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United Kingdom Homecare Association

Commissioning Survey 2011

This briefing is designed to provide top-level information about a survey of

homecare providers’ experience of the recent purchasing arrangements

and tactics used by local authorities who commission homecare services.

1. Abstract

United Kingdom Homecare Association undertook a study of the

commissioning practices of local authorities to understand the impact of

local authority commissioning decisions in the context of stringent public

spending cuts.

We were provided with examples where the dignity, quality and safety of

elderly and disabled service users could be placed at risk. Regrettably,

the link between the quality and cost of homecare services is not always

reported in the context of commissioning decisions made by local

authorities who are responsible for arranging four-fifths of all homecare in

the UK.

We found that up to 82% of councils were reducing how much care they

would pay for, and reducing the number of homecare visits people

receive. 58% of councils appeared to have cut the price they pay

independent and voluntary sector providers for homecare. The use of

short visits of around 15 minutes or less to undertake personal care

appears to be increasing rapidly.

We found that a wide range of care activities were being curtailed or

withdrawn from service users’ care plans, particularly reducing social

contact and checks on safety. Activities that help people stay at home,

including shopping, help with bill-paying and laundry were most likely to

be stopped all-together.

Employers reported increasing difficulty recruiting and retaining

careworkers to undertake homecare, particularly in rural areas, and that

the wages they could pay their workforce was increasingly threatened by

very low fee levels from councils.

A series of short, anonymised case studies drawn from the survey are

provided in Appendix 1. Information about the survey design and

response rates are provided in Appendix 2. A brief description of the role

of United Kingdom Homecare Association is given in Appendix 3.

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2. The issues and context

UKHCA has monitored and commented on the homecare sector for over

20 years. With recent public spending cuts, our member organisations

describe increasingly challenging market conditions created by local

authorities, who are the sector’s majority purchaser.1,2

There are clear concerns, borne out in UKHCA’s survey and recent media

coverage, that the quality of homecare services could be adversely

affected by the commissioning practice of councils.

This can be characterised as an attempt to reduce spend adult on social

care services by:

reducing access to state-funded care;

reducing the amount of time allowed to meet people’s needs;

reducing prices paid to independent and voluntary sector providers.3

Although around 6.6 million hours of homecare is delivered safely and

effectively every week, UKHCA believes that these trends in council

commissioning are likely to increase the danger of developing homecare

services that:

do not fully meet the needs of people who use home-based care;

appear to be hurried and lack dignity;

increase the risk of injury to homecare workers and the people to

whom they provide care.

1 In Northern Ireland social care is commissioned by Health and Social Care

Trusts. Throughout this paper references to “councils” and “local authorities”

should be assumed to include Health and Social Care Trusts.

2 UKHCA estimates that the state purchases around 80% of all homecare

services provided in the UK. The majority of state-funded care is delivered by

independent and voluntary sector providers.

3 For brevity references to the “independent sector” should be assumed to

include both private and voluntary sector providers.

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Our survey provided 47 case studies about individual service users from

providers who believed they now receive inadequate care to meet their

needs as a direct result of recent commissioning decisions. For the

purpose of comparison, providers said that 17% of packages had been

insufficient to meet the user’s needs before they were changed by the

council. After changes were implemented, 55% were described as

receiving 'somewhat insufficient' care and 45% 'seriously insufficient'

care.

3. Most significant trends identified

Our survey provided 206 separate impressions of recent local authority

commissioning practice, covering 111 statutory sector purchasing

authorities across the UK (see Appendix 2 for survey design).

We found evidence of councils engaging to some degree in a wide range

of cost-cutting measures,4 the most common being:

Active reduction in the amount of time allocated for care for at least

some service users (82% of councils);

Reducing the number of visits that people receive by careworkers

(76% of councils).

From the case studies submitted to the survey, we estimated that not only

were fewer visits being made, but the average visit length was reduced by

around 10 minutes (22%), from 48 to 38 minutes.5 However, we saw

many examples of care where very short periods were allocated for

assistance with hygiene and mobility needs or meal preparation was

constrained to very short periods of around 15 minutes.

