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Agenda item

Scrutiny Review - Adult Paid Carers - witness evidence - verbal


Jess McGregor and Jon Tomlinson Service Director Strategy and Commissioning, and Assistant Director Strategy and Commissiong, Adult Social Services, L.B.Islington, and Simon Bottery, Kings Fund, were present for discussion of this item, and made a presentation to the Committee, copy of which is interleaved


During consideration of the presentation the following main points were made –


·         Domiciliary/Home Care is the front line delivery covering personal care: (help with washing, dressing, and eating) to people with long term care needs is the core service provided by most local authorities. Home Care can also extend to re-ablement services for people leaving hospital, or receiving crisis interventions to avoid hospital attendance in the first place. This can include household tasks – mopping and shopping tasks to help people remain independent

·         The UK Homecare Association estimate that 249 million hours of home care are delivered in England each year

·         In 2015 more than 350000 older people in England were estimated to use the service – 257000 of whom had their care paid for by the Local Authority. A further 76300 younger people with learning disability, physical disability, or mental health issues were also estimated to be publicly funded home care

·         Home Care agencies employ around 680000 people but more people will be needed moving forward, there are around 11000 vacancies at any one time

·         The average package of care commissioned was 10.8 hours in duration. 7% of the packages of care were based on outcome focused commissioning

·         The average lowest price for a care package was £13.64 per hour, and the highest £21.69. The average price of homecare across the region was £16.63

·         4 Boroughs commissioned 50% or more of their homecare needs for the requested week to 2 providers

·         Domiciliary Care – basic facts across London – single week review 2018 – 624 providers were commissioned across the region. There were 32167 packages of care commissioned for the sample week. 11.7% of the care packages were double handed and circa 20% of the packages of care went to just 10 providers across the region

·         Domiciliary Care – Older Adults, some basic facts – L.B.Islington – Older adults, people aged 65 or above, make up 9% of the population of Islington. In 2017 there were an estimated 20786 older adults in Islington, and an estimated one fifth of older adults across Islington and Camden are from BAME communities. By 2035 the older adults figure is set to grow to 12%, a 605 increase in older adults

·         The sharpest increase is expected to be amongst the very old, people aged 85 or over

·         Package size – Large block and spot contracts > 14 hours per week or over have an annual cost of £9793071.49 with annual hours of 564068.39. Medium large and spot contracts > 7-14 hours per week have an annual cost of £3966272.50 with annual hours of 225.478.75 and small block and spot contracts 7 hours per week have an annual cost of £1993176.46 with annual hours of 113,276.88. This is a total annual cost of £15752523.45 and annual hours of 902824.02

·         There are 23% if small packages, 19% of medium packages and 40% of large packages are placed with spot providers. The hourly rate paid for block contracted hours is £18. A small package may typically include shopping, lunch calls supplemented by day centre or outreach support. A large package may include 4 calls a day, meals and a bedtime call

·         Following a procurement exercise, block contracts were awarded to five homecare agencies in September 2017, and commenced in April 2018 for a 4 year term, with the potential to extend for 2 plus 2 years. Following the failure of Allied Healthcare in December 2018 there are now 4 block contracts with Mihomecare, CRG, London Care and Mayfair

·         Quality assurance for the block contracts is provided by contracts officers who are responsible for holding providers to account, and implementing performance improvement plans, where necessary

·         There is also and LBI re-ablement team based in provider services within Adult Social Services. Block contractors provide support to around 800 L.B.I. residents, with a projected annual spend circa £9.5m. Spot purchase providers support a further 300 L.B.Islington residents, with a projected annual spend of circa £5.2m

·         Over 17000 hours of domiciliary care are commissioned across the borough every week. Over 1100 people are recorded as receiving domiciliary care packages every week. In one week in March this year, there were around 400 carers delivering services through our block contracts. Overall placements in residential/nursing care (paid for by I.B.I.) have reduced overall since 2013/14 from 542 to 425 in 2018/19

·         The biggest reduction has been in standard residential care, where numbers over the same period, have dropped from 84 to 36

·         The responsibilities under the Care Act – the core purpose of Adult Social Care an support is to help people to achieve the outcomes that matter to them in their life. Local Authorities must promote wellbeing when carrying out their care and support functions, in respect of a person. The wellbeing principle applies in all cases where a local authority is carrying out a care and support function, or making a decision in relation to a person. Wellbeing is a broad concept but relates to the following areas in particular – Personal dignity, physical and mental health and emotional wellbeing, protection from abuse and neglect, control by the individual over day to day life, including over care and support provided, and the way it is provided. Also included are participation in work, education, training or recreation, social and domestic wellbeing, suitability of living accommodation, and the individual contribution to society

