A technical report for the research onProductivity

ADULT SOCIAL CARE

March 2019

Authors: Carol Atkinson, Sarah Crozier and Atif Sarwar, Manchester Metropolitan University Business School’s Centre for Decent Work and Productivity

The Centre for Decent Work and Productivity was established in 2018 by bringing together researchers in human resource management, organisational behaviour, strategy, entrepreneurship and diversity to think across disciplines about the future of work. Like the International Labour Organization and the United Nations, they passionately believe that all people deserve ‘decent work’. Clearly, for work to be decent it must be sustainable and, so, productive. UK policy is also deeply concerned with creating ‘good work’ and solving our productivity puzzle by making more work productive. They bring knowledge and stakeholders together to think about what causes decent work and productivity, who has decent and productive work and what can be done to shape a bright future for workers and work.

The centre comprises of a group of internationally renowned scholars and experts. With more than 25 full members, approximately 30 PhD researchers, and a range of associated academics, they are at the heart of local, national and international efforts to develop research, and engage with organisations and policy-makers, to shape the nature of decent work and productivity.

The views expressed in this report are those of the authors and, as usual, errors and omissions in this report remain the responsibility of the authors alone.

The Greater Manchester Independent Prosperity Review was commissioned to provide a detailed and rigorous assessment of the current state, and future potential, of Greater Manchester’s economy. Ten years on from the path-breaking Manchester Independent Economic Review, it provides a fresh understanding of what needs to be done to improve productivity and drive prosperity across the city region.

Independent of local and national government, the Prosperity Review was carried out under the leadership of a Panel of six experts:

Professor Diane Coyle Bennett Professor of Public Policy, University of Cambridge, and Chair of the Greater Manchester Independent Prosperity Review

Stephanie Flanders Head of Bloomberg Economics

Professor Ed Glaeser Fred and Eleanor Glimp Professor of Economics, Harvard University

Professor Mariana Mazzucato Professor in the Economics of Innovation & Public Value and Director of UCL Institute for Innovation and Public Purpose

Professor Henry Overman Professor of Economic Geography, London School of Economics, and Director of the What Works Centre for Local Economic Growth

Darra Singh Government and Public Sector Lead at Ernst and Young (EY)

The Panel commissioned studies in four areas, providing a thorough and cutting edge analysis of key economic issues affecting the city region:

• Analysis of productivity, taking a deep-dive into labour productivity performance across Greater Manchester (GM), including a granular analysis of the ‘long tail’ of low-productivity firms and low pay;

• Analysis of education and skills transitions, reviewing the role of the entire education and skills system and how individuals pass through key transitions;

• Exploration of the city region’s innovation ecosystems, national and international supply chains and trade linkages; and sources of global competitiveness, building on the 2016 Science and Innovation Audit; and

• Work to review the infrastructure needs of Greater Manchester for raising productivity, including the potential for new approaches to unlock additional investment.

A call for evidence and international comparative analysis, developed in collaboration with the Organisation for European Cooperation and Development (OECD) and European Commission, also supported this work.

All of the Greater Manchester Independent Prosperity Review outputs are available to download at www.gmprosperityreview.co.uk.

This technical report is one of a suite of Greater Manchester Independent Prosperity Review Background Reports.

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TableofContentsExecutiveSummary........................................................................................................................6

Introduction...................................................................................................................................9

WhatdowecurrentlyknowaboutworkforceandproductivityinadultsocialcareinGM?..........10

TheadultsocialcarecontextinGM.............................................................................................10

WorkforceinGM..........................................................................................................................11

ProductivityinadultsocialcareinGM.........................................................................................13

Whatcanwelearnfromnationalandinternationalapproaches?..............................................15

WhatoptionsarethereforthestrategicdirectionofadultsocialcareinGM?..............................19

Workforcesustainability..............................................................................................................19

Healthandsocialcareworkforceintegration..............................................................................21

Commissioningofoutcomes-basedcare......................................................................................22

Digitalcare....................................................................................................................................23

Productivity..................................................................................................................................24

Scalingupinnovation...................................................................................................................25

Wheredowegofromhere?.........................................................................................................26

References....................................................................................................................................29

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ExecutiveSummaryThis technical report examines adult social care provision within Greater Manchester (GM). Itinforms theGreaterManchester IndependentProsperityReview1,which in turn formspart of theevidencebaseforGM’slocalIndustrialStrategy.Itaddressesthefollowingquestion:

Howshouldwereformtheadultsocialcaresectortoprovideamoresustainableworkforceandmaximiseservicequalityandproductivity?

The technical report’s emphasis is accordingly on the funding, commissioning and integration ofadultsocialcare(ASC)andtheirimplicationsforworkforce,servicequalityandproductivity;reformofclinicalservicedeliveryisnotakeyfeature,otherthanwhereitintersectswithworkforceissues.The technical report focuses on ASC provision in the private sector. Key aspects of the technicalreportaresummarisedbelow.

WhatdowecurrentlyknowaboutadultsocialcareinGM?

GM is embarking on an ambitious programme of adult social care (ASC) transformation that hassubstantial potential to drive change. This is, however, largely predicated on existing funding andcommissioningprocesseswithwell-recognisedconsequencesforworkforcesustainability.Thiscouldbedetrimentaltothesuccessofthetransformationprogramme.

GM’sworkforcechallengesreflectthoseacrossEngland.Concernsaroundquality,recruitmentandretention are coupledwith a growing demand for careworkers, in the face ofwider competitionfromother sectors and an ageingworkforce.Urgent attention to this, especially the employmentdeal, is required to ensure high quality adult social care. ASC in GM is also labelled as lowproductivity, but this is contentious, given its delivery within a cost-constrained context and theacknowledgedintensificationforitsworkforce.

National and international models could offer further scope for GM reform. Urgent review offundingmodelsisneededandinternationalexamplesmayberelevant.Whileitisbeyondthescopeof this technical report to recommend one preferred solution, it is beyond doubt that there is a‘burningplatform’thatshouldgive impetustoactionfromlocalandnationalpolicy-makers.Thereare also important choices to be made around commissioning models and again internationalmodels offer potential shifts tooutcomes-based rather than time- and task-based commissioning.Furtheractiononhealthandsocialcareintegrationisneeded,asinGMandEngland,thishasbeenlargely process focused and limited progress has been made on budgetary and workforceintegration.

Current funding and commissioning processes, together with limited health and social careintegration, have substantial and negative implications for workforce quality, recruitment andretention.Theofferofamuch-neededenhancedemploymentdealmustbeaddressed.Approachessuchasself-managedteamsmightalsoimprovetheexperienceofworkinginASC.

In summary, substantial programmes of reform are underway in GM, but challenges to this areevidencedhereinanongoingrelianceonexistingfundingandcommissioningmodelsandthepartialintegrationofhealthandsocialcare.Thesepresentongoingchallengesforworkforcesustainability.

1 https://www.greatermanchester-ca.gov.uk/what-we-do/economy/greater-manchester-independent-prosperity-review/

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WhatoptionsarethereforthestrategicdirectionofASCinGM?

Stakeholder interviews demonstrate the enormous scale of innovation in ASC in GM.Within theconstraintsofasingletechnicalreport, it isnotpossibletocaptureallongoing innovationandthefocus here is on exemplar innovations that centre on workforce sustainability, working towardshealthandsocialcareintegration,outcomes-basedcommissioninganddigitalcare.

Workforcesustainabilitycouldbe improvedthrough initiatives includingvalues-basedrecruitment,team-based working and leadership development programmes. Aspirations that ASC work beproperly remunerated were accompanied by recognition of a multi-million funding gap andpessimismastothelikelihoodofsubstantialimprovementinemploymenttermsandconditions.

Further integration of health and social care affords opportunities such asmulti-disciplinary teamworking, rolere-designand integratedapprenticeships.Overall,progressonmeaningfulworkforceintegrationappearstobesomewhatlimited,althoughsmall-scalepilotsoutlinedheredemonstratesubstantialopportunityforrolere-designandtheofferofmorehighly-skilledcareerpaths.

Outcomes-basedcommissioning isbeing trialled insomeareaswithpositiveearly signs.Therearetwo key challenges: first, the increased funding required and second, cultural resistance, fromproviders,staffandcarerecipients.Asubstantialamountofongoingworkisneededtodeliverthepotentialbenefits.

Digital care is again being trialled. Despite pockets of highly innovative practice, technologicalinnovationinthesocialcaresectorissubstantiallybehindthatinthehealthsectorandisanareaforfurtherdevelopment.

