1. Commissioning care and support in Extra Care housing
Sue Garwood
Extra Care Specialist
Commissioning care and support in Extra Care housing
West Midlands Commissioners’ Workshop
12th April 2011

2. Presentation links in to Technical Brief no:1 where greater detail and case studies.

3. Today’s focus
Social Sector or hybrid ECH where the local authority funds some or all of the care and support
Important features of ECH
Things to take into account when choosing an approach to commissioning care and support
Models for procuring or funding the care
Some good practice pointers
Updates and changes on the way
Technical Brief – content and key points – separate handout

4. Distinctive features of extra care
24/7 cover
Domiciliary, not residential, care
Community life
Promoting independence
Flexibility and responsiveness
Synergy and team work

5. Additional drivers Personalisation (P22) including:
Personal budgets
Personalised support at an individual level - choice and control
Voice, choice and control – collective level
Outcome based commissioning – p34
Funding constraints

6. Key Questions in assessing approach to care
Does it offer more than standard sheltered and an alternative to residential care?
Is individual choice, control and personalised provision optimised?
Does it optimise genuine involvement, co-production and control of on-site services?
Does it retain at least the possibility of cohesive, co-ordinated service delivery?
Does it enable a flexible, responsive service?

7. Key Questions 2 Is the approach transparent and understandable?
Is it cost-effective and affordable to all stakeholders?
Are charging arrangements lawful, fair and clear? (p64)
Does it minimise the risk of care home registration? (p12 and 70)
Does it minimise the risk of falling foul of housing benefit regulations? (See Turnbull p21)
Very nerdy stuff, I’m afraid!

8. Commissioning models
Some overlap between them and enormous variations within them
Range from “micro-commissioning” at one end of the spectrum to “package holiday approach at the other”
Spot purchasing – p25 and case study 1, 6B
Core and add-on – p26 and case studies 1,2,3,4
Block contract all care with opt out – p28, cs 5,6A
Block contract with no opt out – p29, cs 7
Co-production – p30, cs 9
Pump-priming – p30 and cs 8
“Framework contracts” – p37 and cs 1

9. A. Spot-purchasing or micro-commissioning – p25
Either provider takes risk of ensuring 24/7 cover or there is no 24/7 cover, at least initially
Can work where
Developments large enabling economies of scale and reduced risk, e.g. villages
Providers’ own “wellbeing” charge tips this approach into a variation on core and add-on – see slide 15
Confidence about demand, e.g. pre-existing scheme – see case study 8

10. A. Spot purchasing advantages
Maximises freedom of choice, so meeting Putting People First and personal budget agenda
No money tied up in block

11. A. Spot purchasing disadvantages
Risk of fragmentation, lack of cohesion and co-ordination between different providers, especially between on site provider and individual’s provider
Challenges of staffing adequately to provide continuity and flexible, responsive service
No 24/7 cover because providers unwilling to take the risk especially in small schemes
If no 24/7 cover, limit to who can move in
? Cost-effectiveness
If lots of different providers, building security issue

12. B. Core and add-on – p26
Fundamental core service commissioned or grant aided by local authority, or delivered by provider at own risk
Personal budgets used for individual packages of support
Variations around:
What constitutes the core
which functions, e.g. care only, HR support only or combination, activities facilitation etc
how much – o’night only; min 24/7; more generous core
Who provides it
Whether there is a charge for core and who makes it (P68)
Who holds the contract for it with the resident
Who collects the charge

13. B. Core and add-on advantages – p26
Probably optimises balance between requirements of PPF and maintaining benefits of ECH, including 24/7 cover
Incentivises on-site provider
Residents have open choice for 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

14. B. Core and add-on disadvantages – p27
Depending on choices made by residents, still risk of fragmentation, loss of synergy and co-ordination
Potential loss of flexibility and responsiveness, features especially important for people with dementia
Depending on use of core time, may be issues around cost-effectiveness, especially small schemes
If lots of different providers, building security issue
Slight risk of care home registration depending on service configuration and contracting arrangements – in practice not an issue so far (p12 and 70)
Challenges of recruiting and retaining staff
Provider concern about competitor cherry-picking

