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The future of care - round table summary

14 May 2021

Welcome to our summary of the insights gathered from our recent roundtables dedicated to the future of care.

During March 2021 we held three virtual round tables looking into various areas of the care sector from elderly care to learning disabilities and from retirement living to supported living. With over 20 attendees from various organisations operating within the sector we had representation from providers, commissioners, regulators, funders and insurers. It was a fascinating snapshot of how providers have dealt and are dealing with the current Covid-19 pandemic, to where we think the sector is heading.

Care is an extremely complex and diverse sector. The past 12 months have proven some of the most difficult in living memory, but there are many examples of genuine innovation and joint working that have helped to ensure that the sector has emerged stronger. It is beyond question that the sector and the dedicated staff within it have proved to be resilient. Issues such as the potential impact of new legislation, emerging technology and Brexit are front of mind currently, alongside challenges including staff recruitment, mandating vaccines and national pricing - all of which were discussed within the virtual round tables.

Undoubtedly, new legislation will introduce or amend existing duties for health bodies and commissioners (including local authorities and care providers). Further collaboration within the sector is inevitable and essential. The Health and Care White Paper sets out how co-working between the NHS, local authorities and independent health is increasingly necessary but other proposed legislation and approaches to regulation may have more immediate impact on providers and local authorities.

We will continue to bring our clients and wider network together to share the latest insights and experiences in defining best practice across the sector as we emerge from the Covid-19 pandemic. We hope to be able to run our next series in person.

Thank you for reading the insights we’ve set out in this summary - we welcome your thoughts and experiences in this field and we hope you find the insights as interesting as we did. Please do get in touch if you’d like to discuss any aspect further or see our website for our wider insights into the sector.

Social care in an integrated care systems (ICS) world

  • The Health & Care Bill is expected in Spring 2021, but we expect that much of the detail will follow and develop via guidance and, potentially, secondary legislation.
    • Whilst the White Paper was broadly welcomed, it may be challenging to actually implement all that it sets out to achieve before April 2022. There was speculation whether it could actually be a 2 or 3 year project before the objectives are met.
      • Attendees believe the Bill should at least give social care a greater voice in the planning of NHS services and the sharing of data. The powers of the secretary of state to make direct payments to social care providers should also assist in avoiding some of the cashflow issues experienced during the pandemic where commissioner funds were tied up elsewhere.
      • Social care has a critical role to play but there is a great deal of complexity to navigate in delivering national reform, through local authorities, in a way that respects the importance of responding to needs at the level of place.
      • At local authority level, social care has to compete with investment in such things as housing, transport and regeneration for attention and funding. In principle this could provide systems with additional levers to promote health and support care, but in practice this is difficult to implement in circumstances of constrained resource.
      • Social care can play a key role in prevention strategy planning. This has been experimented with via the Better Care Fund (albeit with constraints on use of the fund due to austerity) but there is still more than can be done, with the best implementation likely being an evolutionary, gradual change model. The discharge to assess process can also be a tool to help achieve this when the risks are managed.
      • It will be difficult to align the means tested nature of social care funding with the ‘free at the point of use’ nature of the NHS.
      • Unfortunately, the experience of our attendees of IJBs in Scotland (their bodies most akin to ICSs) has not been a positive one and they were largely cut out of the dialogue, leaving the same conversations to take place between LA and NHS figures as had always been the case. That said, attendees confirmed they have been able to achieve some positives such as a funded Scottish Carers’ Living Wage that is above National Living Wage (NLW) and applies in full from the age of 18 (rather than 25) and a better nursing bursary to make the profession more attractive for the workforce.
      • To replicate Scotland’s workforce progress in England would likely require a long-term approach with a taxation effect, albeit one that is necessary to make working in the sector more attractive than it currently is. This may need to take the form a cross-party 10 year funded social care plan and could be assisted by progress on the classification of care workers entering the UK from outside of the EU.
      • The social care market in England is very fragmented, with the top 10 operators comprising just under 20% of the market. Without a single voice representing the sector it is difficult for the government to know who connect with to drive any form of real change. Care England only represents around 27-28% of provider beds in England. Compare that to the position in Scotland where Scottish Care represents c. 85% of the sector and has been able to negotiate a national care contract with a standardised fee rate and it is clear what could be achievable.
      • That said, provider memberships in England have improved communications and discussion with LAs have shown much more mutual support and improved relations over the course of the pandemic. There still needs to be more joint thinking in these areas, however, with a mixture of national representation for bigger providers and specialists at a local level being preferable.
      • Competitive advantage has arguably been lost as consequence of capacity tracking by LAs to monitor funding since it also reflects occupancy levels which can feed into rates. The rates themselves are already below what is sustainable for most providers, with subsidy by private payors inevitable (and the same applies in Scotland despite the existence of their national contract).
      • Insurers have ‘moved the goalposts’ and changed coverage for certain events though there has not been the vast numbers of actual claims coming that many feared (though numbers are expected to increase over time).
      • It would be helpful if the Covid indemnity provided under the Coronavirus Act extended to social care or a Government backed scheme. Without that, social care continues to face greater exposure than the health service. It is felt the Secretary of State understands this.
      • Social care has a better standing in the public perception post Covid-19. There is a real opportunity to seek a greater slice of public funding whilst such support exists.
      • The increased use of technology in the delivery of health and social care at an unprecedented rate as a consequence of the pandemic has driven innovation.
      • The challenges that have been overcome show what can be achieved through focussing on doing ‘the right thing’ and sharing data.
      • The wellbeing and retention of staff post-pandemic was the primary concern. The adrenaline of rising to the challenge has kept many staff going over the past 12 months but there is a worry that there will come a time when reflection on what they have been through will hit some workers hard. It will be a challenge to pick them up and allow them the opportunity to digest, without losing them to other industries that have comparable pay without the same levels of stress.
      • Whilst it has not yet been as prominent as many feared, it seems inevitable that claims companies will drum up an increase in claims brought by service users who have contracted Covid-19 and employees who have suffered the same or have faced the mental stress of carrying on in a high pressure environment. Such claims will take up resources in terms of both time and finances (which are already limited in many cases).
      • Providers will be closely watching when the government starts to allow visitors to return to care homes. Getting the timing right, and it being safe to do so, is crucial to ensure that all the hard work is not quickly undone simply to demonstrate progress to the electorate.