Insummary,GMisexperimentingwithhighlyinnovativepracticeandfurtherinvestmentcouldreapdividends,butcurrentprocessescouldposesubstantialbarrierstosuccess.Mechanismstosupportscaleupofsuccessfulinitiativesareneeded.

Wheredowegofromhere?

Funding

ThereappearstobewidespreadagreementthatthecurrentASCfundingsystemis‘broken’andthaturgentreformisneeded.ReducingdemandforASCanddeliveringcostandotherefficiencieswillbean important part of this. However, for the system to truly function effectively it must beunderpinnedbyanappropriatefundingmodel.Anumberofoptionsarepresentedinthetechnicalreport.

Commissioning

Followingdevolution,GMhaspromotedperson-andcommunity-centredapproaches(PCCA)tocaredelivery. These focus on delivering outcomes that are important to care recipients and underpinimproved care quality. These approaches also offer improved job satisfaction to care workers,contributing to building a stable workforce. Changes in commissioning processes that focus onoutcomesareunderwaybut at early stages andwill require additional funding.Options are againpresented.

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Healthandsocialcareintegration

Thedevolutionofhealthcarebudgetsin2015createdtheopportunitytoaccelerateintegrationofhealth and social care inGM. Itwould appear that this hasbeenmore successful on some frontsthan others, with reasonable progress being made on processes, some progress on budgetaryintegration, but limited progress on workforce integration. Further integration is necessary,particularlytodirectincreasedfundingtoASCandaddressthepoorimageofworkinginthesector.Anumberofoptionsaresuggested.

Workforce

Low pay and other poor employment terms and conditions coupled with the negative image ofworking in social care have created substantial labour shortages inASC. This is despite careworkbeing an intrinsicallymeaningful occupation that can deliver high job satisfaction. Given that fullworkforce integration isunlikely in theshort term,othermechanisms toaddressworkforce issuesaresuggestedthatcentreonimprovingboththeemploymentdealandthestatusofASCwork.

Digitalcare

There are pockets of advanced practice in digital transformation in GM, but these appear to belimitedascomparedtodigitalhealthinnovations.Developmentsaresuggested.

The challenges inASCare variedand complex.Addressing themwill require a co-ordinatedeffortacrossarangeofstakeholdersandtheoptionsoutlinedaboveofferastartingpointforthisprocess.

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IntroductionThis technical report examines adult social care provision within Greater Manchester (GM). Itinforms theGreaterManchester IndependentProsperityReview2,which in turn formspart of theevidencebaseforGM’slocalIndustrialStrategy.Itaddressesthefollowingquestion:

Howshouldwereformtheadultsocialcaresectortoprovideamoresustainableworkforceandmaximiseservicequalityandproductivity?

The technical report’s emphasis is accordingly on the funding, commissioning and integration ofadultsocialcare(ASC)andtheirimplicationsforworkforce,servicequalityandproductivity;reformofclinicalservicedeliveryisnotakeyfeature,otherthanwhereitintersectswithworkforceissues.ThetechnicalreportfocusesonASCprovisionintheprivatesector.

The technical report has three sections. First, it provides an overview of the current state ofknowledge on ASC in GM and then draws on national and international evidence to consideralternativeapproaches.Second, itpresentsa rangeof stakeholderviewson innovations to informstrategic direction in Greater Manchester. Drawing these together, it presents a series of policyoptions.

2 https://www.greatermanchester-ca.gov.uk/what-we-do/economy/greater-manchester-independent-prosperity-review/

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What dowe currently know aboutworkforce and productivity inadultsocialcareinGM?ASC comprises a range of services and support that enables older people, those with learningdisabilities,mentalhealthandotherneedstoliveindependent,highqualitylives.Asthepopulationagesandmoreadultslivewithlong-termconditions,demandforASCservicesisrisinginexorably,asare associated costs. As a result, existingmodels of care aredeemed tobeunsustainable (ADASSNW,2018b).ProvisionandreformofASCisthuscentraltopolicydiscussions,locally,nationallyandinternationally (Malley et al., 2012), with particular emphasis on shifts to home-based care as ameans to more effectively support (fewer) people (ADASS NW, 2018b). While sharing the sameconcern of providing high quality care, social care systems around the world are organiseddifferently. ASC provision in GM is first discussed, before considering alternative national andinternationalmodels.

TheadultsocialcarecontextinGMASCinGM,alongwiththerestofEngland,isprovidedbylocalauthorities.AcrossGM’s10boroughs,local authorities offer in-house, short-term re-ablement ASC services andmost of the remaining,ongoing provision is commissioned in the independent (private and voluntary) sector. Theindependentsectorthusprovidesaround80%ofASCinGM.Provisioncomprises:

• residentialandnursinghomes,withGMprovidingnearly18,000bedsthatoperateat90-100%ofcapacity

• domiciliary(athome)care,whereGMcurrentlysupportsover26,000residents• learningdisabilityservicesforover7,400people(GMCA/NHSinGM,2018).

ThecommissioningofASCintheindependentsectorfollowsa30yearprogrammeofmarketisationin theUKpublic sector.Marketisationwas intendedtoenhancecarequalityand improve itscost-effectiveness, yet across an extended period of austerity, substantial concerns over quality havegrown as funding has failed to keep pace with the demand for ASC.Most care is commissionedthroughframeworkagreements,whichseektoassureproviderquality,andprovidersthentendertodelivercare.Careservicesarepredominantlycommissionedonapay-when-usedbasisusingatimeand task approach, rather than a block basis, and this creates instable funding streams3. Further,financialpressuresconstrain fundingrates; indomiciliarycare, forexample,GMratesaretypicallybelow the UKHCA-calculated hourly cost delivery of £18.01 (UKHCA, 2018). There isacknowledgementatnationallevelofsystemicpressuresandGMsimilarlyrecognisestheenormousstrainoncommissioningarrangementsinthefaceofunsustainablefundingconstraintsandinstablemarkets (GMCA/NHS inGM,2018),whereproviderwithdrawalorthehandingbackofcontracts ismarkedlyincreasing(ADASSNW,2018b).

Acknowledgingthesepressures,anASCtransformationprogrammehasbeenestablishedinGMthatcomprisessixpriorityworkstreams:

• Livingwellathome(domiciliarycare):aimedatstabilisingamarketwithhighqualityprovidersandreducingoff-frameworkpurchasingofcareservices

• Residentialandnursingcare:improvingqualityofcaredeliveryandlinkstoprimarycare

3 Current pilots of alternative commissioning models are discussed below

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• Learningdisabilities:improvedcarequalityandsupportintoemployment,betterfamily-basedcareanddata-ledcommissioning

• Supportforcarers:offeringsupport,recognisingexpertiseandenablingeducationalandemploymentaspirations

• Workforce:recruitment,developmentandretentionofskilledcareworkers• Supportedhousing

Theaspiration isto improvesupportto livewellathome,thusreducingneedfortraditional, long-termresidentialandnursingcare.GMisalsoparticipatinginTeachingCareHome/InstituteofCareprogrammesoperatingatnationalandboroughlevels.Asevidencedinalaterstakeholderinterview,workforce iscritical toeffectivedeliveryofASCandhasrecentlybecometheprimary focuswithintheASCtransformationprogramme.Itisaccordinglyakeyaspectofthistechnicalreport,withagainemphasisonthoseworkingintheprivatesector.

Traditionally, health and social care in GM have been separately managed. Following the 2015devolutiondeal,however,GMbecameresponsibleforits£6bnspendonhealthcareservices,whichcreatedopportunityforgreaterintegrationofhealthandsocialcaretodelivermoreefficient,higherqualityservices.LedbytheHealthandSocialCarePartnership,GMisnowdevelopinganIntegratedCareSystem4andeachofthe10localities isestablishingaLocalCareOrganisation.Hereallhealthand social care servicesoutside theacute sector areorganisedbyneighbourhood. Eachof the10boroughs has teams that comprise medical, nursing and social care leads. Each borough isapproaching its governance arrangements independently and the degree of integration varies. InSalford,forexample,formerlocalauthorityworkershavebeentransferredintotheemploymentoftheClinicalCommissioningGroup,whereas separateemploymentarrangementscontinue inmanyother boroughs. Front-line care workers across all boroughs however, remain predominantlyemployedintheindependentsector.Itisalsoworthnotingthatthebulkofhealthandcarebudgetsare separately managed with relatively small proportions pooled, although again the extent ofintegrationvariesbyborough.

