1. Care and support in Housing with Care – current trends and issues East of England Housing LIN meeting 1 st October 2013

2. Plan for this session To briefly outline changes in the procurement and delivery of care and support in Housing with Care for older people To explore the impact of these on quality and outcomes To hear the experience of those present Drawing from – Funding Technical Brief – Care and Support in ECH Technical Brief – Own observations based on four reviews of care in ECH, scheme visits and conversations, and feedback to discussion document 2

3. Personalisation – the ethos Holistic support tailored to the needs and aspirations of each individual Maximising choice and control – both at individual level and group or community level Self-directed support – The process by which personalisation put into effect....in theory – Individual defines outcomes – Can choose who provides support – Can determine what shape that support takes – Can take as much control over support as s/he wants – Signed off by local authority Opportunity for out-of-the-box, innovative solutions/services – dynamic process at its best One route to enabling choice and control is personal budgets 3

4. Personal budgets (PBs) Part of personalisation and self-directed support An up-front allocation – transparency & portability Personal budgets becoming the standard “currency” by which Adult Social Care authorities provide services for people who have eligible community care needs Intended to have flexibility around what PBs can be spent on to achieve identified outcomes Emphasis on individual choice and control – this should include how that budget is managed or deployed Can be “managed” budgets, or direct payments Brokerage and Individual Service Funds as a means of supporting individual to manage PBs Care Bill – PBs will be used as the basis for cumulative care account for calculating cap 4

5. Care in Housing with Care With advent of personal budgets and austerity, the way care is procured, configured and charged for is changing Need to retain viability and benefits of HWC while maximising choice and use of portable PBs... arguably HWC is not HWC without 24/7 care on site We are seeing a shift away from large block contracts Models range from “micro-commissioning” at one end of the spectrum to “package holiday approach at the other” Between these two extremes, a mix of spot purchasing for planned care, and other approaches to cover the availability of care around the clock - the “core and add-on” approach. See Technical Briefs and West Midlands powerpoint for more detail 5

6. Core and add-on – gaining traction? Bulk of the care in the form of personal budgets used for individual packages of care & support Core (shared) service commissioned or grant aided by local authority, or delivered by provider at own risk Variations around: – What services constitute the core – How generous the care element is – Who funds the core – Contractual basis with occupant – Who charges for it – peace-of-mind/wellbeing charge – Whether a separate charge or part of over-arching service charge – The level of the charge and how it is decided 6

7. So – what impact is all this having? 7

8. Improved personalisation in older people’s Housing with Care? Discussion paper to explore the impact of personal budgets and other changes on care provision and resident outcomes The way in which the care in HWC is procured affects the way it is structured and delivered That in turn can affect the quality of life and health and wellbeing outcomes for residents Other things which appear to impact include: – Tightening budgets and amount in PBs for older people – Loss or reduction of Supporting People funding in many schemes – Local implementation of support planning and personal budgets 8

9. Discussion document responses Went out to members of Housing LIN, UKHCA and National Care Forum 24 responses of which – 7 local authority commissioners (incl: 1 social worker) – 5 providers of housing and care – 5 housing providers – 1 domiciliary care agency – 3 independent consultants – 2 researchers – 1 group response from regional LIN meeting in north-west 3 from the East region Not enough to get definitive overview but a bit more certainty about what is happening across the country 9

10. Original impressions in blue. Conclusions following feedback in Mauve Commissioning approach Core and add-on gaining traction 1.Are still places where block contracts prevail 2.However, variations on core and add-on definitely the direction of travel 3.Some evidence of schemes with no 24/7 cover 10

11. Another potential boundary issue? A new potential “boundary” dilemma between planned care and the core (wellbeing/ emergency /floating provision) seems to have resulted 1.Whatever the model, boundary issues have been a challenge and dealt with better in some schemes than others 2.However, core and add-on introduces another layer of complexity 3.Most challenging is where there are several off- site providers delivering planned care 4.So far residents moving towards, rather than away from, on-site care providers 11

12. Flexibility and responsiveness? Care and support delivery in HWC schemes seems to be becoming less flexible and responsive 1.Flexibility of block contracts not inevitable – depends on resourcing, specification and implementation 2.More difficult to provide a flexible service with core and add-on – skeletal core (or no core) problematic. 3.While PBs driver for the change in commissioning approach, reduced funding may have more impact on delivery and outcomes than commissioning approach as such 12

13. Challenge of meeting unpredictable needs Residents with unpredictable needs, such as those with dementia or anxiety, appear more likely to lose out under core-and-add-on approach 1.Yes. Probably the most critical issue 2.Partly because core is skeletal in some cases, and boundary between core and planned care not clear 3.Also because, despite PBs, care plans still rigid time and task-based – will not suit those with dementia who need a more flexible and responsive service 4.Also more challenging to provide continuity of care – workforce issues 13

