Welsh Government dragon logo used for stickers and snacks - BBC News

 

Last updated: 30/03/20

 

Introduction

This guidance note has been co-produced by the Association of Directors of Social Services in Wales (ADSS Cymru), Care Inspectorate Wales (CIW), Social Care Wales (SCW), the Welsh Local Government Association (WLGA) and the Welsh Government and is for Local Authority commissioners. It is designed to summarise pressures on social care Providers in Wales arising from COVID-19 and to put forward ways in which commissioners can alleviate these pressures.

This guidance comes from a shared ambition to ensure that Providers are supported to maximise availability of care and support and to remain operationally and financially resilient.

This guidance does not deal with issues of infection control, which can be accessed from Public Health Wales. The guidance also focusses on what Local Authority commissioners can do, in the knowledge that Welsh Government and other organisations such as Care Inspectorate Wales and Social Care Wales are also giving their own guidance and mitigation to support the sector at this time.

This guidance lists a range of pressures and actions that commissioners may take to address them. Local government makes decisions within the confines of the law and considering local factors. It is anticipated that emergency legislation will soon be in place to provide additional powers and guidance will be updated accordingly. We describe these actions as what commissioners “can” do: our shared expectation is that commissioners actively consider all these issues and possible mitigating measures and do what is necessary to support their local Providers. We also recognise they will be working with their local Providers and County Voluntary Councils (CVCs) on a collaborative basis to identify issues and agree actions and mutual expectations.

This is a first iteration of our guidance and has been produced quickly but in the knowledge that other issues will emerge. We would therefore expect to supplement this guidance in the light of such issues.


Collaboration and communication

Providers face a fast moving and uncertain operational environment, we anticipate pressure on services to increase in the coming days and weeks. They will need the ability to raise issues and get answers quickly, and to be able to solve problems collaboratively, both with commissioners and with each other.

Recommended actions:

Action

Who

Ensure effective two-way communication:

  • Advise Providers who and how to contact the Local Authority and Health Board on a 24/7 basis.
  • Identify the point of contact for each Provider (ensure this is communicated within your organisation).
  • Ensure outward communication is streamlined and consistent, directing Providers to national advice where appropriate.
  • Provide regular briefing / update mechanisms i.e. through weekly meetings and / or written briefings from and to main points of contact.  When Providers are asked for updates they can do so in a “tell us once” way with regular updates, with a need to also capture the challenges which can be used to inform the sector where it needs support.

 

 

 

 

 

 

 

 

Local Authorities in conjunction with Local Health Boards – ideally this would be collated on a Regional Partnership Board (RPB) level where appropriate and linked into Local Resilience Forums (LRF).

 

 

Commissioners (ideally at a Regional Partnership Board level where appropriate) to issue communications to Providers about service prioritisation (e.g. relevant excerpts from local prioritisation framework) and support available for access to PPE, food supplies, child care etc. This should be guided by the expertise in the profession –recognising the unique circumstances we are operating within.

Share infection control policy & procedures and training materials (including access to online training) with Providers to ensure policy and practice follow up to date Public Health / Health & Safety advice.

Provide information (e.g. FAQs) and guidance for informal carers, Direct Payment recipients and their Personal Assistants and self-funders (Providers and third sector organisations will be able to assist with dissemination). This should include points of contact in the event that individual care arrangements breakdown.

 

Business Continuity Plans

Good business continuity planning assists resilience. Ensuring service continuity will require collaborative working and flexibility of all partners.   Commissioners should avoid simply asking care Providers to submit their own Business Continuity Plans (BCPs) or requiring them to submit information, unless there is an intention to analyse the plans collaboratively and offer constructive guidance. BCPs should be the starting point between Providers and commissioners to identify which parts of a BCP seem robust, and which aspects need further work. Where possible such analysis should be undertaken at a regional / national level and shared e.g. Children’s Commissioning Consortium Cymru (4Cs) are collating and analysing residential and fostering Framework Providers’.

There should also be a recognition that some aspects of the plans rely on support from other organisations within the Local Resilience Forum (LRF) community.

Commissioners can also help Providers by ensuring they share their own local resilience plans, and by ensuring that Providers are linked into the wider considerations and plans of LRFs, such as school and transport closures.

Recommended actions:

Action

Who

Identify mutual support opportunities (internal & external partners):

- Avoid duplication of professionals' visits to people's homes for different tasks and explore efficient use of health and social care workers time.

 - Share tools for staff impact analysis and skills mapping, HR advice on changes to working arrangements such as agile working and increasing staff working hours (part and full-time staff to meet demand).

 

Providers, Local Authorities and Local Health Boards – ideally this would be collated on a RPB level where appropriate and linked into Local Resilience Forums (LRF).