GMpromotes outcomes- andperson- and community-centred approaches5 (PCCA) or asset-basedapproaches to commissioning (ADASSNW, 2018a). These have been particularly successful in theWiganborough.6Here,outcomesareagreedbycareproviders in conjunctionwith care recipientsand their families and services are co-designed and co-delivered (Burns et al., 2016). The ASCworkforce is central to this and these approaches to commissioning are considered here to theextent that theyare relevant to theworkforce.Carers7,unpaidandusually familyand friends,arecentral toasset-basedcommissioning: thereare280,000 inGM,andtheir support isoftenpoorlyrecognisedandco-ordinated(GMCA/NHSinGM,2018).Addressingthesecommissioningchallengesaffordssubstantialopportunitytoimproveservicequalityandproductivity.

WorkforceinGMSuccessful delivery of ASC depends upon the workforce and their abilities, meaning it is vital tounderstand skills, size and structure (Hitchcock et al., 2017).Workforce sustainability in GM is a4 https://www.england.nhs.uk/integratedcare/integrated-care-systems/ 5http://www.gmhsc.org.uk/wp-content/uploads/2018/04/GM-Partnership-Commissioning-Strategy-FINAL-web.pdf 6 https://www.scie.org.uk/future-of-care/total-transformation/blogs/the-wigan-deal 7 Carers are beyond the scope of this technical report, other than later consideration of their contribution to productivity calculations, as the focus is predominantly on the front-line ASC workforce.

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significantissue,againreinforcedinlaterstakeholderinterviews.Keychallengescompriseworkforcequality, recruitmentand retention (ADASSNW,2018b).Central to thisarebothpooremploymentconditionsandthenegativeimagethattypicallyattachestocarework.Theseareparticularconcernsintheprivatesectorworkforce,oftenasaresultofcommissioningpressuresoutlinedabove.Herecare workers experience much less favourable employment than those in the statutory sector,where localgovernment termsandconditions typicallyapply.Privatesectorcareworkersarealsousually paid less than those in the voluntary sector, as providers here are often able to focus onbetter-paidtypesofcarepackagethatalsoofferlongervisittimes.

InGM,front-linecareworkernumberstotal64,000(SfC,2018),50,000ofwhomareemployedintheindependentsector(GMCA/NHS_in_GM,2018).WhilelowpayisafocusoftheProsperityReview,andindeedpayratesaretypicallyatoraroundtheminimumrequired,othertermsandconditionsofemploymentareequallyproblematic.Forexample,around20%of frontlinecareworkers,more indomiciliarycare,areemployedonzero-hourcontracts.SfC(2018)analysisindicates:

• Only50%ofcareworkersholdaLevel2qualification• Lengthofserviceis5yearsinroleand8yearsinthesector• Highturnoverrates,especiallyfornewstartersandthosenewintoASC(usuallyaroundone

thirdofnewstarters)o Turnoveris24.3%,whichisslightlylowerthanrateforEnglandat27.8%,andvaries

byboroughfrom18.7%to36.1%.Stakeholderinterviewsindicatethatsomeoftheboroughvariationmaybeduetodatacaptureissuesratherthanlowerturnover

• Highvacancyratesof5%,againsttherateforEnglandof6.6%,withagainboroughvariationsfrom2.2%to8.1%.

Qualification rates and levels reinforce the low-skilled perception of the sector. Carework is not,however, low in skill, rather this label applies as the workforce is over 80% female and care isconsideredtobe‘women’swork’(AtkinsonandLucas,2013).Itisanimportantpointtoaddressandinitiatives to offer workforce development and raise its status are integrated into Teaching CareHomeandInstituteofCaremodelsthattargetwiderASCreform.Workforcemakeupis90%British,3% EU and 7% non-EU (SfC, 2018). This suggests that Brexitmay be less of an issue in GM thanelsewhereinthecountry,althoughstakeholderinterviewsindicatethattheuncertaintyitgeneratesisneverthelessacauseforconcern.Thesectorisalsoover-reliantonolderworkerswhich,coupledwithbeingfemale-dominated,suggestsalackofdiversityintheASCworkforce.Thisisproblematicasitagainreinforceslow-statusperceptionsoftherole.

Pooremployment termsandconditions raisequestions forworkforcesustainability,particularly intheprivatesector.TheSfC(2018)report,forexample,demonstratesthat,inGM,turnoverislowerwhererelevantqualificationsareheldandforthosewithlongerservice,higherhourlypayratesandguaranteed-hours contracts and for olderworkers. At national level, the key role of employmentconditionsonrecruitmentandretentionhasalsobeenevidenced(Atkinsonetal.,2018).Recognisingthis, GM has established a ‘workforce deal’ for its domiciliary careworkforce, for action by bothcommissionersandproviders(KPMG,2018).It isaspirationalandvoluntaryforlocalauthorities,itskeyelementscomprising:

• flexibilityandbenefits:salariedemployment,paidtraveltime,bankholidayuplift• training:12weekspaidtraining,inductionandbuddying,basicskills,apprenticeshiplevy,• supportandprogression:apprenticeshipsandaccreditation(age-dependent)

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• perception,leadershipandrecognition:whereperceptionincludesmessaging,brandingandsupporttocreateapositiveimage,values-basedrecruitmentandeducationlinkstopromotecarework;strongleadershipisrequiredbykeystakeholdersincludingtheMayor;andrecognitioniscreatedviaeventsandpromotionofASCachievements

Additionally, the deal should offer interest free loans for driving lessons and costs and a winterpressuresuplift.Thecalculatednetoutlayofthesemeasuresis£15mover3years,withanetbenefittoprovidersofc.£5m. Ifeffective, itwouldunderpintheapproximately30%increase involumeofdomiciliary care needed (KPMG, 2018). Funding constraints have, however, meant that theworkforce deal has not yet been fully implemented and GM’s transformation programme isoperatingwithinacontextofpoorqualityemploymentfortheindependentcaresectorworkforce.

GM’sworkforce challenges reflect those across England and the rest of theUK. Concerns aroundquality,recruitmentandretentionarecoupledwithagrowingdemandforcareworkers,inthefaceofwidercompetition fromothersectorsandanageingworkforce (SfC,2018).Urgentattention tothisisrequiredtoensurehighqualityadultsocialcare.

ProductivityinadultsocialcareinGMGreaterManchester Combined Authority’s (GMCA) ‘Low pay and low productivity briefing note’8positionedsocialcareasalowproductivitysector9,withaGrossValueAdded(GVA)forhealthandsocialcareof£31,000.Thenationalfigureforadultsocialcareseparatelyis£19,700(SfC/ICF,2018).Whilebothare indicativeof lowproductivity, this isa contentious label forASC,given itsdeliverywithinacost-constrainedcontextandtheacknowledgedintensificationforitsworkforce.AlternativemeasuresthatmightbetterreflectthevalueofsocialcarearepresentedseparatelyinathinkpiecebytheMMUDecentWorkandProductivityResearchCentre.10

ThebroadercontextisoneinwhichGMhaslowcommissioningratesascomparedtoboththerestof theNorthWest (ADASSNW,2018b) and to England, particularly in relation todomiciliary care(UKHCA,2018,Figure1).

8 https://www.greatermanchester-ca.gov.uk/info/20175/research/140/low_pay_and_productivity 9 Sectors at/or around £30,000 GVA per employment are categorised as low productivity 10 https://www2.mmu.ac.uk/decent-work-and-productivity/

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Figure1:DomiciliarycareratesinEngland

Source:UKHCA(2018)Aminimumcostofhomecare

At£450perweekforresidential/nursingcareand£164perweekfordomiciliarycare,GMratesarethe lowest in the North West. Given the substantial anticipated growth in ASC costs, increasedfinancial pressures and provider withdrawal are a substantial concern. ADASS NW (2018b) alsoquestions theextent towhich low fees andpoorquality are linked.October 2018 figures suggestthat 70% of care home have received a good or outstanding CQC rating with the figure fordomiciliarycarebeing86%.Whilethisisanupwardstrajectory,ADASSNW(2018b)hascautionedonemerging problems in maintaining these quality improvements. Certainly, other research hasdemonstratedtherelationshipbetweenlowcommissioningratesandpoorqualityoutcomes,oftenviathepooremploymentofferandrecruitmentandretentiondifficultiesthatresult(Atkinsonetal.,2016;Moore,2017;Grimshawetal.,2015).

