Cardiff and the Vale of Glamorgan Regional Partnership Board Market Stability Report For The Regulated Social Services Care and Support Market
The Social Services and Well-being (Wales) Act 2014 requires Local Authorities within each Regional Partnership Board (RPB) area to work with their local health board to develop a Regional Market Stability Report (MSR).
This MSR is a high-level strategic assessment of whether the regional care and support market can meet the care and support needs established through the Population Needs Analysis (PNA) to 2026. It considers the overall sufficiency and stability of the care and support market for regulated services. It is based on three workstreams:
Work stream 1 – “As Is” Market Analysis. This assessed the diversity and sufficiency of the markets to meet the population’s support needs now. It was based on a snapshot of current providers and activity as at the middle of February 2022 (for Adults) and the beginning of March 2022 (for Children)
Work stream 2 – “Predictive Analysis” of likely costs and activity volumes to 2026. This forward look was based recent PNA research findings to assess likely future support needs compared to current market capacity.
Work stream 3 – Market issues, risks, and strengths. This was based on interviews with commissioners and providers and on citizen’s feedback received during the PNA process. This workstream identified market issues, risks, and strengths.
For Older people’s bed-based care and support the key issues are:
While capacity is mostly sufficient at present the care and support models need to change. We need less generic residential care and more specialist capacity to support people with dementia and at the end of their life. Demand for nursing care will also continue to increase over the next five years at a rate of 58 extra places per annum. So, we need to secure more of this capacity “in area.”
Market stability is uncertain. Some care home providers are operating with occupancy levels below sustainable levels and many lack confidence about the future viability of their business models. There is a risk of disorderly withdrawals from the market that could destabilise markets and disrupt the lives of residents.
For domiciliary care, the key issues are:
- Capacity is not sufficient now and demand is rising. By 2026 we estimate we will need to have 3.500 more hours in total and to meet need with locally based providers we need 12,300 hours of extra capacity per week based “in area”.
- As with bed-based care we need more specialist care. For example, to support people with dementia or other complex needs who want to stay living at home.
- The main barrier to sustaining a stable domiciliary care market is a serious shortage of skilled workforce. Providers are also concerned about increasing costs. So, it is important that fees remain fair and sustainable.
For adults, whose primary care and support needs are learning disabilities, mental illness, physical disability, or sensory impairments the crucial issues are insufficient “in area” capacity of:
Specialist Learning Disability/ASD residential care services for adults aged 18-64. This leads to 46% of placements being OOA. We know there are groups of people with similar support needs who (if compatible) could be brought back and supported by small specialist “in area” services.
Specialist domiciliary and residential care services for people aged over 65 whose primary support need is Learning Disabilities.
We need to specialist residential care capacity for younger people (including people with learning disabilities) living with early onset dementia.
This market has been destabilised by the impact of COVID and its capacity has reduced. At present capacity is not sufficient to meet demand. This gap leads to excess demands for other substitute services.
Children and Young People (C&YP) Services
The main challenge is a lack of sufficient foster care capacity to meet needs in the best way. Consequently, for some children, we use residential options more than is ideal and, due to a lack of “in area” residential capacity, a high proportion of residential placements are “out of area.” (OOA). It is important also to continue to assess kinship carers as an option for children within their families. We expect our need for:
- Kinship care placements to increase 57% from 265 placements in 2021-22 to 416 in 2025-26
- In-house foster placements to increase 47% from 189 in 2021-22 to 278 in 2025-26
- Agency foster placements to increase 12% from 387 in 2021-22 to 432 in 2025-26
- Residential placements to increase 27% from 116 placements in 2021-22 to 147 placements in 2025-26
- Adoptions to remain at similar levels as now until 2025-26
The foster care market is highly reliant on a few key providers with the top five providers accounting for 71% of spending. The failure of one of these large providers could be difficult to manage. However, the degree of market stability risk is dependent on the ability of other providers and in-house services to absorb displaced capacity if a provider were to fail or withdraw from the market. Therefore, having oversight of provider stability, provider strategies, and maintaining the ongoing risk assessment of the market concentration are all important.
It is also important that we continue to develop in-house capacity and develop close relationships with all providers to enhance our ability to identify placements and to mitigate the likely impact if a provider were to fail or withdraw from the market.