      The future of care - mental health and learning disability services for the future

      • Despite the devastating effect of Covid-19 on social care, the increased funding has been concentrated on NHS acute care and the financial impacts of the pandemic make a funding solution for social care seem further away.
      • Will commissioners seek to reduce fees to take account on sleep-ins judgment?
      • Will the commitment for more mental health funding materialise?
      • There are uncertainties around staffing with Brexit effects and difficulties keeping up with minimum wage increases to attract workers from other sectors. There is a need for many more trained staff, especially nurses and psychiatrists.
      • What impact will ‘no vaccination, no job’ proposals have on the sector?
      • Legislative and Care Quality Commission (CQC) regulatory changes are not yet sufficiently clear.
      • At present all of the above and the amount of distressed businesses is creating investor reluctance, but the panel were optimistic that this would change as the pandemic eased as health and care is largely recession-proof.
      • There have been examples of great collaboration & transparency between stakeholders – true coproduction, such as between NHS England and providers.
      • Covid-19 has highlighted a variety of inequalities and therefore an opportunity to address them, including in access to care, influence and autonomy. CQC have recognised this, particularly with regard to individuals with mental health needs and learning disabilities.
      • The pandemic has brought about an increased appreciation of NHS and sense of community; the response to the pandemic has had to be societal not individual.
      • There has been an irreversible, accelerated adoption of technology, such as remote GP appointments, videos to share staff experiences and remote working.
      • There has been a renewed focus on well-being and mental health overall.
      • The government has now published the Mental Health Act white paper, setting out their plans to reform the act. If the proposals are accepted, we will see the introduction of some of the most significant changes to the existing legal framework in relation to mental health law since 1983. These include a change to the statutory criteria for detention in Part II cases, shorter detention times, widened scope of the Tribunal, changes to the consent to treatment provisions, to the nearest relative legal framework and a change to the approach for treatment of individuals with a learning disability to mention just a few.
      • A summary to the white paper can be accessed here. The white paper was published 13 January 2021. It is now subject to a 12-week public consultation which closes on 21 April 2021. There are 3 parts to the white paper: legislative reforms, reforming policy and practice, and the government response to the independent review.
      • Whilst some of the proposals were welcomed by the panel, there was general agreement that the changes proposed will need to matched by the necessary investment to provide the required supporting infrastructure (placements and work force) for the changes to be effective. This is particularly so with regards to the proposals to effectively take large numbers of people out of the MHA 1983 framework and provide care for them instead in the community (due to proposed higher thresholds for detention and changes re detention of those with a learning disability).
      • There will be likely issues with developers / funding / the land providing accommodation required and there will need to be improved joint working between social and clinical care teams.
      • There was some concern about the potential impact on patient care of some of the proposals, about the potential Impact on private providers and a possible reluctance in this context to provide services that are too commercially risky thereby leading to services closing and the “most difficult patents” being be directed to NHS services in the future.
      • The panel felt that there was a long way to go in developing effective collaboration between Care Quality Commission (CQC) and providers. However, this is lacking from the CQC’s recent strategy proposals. Hopefully the final strategy will place more emphasis on this.
      • Greater respect for the expertise of providers could form a starting point with an acceptance that, rather than acting as mentors, CQC inspectors can learn from providers as well, particularly in specialist services.
      • The CQC remains too rigid in its approach to allow barriers to commissioning to be broken down through innovation. This is particularly acute in respect of complex learning disability and autism needs, where registration rules in the community are prescriptive but in-patient providers are judged harshly when caring for individuals who should be discharged with support.
      • The panel saw the CQC’s new strategy as an opportunity for greater transparency and a leadership role for CQC in the sector, which they felt had been lacking during the pandemic.
      • Equally the benchmarking promised by CQC would be welcomed as the panel identified inconsistency in regulation as a reoccurring problem.
      • The panel welcomed the idea of increased collaboration within the system that is the aim of Integrated Care Systems and the potential for CQC scrutiny to be on those systems and commissioning as well as providers.