Emphasis on productivity can also have negative consequences for care delivery. Formany years,commissioninghasbeenbasedontimeandtask,creatingoutcomesindomiciliarycaresuchasveryshortvisitsof,forexample,15or30minutes.Whileinonesensethisisaveryproductiveuseoftimeandresource, it isneverthelessdetrimental tocareworkerandcarerecipientexperiences.Recentresearch, forexample,hasdemonstratedthatzero-hourscontractsandshortvisitsareparticularlyproblematicforsubjectivedimensionsofcarequality(AtkinsonandCrozier,Forthcoming).Thisbegsthe question about the balance between efficiency and quality in ASC. Commissioners areincreasinglyexperimentingwithdifferentapproaches,apointreturnedtoinstakeholderinterviews,butspotpurchasingonframeworksprevailsoverblockpurchasingofcareinmanyboroughs.

To summarise, GM is embarking on ambitious programme of ASC transformation that hassubstantialpotential.Thisis,however,predicatedonexistingfundingandcommissioningprocesseswith well-recognised consequences for workforce sustainability. These factors could well bedetrimentaltothesuccessofthetransformationprogramme.

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Whatcanwelearnfromnationalandinternationalapproaches?TheASCterrain ishugeandcomplex.Accordingly, thissectionconsiders issues thatpertain to thetechnicalreportbrief,lowpayandproductivity,anddrawsonevidencebeyondGM.Inparticular,itexamineskeyaspectsofcareprovision,thatis,funding,commissioningandintegration(Gorietal.,2016)andconsiderstheirimplicationsforworkforcesustainability.

Takingfirstfunding,theGMcontextoutlinedabovelargelyreflectsEngland’sliberalwelfaremodelthat operates a local, marketised and means-tested system for adult social care (Petersen andHjelmar,2014). Localauthorities commissioncareand funding is locallygeneratedviaCouncil Taxreceipts. In the face of substantial funding pressures, local authorities have, since 2016, beenpermitted to chargea small Council Taxprecept that generates additional funding ring-fenced forASCprovision.AdditionalfundingisalsoprovidedonanadhocbasisbycentralGovernment,as inthe October 2018 budget, in an attempt to relieve pressures. These funding mechanisms aresuggestedtobeinadequateand‘stickingplaster’innature,withlonger-termsolutionsneeded.LGA(2018) confirms thatmany of the issues faced in GM are reflected across England and other UKnations e.g. Wales (Atkinson et al., 2016), Scotland (Cunningham, 2016) and internationally incountriesthathaveadoptedamarket-ledapproach(e.g.US,Australia,CanadaandJapan).

ThereiswidespreadagreementontheneedforreformtoEngland’sASCfundingmodel,butpoliticalpartiesofallpersuasionshave failed toaddress thisanda long-overduegovernmentGreenPaperhasbeenfurtherdelayed.ArecentLGA(2018)GreenPapersuggestspayingprovidersafairprice(toinclude inflationary pressures and increasing demand) and introducing a cap on care recipientcontributions and a more generous lower threshold on the means test. Options suggested forfunding this include: taxeson income (tax,NI, council tax), onpropertywealth, and cuts tootherpublicspending.AllthisispredicatedoncontinuationofalocalmodelandtheLGAGreenPaperalsoquestionswhattheroleoflocalgovernmentshouldbe.Thisreflectswiderconcernsoverthelimitsof local approaches from nations that have adopted national fundingmodels (Amin-Smith et al.,2018).TheNetherlandsandmostScandinaviancountries, forexample,haveadoptedstate-fundedwelfare system models (Alders et al., 2015; Kroger and Bagnato, 2017). In line with their socialjustice approaches, care is universally available and free at thepoint of use. Costs are, however,rising given growing demand and some services have been cut in the face of increasing financialpressuresin,forexample,Denmark,FinlandandIceland(KrogerandBagnato,2017).InEnglandandGM, there isunlikely tobe thepoliticalappetite toadopt thismodel,especiallygiven thescaleofcostpressuresintheNHS,whichreliesuponasimilarmodel.

An interesting alternative is Germany’smodel11, introduced about 20 years ago following a crossparty initiative on a series of reforms when the country was facing similar issues to England.Responsibility for social care was transferred to national government and a collective socialinsurance scheme established. Here workers, retired people and employers contribute and allmoneyraisedgoesintoaring-fencedfundusedforadultsocialcare.Accesstosocialcareisonthebasisofassessedneed,ratherthanmeans-tested,butonlybasicneedsarecoveredsosomeprivatefundingmaystillbeneeded.Costcontrolhasbeenmanaged,withsofarsmalltaxincreasesdespite

11http://www.if.org.uk/2018/03/27/englands-social-care-crisis-germany-answer/;http://blogs.lse.ac.uk/politicsandpolicy/german-approach-to-long-term-care-funding/

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expansionofcover,butthereareofcourserisksof future increasesasdemandgrows.Mandatoryinsurance to cover social care costs has also been introduced in other countries includingNetherlands, Sweden, France, Japan, though many have again experienced financial pressures(Robertsonetal.,2014).

Fundingisacontentiousandcomplexmatterandthereisnosinglemodelthataddressesallissues.Current GM/English approaches have, however, created unstable provider markets with, forexample, a growth in handing back of contracts as these become uneconomic for independentproviders(LGA,2018).Fundingpressureshavealsohadsubstantialimplicationsforcarequality,witha number of high profile scandals, and also for workforce quality, recruitment and retention(Atkinson et al., 2016). Urgent reform is clearly needed. While it is beyond the scope of thistechnical report to recommendonepreferredsolution, it isbeyonddoubt that there isa ‘burningplatform’thatshouldgiveimpetustoactionfromlocalandnationalpolicy-makers(e.g.DromeyandHochlaf,2018).

While debates exist as to national versus local funding, there is general consensus that localcommissioning is essential tomeeting local need. Clearly funding has substantial implications forcommissioning practice and financial pressures over recent decades have led, acrossGMand therestofEngland,toemphasisoncostefficiencies.Time-andtask-basedcommissioninghasresulted,withpracticessuchveryshortvisitsfordomiciliarycarerecipientsbeingseenashighlyproductive,despitenegativeeffectsonbothworkersandcarerecipients.ElsewhereintheUK,therehasbeenaregulatoryshift tooutcomes-basedcaree.g.WelshGovernment (2015),althoughthis is in tensionwitha continuanceof time- and task-based commissioning (Atkinsonet al., 2016).Across Europe,asset-based commissioning is also being promoted as part of moves to de-institutionalise adultsocialcareanddeliveritinthecommunity(Deusdadetal.,2016;Colomboetal.,2011),e.g.ashiftfrom residential to domiciliary care in Netherlands (Alders et al., 2015). It is considered a cost-effectivewaytodelivercarein,forexample,CanadaandJapan(Parketal.,2014;Tsutsui,2014).Thisformofcommissioning involvesoutcomesbeingagreedbycareproviders inconjunctionwithcarerecipientsandtheir familiesandservicesbeingco-designedanddelivered. Itdoes,however,placegreaterdependenceoneffectivedomiciliarycaresystems,manyofwhichareincrisis.Italsoraisesquestionsaboutformalversusinformalcareandagainthereisadifferentbalanceacrosscountries.Scandinavian countries relymainly on formal care and informal care is a choice not anobligation(Aldersetal.,2015;KrogerandBagnato,2017).ThisfundamentallydiffersfromtheliberalwelfarearrangementsoftheUK,AustraliaandnewZealand(PetersenandHjelmar,2014)whereincreasingeligibilitythresholdsforce informalcare (Atkinsonetal.,2016). There isalsosubstantialemphasison informal careas it is seen tobe costeffective (HegerandKorfhage,2018), although increasedlabour market participation of women (who traditionally deliver informal care) makes relying oninformalcarerisky,asdoestheeconomicdis-benefitoftheirabsencefromthelabourmarket.ThisisdemonstratedinthediscussionofhowtomeasurethecontributionoftheASCsystem.Clearlythereareimportantchoicestobemadearoundcommissioningmodelsandalaterstakeholderinterviewpresents apilotwithinGM that emphasises asset-based commissioning and supports thiswith anadaptedfundingmodel.

Integration of health and social care systems, accounting for all of a care recipient’s needs, isfundamental tooutcomes-basedcare.Therearehowever, inmostcountries, structuralbarriers tointegration,includingleadership,governanceandIT(Schlaefferetal.,2017).Whilethishasbeenthe

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focus of substantial attention in GM and England, integration has been largely process focused.More limitedprogresshasbeenmadeonbudgetaryandworkforce integration.ScotlandhasseenmorestructuralintegrationwithitsHealthandSocialCareBoardsandsupportforcommunity-basedintegrated care teams (Baird et al., 2014). These have streamlined processes and reducedduplication,butworkforce integrationhasbeen limited topublic sectorworkersandcareworkerscontinue to be employed in the independent sector. Internationally, integration is also processratherthanworkforcefocusedandhugechallengesremaininthisextremelycomplexmatter.

