Shared guidance to local authority commissioners from the Association of Directors of Adult Social Services (ADASS), the Local Government Association (LGA) and the Care Provider Alliance (CPA).
The shared guidance below was issued on 13 March 2020. Subsequently on 8 April 2020 ADASS and LGA issued a note from Ian Hudspeth, Chair of the LGA’s Community Wellbeing Board and Julie Ogley, President of ADASS to councils.
On 4 June LGA and ADASS issued the following briefing to councils: financial pressures in adult social care: information provided to the Minister of State for Care.
This guidance note - issued on 13 March 2020 - is for local authority commissioners. It is designed to summarise pressures on social care providers arising from COVID-19, and to put forward ways in which commissioners can alleviate these pressures.
This guidance comes from a shared ambition to ensure that providers are supported to maximise availability of care and support and to remain operationally and financially resilient.
This guidance does not deal with issues of infection control, which can be accessed elsewhere. The guidance also focuses on what local authority commissioners can do, in the knowledge that central government and other organisations such as CQC are also giving their own guidance and mitigation.
The guidance lists a range of pressures and actions that commissioners may take to address them. Local government makes decisions within the confines of the law and considering local factors. We describe these actions as what commissioners “can” do: our shared expectation is that commissioners actively consider all these issues and possible mitigating measures and do what is necessary to support their local providers.
The guidance deals with potential actions for commissioners, but we recognise that they will be working with their local providers on a collaborative basis to identify issues and agree actions and mutual expectations.
Commissioners will incur extra costs in meeting this guidance, and this will be a suitable use of each local authority’s share of the £5 billion announced in the Spring Budget 2020.
This is a first iteration of our guidance and has been produced quickly but in the knowledge that other issues may emerge. We would therefore expect to supplement this guidance in the light of such issues.
Collaboration and communication
Providers face a fast moving and uncertain operational environment. They will need the ability to raise issues and get answers quickly, and to be able to solve problems collaboratively, both with commissioners and with each other.
Commissioners can support collaborative working by ensuring that there is good two-way communication, so that providers can raise issues both individually and collectively. They should also ensure that all providers know where to access relevant information produced locally and nationally. They can ensure that outward communication from councils and Local Resilience Forums (LRFs) is streamlined and coherent, rather than fragmented. Where commissioners need to ask providers for updates they can do so in a “tell us once” way with regular updates.
Business Continuity Plans
Good business continuity planning assists resilience and should therefore be in place. However, this should be done in a collaborative way rather than commissioners simply demanding that care providers to submit their own Business Continuity Plans (BCPs).
Routine requests for providers’ BCPs should be avoided, unless there is an intention to analyse the plans collaboratively and offer constructive guidance. BCPs should be the starting point between providers and commissioners to identify which parts of a BCP seem robust, and which aspects need further work.
There should also be a recognition that some aspects of the plans rely on support from other organisations within the Local Resilience Forum (LRF) community.
Commissioners can also help providers by ensuring that they share their own local resilience plans, and by ensuring that providers are linked into the wider considerations and plans of LRFs, such as transport or school closures. These wider links are important, for example enabling care staff to continue to work if schools close or transport links are affected or supporting providers with supply chain resilience.
Cashflow
Invoice generation will become an increasingly complex activity. Providers will be focused on delivering support to people and managing sickness absence in their own workforce.
Homecare services
Reduced cashflow will especially impact home care providers, as they are usually expected to submit itemised invoices of hours delivered for each person. In such cases there may be a time lag of up to eight weeks between delivery of support and payment to the provider. Delays in invoicing, invoice disputes and non-payment of invoices will have a serious negative impact on providers’ cashflow.
Commissioners can mitigate this pressure by paying for homecare “on plan” (ie. The planned hours for each person receiving homecare). In the knowledge that actual delivery of support may on average be less than plan, commissioners might agree a small discount on plan, but should also recognise that many providers could be delivering additional care at short notice to people discharged from hospital, or where regular informal support ceases to be available for example due to carer illness. There can be a later reconciliation to actual support delivered.
Residential care
Cashflow can also affect care homes, and commissioners can again offer support by paying on the planned support for people in given care homes and the reconciling for any adjustments due to deaths or other factors. This is even more important as occupancy levels may become more volatile, with potentially more voids due to infection control measures possible offset by extra demand. Commissioners can agree with local care homes what level of certainty in terms of planned payments will help them through this volatility.
Retrospective reconciliation
This will need to be handled transparently and through discussion, rather than unilateral imposition. Reconciliation is appropriate when actual levels of support differ markedly from what was planned. Commissioners should be mindful of all the extra costs incurred by providers during this period, and of problems they may face in reducing variable costs in such a volatile operating environment. Providers should be mindful that, where actual support levels are significantly below plan, commissioners may have needed to fund support elsewhere.
