CEO Blog – Homecare market and UKHCA priorities
This is my first blog post since being appointed as permanent Chief Executive Officer of the United Kingdom Homecare Association (UKHCA) on 19 June 2019.
I am delighted to be leading UKHCA and working with our experienced team to support and represent our members. This is an important time as the UK gears up to exit the European Union and we prepare to respond to the long-awaited green paper on social care. Shortly, we will be seeking to influence the comprehensive spending review and Budget, which will determine short and medium-term funding available to social care.
Our aim is to use our blog to share news and views related to homecare, in addition to communications via our other channels.
Having been a care provider myself, and taken time in my first three months at UKHCA to meet with and listen to a substantial number of our members, I would like to share my view of the homecare market and some thoughts on our priorities for the future.
Prospects for homecare are promising
Exciting times lie ahead for the homecare sector.
People want to remain at home as independently and healthily as possible until the end of life.
Policy makers in Government recognise this and are encouraging a shift away from residential care.
Entrepreneurs see a developing marketplace for innovations to enhance quality of life and promote independence for growing numbers of older and disabled people.
The private-pay market for homecare is growing sustainably. And providers of housing, health and homecare are finding creative ways to integrate services, aligning social purpose with business success.
Whilst prospects are promising, and some parts of the market are flourishing, a number of challenges remain.
Inadequate funding for state-funded care
Historically, local councils were able to support a wide range of people’s needs, from vital preventative work through to high dependency complex care. Now, due to budget cuts, many local authorities are reduced to offering only partial support to people with even the most complex needs.
This has resulted in huge pressure on families to care for their loved ones.
Nearly half of the money that local authorities currently spend on adult social care goes on younger people with disabilities. Over the 20 years to 2040 spending on this group is expected to more than double.
Others are in their 70s and 80s themselves and caring for parents in their 100s.
A substantial proportion of the population have no children or family to support them and are totally reliant on their local communities. It is estimated that over 1m childless people over 65 are left dangerously unsupported.
Benefits of homecare
In the second episode of Panorama’s “Crisis in Care” programme, we met Pat.
After 6 months in hospital, Pat received three visits from a British Red Cross volunteer, who accompanied her shopping. After this, Pat was on her own.
When the film crew returned a few months later, the deterioration in Pat’s condition and mood was striking. BBC Social Affairs Correspondent Alison Holt wrote:
“The change from the woman walking determinedly around the supermarket is a shock. She speaks very quietly and is hard to hear. When she gets out of her chair to go to the kitchen she moves slowly, leaning much more heavily on her walking frame. She fell a few days before our visit. “I don’t want to fall,” she whispers. “It gets to a point where you are so off balance you actually do go down.””
A neighbour she used to chat to had died.
Pat said quietly:
“Occasionally, I feel like I’d like to see somebody, but there isn’t anybody who can come.”
It was a heart-breaking scene.
Pat’s story highlights the vital role that even low levels of lifestyle support and homecare can play in maintaining well-being and promoting independence.
We know that high quality homecare can improve outcomes and quality of life for people; delay or prevent admission to hospital and residential care; and save money for the health and care system.
State funding for care is, however, stretched to the point that people with low to moderate needs are now typically left unsupported.
Growth in the self-funded homecare market
Those able to pay for themselves can access high quality lifestyle support and care in their own homes from numerous homecare providers, many of which are members of UKHCA.
We have thus seen substantial growth in the self-funded market for homecare over the last decade and it is thought to amount to almost 30 per cent of all hours of care purchased. Government doesn’t collect figures on the self-funded homecare market and the total value could be even higher.
Franchise models have proved particularly successful in homecare. Some companies have expanded rapidly and sustainably, with the largest growing from zero to 200 branches over the last 15 years. Many focus predominantly on people who are funding their own care.
The state-funded homecare sector remains under pressure
Providers in the state-funded homecare market have, however, struggled to operate in a financially sustainable manner, particularly where their main customers are cash-strapped local councils.
Rising costs, due to increases in National Minimum Wage, pensions, the apprenticeship levy, regulatory fees, insurance premiums and general inflation, coupled with a squeeze on local authority fee rates, have led to providers not bidding for contracts with councils and/or handing contracts back. According to the 2018-2019 Association of Directors of Adult Social Services (ADASS) Budget Survey, over 10,500 people were affected by homecare provider failure or hand back of contracts.
Councils taking homecare services back in-house
Some councils have responded by taking homecare services back in-house, at an average cost of £32.90 per hour in 2017/2018, according to the Kings Fund.
This contrasts with the national average fee rate being paid by councils to independent providers of £16.77 per hour. This is substantially below UKHCA’s Minimum Price for Homecare, which was £18.01 per hour in 2017/2018 and £18.93 per hour in 2019/20.
Historic data from NHS Digital indicates that in-house council provision of homecare is on average 2.5 times more costly than independent provision.
Councils delivering homecare themselves appears not to be an efficient use of scarce resources.
Personal assistants and micro-providers
Other councils have responded by encouraging personal assistants and micro-providers to start up in the market.
