A partnership of providers is offering councils an integrated set of services, which they say will deliver better outcomes at lower costs. Mithran Samuel examines their proposal
As councils set their 2011-12 budgets this month, many are responding to government cuts by squeezing adult social care service users and providers alike. Plans are afoot to raise eligibility thresholds and charges for users, and to freeze or cut fees for providers.
However, three providers from different sectors have now teamed up to offer councils an alternative, which they claim will improve user outcomes and save money.
The proposal from the partnership of housing repair and domiciliary care provider the Mears Group, telecare body Tunstall and housing adaptations organisation AKW Medicare is based on a critique of commissioning practice.
Councils currently commission all these services separately, which, the partnership argues, is inefficient and leaves service users facing multiple visits and worse outcomes. Given rising demand and falling resources, councils cannot afford to continue in this vein, the providers say, and need to commission integrated services that are focused on improved outcomes, paying providers by results.
The partners, which are also backed by Foundations, the umbrella body for home improvement agencies, are offering councils a way in which they can commission all their services through one route, with contracts focused on outcomes.
Senior care staff from Mears would be trained in assessing and reviewing service users’ needs for home care, adaptations and telecare. And Mears would purchase telecare for its council-funded home care clients, on the proviso that it would gain a share of any savings to the public purse by preventing hospital or residential care admissions.
The providers are now lobbying commissioners and politicians, and are hoping to influence this year’s adult social care White Paper. Their message is robust.
“What we will say is that you can take 10% off fees to providers and raise eligibility criteria but all you’re doing is trying to push water up a hill,” says Mears executive director Alan Long. “You’ve got more people coming in; you’re not going to get more money; you’re going to have to think differently. At the moment, 99% of councils are applying a sticking plaster [to services].”
The savings to councils from telecare and adaptations are well documented. North Yorkshire Council, which invests significantly in telecare, has identified that it has cut average annual care costs for service users by 38%, or £3,650 a person, by delaying or reducing admissions to residential care or use of domiciliary care.
A 2007 report for the government’s Office for Disability Issues found that adaptations paid for themselves in reduced care costs within a period ranging from a few months to three years, and then released annual savings.
However, Long says this potential has been blunted by the separate commissioning of services: “In my experience as a domiciliary care provider, when telecare goes in, the care plan doesn’t change very much and the care worker is not really aware of what telecare can do.”
This, he says, is why Mears is willing to take the “risk” of paying for telecare itself for its home care clients in any local authority that commissions the providers’ integrated package.
“Costs go down from day one [for the council] because they are not paying for telecare,” Long says. “I am prepared to take a gamble to change the way the market is commissioned.”
Reactions from the sector to the proposals have been positive, though with caveats.
“It’s a clever idea – we are going to be seeing councils asking for reductions in price or other cost-saving measures and what these providers have done is find a way in which everyone can win,” says Colin Angel, head of policy and communication at the United Kingdom Homecare Association.
However, he warns that this would not be an option open to smaller providers. Mears is a relatively large domiciliary care provider, as well as the largest provider of housing repairs for social landlords; Tunstall is the country’s biggest provider of telecare; and AKW is the leading provider of kitchen and bathroom adaptations.
Angel also warns that commissioning home care on the basis of outcomes, rather than inputs, such as hours of care, is not easy.
“How are you going to know if an outcome is achieved and how do you know you’re going to have sufficient resource to deliver it? The danger is that services are delivered below cost. It puts a lot of risk on the provider.”
This is echoed by John Bolton, who was until last year the Department of Health’s strategic director for social care finance.
“Providing reward for savings is very hard,” he says. “There would have to be a very clear baseline established and a performance framework for councils to have the confidence if they were to procure in that way.”
He says the ideas put forward by the partnership are not new and were discussed by the DH during his time there. He is generally supportive of the idea as a way to reduce costs and says it is particularly applicable to preventive interventions designed to stop people needing ongoing care.
Sarah Pickup, the honorary secretary of the Association of Directors of Adult Social Services, rejects the idea that the proposed approach is not being practised by commissioners.
She cites a reablement service launched last year by her own council, Hertfordshire. This combines outcomes-focused commissioning from a provider, Goldsborough Home Care, with an expectation that any need for adaptations or telecare is also identified by the provider.
Pickup also points out that, under personal budgets, councils take account of the full range of service users’ needs during the support planning process, allowing integrated commissioning at the individual level.
She welcomes the contribution from Mears, AKW and Tunstall. “The market needs to be thinking about what it can offer us,” she says.
However, she adds: “They won’t benefit from coming at it from an approach that criticises commissioners.”
A hypothetical case study: how the model would work
Providers the Mears Group, Tunstall and AKW Medicare are proposing that home care, telecare and adaptations should be commissioned on an integrated basis, with providers paid by results. This is an example of how it might work:
Situation: Mrs Jones is in hospital for a hip replacement and wants to come home but needs a combination of adaptations, telecare and home care to do so.
Single assessment: Providers offer a joint assessment of her needs, which identifies that she is unable to use the stairs to reach her bedroom or bathroom, or use the toilet or get out of bed without assistance.
Outcome-focused commissioning: Providers agree with the council that Mrs Jones should be able to return to get to her bedroom, maintain personal hygiene herself, manage daily living tasks and be able to get out to meet friends, within eight weeks.
Integrated provision: Adaptations, telecare and home care work are integrated to maximise outcomes. Mrs Jones’s bed is brought downstairs, while she receives support to improve her mobility from home care staff and an occupational therapist. Meanwhile, additional handrails are fitted to the stairs and upstairs bathroom. She is also given an alarm pendant to alert staff to falls or other safety issues. When she can climb the stairs her bed is moved back up.
Payment by results: Providers are paid if outcomes for Mrs Jones are achieved within the eight weeks.
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