15. Grant vs contract A few benefits of grants But: See case study 1
No complex procurement processes
Grant conditions can specify key elements
No Fairer Charging assessment which can be complicated if resident not eligible for social care under FACS
Potentially addresses wellbeing and preventative agenda
But:
If provider charges assume AA, could preclude those with low level needs – affordability issue and how AA treated in Fairer Charging assessments
LA can’t recover any charges
If provider makes the charge, it’s compulsory, and care in emergency included, SLIGHT risk of care home registration
See case study 1

16. Provider risk variation
Provider delivers 24/7 cover without any contract for core with LA, or financial contribution from LA
Usually, risk reduced by provider charging a well-being/ peace of mind charge to cover the core
Helpful pre-conditions
Confidence in the market/ likely demand
Close co-operation and trusting relationship between provider and LA rather than LA trying to impose it
Theoretical risk of registration as care home. Personal budget mitigation
Remain aware of LA duties under community care legislation and Fairer Charging

17. C. Block contract – freedom of choice
Whole care/ care and support service block contracted by local authority
Residents has the choice to spend PB on contracted service or other
Many variations in what constitutes “whole service”
Block can be expressed in volume terms or numbers in bands
Should be outcome based

18. C. Advantages of block and opt out – p28
Probably optimises benefits of ECH while occupants retain choice and control – individually and potentially collectively
Ensures availability of 24/7 care and support and probably supports community life
Incentivises quality and transparency
Retains benefits of on site team – cohesion, staff continuity, flexibility and responsiveness, stability
Eases inter-agency partnership working and communication
Economies of scale maximising cost-effectiveness?
Keeps accommodation and care contractually separate

19. C. Disadvantages of block and opt out – p28
May not satisfy PPF aspiration of minimising block contracting
Issues around what can and can’t be opted out of, and implications
Potential risk of double-paying – mitigated by agreement to review and reduce block accordingly
Over-generous blocks can create a dependency culture

20. D. Block contract – no opt out – p29
“Package holiday” approach – choice made at point of entry
Advantages – p29
Broadly similar to C
Virtually no risk of fragmentation
Service can still be personalised
Disadvantages – p29
Tantamount to accommodation and care together
Takes away choice once person has moved in
Reduced incentives to achieve quality, cost-effectiveness and transparency

21. E. Co-production – p30
In italics because essentially a process which could result in or be part of a range of different models
Advantages
Empowers residents to shape services, costs and who provides at a collective level
Can apply not only to care and support but also social activities
Disadvantages
Level of frailty of some residents may preclude meaningful participation
Not practical for new schemes where resident group not known

22. F. Pump-prime approach – p30
Core or full service block contracted for a pre-determined period only
Again, not a long-term model as such but a viable pre-cursor
to using co-production to determine the service and/or
to spot-purchasing where existing resident group and potential demand is likely to boost provider confidence

23. F. Pump-prime pros and cons – p30
Advantages
Ensures 24/7 cover in place from outset, ensuring scheme a viable alternative to residential care
Provider infrastructure in place from outset
Combines reassurance and certainty at outset for provider with incentive to deliver services that residents will continue to choose
Disadvantages
If something goes wrong, council may still have to step in

24. G. Framework Contract – p37
“Outcome focused framework contracts aim to assure quality and supply through pre-selection or validation of providers”
Will specify way in which services to be delivered, e.g. more personalised
No guarantee of volume – spot purchasing within a framework
Advantage – seeks to ensure quality & outcomes
Disadvantage – with no guaranteed volume, providers may be reluctant to enter into agreement or keep prices at block contract levels

25. Good practice pointers
Treat providers as partners, not “hired hands”; recognise and use their expertise – p38
If tendering for care, ensure that the housing provider has opportunity for proper input – p38 & 39
Do at least consult and at best properly involve residents in shaping the service when re-tendering – p35 & 39

26. Updates and changes Feedback shows all models still in operation
Increasingly seeing RAS determining PBs, with points sometimes tied into occupancy or dependency bands (see cs2), but also reported challenges in getting RAS levels right
Future changes with possible implications for care in ECH:
Benefit changes – HB and future of AA(?)
Law commission report
Social care funding commission report

27. Contact details and links
Technical Brief 1: Care and Support in Extra Care Housing
Sue Garwood – Extra Care Specialist
Phone:
Mobile:
Web: