Market Position Statement: Long Term Care 2013-2014


North East Lincolnshire CCG

Market Position Statement – Long Term Care

2013/14 to 2015/16

DRAFT v2, 22nd April 2013


1 Introduction

1.1 Purpose of the document

This document provides details about the way in which the Clinical Commissioning Group (the CCG) will work with providers of long-term care to secure the services that the people of North East Lincolnshire need over the next 3 years and beyond.  It supports the overarching Framework Market Position Statement and provides details in respect of the long-term care market.  

1.2 Underpinning principles

The Framework Market Position Statement states how the CCG seeks to encourage quality, consistency and innovation  in all the services it secures for local residents.  This ensures the right balance between value for money and the best possible outcomes for people.  Care should be close to home wherever this is safe and appropriate, and should be supported by appropriate technology.
We also want to make sure that the relationships between the CCG and the organisations that provide services that we buy is healthy.  This is a corporate responsibility, but also needs to be reflected in behaviours at all levels of the CCG and our partner organisations.  Openness about the nature of our commitment to the services we currently buy, and what might make us review this commitment, is the basis of a trusting relationship.  However, we expect this openness to be reciprocated through the ongoing dialogue in which all partners commit to the principles outlined above.

1.3 Financial context

The Local Council faces significant challenges in meeting its obligations with reducing financial resources, whilst the health sector continues to face its own pressures from rising demand from a number of sources.  Money spent on long term care by the CCG comes predominantly from a Partnership Agreement between the Local Council and the CCG, although some of the spend on Nursing care and on Continuing NHS Healthcare, is part of the local Health budget.
The Partnership Agreement for 2013/14 sees £49.4M being delegated to the CCG for spend on Adult Social Care, of which £16.9M is spend on long and short term placements in the care home sector.  In addition, the spend by Health on Funded Nursing Care and Continuing Health Care in this sector is £2.8M .  The value of the local market for long term care is therefore £19.7M. 

1.4 The role of the CCG

In securing the market for long term care outlined in this document the CCG will:
• Promote quality as its overarching goal and will strategy its reward structure in line with levels of quality;
• Provide good information to the market and potential new market entrants;
• Provide good quality information to local people through web based portals – to become the first port of call for anyone looking for residential care;
• Introduce a ‘trip-advisor’ model to complement quality;
• Take a hands on approach to market shaping;
• Commission specialist provision to meet specific demand.


2 The long term care market for frail older people

2.1 Key messages - Commissioning priorities and aims

In developing the market for long term care for frail older people the CCG:
          • Is working to improve quality, and to reward this in its fee rate structure, through its quality framework and will not contract with providers who do not meet minimum standards;
          • Recognises the current over-supply in this market, reflected in occupancy levels at the start of 2013 of 76%, which mitigates against the delivery of quality care;
          • Will continue to develop alternatives to residential care in the community, including its commitment to invest in Extra Care Housing;
          • Will work with the care home owners and associations to further these aims.

There should therefore be no automatic assumption that the CCG will contract with new providers who open for business in North East Lincolnshire.  Contracts will also only be let where providers actively engage with the quality scheme and achieve a minimum of bronze standard and only where providers accept standard fee levels.

2.2 Current supply to the long term care market

On the 31st December 2012 a snap-shot of the local care home market produced the following picture:

Figure 1: Care home use in North East Lincolnshire on the 31st December 2012 (all client groups including short term stay placements).

The 975 places that were receiving funding as either Local Authority or Continuing Health care eligible clients therefore occupied just over half (54%) of the available beds in North East Lincolnshire.  This included short term placements and specialist placements such as those for enhanced dementia care.  The CCG is concerned that current levels of occupancy make it difficult to deliver quality care due to the impact of overhead costs associated with vacant beds. 


2.3 Future demand and needs

Demand for long term care in residential or nursing care homes is driven by a number of factors:
          • The number of frail older people in the population;
          • How and when we assess for the need for care home provision for those eligible for Local Authority funded care,  particularly by providing intermediate care services that optimise people’s rehabilitation and reablement following, for example, a stay in hospital;
          • What alternatives are provided that give people the necessary support and care in the community or, for example, in extra care housing;
          • What decisions those who would fund their own care make about entering a care home;
          • The support we provide to carers at times of crisis and on an ongoing basis, recognising that it is often the ability of carers to continue to support vulnerable older people that delays or avoids the need for an admission to a care home.

Demographic change is therefore not the only determinant of future need for care home provision.  Whilst recognising the contribution that this type of care can provide, and that for some it remains the best option, the CCG and its predecessors have already invested heavily in providing improved choice at times of crisis, and the alternative services that can meet this choice.  This theme will continue into the future particularly with the development of Extra Care Housing.  The combination of these factors provide the back-drop to recent reductions in the number of people that the Local Authority supports in care homes. Between April 2011 and April 2013 the number of people supported has reduced from 650 to just over 600.