Funding, commissioning and lack of integration have had substantial implications forworkforcequality, recruitment and retention (Rubery and Urwin, 2011; Cunningham, 2008). Independentsectorprovidershavetransferredriskfromlowandunstablefundingstreamstotheworkforcewitha ‘race to the bottom’ in employment terms and conditions. Further, terms and conditions varywidelyacrossthepublicandindependentsectorswithcareworkerstypicallypreferringtoworkforlocal authorities or even to move into healthcare roles, both of which offer better pay andassociated conditions. Even within the independent sector, voluntary providers pay more thanprivateones,leavingthelatterstrugglingtoattractworkers.Termsandconditionsarethuscentralto the ASC workforce crisis (Rubery et al., 2011; Rubery et al., 2015; Grimshaw et al., 2015;Cunningham et al., 2014), with evidence that improving these can improve recruitment andretentionandpositivelyimpactcarequality(Atkinsonetal.,2018;Atkinsonetal.,2016;RuberyandUrwin,2011).ThislogicunderpinneddevelopmentofGM’sWorkforceDealand,whilethismaynotyetbeaffordable,thereareothernationalandinternationalsolutions.

In the UK, Unison has introduced an Ethical Care Charter. This is voluntary but invites localauthorities to adopt it within their commissioning and framework agreements to improveemployment terms and conditions. A recent evaluation indicated use of the charter was largelypositive indeliveringbetterpayand jobsatisfaction,reducingturnoverand improvingcarequality(Moore, 2017). There are, however, cost implications to its adoption and thus far, in GM, onlyManchester City Council has signed up to the Charter12. Increased funding is again likely to beneededtosupportwidespreaduptakebut is, in isolation,unlikelytobesufficient.Grimshawetal.(2015)demonstrate,forexample,thatonlyasmallproportionofincreasedfundinggoestoimprovepay and other terms and conditions. In amarketised system, regulationmaywell be required toestablish a floor of employment terms and conditions.WelshGovernment actedon thiswhen, inspring2018,itintroducedregulationthatprovideddomiciliarycareworkerswiththerighttorequestguaranteedhourscontractsafter3monthsemployment.Whilepositive,widerreformisalsoneededasMoore(2017)hasdemonstratedthatcareworkersareconstrainedintakingupguaranteedhourswheretheseareinflexibleduetoboththeircaringresponsibilitiesandthewiderwelfaresystem.

Trainingandcareerpathsareimportanttoworkforcequality,recruitmentandretention.InEngland,integratedhealthandsocialcareapprenticeshipshavebeenadvocatedasameans todeliver this,although independent providers have expressed concerns that they will be a training ground forother sectors. Indeed,ADASS_NW (2018a) promotes these as a bridge tonursing careers. Lackofworkforceintegrationisagainproblematicand,whilethisisexperiencedinternationally,practiceinGermany and the Netherlands could offer food for thought. In Germany, there is a ‘ two tier’workforcemodel(Gospel,2015).Oneishigherqualified,offeringimprovedstatusandalsoacareerpath from the lower-qualified role. In the Netherlands, a model of team-based working called12 http://www.unisonnw.org/manchester_city_council_commits_to_unison_ethical_care_charters

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Buurtzog,whichmeans‘neighbourhoodcare’13,hasbeendeveloped(White,2016).Buildingontheconceptofasset-basedcommissioning, thisoffersworkers theautonomytomakedecisionswhilstworkingcloselywithpatients,takingintoaccounttheiremotional,physicalandpsycho-socialneeds.Itprioritisesrelationship-basedpractice, improvingcontinuityofcareascomparedtoatask-basedtraditionalmodel(NandramandKoster,2014).Itsteam-basisoffersaneffectiveandefficientwayofdeliveringcare(MonsenanddeBlok,2013)thathasimprovedcosteffectiveness,enhanceduserandstaffsatisfaction(White,2016)andreducedburnout(Grayetal.,2015).Whiledevelopedinitiallyfornurses, ithasbeenextendedtosocialcareandservesto improve jobsatisfactionandoffercareerprogression, in what should be intrinsically meaningful work but which is often dominated byproblematic employment practices. Buurtzog reduces the bureaucratic pressures and obstacles oftraditionalhealthcaresystemswhichcanreduceproductivity(Genowskaetal.,2017).TheBuurtzogmodelhasbeenusedwithsomesuccess(Drennanetal.,2018),althoughtherehasbeenlittleformalevaluationand it facesdifficulties inhighlybureaucratic environments. Therehas alsobeen somecriticism of its claims to bemore cost effective. A study conducted by KPMG showed that whenadjusted for other costs,money spent per patient byBuurtzorg teamswas equivalent of nationalaverage(Grayetal.,2015).Itmay,however,bebetterqualitycareisofferedalbeitatasimilarcost,intandemwithimprovingemploymentqualityandalleviatingrecruitmentandretentiondifficulties.

In this section, the position of ASC in GM has been outlined and alternative national andinternational models presented. Substantial programmes of reform are underway in GM, someexamplesofwhicharepresentedinthefollowingsection,butchallengestothisareevidencedhereinanongoingrelianceonexistingfundingandcommissioningmodelsandthepartialintegrationofhealthandsocialcare.Thesepresentongoingchallengesforworkforcesustainability.

13 https://www.buurtzorg.com/about-us/buurtzorgmodel/

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What options are there for the strategic direction of adult socialcareinGM?ThissectiondiscussesfuturestrategicdirectioninASCinGM.Seveninterviewswereconductedwithacross-sectionofstakeholders14andtheenormousscaleofinnovationwithinthesectorisapparentfromthissmallnumberalone.Withintheconstraintsofasingletechnicalreport,itisnotpossibletocapture all ongoing innovation and it is recognised that there will be transformation work notreported here. Accordingly, this section has three aims: first, to report exemplar innovations thatmightbeappliedelsewhere;second,torecognisethelimitationsof innovationthatoperatewithincurrentfundinganddeliverymodels;andthird,tooutlinethewell-recognisedconstraintsofscaling-up‘bottomup’innovationandconsiderhowthesemightbeaddressed.Innovationsreportedcentreon workforce sustainability, working towards integration, outcomes-based commissioning anddigitalcare.StakeholderviewsonproductivityinASCarealsopresented.

WorkforcesustainabilityThepressingneedtoimproveemploymentconditionsasasourceofgreaterworkforceengagementwith innovation and improvements in care quality is well-recognised (Rubery and Urwin, 2011;Dromey and Hochlaf, 2018). All stakeholders here emphasised deep concerns around workforcequality,recruitmentandretention.Indeed,aHealthandSocialCarePartnership(HSCP)stakeholderindicatedthat inrecentweekstheworkforcepackageofthetransformationprogrammehadbeenmadethekeypriorityandsuggestedthatgovernancewouldbeshapedaroundit.Thiswasdrivenbyacrisisinlaboursupplysoextremethatsomeproviderswereunabletotakeoncarepackages.Careprovidersconfirmeditwasthesinglebiggestissuethattheywrestledwithonadailybasis:

Inthegeneralcareworkforce,therearehighvacancyratesandhighturnover.Year1isthehighest.Ifpeoplestayformorethan3years,theytendtostay….Westruggletorecruit,butifwedon’t[also]tackleretention,it’saproblem.

Employment terms and conditions, coupledwith the image of carework,werewidely held to becentral to this, and their implications felt to be wide-ranging. One stakeholder, for example,suggestedthat:

Innovationisbuiltontheshakyfoundationsofpay.TheKPMGstuff[WorkforceDealreport]wasveryclearaboutthat.Gettheworkforcedealstuffrightbeforeinnovation[canwork]

Thefragilityoftheworkforceandthusprovidermarkets,withanincreasinginabilitytotakeoncarepackages due to staff shortages, was considered to be a substantial threat to innovation. Somequestionedtheextent towhich realprogresscouldbemadewithincurrent fundingarrangementsthatprecludedimprovementstoemploymentconditions.

