region to monitor market trends and developments, our ability to pay sustainable rates will be linked to the funding available for this. The Adult Social Care Reforms will represent a new burden for local authorities and therefore must be linked to sustainable funding.

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