14. Improved personalisation? Care and support plans appear no more life-enhancing, holistic, imaginative or outcome-based than they were before the advent of personalisation, while supplementary services may also have been reduced 1.Yes. Probably a reflection of amount in PBs being too low for anything other than care essentials 2.Some limited evidence of care plans including support to take part in on-site activities 3.Applies across domiciliary care for older people – not unique to HWC 14

15. Choice and control? Choice of PB deployment mechanisms is not always made available, and residents may even be unaware that they notionally have a personal budget, so the opportunities for genuine choice and control over their support plan seem limited (See Age UK reference ) 1.Yes 2.Most PBs in the form of managed budgets 3.Very little evidence of use of Individual Service Funds despite some providers asking specifically to be able to offer them 15

16. Workforce issues Meeting the ebb and flow of demand, and providing staff continuity and a stable workforce is a greater challenge, with more nil hour contracts being used 1.Yes. Planning at the start of a scheme particularly challenging, especially when insufficient lead-in time allowed, and inadequate information-sharing and joint working 2.Having a local presence serving the wider community helps to spread infrastructure costs and call in extra staff when needed If HWC is to continue to offer an alternative to residential care for people with dementia, and promote wellbeing and quality of life for all, we need to avoid undermining its benefits over standard domiciliary care. Can we...... 16

17. Make the most of core and add-on advantages Probably optimises balance between requirements of personalisation and maintaining benefits of ECH, including 24/7 cover Frees up LA budgets for PBs and avoids “wastage” Incentivises on-site provider Opportunity for more choice over planned care/support If on site service is flexible, responsive and person- centred, residents likely to see advantages of using it and choose it – must be registered to provide care for this to be possible With separate charge for core, likely to be shared more fairly More transparency and alignment between service & charge 17

18. Address core and add-on disadvantages Depending on choices made by residents, greater risk of fragmentation, loss of synergy and co-ordination Potential loss of flexibility and responsiveness Depending on use of core time, may be issues around cost-effectiveness, especially small schemes If lots of different providers, building security and ‘duty of care’ issues Challenges of recruiting and retaining staff and providing staff continuity Provider concern about competitor cherry-picking May be affordability issues for residents depending on charge levels and charging policies Small risk of care home registration 18

19. How? Some possible ways forward A core service is needed and should not be too skeletal Effective commissioning is key, needs to involve all partners, and apportionment of risk should be balanced and fair Importance of making clear – what schemes do and do not do – what the charges are, and what they do and do not cover A reasonable lead-in time is needed for recruitment and joint planning Care and support planning needs attention - perhaps specifying amount in budget and outcomes, and allowing provider and resident to agree support delivery – via ISFs? Operational collaboration and flexibility at the edges (See also Better Life findings) 19

20. And the future? Care Bill making its way through parliament – will be updating the Care Technical Brief once provisions clear. – Dilnot – cap on amount individuals pay for care – Charging arrangements – National eligibility threshold Changes to funding of supported housing Welfare reform – current exemptions for older people less likely to apply in next parliamentary term irrespective of who’s in power Cumulative impact of different changes?? Caring for our future consultation - and Housing LIN submission http://www.housinglin.org.uk/News/Latest/HousingNews Item/?cid=8941 http://www.housinglin.org.uk/News/Latest/HousingNews Item/?cid=8941 20

21. More information Garwood, S – Care and Support in Extra Care Housing (2010) http://www.housinglin.org.uk/_library/Resources/Housing/Support_materials/Te chnical_briefs/Technical_Brief_01_0610.pdf Garwood, S – Discussion paper: Improved personalisation in Older People’s Housing with Care? (May 2013) http://www.housinglin.org.uk/_library/Resources/Housing/Support_materials/Dis cussion_papers/HLIN_DiscussionPaper1_PersonalBudget.pdf Age UK - Making Managed Personal Budgets Work for Older People (April 2013) http://www.ageuk.org.uk/professional-resources-home/services-and- practice/care-and-support/personalisation-hub/making-personal-budgets- work-for-older-people/ Head, J et al – Funding Extra Care Housing (May 2013) http://www.housinglin.org.uk/Topics/browse/HousingExtraCare/FundingExtraCar eHousing/ Presentation: Funding Care and Support in ECH http://www.housinglin.org.uk/Events/ArchivedEvents/ArchivedHousingEventDetai l/?eventID=763 JRF Better Life reports 21

22. What is happening in our region and how do we retain HWC benefits? 1.Arrangement with local authority 2.Boundary issues between service elements 3.Flexibility and responsiveness 4.Meeting unpredictable needs 5.Improved personalisation? 6.How much choice and control? 7.Workforce issues 8.Practice examples 22

23. Thank you for listening Contact details: sue@suegarwood.co.uk www.suegarwood.co.uk Sue Garwood Extra Care Specialist