·         The Local Authorities Care Act responsibilities for market shaping and commissioning of adult care/support. Local Authorities should encourage a wide range of service provision to ensure that people have choice of appropriate services that respond to the fluctuations and changes, in people’s care and support needs, and are Equality Act compliant. Local Authorities should commission services having regard to cost effectiveness and value for money. Local Authorities have a range of responsibilities around the wider care and support workforce and must have regard for ensuring sufficiency of provision

·         New models of care include – Love2 Care Devon, Wellbeing team approach, outcome based commissioning approach Wiltshire, Strength based – community assets and connecting communities, integrated health and social care teams Torbay, and Community Circles and Living Well

·         It was stated that Islington carers are relatively well remunerated in comparison to other providers, and block providers paid the LLW. Work is taking place to investigate the provision of LLW to spot providers, as spot provision is quite high

·         Reference was made to new models of working and that it is hoped that this scrutiny could look at alternative models that can be used

·         In response to a question it was stated that block providers sometimes found it difficult to meet specific needs, however there is no evidence that people are going without care. However, it is felt that there is a need to assess care requirements at an earlier stage where a person has been hospitalised

·         In response to a question as to catering for the needs of the LGTB community it was stated that work had taken place with specific housing and social care providers, however this could be raised with providers when they submitted witness evidence

·         Discussion took place as to the collapse of Allied and that the Council had coped with the situation well, and block contracts had been transferred. It was added that the Council needed to ensure that there is an adequate mix of contracts to suit resident’s needs, however this needed to be kept under review

·         It was felt that to maintain the best service possible the best workforce available is needed and they need to be incentivised

·         It was noted that the Council, when letting contracts, had only been able to obtain 4 block providers, through the procurement process

·         Members noted that it was felt that the issue of personalised budgets needed to be looked at

·         Members were informed that in terms of the national position, there were differences between the rural and urban markets.  It is often more expensive to provide care in rural areas due to travel time, and in more affluent rural areas it is more difficult to attract staff, as pay rates need to be higher

·         There are currently 9000 home care providers but there is a high churn of providers, as it is quite easy to set up a company, however a large number of providers then find the problems of operating such a service

·         On the national level providers are finding it difficult to remain viable, given the level of remuneration

·         There are 249 million home care hours allocated and the great majority of these are publicly funded

·         In terms of commissioning and rates of pay this varied from circa £14 in the North East, to £18 per hour in the South West. Greater London is roughly £16, however Islington is the third highest payer in London, and Islington paid £17.71 per hour. The trend nationally is that hourly rates are rising faster than inflation

·         In terms of workforce, half of carers are on zero hours contracts, and 38% of carers leave their provided within a year, however they often move to a different provider for increased hourly rates. There is around a 10% vacancy rate. The payment for carers is complex and different providers calculated pay rates in a different way. It was noted that zero hours contracts did work for some people in the service

·         In terms of the future, the number of users of the service will increase over the next 20 years, and BREXIT will have an impact on the workforce, and combined with the 10% vacancy factor that already exists will be problematic

·         New models of care – It is felt that there are opportunities to improve health and care, and for the sectors to work together with health providers to look at better quality of healthcare. There may be an oversubscribing of care that may not be needed after a period of time, and Local Authorities were spending more on re-ablement than in the past

·         It was noted that 92% of home care provided is from the independent sector, and the other 8% are most re-ablement services. In house service provision tended to be twice as expensive as private provision, however re-ablement may be a factor in this. In addition, local authorities had certain overheads that they had to meet such as terms and conditions, pension costs etc.

·         In response to a question it was stated that Islington was well advanced in terms of quality of care and remuneration for the workforce



That the presentations be noted and the following amendments be made to the Scrutiny Initiation Document –

·         Add to witnesses – 2 Block providers and 1 small provider and person in receipt of care/next of kin

·         How caring can be promoted as a career

·          Rates of staff attrition/sickness levels that may impact on provision of care

·         New models of care – examples of what is working well, and areas of best practice that can be adopted e.g. examples of innovative Local Authorities

·         Charging policy – how does Islington compare to other Local Authorities

·         In house service – is it a practical model e.g. costs, level of service provided

·         Examples of where people ‘falling through the cracks’, and if there are ways to address this

·         Whether joint action with health on care packages can lead to reduced admissions to hospital/re-ablement packages that meet the needs of those in receipt of care, and if savings can be achieved from more integrated work with health providers that can be reinvested in the service

·         Consideration of other Local Authorities who operate ‘in house’ services




The Chair thanked Simon Bottery, Jess McGregor and Jon Tomlinson for attending