2. Changing lives through changing policy Harold Bodmer Director of Community Services

3. The National Picture Today 380k 1.1m 1.8m 5m Care and support affects a large number of people. In England there are… People in residential care People with care at home People employed in the care workforce Informal carers Statistics from “Caring for our future: reforming care and support”, White Paper July 2012

4. What are our chances?

5. The Picture in Norfolk Norfolk has the “oldest” population in the region Whilst the overall population of Norfolk is predicted to increase by 25% between 2008 and 2033, the number of people aged 65-74 is likely to increase by 54%, and the number of people aged 75+ should go up by 97%. In the same period the North Norfolk district is likely to develop one of the largest proportions of older people aged 65+ in the country

6. Service Delivery to Commissioning History of social care delivery - Great Hospital in Norwich 25 years ago - very little social care market Almost all service in-house, Home Care (helps), day centres, residential care homes, day centres NHS Long stay hospitals Little or no choice

7. Revolution 1 A market for social care NHS and Community Care Act - the development of markets Social care took on contracting, then gradually the concept of social care commissioning The role of social workers as the gatekeeper of eligibility Choice starts to be important

8. Revolution 2 People in charge The Direct Payment movement, a social movement, adopted by policy makers Importance of User Led Organisations Significant change for local authorities People in charge, people set the agenda Followed by Individual then Personal Care budgets, then Personal Health Budgets Now hardwired into policy

9. Age is just a number… 50 – 65 66 – 80 81 - 100 ‘Ageing (living) well’ Keeping independent Care, support and sharing experiences A change of response: Solutions based on local communities Integration of health, social care, housing, voluntary and independent sector A shifting concept

10. Revolution 3 Integration with the NHS Been with us for years/ different models/ joint funding/ joint arrangements Now firmly in policy, Better Care Fund, pooling of resources Integration of Commissioning Integration of Social Care provision Join up experience for people

11. Revolution 4 The Care Bill Promote well-being, prevent and postpone need for care Cap on costs that people have to pay for care Element of response to Francis inquiry National eligibility criteria Equality for carers Promotes integration

12. Revolution 4 The Care Bill Providing information and advice Market shaping Co-operation

13. The new approach Numbers up…. Funding down, the perfect storm? The new contract. A public debate about expectations for health and social care Positive image for ageing Beyond personalisation A new role for councils in this. Whole lives and whole communities Role of Health and Wellbeing Boards Challenge established rules in way operate Change our joint working culture

15. Top issues for homecare providers Great British Care Show, Norwich Andrew Heffernan, Membership and Marketing Director 2nd April 2014

16. Issues for the homecare sector Operating environment: o Commissioning of state-funded care o Short visits, “bad news” stories Workers’ terms & conditions: o National Minimum Wage, Zero-hours contracts Regulation: o New inspection methods, Quality Ratings, market oversight Recruitment: o Cavendish Review, recruiting values, supply of workers Legislation: o Care Bill

17. The operating environment Council commissioning is getting worse: o Either: Reduction in number of “approved providers” or: Volume spread thinly through framework agreements o ADASS: 15-min visits account for 16% of all purchase o Providers’ over-reliance on state-funded business Public not aware that social care is means-tested o “Dilnot-style” funding cap in Care Bill o Responsibility between individual and the state unclear o Residential care still seen as the default option

18. Equality & Human Rights Commission Close to Home Recommendations Review Links commissioning, workers’ Ts&Cs, staff turnover & quality UKHCA helped EHRC produce questionnaire, which found: o 1 in 5 LAs with rates of £8.96-£11 o 1 in 3 LAs setting maximum prices EHRC recommends: o CQC to monitor commissioning o NMW compliance clauses

19. UKHCA’s minimum price of £15.19/hour BBC Radio 4 finds: o 97 of 101 councils pay prices below £15.19 o Average minimum rate £12.26 Coverage on: o BBC Breakfast o BBC News Channel o BBC Radio 4 & 5-Live o BBC Local Radio

20. Assumptions used in our minimum price Minimum Wage:£6.31 Travel time:11.4 min Travel costs:4 miles £0.35/mile NI:9.5% Holiday Pay:10.8% Training:1.73% Pensions:1% Gross margin:30% Based on fee of £15.19 per hour to provider for contact time only

21. How can you use UKHCA’s Minimum Price? Support discussion with local commissioners Send to local councillors asking why council paying below UKHCA’s rate Use UKHCA’s Costing Model to calculate actual costs: o www.ukhca.co.uk/CostingModel Challenge council to open- book costing exercise

22. Quality and flexibility: 15-minute visits Debate about short visits is helpful for highlighting commissioning issues Media now understand that inadequate care is part of a wider problem Prepares argument for why keeping head of NMW is challenging Guardian/EHRC etc also identify inflexibility of visits and choice of worker