4 Quantifying the extent to which these activities are being undertaken was

outside the scope of this survey.

5 The case studies in our survey were selected from those where, in the

providers’ opinion, the council had changed the package of care to a level that

was “somewhat insufficient” or “seriously insufficient” to meet the user’s

needs. We should emphasise that these figures are not intended to represent

the national picture for all people receiving homecare in the UK, however, they

provide an impression of the experience of those who may be particularly

disadvantaged by their council’s commissioning practices.

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These actions carry considerable implications for homecare services:

Reducing the time permitted for personal care to be completed can create

undignified, hurried and impersonal care; or make it difficult to meet a

person’s care needs. In extreme cases it increases the risk of unsafe

working conditions and injury to service user or careworker.

Reducing the number of visits to the service user’s home can increase

social isolation for many older, frail or incapacitated individuals who live

alone, and place additional strain on care provided by family members

and unpaid carers.

Case study: A gentleman in his 90s had his care reduced by 92% after

his council in the Yorkshire and Humber region cut his original 28 visits

per week (each lasting 45 minutes) down to just 7 visits per week (each

lasting only 15 minutes). The council saved around £230 per week, and

now spends just £20 a week on 1.8 hours of care, which is

understandably described as 'seriously insufficient' by the provider.

Most councils calculate payment for services based on “contact time”, the

time actually spent inside the service user’s home. Shorter visit times

generate lower fees which must still accommodate the costs of travel to

and from service the service user’s home, and makes it harder to offer a

pay rate sufficiently attractive for workers to undertake very short

episodes of work.

Short visit times are a particular problem in rural areas, where travel time

often far exceeds time spent delivering care. Providers repeatedly

reported difficulties recruiting and retaining careworkers with the right

skills and experience because of these issues.

10% of providers told us that councils’ cost-saving measures had led to

them turning-down work in rural areas, or where visit times were

inadequate for the care required, or had become unprofitable. We believe

that this will increase over the next few years and may threaten the

availability of services, particularly in rural areas.

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We heard repeatedly about careworkers leaving the sector and a difficulty

recruiting because of the pay rates providers could offer. Providers cited

short visits with long travel time as causing difficulties in staff retention.

We heard from at least 4 providers (3%), who had already cut wages in

order to remain in business, and 12 providers (8%) considering ceasing

trading with councils or stopping provision in the local area.

From our case studies we analysed the different types of care that were

most likely to be restricted or withdrawn as councils reduce the care

people receive (see Figure 1.)

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Figure 1.

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Our impression is that people are most likely to receive less assistance

with:

maintaining social activity or social contact;

checks on safety;

prompts and reminders to self-care;

washing, bathing or showering;

assistance with healthcare needs.

However, it was also noticeable that services most likely to be stopped

completely also included activities which actually help people remain in

their own homes:

shopping;

managing their finances and bill-paying;

help with laundry.

Case study: A lady in her 90s no longer receives the seven evening-time

visits to help with personal care and check-up on her safety. Since the

council in the South West of England reduced her care by 41% in January

2011, she has been scalded attempting to make a cup of tea; has spent a

night lying on the floor undetected after a fall; and a skin condition has

deteriorated as she is unable to apply the lotion she needs. She now

regularly telephones her daughter in the evenings in a state of distress.

This has saved the council £62 a week.

We saw a range of other cost-cutting measures undertaken by councils

(see Figure 2.), including:

58% of councils were attempting to push down prices previously

agreed in established contracts with providers;

50% of councils removing enhanced rates to incentivise work in the

evenings, weekends and public holidays (when workers reasonably

expect enhanced pay rates);

41% of councils were reducing the use of pairs of careworkers in a

single visit. These double-ups are generally used for safety reasons

during manual handling procedures.

Around 18-21% of councils were removing one or more of the

payments they had previously made towards careworkers’ travel time

or travel costs, or premium payments to incentivise work in rural

areas, where travel time can be considerable.

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Figure 2.