With that caveat, therewereanumberofworkforce innovations that,while in their early stages,weredemonstratingpromisingresults.Thefirstofthesewasadoptionofvalues-basedrecruitment(VBR).Hererecruitmentandselectionwasbasedaroundaclearsetofvaluesappropriatetothecaresectorandaimedatensuringagoodfitwithit,mirroringFiggett’s(2017)workonrecruitingfortherightvalues,behavioursandattitudes.Thisseemedbothtoattractahighproportionofapplicants

14 Interviews were held with representatives of: Health and Social Care Partnership (2); Health Innovation Manchester (1); Local Authority Commissioner (1); Skills for Care (1); GM Independent Care Sector Network (1); and an independent domiciliary care provider (1)

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from outside the social care, as fit rather than prior experience, was prioritised, and to improveretention:

Westartwiththevaluesoftheorganisation.Ifwewerelivingthesevalueshowwouldtheyshowwithinourrecruitmentprocess.Welookforagoodfitwithourvalues,notlookingforpeoplewithexperienceorqualifications

One stakeholder suggested that, while VBRwas becoming awidely used term, it was in practiceoften not properly implemented. The example of providers claiming to be values-based but stillusingCVswasanexamplegiven.FullerunderstandingofVBRisimportanttoderivingitsfullbenefit.

Self-managed teams was another innovation presented as effective in workforce retention, as itoffered greater autonomy and improved job satisfaction and supportedbetter continuity of care.Hereresponsibilitywaslargelytransferredtocareworkers,withsometeamleadersupport:

Therolesthatwouldbedonebythemanagerareinsteadsharedbytheteam,givingahighlevelofdecision-makingpower.Theydotheirownrotas,allsharedwithinteam.Theydecidewhatrolestheyaregoingtodoinprovidingperson-centredandcompassionatecare…[Thisprovides]ahigherdegreeofautonomyandteamworkandprovidessocialsupporttohelpdeliveraworkplacethat’smoreappealingtoworkinandismoresupportiveof[worker]healthandwellbeing.

Self-managed approaches also reduced infrastructure costs and thus increased pay rates for careworkers.Providerswhooperatedtheseapproachesnotedthat thebenefitsof increasedpaywerenotinisolation,however,sufficient.

Thereissomethingmuchmorefundamentalthatneedstochangeifwearegoingtoattractpeopleoutsideofhealthandsocialcare,aroundthestructureoftermsandconditionsandrotas.

Vitaltorecruitmentandretentionwastheofferofguaranteed-hourcontractsandwiderimprovedtermsandconditions,e.g.flexibility.Thoseherewhohadintroducedself-managedapproacheshadalsooffered,at theirownfinancial risk,guaranteed-hourcontracts. Itwas thisbroaderpackageofless precarious employment, payment for all time worked and thus paid travel time that wasthoughttohaveimprovedbothattractionofapplicantsfromothersectorsandretention.Thisagainunderlines the importanceof anappropriateworkforcedeal inunderpinning sector reform. Somestakeholdersnotedthe increasedrisk inmovingtoself-managedteamgivenreductions incontrol.Havingtherightstaffwasessentialtoitssuccess,goingbacktotheimportanceofeffectiveVBR.

Leadershipprogrammes topromote skilldevelopmentandbringabout culture change in thecareenvironment were also discussed alongside other initiatives such as teaching care homepartnerships:

Registeredmanagers[havebeen]identifiedasaprioritygroup.They’veoftenfoundtheirwayintothatrolewithverylittlesupport.We’veco-designedwithprovidersaRMleadershipprogramme…theideaistolookatamodelthatwillbringindifferentaspectsthatareimportantforRMsinGM–reflectivestuffaroundselfandothers.Differentleadershipmodels…andgetthemtothinkaboutperson-andcommunity-centredapproaches–creatingaculturewithinthehome.

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The logistics of scaling up these initiatives were substantial in both size of task and budgetaryconstraintsgiventhenumberofRMsacrossGM.Otherinitiativescentredonaplannedcampaigntoimprovethe imageofcarework inGMandapilot to increasethenumberofsingle-handedvisits.The latter involved improved manual handling training and, if successful, would substantiallyimproveprovidercapacityinreducingtheneedfordoubled-upvisits.Thispilotwasbeingreplicatedfrompracticeinanotherlocalauthority,againindicatingchallengesforwidelyscalingupbottomupinnovation. Stakeholders recognised the skilled nature of care work, addressing the needs ofvulnerablegroups,andnotedaspirationsthatitbeproperlyremunerated.Alongsidethis,however,was recognition of a multi-million funding gap and pessimism as to the likelihood of substantialimprovementinemploymenttermsandconditions.

HealthandsocialcareworkforceintegrationOne stakeholder indicated that every borough should have a workforce strategy that includedindependent sector care workers, but suggested that most did not. Rather, local authority andclinical commissioning group workforce plans tended to focus on those employed in the publicsector.Thiswasproblematic,both inaddressing(ornot)system-wideworkforcechallengesand infailing to promote fuller integration of health and social care operations. In a number of cases,frustrationswereexpressedaroundduplicationofeffortandinefficiencyofhistoricwaysofworking:

Theamountofmoneythatisbeingwastedwiththeduplicationofeffortarounddistrictnursingandhomecareisphenomenal.

Needtoreducethenumberofpeoplecomingin–nurses,healthvisitorsandhomecarers.Sometaskscouldbedonebythesamepeopletosavethepublicpurseandalsoforthe[carerecipient]lesspeoplecomingintothehome.

More positively, however, integration was promoted as having positive outcomes for social careworkers, particularly with the operation ofmulti-disciplinary teams. The negative image of socialcareworkhasbeenraisedanumberof timesalready in this technical reportandsomesuggestedthatcloserworkingmightbenefitsocialcareinspreadingsomeofthe‘shinyimage’thatattachestoworkingintheNHS.Rolere-designacrosshealthandsocialcarewascentraltothis,withaparticularemphasishereontheinterfaceofworkersindomiciliarycare.Someearly-stagepilotswereworkingtotransfersomedistrictnurserolestodomiciliarycareworkers:

Lookingattheroletheirhomecareassistantscarryout.Theyaretakingonmoreaspectsofadistrictnurserole,pressuresoresanddressings,workingwithdistrictnursestograduallytraincareworkers.Westruggletorecruitdistrictnurses,soit’stakingpressureoffthem…Weareupskillingcareworkersandpayingthemmore.

Here,rolere-designandbetterintegrationisreducingpressureonanothershortagegroup,districtnurses,whileprovidingbetterpaidandhigher-skilledwork forcareworkers.Noformalevaluationhas yet taken place of the pilots, but anecdotal evidence suggests better job satisfaction andimprovedrecruitmentandretention.Certainlythiskindofre-designiscentraltoprovidingthemuchneeded career pathways in social care,with careworkerswho carry out previously nursing taskshaving theopportunity toworkatmore senior levels. Carefulmanagementof resistance to thesechanges, particularly around health care staff, has been needed, together with re-design of

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budgetaryandauthorisationprocesses.Thelevelofchallengeandcomplexityaroundthisshouldnotbeunder-estimated.

Integratedapprenticeshipswerealsopresentedasamechanismforcreatingmoreformalpathwaysandimprovingtheimageofthesector:

Howdowecreatecareerpathwaysthatcutacrossbothhealthandsocialcare?Wereallyneedtomapthatout,whataretheentrypointsandrequirementssowecanlookathowitfitstogether.Forthepromotionofhealthandsocialcareasacareer–asyouknowwestruggletogetyoungpeopleintothesector.Weneedtoshowandarticulatetheopportunitiesandwhattheyleadto.

It shouldbenoted,however, thatwithincurrent structures independentcareprovidersexpressedsubstantial concern about these apprenticeships.While recognising them as a good opportunity,therewasalsohighriskthat,intheabsenceoffullyintegratedcareerstructures,socialcarewouldoperateasatraininggroundandthat,oncequalified,workerswouldseektoprogress intohigher-graded,betterpaidhealthcareroles.Whilemanyproviderscouldseethepositives forworkers inthis,therewereneverthelessconcernsastothenetbenefitforcareproviders.

Overall, progress onmeaningfulworkforce integration appears to be somewhat limited, althoughsmall-scalepilotsoutlinedheredemonstratesubstantialopportunityforrolere-designandtheofferofmorehighly-skilledcareerpaths.

Commissioningofoutcomes-basedcareInanearliersection,thistechnicalreportdiscussedoutcomes-basedcareandtensionsbetweenthisand the continued operation of a time- and task-based commissioningmodelwhich had led to a‘racetothebottom’inemploymentconditions.Onestakeholder,however,suggestedthatoverthepasttwotothreeyears,therehadbeena‘massiveshift’incommissionerunderstandingofprovidermarketsanda‘racetothetop’inwhichcommissionerswereworkinghardtodelivergooddealsforindependentproviders.

