Written evidence submitted by East Sussex County Council [ASC 021]
• How has Covid-19 changed the landscape for long-term funding reform of the adult social care sector?
The challenges facing the adult social care market prior to the pandemic are well documented and, in many cases, have been brought into sharp focus over the last 12 months.
Local Authority published rates; contract arrangements (e.g. block arrangements); commissioning approaches (e.g. strategic partners) and CCG funding agreements including Better Care Fund allocations are all key funding reform considerations which sit alongside the necessity to offer choice, personalised care and high quality, safe services.
Residential and nursing care
There are 306 registered care homes in East Sussex – the majority are small independently run homes, which don’t have the wrap-around organisational infrastructure enjoyed by larger / national providers. In East Sussex, Local Authority placements are made across around one-third of the residential and nursing care market.
At the peak of the second wave over 100 care homes in East Sussex were closed to admissions due to Covid outbreaks. Week commencing 04/01/21 there were 853 confirmed cases of Covid19 in East Sussex care home settings. During 2021, as of the week ending 19/03/2021, East Sussex has had 2,404 deaths registered in total and 1,110 of these have been attributable to COVID-19, of which 597 have occurred in hospital and 436 have occurred in care homes (LG reform data).
In the two years up to April 2019, there were 26 residential and nursing home closures in East Sussex resulting in a loss of 435 beds, across all care groups. Care Home owners indicated several reasons for home closures, including staff recruitment, occupancy levels, poor CQC ratings or personal reasons (including retirement).
Since the start of the pandemic, there have been a handful of further home closures in East Sussex, with some of these homes having residents with more challenging behaviours, including mental health issues, alcohol dependency and a lack of social and life skills. Finding suitable, alternative placements for this client group is particularly challenging.
Residential care homes were experiencing significant level of vacancies in the county prior to the pandemic. The number of people moving into residential care has been gradually reducing over recent years. That said, demand for residential care settings which can accommodate more complex needs, in-particular dementia, is rising significantly. From a Local Authority perspective, any funding reform needs to reflect the variation and complexity of individuals needs that the market is expected to meet. The more specialist, complex provision in both residential and nursing care needs to be recognised and Local Authority funding must be able to secure appropriate, quality provision to meet these needs.
Whilst it is not possible to quantify at this stage, if vacancy levels in residential and nursing homes remain high and referrals from self-funding individuals remain low, there will inevitably be a long-term impact on the overall market. Again, it is well understood that the financial model operated by many care home providers who accept referrals at Local Authority rates, relies upon higher self-funding rates to ensure financial viability of their business. Continued or even increasing placements at Local Authority rates will not mitigate this risk unless local authority rates can better compete with self-funding rates.
The wider adult social care market – considerations for long term funding reform
How people choose to have their needs met may well change because of Covid19 or indeed the impact of Covid19 may accelerate trends which we were already experiencing.
In September 2020, there were 63 Home Care agencies registered in East Sussex. The Local Authority commissions circa 22,000 hours of home care per week. During the 12 months of Covid19 to April 2020, East Sussex has experienced an increase in homecare placements of 15-20%.
In East Sussex we have seen a small number of day care providers leave the market during Covid19. Prior to the pandemic, the use of building-based day care for older people and working age adults with physical difficulties was in decline. The impact of the pandemic may accelerate this trend as more people seek alternatives, such as engaging a Personal Assistant.
Personalised Care is now also one of the five major, practical changes to the NHS that will take place over the next five years, as set out the recently published NHS Long term Plan. This includes the proposed rolling out the NHS “Comprehensive model of Personalised Care”. Approximately 35% of Adult Social Care clients in East Sussex hold a direct payment, out of the number of adults and older people receiving long term community-based services. There are over 1,000 Personal Assistants operating within East Sussex. During the last 12 months we have had 117 new applicants to the East Sussex Support with Confidence scheme (vetted and approved providers who offer home care and support services for adults in East Sussex), without any scheme promotion. Again, the impact of Covid19 may accelerate the trend towards people seeking different ways to meet their care needs, through personal assistants and micro-providers.
Local Authority funding to commission more personalised services; offer annual uplifts to enable direct payment users to employ personal assistants at competitive rates etc, need to be considered as part of the long-term funding reform. More broadly, the predicated economic downturn will directly impact on demand for social care, not least any increases in street homelessness and the need for wrap around support for individuals in crisis.
• How should additional funds for the adult social care sector be raised?
No response being submitted to this question
• How can the adult social care market be stabilised?
Longer term funding settlements are required to enable Local Authorities and Integrated Care Systems to strategically plan around market sustainability. Working with care providers to adjust and flex provision to meet increasing complexity in need, designing, developing and testing new and different models of service provision.
Over recent years several temporary grants along with the council tax precept have been allocated and/ or ringfenced to Adult Social Care including the Improved Better Care Fund; winter pressures funding; social care support grant. Whilst welcomed, there is no direct relationship between council tax and the level of need in any given area. This is a particular issue in East Sussex and one which has been raised through various regional and national fora.