The number of frail older people in North East Lincolnshire is, however, projected to rise in coming years as shown in Figure 2.  The increase is expected to be about 15% over the next 6 years, or about 2½% a year.  Were this to translate directly into increases in the number of care home places it would suggest a further 207 places would be needed (for all categories, i.e. including self funders and people funded by other Local Authorities) by 2019.  However, this is significantly less than the current level of vacancies in the sector (estimated at 441) and does not take account of the alternatives being developed, in particular extra care housing.


Figure 2          Estimate for the number of frail older people in North East Lincolnshire


To understand the balance demand drivers and the impact of developing alternatives to care home admission the CCG has undertaken extensive capacity modelling.  The outcome from this modelling work is shown in Figure 3.  This shows that the number of permanently funded places is expected to remain level for the next 8 years.

Figure 3: The number of permanently funded people in local care homes by either the LA or through CHC between April 2011 (week)) and April 2021 (week 520).

2.4 Sectors of care


2.4.1 Supporting people with dementia


As well as the primary goal of improved quality in local care homes the CCG and its predecessors have responded to the increasing level of needs of people in this sector, particularly where people have dementia.  Historically the Local Authority has offered a premium payment of £42pw for ‘EMI’ placements.  However, with a greater proportion of people with mild to moderate dementia in care homes this approach had the potential to disadvantage people who may have dementia or confusion but who were not deemed ‘advanced’ enough to qualify for this additional payment.

During 2012/13 additional capacity has therefore been commissioned within the local market, increasing this sector from 11 to 38 beds that provide enhanced dementia care.  These have been contracted for after an invitation to the market to tender.  Fee rates in this sector are significantly greater than the combined residential fee rate plus EMI top up and are currently in excess of £600pw.

There are no immediate plans to increase this capacity from the existing 38 beds but this situation will be kept under review in respect to both quality of care, outcomes for people supported and whether such capacity is sufficient.

The corresponding change, which recognises the increased presence of dementia and confusion amongst the care home population, is to reward all care homes according to the quality of care provided.  From April 2013 no new placements are therefore being made with the EMI top-up whilst at the same time the existing quality scheme is being extended with higher rewards being available for those providing the highest quality of care.

Figure 4 puts these decisions together and shows the impact on the different categories under which people will be funded.  This shows:
          • The increase in capacity for enhanced dementia;
          • The reduction in residential EMI payments as no new placements are made and existing clients receiving this top-up move out of the system;
          • The corresponding increase in the number of people in ‘standard’ residential care, where reward will be based on quality of care.

Figure 4:  Changes in the expected number of residential, residential EMI and enhanced dementia permanently placed clients from April 2011 to April 2021


2.4.2 - Nursing Care

Across the UK, there is significant variation in the quality of adult social care. In particular, people in nursing homes tend to receive much poorer care than those living in residential (non-nursing) care homes. This discrepancy was highlighted in CQC’s State of Care 2013-14 Report and furthermore, the report identified a shortage of nurses in Adult Social Care services. 

A Quality Framework has been developed to drive up the quality of care for those residing in local care homes; this results in homes achieving awards of Gold, Silver and Bronze. The outcome of the Quality Framework 2013-14, showed that the local picture is similar to that of what is being experienced nationwide. Respectively, nursing homes received a lower award level than that of their residential counterparts.

When considering the whole context of the residential care market in North East Lincolnshire, a much higher proportion of residential care placements are offered than in comparable areas. Although in comparison to other Local Authorities, North East Lincolnshire funds fewer permanent placements in nursing care. It is recognised that further nursing provision is required in the area and this would form part of a rebalancing of care provision across the two sectors rather than an increase in overall capacity.

The proportion of nursing care offered is at least in some part attributable to the difficulty recruiting and retaining nurses in adult social care services; this issue is being felt locally, across the Humber region and nationwide. This issue is a high priority for the CCG with particular consideration being given to encourage more nurses to work within adult social care and the on-going development of a more sustainable service provision.


2.5 Extra care housing

Extra Care will begin to accept new residents from early 2014 with plans being developed to provide between 300-400 units by 2018.  The CCG have partnered with a developer to secure this programme but opportunities for potential providers remain in areas of catering, ground works and retail/business unit opportunities.

The current assumption is that those entering would not typically have entered residential care until a year later.  Impact before April 2016 is therefore minimal but is built into assumptions about the medium to longer term.  Figure 6 therefore illustrates the anticipated impact of developing 300 Extra Care Housing units (line 2) compared to the situation were these not developed (line 1).  The assumptions underpinning this modelling take account of a number of factors that have been evidenced elsewhere, including the anticipated earlier entry to extra care compared to residential care and the fact that a small number of people, having entered extra care, may still need a period of residential care as their needs progress. 