Further, stakeholders noted substantial shifts towards outcomes-based, or person-centred,approachestocareandtheirbenefitsforworkersaswellascarerecipients:

Thesatisfactionoftheteamsandthesenseofhowtheyworktogether–inthelongerrun,itwillhaveincreasingpotentialbenefitsforthepeoplewesupport.Weareworkingreallyhardtomakesurethatthereareaminimalnumberofpeoplelookingaftereachindividual.Eachpersonhasaprofileofthepeoplewhowillbedeliveringtheircareandwearearelationship-centricorganisationsoweencouragecloserelationshipsratherthandiscouragethem.

Again pilots are underway in a number of boroughs to adapt commissioning models to supportoutcomes-based commissioning, and thedetail of one is reportedhere. In this pilot, care is blockcommissionedaroundanoverallcareplanandhoursnotusedcanbebankedandusedelsewheretooffer greater flexibility. The approach is not based on cost savings, indeed it is initially moreexpensive, ratheronmanagingdemandandsupportingmorepeople,as fewercarehoursmaybeneededwheresupportisstrong.Commissioningrateshaveincreasedbyaround£2.50perhourandcareprovidersarerequiredtopaycareworkers£9perhour.Thishasbeencombinedwithrolere-designsothatcareworkerstakeonadditionaltasks.Againanecdotally,asthepilotissmall-scaleandbegan in February 2018, providers feel that recruitment and retention is improving as is job

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satisfaction, alongside reduced sickness absence.Providers are graduallydeveloping confidence inthesystemtoofferguaranteed-hourcontracts.

While early signs are positive, there are two key challenges. The first is financial. The pilot iscurrently supportedby £3mofGM transformationmonies andwill experience a predicted £1.7mshortfall if it is to be continued at the end of the current 3 year funding period. In theory, asubstantialproportionofthehealthandsocialcarebudgetinthisboroughispooledandpredictedsavings to the health care system could enable a transfer of funds from one area of delivery toanother.Inpractice,thiswasseentobea‘hardconversation’tohavewithcolleaguesandconcernsover ongoing funding continued. The second challenge is to overcome cultural resistance, fromproviders, staff and care recipients. It was seen to be difficult for providers who operated in ademandingmarket,asubstantialshiftforsocialworkerswhohadoperatedinadifferentmodelformanyyears,andforcarerecipientswhowereusedtoamodelthatspecifiedaparticularnumberofcarehours.Asubstantialamountofongoingworkisneededtodeliverthepotentialbenefits.

DigitalcareWhile somewhat beyond the remit of the technical report, interesting examples of digitaltransformationemergedandarepresentedbrieflyhereasrelevanttotheproductivity/efficiencyofthesector.Theseareagainlargelyintheirinfancybutwerebeingpilotedwithpromisingresults.

Generallythesectorwasseentobesomewhatlackingdigitally,withmanycareplans,assessmentsand so on being paper-based. Domiciliary care providers, however, typically provided staff withsmartphonesthatoperateelectroniccallmonitoringsystemsandinsomecasesrosteringsystems.Stakeholderscalledforthewideruseofelectroniccareplanningsystemsthatsupportedoutcomes-basedcareinbeingeasytoupdateasneedschangedandalsotosharewithcarerecipientsandtheirfamilies.Relatively straightforwarddevelopments suchas carehome-wideWIFI systemswouldbeneededtosupportthis,albeitfewerthanafifthofcarehomesnationallycurrentlyoperateWIFI15.

Otherusesoftechnologyincludedvirtual/skypetriagesystemsinwhichcarehomestaffcanspeaktohospitalstafftotriageacarerecipient.

Ifthecareteamthink‘Mary’ispoorlyandneedsapotentialtransfertohospitaltheyusethetooltohelptheirdecisionmakingprocess.Itwilleithermakearecommendationformanagingwithinthehome,orrefertoGPortransfertoA&E.Itempowersthecarehometeamwithknowledgeandgivesthemsomegovernanceandassurancearoundtheirdecisionprocesses.

This has seen substantial falls in Accident and Emergency admissions and is being rolled out todomiciliarycareworkers,whowillalsohavetabletstomeasurebloodpressure,heartrateandsoontofeedintothetriagediscussion.

TheHIMstakeholderoutlinedongoingworkinwearabletechnologiesthatwouldbeusedtosupportcarerecipients:

Wearetestingoutadifferentuseoftechnology…andworkingwithanorganisationtolookatdehydrationandfallrisksby[usingwearabletechnologies]thattrackstumblingandsleep.

15 http://www.carehomeprofessional.com/exclusive-scie-chair-burstow-calls-wifi-every-care-home/

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Wearelookingathowwecanusethatdatatorefineoursupportandmakeitlesslikelytheyneedtogotohospital.

Dehydration and falls are the two biggest causes of hospital admissions for the elderly andreductionsinthesewouldhavesubstantialcostbenefit.

Despitepocketsofhighlyinnovativepractice,stakeholdersindicatedthattechnologicalinnovationinthesocialcaresectorwassubstantiallybehindthatinthehealthsector.

ProductivityFew stakeholders were familiar with GVA as a productivity measure. Rather, they argued thatcommonmarkersofproductivity, forexample, volumeand speedof visits,werenot conducive tohighqualitycareoutcomes.Instead,afocusoncarerecipientoutcomesandworkerjobsatisfactionweredeemedimportant:

Wearefocusedonproducingmoreforless,morevisits,morethis,morethat–butactuallyit’saboutculture,leadershipandemployeewellbeingandhowitismeasured.

Metrics that emphasisedoutcomesover time and taskwere seen as essential, but complex. CareQualityCommission(CQC)scores,forexample,hadlimitations:

Whataretherelevantoutcomesandhowdowemeasurethoseisanimportantquestion.Acarehomethathasahighrateoffallsmightneedtoimplementafallsriskassessmenttool.Abestpracticeexampleoflowratesoffallsmightachievethatthroughcultureiftheydon’tmobilisetheirresidentssotheystayinbedallday.Soweneedtolookatqualityoflifeagainstaccepteddegreeofriskaroundfalls,butmakeyourCQCscoresgood.Sothemeasuresaren’tsubtleenoughtopickupthosethings.

Productivitymeasuresshouldencapsulatepreventativefactors,incorporatingbothhealthoutcomesandsubjectivesatisfaction:

So,forcommunitycentredapproaches,usingassetsthatarealreadythereordon’tcostmuchareinexpensive,it’saboutserviceusersatisfaction,isolationandwellbeing–allthedifferentthingsthatkeeppeoplewellandoutofhospital.Veryhardtomeasure.

Employeewellbeingwasalsopresentedas a keymeasureas ‘happy staff lead togreaterquality’.Social care image and career paths were important, as productivity is likely to be higher inorganisationsthatcansecureandmaintainrecruitmentofahighqualityworkforce:

We need to think differently about productivity – social care is seen as the poor relation.Absolutelykeyishowtochangethoseperceptions.It’squalityofworkforceandsustainabilityof recruitment that impactsonthat. It’showyoutransformthe imageofworking insocialcare.

Theemploymentdealwasagainseenascentraltothis,workersneedingtoearnalivingwageandhavestableworkinghours.Zero-hourscontracts,forexample,oftenmeantthatstaffsoughthighercallvolumestomaximiseincomes,butthatthiscouldbedetrimentalbothtotheirandcarerecipientexperiences.

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A great deal of further work was seen to be needed in capturing measures of productivity todemonstratehowdifferentskillsetsmaptocarequalityoutcomesindifferentcaresettings:

Aworkforceplanningstudywouldbeonewayofgeneratingevidenceforsupport–ifyoucouldevidencethat,band3and4s-competenciesandcapabilitiestoalignwiththoseworkingwithdifferentpatients.Dementiacarehomeisaclassicexample–itisgoingtolookverydifferentfromclassicresidentialcarehome.

To summarise, care recipient and care workers measures were seen as much more importantmeasuresofsectoreffectivenessthanGVA.

ScalingupinnovationThechallengesofscaling-uplocal innovationarewell-recognisedandencapsulatedinSCIE’s(2018)recentreportoninnovativemodelsofcare.Inessence,whilelocal,bottomupinnovationiscentraltodrivingchange thatmeetsneedat local level, thesizeandcomplexityofhealthandsocial caresystemsareproblematicwhenseekingtoextendthese innovations.Ofparticularnotearefundingpressures, outdated commissioningmodels, lack of leadership and lackof skills and capacity. Thissectionhaspresenteddetailonsubstantialinnovationinvariousboroughs,thequestionbeinghowto ensure that GMmore widely benefits from the success of this innovation. As the SCIE (2018)reportnotes:

Togettothepointwherethesemodelsbecomepartofthemainstream,therewillneedtobebraver decisions about how local resources are spent, withmoney being transferred overtimefromlow-quality,low-outcomeservicestoimpactfulinnovativemodelsofcare.