The various funding allocations sit alongside the delivery of significant Local Authority savings requirements. For example, between 2013 and 2016, £27.8m of savings were delivered by Adult Social Care in East Sussex. In 2018/19 the East Sussex Adult Social Care savings requirement was £9.6m, although some of this savings requirement was mitigated by the 2018/19 Adult Social Care Support Grant. For context, the net Adult Social Care Budget was £183.1m in 2020/21 and the overall Council budget was £403.4m
Furthermore, ASC faces continued and growing financial pressures due to increasing demand for services and complexity of need, as well as the need to maintain the local care market by uplifting the fees paid to providers. Total demand and inflationary pressures were £34m in the three years between 2018/19 and 2020/21.
Time limited funding and annual spending reviews make longer term market development and strategic planning difficult. ‘Uncertainty over the long-term sustainability of funding has made it difficult for local authorities to plan how much care, and at what price, they will be able to purchase beyond the current financial year, constraining innovation and investment.’ The adult social care market in England, National Audit Office report March 2021.
During the pandemic, the focus on hospital discharges to ensure there was enough acute bed capacity to treat Covid positive patients was intense and relentless. When considering long term funding reform, it is essential that the adult social care provided to individuals, which has nothing to do with hospital discharge, is given full consideration. Four in five referrals to Adult Social Care come from community, as opposed to hospital settings. Pathways out of hospital play a crucial role in ensuring people receive appropriate and timely support to meet their social care needs, however it should not detract from the equally important need to commission services and support to prevent avoidable hospital admissions.
Similarly, over the last twelve months there has been a national focus on care home settings and older people. However, demand for social care from adults aged 18-64 is expected to far exceed the expected population growth for that age group going forward. Younger adults are more likely to have mental health problems or social care needs relating to a learning disability; they are more likely to require continuous support in a community setting and are less likely to contribute to their care costs. Any funding reform needs to acknowledge the range of needs; longevity of support required and different types of specialist and personalised care that younger adults will increasingly require.
The March 2021 National Audit Office report states: The Department (Dept of Health and Social Care) acknowledges that most local authorities pay care providers below a sustainable rate but does not use this analysis to challenge local authorities directly. East Sussex Adult Social Care secure over 95% of residential and nursing home placements on published rates. We are aware that this is a significantly higher proportion of placements than some of our ADASS regional colleagues are able to secure, and that East Sussex published rates are generally lower than rates paid by our neighbouring authorities.
We are also aware from the ADASS regional network that the highest hourly rates paid by East Sussex for home care (e.g. in rural areas) are less than the lowest rates paid by some of our regional colleagues. That said, East Sussex offers free training to independent sector providers, whilst other Authorities charge for training provision. Local market forces and market relations are key factors that play into annual fee negotiations with care providers, as are the strength of the local self-funding market and block contract arrangements. Whilst all Local Authority spend needs to be transparent, the basis upon which local authorities could be challenged on the rates paid to care providers needs to take into consideration a range of factors and be based on a consensus about what good looks like. We would suggest that any assumptions about sustainable rates in the context of long-term funding reform need to be approached with caution.
• How can the adult social care market be incentivised to compete on quality and/or innovation?
Local Authorities have limited influence over the social care market, especially where there is a strong self-funding market.
The care sector has struggled to compete with statutory organisations and other industries based on pay and conditions. East Sussex County Council has experienced an increase in homecare placements of 15-20% during the 12 months of Covid19. Overall, as a result of furlough and unemployment in other sectors, recruitment to home care workers has increased significantly so the home care market has been able to meet the increased demand. How long these new recruits continue working in the care sector remains to be seen. Investment is required to make working in care more of a desirable profession than in some cases, a role of last resort.
We understand that the Dept of Health and Social Care has said that a workforce strategy would be dependent on the next spending review settlement and wider system reforms to funding and accountability committed to in the recent white paper. Whilst local recruitment campaigns, values-based recruitment initiatives etc have produced some positive results, a national workforce strategy to encourage people to work in the care sector and to promote career pathways in care is required.
Locally and nationally the care sector struggles to recruit to more specialist roles e.g. nursing staff for care homes. Generally speaking, people are living in their own homes for longer and therefore present increasingly higher levels / more complex needs at the point in which they may move to a care setting. This coupled with the increasing care needs of people being discharged from hospital into care settings means that the need for nursing care and more complex care provision is increasing. Securing and maintaining the necessary staffing levels for nursing provision in care homes is a real barrier to many providers who may otherwise be open to discussion about changing their registration from general residential to nursing provision.
In East Sussex we are aware that whilst price is important, simply offering care providers higher hourly rates does not guarantee quality or continuity of service. For example, offering training and support to avoid the breakdown of care packages is important, especially when care workers are being asked to work with people with more challenging or volatile behaviours. Having appropriate levels of staffing cover in Extra Care schemes, for example, and plans to support people’s behaviours in communal areas etc all play a part in incentivising providers to tender for services and develop their services to meet different care needs.
Commissioning strategic partners for longer contract periods, with clear milestones for service development appears to be an increasingly positive way to commission accommodation and community-based services. Whilst relatively early days, this is an approach we are taking in East Sussex for services including Carers services and Refuges.