Around 240,000 adults, older people and carers were receiving direct payments from councils in 2017. Skills for Care estimates that around 70,000 of these people were directly employing their own staff, creating 140,000 personal assistant (PA) jobs between them.
Viewed as part of an assets-based approach to community development, such models can play a valuable role in supporting people with lower dependency of need.
Some councils are, however, commissioning personal assistants purely because they are perceived to be cheaper.
In some cases, older people with higher dependency of need are taking on personal assistants to provide personal care, without realising that they are also taking on additional responsibilities as employers. Furthermore, the services provided are not subject to regulatory oversight and personal assistants may or may not have received appropriate training.
It is hard to understand the justification for regulating some providers of personal care and not others, particularly as the majority of regulated homecare agencies are also small enterprises.
The Department of Health and Social Care (DHSC) is required to review the so-called “Regulated Activities Regulations” every five years. The next review is due in 2020. UKHCA will be calling for consistency in approach to regulation across the market in England.
Registration of careworkers
Scotland, Wales and Northern Ireland have all created professional registers for careworkers and are at different stages of implementation.
In England, there is currently no register for careworkers.
UKHCA advocates for the professionalisation of the care workforce.
To achieve this end, UKHCA believes that first a workforce strategy must be developed and implemented. This would include projecting population needs for home-based support over the longer term; defining a framework for roles, qualifications, skills and competencies required to meet population needs; mapping out clear career pathways; determining education and training needs and costs; and improving terms and conditions of employment. Only then could any proposed registration of careworkers in England be implemented in a way which would support the professionalisation of the care workforce.
Seeking to introduce a register for careworkers in England, in the absence of a workforce strategy and adequate funding, could have unintended consequences.
UKHCA would not support the introduction of a voluntary register, on the basis that a voluntary register would not be effective.
If a compulsory register is introduced, after a wider workforce strategy is implemented, it needs to include careworkers in currently unregulated services, as well as those in regulated agencies to ensure a level playing field. In other areas of employment, such as child-minders and gas engineers, everyone has to be registered with an appropriate body to operate legally. This does not affect choice and control; it ensures consistent standards of training and proficiency.
In the Devolved Administrations, where registration is already in place, or is being introduced, UKHCA will continue to advise member organisations to comply with the statutory requirements in that Administration.
Role of UKHCA
UKHCA was formed over 30 years ago. At that time, there was no regulation of homecare services. Concerned to ensure quality standards, a group of providers came together to form a professional association.
Over the years, UKHCA has grown and developed. We now have over 2,000 members in all four administrations of the United Kingdom, representing a diverse range of provider types. The desire to encourage high quality homecare remains as strong today as it was when the association was founded.
UKHCA has a crucial role to play in promoting high quality homecare; disseminating best practice; encouraging innovation; enhancing public perception of homecare; helping member companies become more successful and competitive; and contributing to formulation of effective public policy and delivery.
UKHCA acts as a co-ordinated voice of business when talking to Government, regulators, the public, the media and other stakeholders, and offers value in terms of quickly disseminating messages about Government and regulatory policy to members. Productive engagement between the UKHCA and key stakeholders is vital for the policy-making process.
UKHCA also offers products and services to support members. These include technical advice and resources for setting up and running a homecare business; training and educational materials; guidance on policy change and implementation; research reports and publications; and networking opportunities, such as workshops, round-tables, and conferences.
Membership of UKHCA
Over half our members are small businesses, with 1-3 locations providing homecare. Over a third are large businesses, with 20 or more locations. The rest, less than one-tenth, are medium-sized businesses, with 4-20 locations.
Some providers are predominantly state-funded and others are funded mainly by people paying for their own care. Many providers serve a variable mix of state-funded and self-funded clients.
The majority of providers offer general domiciliary care services, whilst others deliver specialist services. The latter include housing with care; live-in care; end-of-life care; and complex care for people with physical and psychological disabilities.
Our members also vary in their stage of business development, from start-ups to mature businesses, including those preparing for sale.
Different types of members have different wants and needs at different stages of their business growth and development.
Our goal as an association is to engage effectively with our members; listen to and understand what they are saying and why; and then to deliver what our members want and need.
Strategic focus for UKHCA
Feedback from our members, regardless of type, size, or stage of business maturity, clearly reveals five issues of common interest:
- Financial sustainability
- Quality, innovation and best practice
- Public perception of homecare
These themes will be central to our work as we develop our new five-year strategy and business plan in the coming months. We will continue to seek feedback and invite members to contribute ideas to help shape our thinking.
In addition to supporting members and influencing policy makers and regulators to ensure the homecare market grows and develops in a sustainable manner, we want to turn our attention to engaging with the public.
We know that high quality lifestyle support and homecare can extend healthy lifespan and enhance quality of life for people; delay or prevent admission to hospital and residential care; and save money for the health and care system.
Improving public understanding of the benefits of homecare and how it can be accessed and funded is a key goal moving forward.
We look forward to collaborating with our provider members, commercial members, partners and other key stakeholders to enable a strong, sustainable, innovative and person-led homecare market to flourish across the UK.