23. National Minimum Wage Increased investigations by HMRC triggered by: o Workers contacting the Pay and Work Rights Helpline o Intelligence about non-compliance from 3rd parties o Risk-based assessment of providers by HMRC Increasing media attention: o Alleged non-payment of careworkers’ travel time o HMRC report – November 2013 o Recent publicity on zero-hours contracts

24. HMRC investigations of 224 social care providers 45% non-complianceAverage under- payment of £139 HMRC (2013) National Minimum Wage Compliance in the Social Care Sector

25. Reason(s) for NMW non-compliance in the homecare sector HMRC (2013) National Minimum Wage Compliance in the Social Care Sector

26. Why’s this important for you? Reputation of entire homecare sector at risk Workers’ rosters make compliance hard to check Commercial damage for non-compliant employers o Repayment of arrears to workers at current rates o Fine of 50% of arrears (minimum £100, maximum £5k) o New rules to “name and shame” in public

27. HMRC may come knocking HMRC likely to ask for: o Pay records o Weekly/monthly rosters o Schedules of pay rates o Workers’ contracts o Evidence of you checking compliance Be confident and cooperative!

28. + Minimum Wage compliance (Highly simplified) Basic rate(s) of pay are used. Do not rely on unsocial hours premiums or enhancements for short visits to achieve compliance with NMW Average pay over reference period of up to 1 month Total pay before enhancements Total contact timeTravel time + Training >= £6.31 Time spent providing care in the service user’s home Includes: Travel between visits and time spent on training approved by the employer Excludes: Journeys to and from worker’s home and other ‘non-working’ time

29. Minimum Wage non-compliance: The risk factors Low rates: o Basic rates around £6.31/hour o Relying on enhancements for short visits/unsocial hours o Not changing rates for younger workers on their birthday Payment for “contact time” only: o Large amount of travel time, relative to “contact time” o Use of very short visits and/or long gaps between them Other issues: o Having insufficient records (eg. travel time) o Deductions for uniforms or accommodation provided

30. UKHCA’s NMW Toolkit Free resource for UKHCA members Based on HMRC documents, obtained under FOI 3 main sections: o How NMW works in complexity of homecare services o How to audit compliance (individuals & samples of workers) o Suggested actions to achieve/improve compliance www.ukhca.co.uk/downloads.aspx?ID=422

31. Forthcoming changes in CQC regulation & inspection New “Fundamental Standards” & regs Specialist inspectors Tougher registration and action against non- compliance, including vacant manager posts On-line “Provider Information Return” to be completed in advance “Market oversight” for largest providers Inspection themes for each service: 1. Is it safe? 2. Is it effective? 3. Is it caring? 4. Is it responsive to people’s needs? 5. Is it well-led?

32. CQC’s Quality Ratings All services to be rated by March 2016: o Wave 1 Pilot (ratings won’t be published) o Wave 2 Pilot (ratings may be published) o All other services (ratings will be published as awarded) Ratings will be: o Awarded at location level o Provided as an aggregated score & for each of 5 themes o Determined by a set of ‘rules’, however… o Inspectors have some discretion to deviate from rules

33. Worker recruitment and training A Certificate of Fundamental Care o Proposed by Cavendish Review o Possible duplication with Common Induction Standards Emphasis on recruiting for “values” o Materials from the National Skills Academy o Increasing interest in profiling workers Councils attempting to limit zero-hours contracts o If your councils do this, can you afford the Ts&Cs?

34. Care Bill Independence and wellbeing Role of Local Authorities PreventionInformation Market shaping: MPs Oversight Facilitation Single consistent route to eligibility Assessment and advocacy Personalisation Co-productionPerson centredSafeguardingPBs and PABs IntegrationBetter care fund Legal and regulatory HR and extension Criminal offence False information from providers CQC: Greater autonomy Ratings Inspections Regulations Legislation: The Care Bill

35. How to contact us Website: www.ukhca.co.uk E-mail: andrew.heffernan@ukhca.co.uk Telephone: 020 8661 8152 Twitter: @ukhca

36. Principles behind our minimum price Fees calculated solely for “contact time” Workers receive flat-rate NMW for “working time”: o Contact time o Supervision and training o Applicable travel time (and reasonable travel costs) Provider can cover: o NI, pensions, training and holiday pay o Reasonable operating costs o Acceptable profit / surplus

37. Market oversight for provider failure DH taken by surprise over Southern Cross Scope: o Councils continue to manage local failure o “Market oversight” through CQC in England o May need cross-border arrangements o Very largest providers to be covered (not franchisees) Features: o Submission of financial data and risk assessment o Scenario panning o Implementation of failure plans

38. Use of CCTV Few restrictions on use in user’s home Your duty to customers: o You do not have to ask if CCTV installed o You may decline to provide service, but not if action could be discriminatory o Users filmed without their knowledge likely to be a safeguarding issue Your duty to careworkers: o Explain the possibility of filming o Inform workers if you are aware they are being filmed (unless requested not to do so by user/family) See UKHCA’s “CCTV and the Law”