Sick-pay
Providers face increased cost pressures due to higher sickness absence rates among their workforce: they have to pay staff Statutory Sick Pay (SSP) or make sickness payments at a higher level than SSP because they have a contractual sick pay scheme (also known as an ‘occupational scheme’), which offer workers payments above the basic minimum amount of SSP, which is £94.25 per week.
When emergency legislation is passed, employers’ liability for SSP will start at day one rather than day four, and requirements for workers to self-isolate will further increase financial pressures. Given that in virtually all cases providers will have to backfill sickness absence to ensure continued delivery of support, this represents a real cost pressure on providers.
Please note that employers are unable to reclaim payments for SSP from Government, except for some temporary arrangements announced in the Spring Budget, which will only be available to organisations with 250 or fewer employees.
Commissioners can mitigate this through funding these extra costs, either through a lump sum or through increasing the fee rate. They can assist with cashflow by agreeing a reasonable amount based on an assumed average sickness absence rate and paying upfront, rather than awaiting detailed records of actual sickness taken and backfill provided and agree reasonable and proportionate ways of later reconciliation. An assumed average rate may be informed by governmental planning assumptions but commissioners should not wait for this if it is delaying necessary financial support.
Workforce availability
Providers will face higher workforce absence rates, through medically-recommended self-isolation, sickness and family caring responsibilities. Other factors, such as the possibility of school closures, may exacerbate this issue.
Care providers will need to be able to deploy their staff flexibly and to hire new staff quickly. They will face increased cost pressures from higher use of agency staff.
Commissioners can mitigate this through recognising and funding these extra cost pressures. They can also ensure that their contracts allow flexibility for providers in hiring and deploying staff, for example allowing recruits to begin working after a DBS AdultFirst check has been obtained, rather than insisting the full DBS checks are returned before a worker can begin providing care, or by allowing staff to be deployed across different care settings or between care providers. Guidance is available from the Care Quality Commission (CQC) (paragraphs 17 and 18).
Rapid adjustment of support
Support will have to be rapidly adjusted. People will be admitted to hospital, care visits changed to meet the most urgent needs and some homecare visits will take longer due to infection control precautions and the availability of staff. Care homes may need to adjust support in order to meet changing needs and to minimise infection risks.
This means that rapid decisions will need to be taken about appropriate adjustments of care packages. It will also increase providers’ costs as it will require extra management time to make these adjustments. There is also likely to be a higher ratio of travel to contact time in home care due to the rapid reorganisation of rounds and rosters.
There are also some places where homecare contracts use electronic call monitoring (ECM) to create a system of a “pay-per-minute” billing or to round visit times into defined bands have a built in ceiling on upwards adjustment of hours, which may make it more difficult to make these rapid adjustments and ensure that providers are paid for them. “Pay per minute” also carries a significant risk of reducing the financial viability of shorter homecare visits (particularly those under 30 minutes).
Commissioners can mitigate this firstly by agreeing with their providers how to adjust packages in a timely and non-bureaucratic way, without requiring prior authorisation, but within agreed limits.
If commissioners choose to retain decision making about changes to care packages themselves, they will need to have enough staff at the right level available to make these decisions rapidly, and have simple processes in place.
Commissioners can also fund extra costs incurred from extra administration and increased travel times and visit lengths in homecare services, and for extra administration within care homes.
Infection control
Providers will face extra costs through the need for more personal protective equipment (PPE), through the need for enhanced cleaning of care home and other premises or people’s own homes, and through the need to adopt different working patterns to minimise the spread of infection, for example zoning some staff within care homes. Providers may also face greater difficulty in obtaining infection control products, PPE, handwash and disposable hand towels, due to increased demand for them.
Commissioners can mitigate this through funding extra costs and through helping providers access PPE, for example using some of their own supply chain contracts. This assistance with access to critical products may extend beyond PPE.
Any stocks of PPE or other equipment provided by central government and held by local councils should be distributed equitably between councils and the independent and voluntary sector. Councils can help this process by issuing clear instructions to their staff about how such stocks should be made available to providers who need them.
Those funding and arranging their own support (“self-funders”)
Providers have to continue to provide support to self-funders, and there is an expectation on commissioners that they have an overall picture of how the whole market is operating, rather just those providers with which an authority contracts directly. Providers may face pressures from sudden decisions by self-funders to refuse support and then refuse to pay notice periods.
Commissioners should already have mechanisms for having an overview of the whole market and should be open to discussing with providers whether there are any changes taking place that have an impact on provider operational and financial resilience.
Requests from commissioners about information from providers about people who fund their own care may be particularly sensitive and should be accompanied by clear advice on why so doing would not be a breach of the General Data Protection Regulation (GDPR).
Use of non-contracted providers
Commissioners who contract with approved providers at fixed prices may also be looking to other non-contracted providers in the local area, as demand for care and support peaks. Consideration should be given to the potential impact of paying contracted providers at a lower rate than providers which are off-framework of off-contract.
Commissioners can mitigate this though careful consideration of the prices it pays for care and the available capacity in the local market and should be mindful of longer term impact on the market if there is more use of non-contracted providers.