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We were particularly disturbed by the number of providers who felt that

commissioners had ignored provider’s knowledge about the service users'

needs and condition. Providers appeared to have no involvement in

commissioning changes in almost two-thirds (62%) of the case studies

they supplied. Indeed, even when involved in reviews of service users’

care, providers felt that their recommendations were either wholly or

partly accepted in just 6 of the 19 cases.

4. Conclusion

The Association is sympathetic to the complex challenges faced by

directors of adult social services and their commissioning teams in

balancing competing demands on constrained budgets. The solutions to

these challenges lie not only with commissioners and providers, but

society and government re-thinking its priorities.

The frequency and severity of issues identified in our survey suggest that

councils themselves and government in all four administrations must ask

serious questions about whether commissioning practices are running

contrary to the needs and wellbeing of service users and their carers.

While not assessed in this survey, the cost implications for the NHS should

also be included in the equation.

Politicians and local communities must question whether councils are

alotting sufficient resources for effective homecare services that can be

delivered to a sufficiently high standard, and keep people at home, rather

than in hospital and residential care.

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Appendix 1. Case studies

The following descriptions are a selection of the 50 case studies submitted

in the second part of the on-line survey.

1. A provider's request for an additional 15 minutes of care each

evening to check on the wellbeing of a lady in her 80s was denied by

a council in the South West of England funding her care. She had

developed an infection, but wanted to stay at home rather than go

into hospital. We estimate that these visits would have increased the

cost of this lady's care by £26 per week, in addition to the £103 the

council already paid. The cost to the NHS would have been

significantly higher.

2. A gentleman in his 90s had his care reduced by 92% after his council

in the Yorkshire and Humber region cut his original 28 visits per

week (each lasting 45 minutes) down to just 7 visits per week (each

lasting only 15 minutes). The council saved around £230 per week,

and now spends just £20 a week on 1.8 hours of care, which is

described as 'seriously insufficient' by the provider.

3. A lady in her 80s in the North West of England lost much of the

assistance she needed to remain at home, including shopping;

paying her bills and help with her laundry. The 7.5 hours of care she

received each week was cut by 67%, leaving careworkers little time

to fit these activities around help with her personal hygiene needs in

the three visits she receives each week.

4. A daily half-hour visit to help a lady prepare a meal and attend to her

personal hygiene in the South East of England was discontinued

without discussion with the agency about her needs. The provider

believes that the council responsible is undertaking a policy of

cancelling packages of care that only require a single visit per day.

5. A gentleman in his 40s in the South East of England receives a

specialist homecare service for people with mental health needs. He

no longer receives sufficient one-to-one care to monitor and support

his psychological state, leaving his provider describing his care as

'seriously insufficient'. The 23 hours of care he received each week

has been reduced by 83% by reducing 14 visits a week down to just

four.

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6. A council in the South West of England reduced the amount of care

for an older lady by declining to pay for a second careworker to help

use a mechanical hoist to use the toilet safely. This measure saved

the council £61 a week, but increases the risk of injury to the service

user or the careworker.

7. A lady in her 80s in East Anglia has Parkinson's disease. The 14

hours of care she received was halved in May, by halving each of her

half-hour homecare visits, despite her needs remaining the same.

Parkinson's is associated with variable exacerbation where people

may require more assistance than usual. The provider said 'on bad

days we have to rush. All four calls per day have been reduced to 15

minute visits, which includes delivery of personal care'.

8. A lady in her 90s no longer receives the seven evening-time visits to

help with personal care and check-up on her safety. Since the

council in the South West of England reduced her care by 41% in

January 2011, she has been scalded attempting to make a cup of

tea; has spent a night lying on the floor undetected after a fall; and a

skin condition has deteriorated as she is unable to apply the lotion

she needs. She now regularly telephones her daughter in the

evenings in a state of distress. This has saved the council £62 a

week.

9. A younger disabled adult in her 30s received the equivalent of over

76 hours of intensive care a week at her home in West Scotland. Her

care was reduced by 26%, after the introduction of a direct payment,

which now only covers two of the four visits where careworkers were

needed in pairs. On the other visits one careworker has to cope

alone. The provider believes the care is now 'seriously insufficient'.