      Retirement living

      • So far, overall demand has been high and, in some cases, has outstripped current supply. However, demand has sometimes been uneven, with quiet periods and then “frenzies” – a strong spring is expected.
      • Viewings have been challenging due to social distancing and the sale process has been slower through the lockdowns, with some reluctance to complete during the lockdowns. This impacts cashflow.
      • Lockdown conditions have been a motivator for people to look to move to a retirement community. Isolation is one of the main reasons people consider a retirement community. Gyms, cafes, restaurants and a social life are scoring higher than healthcare at present. Stamp duty “holiday” may also have impacted demand.
      • Availability of care on site is seen as a differentiator in influencing decisions as to where to move to. Also, the ability to provide both a care home and apartments on the same site or, side by side, is attractive to some operators who deliver a hybrid model.
      • Some are more optimistic than others about whether the benefits which the sector offers are understood and recognised, and whether we will see reform of social care.
      • Those who are less optimistic think:
        • Lots of evidence has been presented already about the benefits but to no avail and that the call for a Housing with Care Task Force is the last roll of the dice;
        • Cash strapped local authorities do not have the budget for extra care; and
        • NHS reform and social care reform is just too much to deal with at once.
      • Those who are more optimistic think:
        • the Social Care Green Paper must come to something soon, although that will probably focus on short term care financing;
        • the demographics are shifting, a quarter of the population will be retired;
        • older people have been recognised as “losers” in the pandemic and there will therefore be pressure to define the older person’s offer in the next 10-15 years;
        • there will be different approaches to health pathways post pandemic;
        • there are too many elderly people trapped in a hospital setting because there is nowhere for them to go, and they need an appropriate setting with provision of suitable care and funding for clinical care where needed – allowing operators to provide clinical care is a bold decision though;
        • perception of some that local authorities think housing with care is “cheaper” than care home provision and are therefore supportive of housing with care;
        • there is significant interest in the sector from substantial investors which it is envisaged will carry influence on unlocking some of the issues which create barriers to the sector providing diversity and scale.
        • the sector may make headway by avoiding getting embroiled in the clinical care/NHS debate and instead focus on some areas “around the edge” where they may be able to gain more traction, such as planning;
        • we have no notion of the full impact of the pandemic on public finances and will not know this for some time, government policy is not necessarily linear, and breakthroughs can happen overnight.
      • Some feel this is a young or maturing market, being around 25 years behind the US who are only just getting there with the rental market. In the US where housing is less valuable and savings are worth a lot more than in the UK, there isn’t the same fear of running out of money as there is in this country. The rental market in the US took off because renters who didn’t need high levels of care didn’t want to live in a care home so looked for something else.
      • It’s a more affordable way to live and it avoids home ownership headaches. Currently it seems most suited to the oldest generation, mid-80’s. They want to realise the cash in their properties for their children or for future care and want to avoid a big move when they are older.
      • There are increasingly more people in this older group who do not need high levels of care and can live independently but are continuing to do this in their own homes. The product needs to be there for people to choose it.
      • Rental income is very attractive to investors and if this type of product was more dominant, there would be significantly more investment available to the sector.
      • The pandemic has highlighted the need to better support older people, and that retirement communities have been able to offer a safe and supported environment to those people, and helped them avoid isolation. These communities take the pressure off the health care system – they are part of the solution.
      • The demographic shift means more people falling into the retired bracket and more people living longer but with some health issues meaning they can predominantly live independently but have some care needs.
      • There are significant amounts of capital waiting to invest in the sector if schemes can be brought forward.
      • The growth in demand in the rental market.
      • Social care reform is still on the agenda. There is cross -society and cross departmental support for change to enable greater provision of housing with care for older people.
      • NHS reform at the same time as social care reform may be too much.
      • Challenges with getting a scheme out of the ground, including obtaining planning and competing with general housing developers for sites, as well as no sector specific legislation providing suitable regulation and alternative tenure models more suited to retirement communities.
      • Insufficient understanding in wider society of how retirement communities operate.
      • Pressure on public finances limiting ability of local authorities to fund care or accommodation.

      To catch up on our on-demand video, please click here to view our series of small, focussed round table discussions with providers, funders, commissioners and developers.

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