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Richard Hills

Domiciliary care: challenges and change

Focus continues to intensify on the domiciliary care market, which remains fragile across much of the country. It was a hot topic at the National Children’s and Adults Service (NCAS) conference in Bournemouth earlier this month, but few clear solutions were forthcoming.

The conclusion was that the market is only going to get tougher, and that councils and their health partners are increasingly going to need to find more funds to stabilise supply. These are funds many don’t have, although the Improved Better Care Fund has been used as a short-term sticking plaster and will provide some cover until 2020.

There were discussions at NCAS about the future landscape, and about how commissioners should be looking to: increase use of direct payments, and grow the market for personal assistants; make more use of telecare and digital solutions; and explore the implementation of new models (such as Buurtzorg in the Netherlands). All these were discussed as potential partial replacements to reduce the over-dependency on traditional domiciliary care. They represent medium to long term strategies that should certainly be explored – but in the short term they could serve to destabilise the market further. Commissioners are already turning their attention to the question of how to keep the immediate supply available over winter.

The average hourly rate for domiciliary care in England is £15.39 (2016/17). The UK Home Care Association (UKCA) believe that the right price to secure a stable (and quality) market would be £17.19 (only about 14% of local authorities currently pay this rate or above). Average rates across the regions vary dramatically, depending on supply and the economic make up of a region. The lowest average rate is found in the north east (£12.07) and the highest average is in the south west (£17.72).

These variations are forcing a rethink from commissioners, and many areas have started to have very different conversations with their local providers, replacing an arm’s length approach to the commissioner/ provider relationship and moving to a much more co-productive approach (similar to that which exists in health between local acute and community health providers). There is less focus on competition, which drove many of the procurement approaches used with the domiciliary care market, and there is now a wider recognition that the market is too unstable to work with in a purely transactional way.

In response, local authorities are offering direct support to their local providers in terms of recruitment drives, training programmes, open book accounting and through offering to cover the costs of DBS checks. Specifications and frameworks are also being scoped and designed with providers in the room, and new locality-based frameworks and core hours agreements are becoming more normal again – which provides good agencies with some level of certainty over their otherwise precarious income streams. ADASS are very focused on this issue and the learning coming out of these new commissioner/ provider relationships, and have produced some useful Top Tips for commissioning from the domiciliary care market.

There may not be a silver bullet, but open and transparent dialogue with your local domiciliary care supply is vital, and local authorities can underpin this new approach in their Market Position Statements to let the market know that things are changing.

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