The main risk affecting adoption is the insufficient supply of prospective adoptive parents for some groups e.g. sibling groups, older children, children of mixed heritage, and children with more complex needs. This highlights the need for new recruitment initiatives.
The main issues affecting Children and Young People residential care are:
A lack of secure accommodation. This is an issue across all of Wales.
The residential providers in the region have difficulty recruiting workforce and some providers are not able to deliver a service in line with their statement of purpose.
A reduced ability to care for children with the most complex needs in the context of some children with lesser needs escalating to residential care due to a shortage of foster care placements.
These capacity gaps lead to a high number of OOA placements and highlights a lack of “in area” capacity to accommodate children with complex needs.
These capacity gaps have cost implications as there can be a “price premium” compared to local provision and quality implications as children are geographically separated from their family and from their local communities and the associated support
1. Address workforce capacity and skills shortages – Recruiting and retaining staff with the skills needed to support people with complex support needs is a particular challenge. The focus for patrners and providers of care and support services will be on recruiting and training staff where an increase in capacity is required:
Children and Young People Services will be on recruiting/training more in-house foster carers, kinship carers and adoptive parents.
Older people’s services will be on recruiting/training domiciliary care staff and specialist dementia and end of life skilled care home staff.
Adult services will be on recruiting/training adult placement/shared lives carers and staff with specialist learning disability, autism, early onset dementia, and mental health care and support skills.
2. Ensure the fees we pay to providers are fair – This is key to addressing the workforce recruitment and retention challenges and to addressing market stability risks where providers of care and support services for adult and older people are concerned about their financially sustainability. Equally, the lack of supply along with growing demand, particularly for those with complex needs, could result in fees that are not value for money.
To help with this the Welsh Government published a toolkit “Lets agree to agree” for commissioners and providers in 2018.
Cardiff Council and the Vale of Glamorgan Council commissioners will use this, and other similar tools to work with providers to evidence the true costs of care delivery in the region, and to inform fee negotiations with providers during the 5-year period covered by this MSR.
3. Develop in-house services to lower market risk – The Regional Partnership Board is a strong advocate of a mixed economy and support for social enterprises.
Commissioners see benefit in having in-house services as part of a mixed economy in terms of, increasing local flexibility, filling gaps in the local market, mitigating risk should private providers fail, and attracting capital investment to the locality.
4. Modernise our approaches to commissioning and contracting by working with providers – To give providers of care and support services the certainty and confidence they need to invest the region will modernise service models where appropriate:
The Regional Commissioning Board, on behalf of the RPB, will support operational teams within the region. They will shape the market by working in partnership with providers and co-produce regional commissioning strategies.
The Regional Commissioning Board will explore new ways of contracting based on outcomes where providers have greater choice, flexibility, and responsibility to deliver services to best meet the needs of citizens. For example, block or community contracts.
To improve our planning evidence base The Regional Partnership Board will develop our modelling capability to underpin the development of preventative services and more integrated health and social care pathways.
Statutory partners will use regional approaches to commissioning where they will provide better value for money or higher quality services.
5. Re-establish and strengthen quality assurance processes -During the COVID pandemic the region adapted or disbanded quality assurance processes to comply with new pandemic regulations. We are now restarting and modernising our approaches:
- Cardiff is implementing interim arrangements for quality assurance until a new quality rating system based on the Dynamic Purchasing System goes live.
- The Vale of Glamorgan has appointed a new quality assurance officer and implemented a new framework for quality.
- The UHB are liaising with both local authorities to collaboratively develop a joint quality framework for quality assurance of UHB commissioned placements within older peoples nursing homes and domiciliary care.
6. Shape the market to close gaps in non-regulated services incl. prevention and early intervention services – The recent population needs assessment process identified many gaps in care and support services relate to non-regulated services.
•There is a link between the gaps and increased need for regulated services.
•If these services were in place and effective, more people would be able to live their lives without needing support from the regulated services in the scope of this Market Stability Report.
•The region will develop our modelling capability to underpin the development of preventative and early intervention services
7. Maximising choice and control by deploying direct payments appropriately – The region plan to increase take-up of direct payments by:
•Reviewing the micro-enterprise model to allow citizens access to alternative care models
•Adapt or develop quality assurance systems so citizens can identify and access good quality support. •Improving access to information and advice that will help citizens make informed choices.