39. NHS Choices and Transparency NHS Choices (www.nhs.uk) o All CQC registered social care providers listed o Likely to become main info source for self-funders o Free advertising for your business Government appetite for transparency o Possible introduction of “Friends and Family Test” o DH want providers to publish “transparency measures” o Third party “Trip Advisor” style comments are included

40. 5 “transparency measures” for homecare services Staff stability (Low turnover) Staff qualifications Resolving complaints within agreed timescale Scheduled visits successfully undertaken Scheduled visits taking place on time

41. Minimum Wage: What you need to know NMW is averaged over a reference period o Your payment period or 1 month (whichever is shorter) “Working time” includes: o Contact time and applicable travel time o Training and supervision It is lawful (but risky) to pay “contact time” only o But you must achieve NMW over the reference period Deductions from pay and non-reimbursement of costs (eg. mileage/fares) are taken into account

42. Challenges and opportunities in homecare DemographicsPublic ImageCare BillEconomy

43. UKHCA Mission and vision StrategySector leadership Improving quality AlertsHelp Line Workshops Conferences Own Others Interest groups People and money 2,200 members 14 FTE Elected Board Membership feesSales Operating environment Standing committees Task and finish groups Campaigning Survey and reports Costing model and “Minimum Price for Care” Responses to consultation

44. Economy Dilnot caps Self funders Pension changes ? Reducing fees Sustainability National Minimum Wage Zero Hours Contracts

45. Impact of short visits Short homecare visits bought by local authorities Rushed, undignified care for highly dependent people Travel time increases as a proportion of total cost Workers dissatisfied with their ability to provide care High staff turnover drains skills & experience and increases costs Potential non- compliance with National Minimum Wage Dissatisfaction with homecare services and adverse publicity

47. INTEGRATION – PARTNERSHIPS FOR SUCCESS Terry Cotton, Executive Board Member Norfolk Independent Care

48. NORFOLK INDEPENDENT CARE Umbrella group representing hundreds of care providers Residential and Nursing Care Homes, Home Care and Day Opportunity Organisations Vision to enhance quality, develop sustainable services, share challenges and solutions

49. Challenges for Norfolk County Council budget cuts 2014 – 2017 Highest proportion of people aged 65 – 84 across Eastern Region Second highest proportion of people aged over 85 By 2033 people aged 65 – 74 expected to increase by 54% By 2033 people aged over 75 expected to increase by 97%

50. INTEGRATION Range from relative autonomy – co ordination, joint appointments, enhanced partnerships and structural integration Integration between service sectors, professions, settings, organisations and types of care (Reed 2005) Macro, meso and micro leve ( Ham and Curry 2010)

51. CURRENT PIONEERS 14 Across Country Barnsley – centralised monitoring centre Cornwall and Isles of Scilly – 15 Organisations working together Islington – CCG and Local Authority Integrated Care Organisation at Whittingdon Health South Devon and Torbay, already well integrated and working to 7 day provision

52. INTEGRATION Local Government Association Value Case for Integrated Health and Social Care Has to be person centred, actively supporting individual in co delivery of their care, removing defined boundaries between professionals and recipients to develop partnerships working towards shared goals Increased efficiency and relieve pressure on acute providers

53. Integration Critical Success Factors Friendly relationships Leadership Commitment from the top Joint Vision Joint Strategy (Petch 2011, Lesson from early adopters)

54. INTEGRATION Role of Health and Wellbeing Board Better Care Funding to drive integration – pooled budget for commissioning of integrated health and social service 2014/2015 – transfer of some £1.1 Billion in total to Local Authorities 2015/2016 - £3.8 Billion linked to achieving outcomes, including plan that meets national standards

55. BETTER CARE FUND NATIONAL INDICATORS ADMISSIONS TO RESIDENTIAL AND CARE HOMES EFFECTIVENESS OF REABLEMENT DELAYED TRANSFERS OF CARE AVIODABLE EMERGENCY ADMISSIONS PATIENT/SERVICE USER EXPERIENCE 7 DAY SERVICE LOCAL MEASURES

56. BETTER CARE FUND “ Essential for CCGs and Local Authorities to engage with providers from the outset to scope increased capacity requirements and idenify mechanisms to best address these. Work with providers will be crucial to manage the transition to new patterns of provision.” Norfolk Health and Wellbeing Board February 2014

57. SO? Norfolk HWB Board has Voluntary Sector representation none from the private Sector West Norfolk was going to be a Pioneer, but special Measures at the Queen Elizabeth Hospital was precluded, but Minister stated would still be able to engage West Norfolk has a Executive Forum, the Forum has voluntary sector representation none from Private Sector

58. Partnership Working Is there still mistrust of the Private Sector at different levels in the Public Sector? Is there a need for an open debate on this issue? Values and culture? “The dark side” Missing a big trick? People who use our service