Local Authorities and Local Health Board can coordinate recruitment adverts and activities aimed at non-practicing experienced health and social care staff within a region and co-ordinate their deployment across statutory and independent sector. This needs to link in with the Wales wide approach through the ‘We Care Campaign’ where there is a ‘regional connector’ identified in each region supporting this for social care

Provide guidance for Providers in regards safer recruitment procedures.

Work will be led by Social Care Wales and Care Inspectorate Wales

Share information about local innovations e.g.

  • Block contracting arrangements in care homes for step up / down services and arrangements for care of people with confirmed COVID-19 status.
  • Payments for retainers and hospital restart services.
  • Alterative accommodation & support options e.g. extra care, shared lives providers, dormant care homes / wards, hotels.

The National Commissioning Board and National Commissioning Group can support with sharing innovations.

 

Cashflow

Invoice generation will become an increasingly complex activity.  Providers will be focused on delivering support to people and managing sickness absence in their own workforce.

Providers may face additional financial sustainability challenges related to loss of income, due to voids (residential / supported living / fostering services) and reduced delivery due to staff shortage.

Providers will also be facing unanticipated additional costs such as increased use of agency staff, increased liability for Statutory Sick Pay, additional use of Personal Protective Equipment (PPE) (including specialist PPE), and increased cost of food.

Recommended actions:

Action

Who

Commissioners should make every effort to prioritise payment to social care Providers and establish flexible arrangements such as:

  • Increasing the frequency of payments, making payments in advance of delivery,
  • Reviewing arrangements for invoice reconciliation in order to ensure expedited payments.
  • Ensuring that disputed amounts, do not delay payment of regular invoice amounts.
  • Increasing the discretion of Providers to deliver more / less care to individuals based on staff supply and priority needs.
  • Paying Providers for planned care when citizens refuse visits without notice. (Commissioners may also need to communicate with people receiving support about how this may impact on charging).

Local Authorities and Local Health Boards.

Mitigate risks by:

  • Paying for domiciliary care “on plan” (i.e. the planned hours for each person receiving homecare, rather than requiring details of actual hours provided to each person and/or signed time sheets). 

 

Local Authorities and Local Health Boards – ideally this would be collated on a RPB level where appropriate.

Qualify and quantify additional costs of provision and make fee adjustments where possible and necessary.

Share local innovations e.g.

  • Contract (payment) variations.

The National Commissioning Board and National Commissioning Group can support with sharing innovations.

Provide formal written communication to Providers detailing variations (to regulation / guidance/ contracts) permitted during this emergency planning period e.g.

  • Safer recruitment
  • Notifications
  • Changes to payment arrangements
  • Additional Provider discretion to amend care provision in respond to need

 

 

Care Inspectorate Wales, Social Care Wales, Commissioners, including Local Authorities and Local Health Boards / Trusts

 

Care and Support at Home (domiciliary support)

Reduced cashflow will especially impact domiciliary Providers. Delays in invoicing, invoice disputes and non-payment of invoices will have a serious negative impact on Providers’ cashflow and sustainability in an already fragile market.


Residential care

Cashflow can also affect care homes, and commissioners can again offer support by paying on the planned support for people in given care homes and the reconciling for any adjustments due to deaths or other factors. This is even more important as occupancy levels may become more volatile, with potentially more voids due to infection control measures possibly offset by extra demand. Commissioners can agree with local care homes what level of certainty in terms of planned payments will help them through this volatility.

Some Care Home Providers may be reluctant to accept new people moving into the home, to support the transfer of residents back to the home from hospital and / or may instigate restrictions on those residents such as self-isolation, which may deprive individuals of their liberty. 

Commissioners (Local Authorities and Health Boards) may need to negotiate the development of new services / contract and fee arrangements

Recommended actions:

Action

Who

Commissioners provide a clear guidance on risk mitigation (e.g. access to testing) and support for Providers aimed at expediting safe discharge from hospital and responsive admissions to care homes, particularly in cases where care and support at home is unavailable.

Local Authorities and Local Health Boards – ideally this would be consistent across an RPB area.

 

Retrospective reconciliation

This will need to be handled transparently and through discussion, rather than unilateral imposition. Reconciliation is appropriate when actual levels of support differ markedly from what was planned. Commissioners should be mindful of all the extra costs incurred by Providers during this period, and of problems they may face in reducing variable costs in such a volatile operating environment. Providers should be mindful that, where actual support levels are significantly below plan, commissioners may have needed to fund support elsewhere.


Workforce availability

Providers will face higher workforce absence rates, through medically-recommended self-isolation, sickness and family caring responsibilities.  While national school closures have been implemented in Wales in line with the other UK nations, plans are being prepared to ensure the children of key workers (defined by the Welsh Government) are allowed to remain in school. Those plans will be implemented within each local authority area and further information can be found here.

Care Providers will need to be able to deploy their staff flexibly and to hire new staff quickly. They will face increased cost pressures from higher use of agency staff. CIW are working with Welsh Government to amend and disapply some of the current regulations following the enactment of the Coronavirus Act 2020. Those changes can be found on the CIW Website.