10. A lady in her 70s has had 5 minutes shaved from each of her 20-

minute visits, despite care being necessary to help with physical

activities, including getting in and out of bed and using the

bathroom. The provider said that 20-minute visits were 'somewhat

insufficient', but rates the shorter 15-minute calls as ‘seriously

insufficient’.

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11. The condition of a frail gentleman in his 90's in Northern Ireland

began to deteriorate. His needs were being met with four half-hour

visits a day from two careworkers, working together. This cost the

local Health and Social Care Trust £305 per week. The Trust

declined to provide any additional time to help the gentleman use the

toilet, wash and dress, leaving the provider describing the care they

were paid to deliver as 'seriously insufficient'.

12. A provider in the East Midlands felt compelled to accept a 20% fee

reduction to enable a younger disabled gentleman to remain with the

agency that he's used for the last 17 years. The social worker

commissioning the care wished to introduce care at a rate below the

£12.73 per hour charged. The provider has foregone £423 a week to

help this gentleman remain with the service he knows and trusts.

However, each time councils push down the price they pay for care,

less money is available to support workers' training, wages and the

agency's other running costs.

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Appendix 2. About this survey

This survey was an online exercise completed by member organisations of

the United Kingdom Homecare Association, the professional

representative association for domiciliary care providers.

The motivation to undertake this survey was the increasing concerns of

independent and voluntary sector homecare providers on the impact of

public spending cuts on the commissioning of homecare services; the

possible risks to the quality, dignity and safety of services; and the threat

to the financial viability of the independent and voluntary sector, who

provide the majority of state-funded care in the United Kingdom.

The survey was undertaken in August 2011. It covers all four

administrations of the United Kingdom and the online questionnaire was

made available to UKHCA's member organisations who currently trade

with local councils (or Health and Social Care Trusts in Northern Ireland).

The survey was divided in two parts, and organisations could select one or

both sections.

Part one

This section looked at providers' general experience of local authority

commissioning:

158 homecare providers responded to this section, supplying:

206 individual reports…

about 111 different councils or trusts

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Figure 3.

Part two

This section was designed to highlight examples of how the general

practice of councils impacted on individual service users. To qualify for

this section, providers were asked to select service users whose care

package had been changed by the commissioner in the 6 months to

August 2011 and where, in the provider's opinion, the care package (or

the fees paid by the council) was insufficient to meet the service users’s

needs. We refer to do these as "case studies" in this report.

50 case studies were submitted, 78% of which were from England. All

eight government regions in England and each of the other three UK

administrations were represented in the results by between one and seven

case studies. The survey therefore presents an impression of

commissioning across the whole of the UK.

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Figure 4.

The survey asked providers for a consistent set of data relating to each

user’s care, both before and after the care package was changed, as

follows:

the number of hours of care councils purchased for individuals (or the

amount the individual could purchase with the cash equivalent, a

"direct payment");

how often service users received their homecare service during a

typical week;

whether care packages commissioned were sufficient for the service

user’s needs;

how much involvement, if any, the provider had in the decision to

change the package of care commissioned.

The survey covers care services to adults of all ages, with around 68% of

them older people aged 65 or above (see Figure 5.)

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Figure 5.

Confidentiality

No personal information about individual service users was collected

during the survey. While providers were asked to disclose the

commissioning bodies concerned, this was with the assurance that this

information would not be reported in the published findings.

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Appendix 3. About UKHCA

UKHCA’s mission, as a member-led professional association, is to promote

high quality, sustainable care services so that people can continue to live

at home and in their local community. We will do this by campaigning,

through leadership and support to social care providers.

Our Vision is of a United Kingdom where a choice of high quality,

sustainable community-based care is available to all.

UKHCA represents 33% of independent and voluntary sector providers in

the UK, and estimates that its member organisations employ over

119,000 homecare workers, who deliver over 2.79 million hours of care

per week to around 166,000 service users, valued at £1.62 billion per

annum.

Colin Angel

Policy and Campaigns Director

United Kingdom Homecare Association

Group House

52 Sutton Court Road

Sutton

SM1 4SL

020 8288 5291

media@ukhca.co.uk

www.ukhca.co.uk

31st August 2011

Registered in England No. 3083104