SCIE(2018)goesontorecommend:

• Innovationfunding,whichsupportsdoublerunningcostsifplaninplacetoextendpilottothemainstream

• Capacitybuildingincludingactionlearningnetworksforbothleadersandworkforce• Developingappropriatemeasuresandtoolsthatcomparesocialandfinancialoutcomesand

supportevidence-baseddecisions• Payingproviderstodeliveroutcomessuchasimprovedresilience,independenceandself-

care

Additionally,technologicalsolutionsmaybeofvalue.Forexample,platformsthatshareinnovationandgoodpracticeenablingtheiruptakebyarangeofstakeholders.

Tosumup,GMisexperimentingwithhighlyinnovativepracticeandinvestmentinscaleupactivityislikelytoreapdividends.

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Wheredowegofromhere?ThistechnicalreporthasexaminedASCprovisionwithinGM.Itconsiderssectorreformsthatcouldprovideamoresustainableworkforceandmaximiseservicequalityandproductivity.Thisevidenceisnowusedtoproposepolicyoptionsthatdelivervaryinglevelsofreform,fromthoseaimedatthe‘paradigm shift’ in funding, commissioning and integration16 recently called for by the ChiefExecutiveofCareEngland,tothoseofmoremodestambition.Thisreporthasalsonotedtheextentof innovation already underway in GM and the challenges of scaling this up, andmechanisms tosupportthisareincorporatedintoeachsection.

The fundamental premise of the technical report is thatGM innovation is currently based on the‘shakyfoundationsofpay’andthatfundingandcommissioningreformandfurtherhealthandsocialcareintegration,howeverconducted,shouldsupportimprovedworkforcetermsandconditionsandimagethatunderpin improvedcarequalityandproductivity,howevermeasured.This isechoedatnationallevelbyaNovember2018IPPRreport:

Thechallengesofrecruitingandretainingworkers inthesector is inextricably linkedtolowpayandpoorworkingconditions.Thisisitselfrelatedtotheunder-fundingofsocialcareandacommissioninganddeliverymodelbasedoncostnotquality.Providershavecompetedbydriving down pay and conditions, and they have faced little resistance given the limitedbargainingpoweroftheworkforceandthelimitedenforcementofemploymentrights.Thesefactorsarecombiningtocreateasocialcareworkforcecrisis.Ifwearetosolvetheworkforcecrisis,weneed to deliver a sustainable long-term funding settlement for social care andatransformation of the social care workforce model. This should be based on theestablishmentofdecentpayandtermsandconditionsthroughsectoralcollectivebargaining,and a professionalisation of the social careworkforce. Thesemeasureswould help ensurehigh-qualityworkforcareworkers,andhigh-qualitycareforthosewhoneedit(DromeyandHochlaf,2018:1).

Funding

ThereappearstobewidespreadagreementthatthecurrentASCfundingsystemis‘broken’andthaturgentreformisneeded.ReducingdemandforASCanddeliveringcostandotherefficiencieswillbean important part of this. However, for the system to truly function effectively it must beunderpinned by an appropriate fundingmodel. It is beyond the scope of this technical report torecommendaparticularmodel,butoptionsinclude:

• GMtolobbygovernmentforanationally-ledfundingsystem,forexample,asocialinsuranceschemesimilartotheGermanmodel

• GMtouseitsdevolvedpowerstoestablishitsownfundingsystem,forexample,asocialinsurancemodel

• GMtoincreaseCouncilTaxpreceptstoprovidefundingincreases• GMtoincreasethetransformationbudgettosupportscaleupofinnovationwithincurrent

fundingarrangements

16http://www.carehomeprofessional.com/care-england-conference-care-england-chief-urges-government-deliver-integration/

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Thefirsttwooptionshavethecapacitytodeliverthesecure,long-termfundingrequiredtounderpinan effective ASC system. The third and fourth do not and substantial reformwill constrained bytheseshorterterm,lesssecurefundingarrangements.

Commissioning

Followingdevolution,GMhaspromotedperson-andcommunity-centredapproaches(PCCA)tocaredelivery. These focus on delivering outcomes that are important to care recipients and underpinimproved care quality. These approaches also offer improved job satisfaction to care workers,contributingtobuildingastableworkforce.Changesincommissioningtosupportthisareunderwaybutatearlystages.Optionshereinclude:

• Continuingtheshiftawayfromtime-andtask-basedcommissioningprocessestothosethatsupportoutcomes

• Increasingtransformationfundstosupportthe(initiallyatleast)increasedcostsofcommissioning

• Processestoenablebettertransferofbudgetsacrosshealthandsocialcare• ServiceproviderandcarerecipienteducationinPCCAcaredelivery

Scaling up of innovation in commissioning requires payment to providers for delivering outcomessuchasimprovedresilience,independenceandself-care.

Healthandsocialcareintegration

Thedevolutionofhealthcarebudgetsin2015createdtheopportunitytoaccelerateintegrationofhealth and social care inGM. Itwould appear that this hasbeenmore successful on some frontsthan others, with reasonable progress being made on processes, some progress on budgetaryintegration, but limited progress on workforce integration. Further integration is necessary,particularlytodirectincreasedfundingtoASCandaddressthepoorimageofworkinginthesector.Optionsinclude:

• Completeintegrationofhealthandsocialcarebudgetstosupportmorestrategicuseoffunding

• Partialbutincreasedintegrationthatoffersmoreeffectivemechanismstosupporttransferofbudgetstowheremosteffectivelydeployed

• Fullyintegratedhealthandsocialworkforces,withstandardemploymentconditionsandintegratedcareerpathstoenablemovementandprogressionwithinandacrosssectors

• Workforcesarenotintegratedbuteachlocalauthorityhasaworkforcestrategythatincorporatesbothpublicandindependentsectorworkers

Moreintegrateddeploymentofbothbudgetsandworkforceisneeded.Whileoptionsoneandthreeoffer this, cost and system constraints are likely to prevent implementation. Themoves towardsintegrationofferedbyoptionstwoandfourarefundamentaltosystemreformandeffectiveness.

Workforce

Low pay and other poor employment terms and conditions coupled with the negative image ofworkinginsocialcarehavecreatedsubstantiallabourshortagesinASC.Thisdespitecareworkbeing

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anintrinsicallymeaningfuloccupationthatcandeliverhighjobsatisfaction.Giventhatfullworkforceintegrationisunlikelyintheshortterm,othermechanismstoaddressthisinclude:

• AdoptionoftheGMWorkforcedeal• AdoptionofUnison’sEthicalCareCharter• Regulationtoimprovetermsandconditionse.g.therighttorequestguaranteedhours

contracts• Healthandsocialcare-widerolere-designthatoffersmoreskilledrolestocareworkers

andunderpinsthecareerpathsproposedabove• Promotionofvalues-basedrecruitmentandself-managedworkingtodevelopmore

skilled,autonomousroles• Developmentofamorediverseworkforce,particularlymalecareworkers,toreducethe

lowstatusattachedtocareas‘women’swork’• Capacitybuildingforbothleadersandworkforcetosupportinnovationscaleup

The first threeoptionsofferdifferentways to improve lowpayandother termsandconditions inASCwork.ThelastfourmechanismsaimtoimprovetheimageofASC.Incombination,thesecouldsubstantially improveworkforcesupplyandquality.AcallalsoemergedforworkforceproductivitytobemeasuredinwaysotherthanGVA,andfurtherconsiderationofthisisneeded.

Digitalcare

There are pockets of advanced practice in digital transformation in GM, but these appear to belimitedascomparedtodigitalhealthinnovations.Optionshereinclude:

• Moreinvestmentinbasicdigitalinfrastructure,forexample,WIFIincarehomesandcareplanningandassessmenttechnologyindomiciliarycare

• Moreinvestmentinadvancedofferingssuchaswearabletechnologies• Technologicalsolutionstosupportscaleup,forexample,platformsthatshareinnovation

andgoodpracticeenablingtheiruptakebyarangeofstakeholders.

The challenges inASCare variedand complex.Addressing themwill require a co-ordinatedeffortacrossarangeofstakeholdersandtheoptionsoutlinedaboveofferastartingpointforthisprocess.

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