Commissioners can mitigate this through recognising and funding these extra cost pressures. They can also ensure that their contracts allow flexibility for Providers in hiring and deploying staff

See also recommended actions in Collaboration & Business Continuity sections above


Sick-pay

Providers face increased cost pressures due to higher sickness absence rates among their workforce: they have to pay staff SSP or make sickness payments at a higher level than SSP because they have a contractual sick pay scheme (also known as an ‘occupational scheme’), which offer workers payments above the basic minimum amount of SSP, which is £94.25 per week. Information on Statutory Sick Pay rights can be found here.

Commissioners will generally have well established arrangements with each of their providers in place, with clear channels of communication. Commissioners should endeavour to do all they can to mitigate SSP cost pressures. They could for example assist with cashflow by agreeing a reasonable amount based on an assumed average sickness absence rate and paying upfront, rather than awaiting detailed records of actual sickness taken and backfill provided and agree reasonable and proportionate ways of later reconciliation.  An assumed average rate may be informed by governmental planning assumptions but commissioners should not wait for this if it is delaying necessary financial support.


Rapid adjustment of support

Support will have to be rapidly adjusted.  People will be admitted to hospital, care visits changed to meet the most urgent needs and some homecare visits will take longer due to infection control precautions and the availability of staff. Care homes may need to adjust support in order to meet changing needs and to minimise infection risks.

This means that rapid decisions will need to be taken about appropriate adjustments of care packages, with a clear decision making process in place. It will also increase Providers’ costs as it will require extra management time to make these adjustments.  There is also likely to be a higher ratio of travel to contact time in home care due to the rapid reorganisation of rounds and rosters.

Commissioners can mitigate this firstly by agreeing with their Providers how to adjust packages in a timely and non-bureaucratic way, without requiring prior authorisation, but within agreed limits.

If commissioners choose to retain decision making about changes to care packages themselves, they will need to have enough staff at the right level available to make these decisions rapidly and have simple processes in place. 

Commissioners can also fund extra costs incurred from extra administration and increased travel times and visit lengths in homecare services, and for extra administration within care homes.


Infection control

Providers will face extra costs through the need for more PPE, through the need for enhanced cleaning of care home and other premises or people’s own homes, and through the need to adopt different working patterns to minimise the spread of infection, for example zoning some staff within care homes. Providers may also face greater difficulty in obtaining infection control products, PPE, handwash and disposable hand towels, due to increased demand for them.

Commissioners can mitigate this through funding extra costs and through helping Providers access PPE, for example using some of their own supply chain contracts. This assistance with access to critical products may extend beyond PPE.

Any stocks of PPE or other equipment provided by Welsh Government and held by Local Authorities should be distributed equitably between Local Authorities and the independent and voluntary sector. Local Authorities can help this process by issuing clear instructions to their staff about how such stocks should be made available to Providers who need them (including 24/7 access) and what stocks (e.g. specialist equipment) are available from Health Boards


Those funding and arranging their own support (“self-funders” and Direct Payment recipients)

Providers have to continue to provide support to self-funders and some Direct Payment recipients, and there is an expectation on commissioners that they have an overall picture of how the whole market is operating, rather just those Providers with which an authority contracts directly. Providers may face financial pressures from sudden decisions by self-funders to refuse support and then refuse to pay notice periods.

Commissioners should be discussing with Providers whether there are any changes taking place that have an impact on provider operational and financial resilience. Requests from commissioners about information from Providers about people who fund their own care may be particularly sensitive and should be accompanied by clear advice on why so doing would not be a breach of the General Data Protection Regulation (GDPR).


Use of non-contracted Providers

Commissioners who contract with approved or ‘Framework’ Providers at fixed prices may also be looking to other non-contracted Providers in the local area, as demand for care and support peaks. Consideration should be given to the potential impact of paying contracted Providers at a lower rate than Providers which are off-framework of off-contract.

Commissioners can mitigate this though careful consideration of the prices it pays for care and the available capacity in the local market and should be mindful of longer term impact on the market if there is more use of non-contracted Providers.

Recommended actions:

Action

Who

Commissioners may have to seek exception to contract and procurement regulations in order to contract with Providers outside of usual contract frameworks / non-approved Providers.

Local Authorities and Local Health Boards – ideally this would be consistent across an  RPB area.

Commissioners should share due diligence information (registration, insurance levels, Dun & Bradstreet checks) etc with other Commissioners in regards Providers outside of usual contract frameworks / non-approved Providers in their area that are approved elsewhere in Wales.

The National Commissioning Board, National Commissioning Group and National Commissioning Units can support with sharing information.

The National Commissioning Board in conjunction with National Commissioning Group and National Commissioning Units will provide support in regards monitoring market sustainability risks.

The National Commissioning Board, National Commissioning Group and National Commissioning Units.

  • Author: ADSS Cymru & Partners
  • Date: 30/03/2020