Figure 6:  The impact of introducing Extra Care Housing on the total numbers supported in permanent care home placements.

The impact on the care home sector is to deflate demand by between 30-40 beds, or just over 10%.  It is, however, recognised that people choosing to enter extra care may still require home care support but again, evidence suggests that the level of home care required is less than that were they to remain at home.


2.6 Fee rates

Fee rates in North East Lincolnshire are based on a standard fee rate for care of £394pw (from April 1st 2013).  Additional quality payments are available at £10, £15 & £20 pw dependant on compliance with certain quality criteria.  Some people placed before the 1st April 2013 will also have attracted an EMI ‘top-up’ of £42 pw.  This is no longer paid for new clients but is retained for those in receipt of this at the 1st April 2013.

Nursing home clients also attract the standard Funded Nursing Care (FNC) payment of £109.79pw.  The Continuing Health Care fee rate for Nursing Care is £570 and does not attract the additional FNC payment.  Continuing Health Care Funded placements in Residential Care are paid at the same rate as the Local Authority’s standard fee rate plus quality.

2.7 Summary

In the light of previous experience and ongoing service improvement in the intermediate and community sectors, and particularly the development of extra care housing, it is the view of the CCG that the number of people supported in care homes will remain relatively level in the short term as demographic pressures match our ability to increase the support we offer in the community. 

However, a key factor in achieving our objective for continued improvements in quality will be an increased occupancy level.  Our modelling of the care home sector demonstrates that to achieve occupancy levels of 90% or over by April 2015 would require the loss from the market of approximately 340 beds. 

The CCG is therefore working with the sector to ensure that any reductions in capacity occur with minimal disruption to residents and are targeted at those establishments that would find it most difficult to improve care quality due to the nature and fabric of their stock.  This also means that the CCG would oppose all new development in care home capacity that doesn’t represent an improvement in physical fabric or quality of care.

3 Specialist long term care for people with severe and enduring mental health needs or a learning disability

Residential and Nursing Care

The purpose of this document is set out the CCG’s adopted strategy in relation to commissioning the long term residential care market in NEL.

In the main it deals with the standard long term care market but specialist sections for the Physical Disability, Learning Disability and Mental Health markets will be presented shortly.

Current Supply

All data correct as of 1/04/2014

The CCG procures all its long term residential care beds from the independent sector. There are no council run care homes in NEL.

Total Number of Registered Care Homes:     51
Residential:                                                           33 (1,201 beds) –(3 of which have enhanced dementia units)
Nursing:                                                                   9                                                            

Specialist residential care homes

LD/PD:                  7 homes (one of which is nursing) (109 beds)
MH:                       2 homes (39 beds)

Occupancy Data w/c 31.03.14:

Total beds in sector:                       1704
Total occupied:                                 1318 (77.4%)

Split by funding type:
LA funded:                                           741 (676 permanent and 65 respite)
Self funded:                                        356 (328 permanent and 28 respite)
CHC:                                                    127 (122 permanent and 5 respite)
Care Plus Group (Rapid Intermediate):                18
Other LA’s:                                           76 (73 permanent and 3 respite)

Split by bed type:
Residential beds:                             890
Nursing beds:                                   158
Legacy EMI:                                       251
Enhanced Dementia:                        19

Future demands and needs
There is no doubt that pressure from an increasing number of older people is already a factor in strategic commissioning plans.  Figure 1 shows that there will be an increase in the number of people over the age of 75 between 2011 and 2018 of c.15%, with a slightly higher increase in the number of people with dementia, which is another indicator of potential need. 
However, it is also well attested that a large proportion of health and social care costs are incurred during the last months or year of life.  The index of expected deaths across North East Lincolnshire is also therefore reflected in Figure 1 and shows a lower increase of only about 5% over the same period. 

Fig 1. Three alternative indices of need for older people in North East Lincolnshire

However, whilst approximately two thirds of spend on adult social care services is for older people there are additional challenges in supporting people with a physical or learning disability or with mental health needs.  Socio-demographic factors as well as advances in medical treatment for the very young will play their part in future funding challenges.  The precise level and growth in overall need for adult social care within the population is therefore unclear, but is likely to be somewhere between the two figures quoted above of 5 to 15% between 2011 and 2018. 

Whilst on the face of it there would appear to be an ever increasing demand for residential care in NEL other factors need to be taken into account.

The current length of stay for residential care is a little over three years. This has reduced steadily over recent years and we project that it will continue to reduce. This in part reflects the CCG’s strategy to offer quality and robust community alternatives to residential care for longer as well as changes to peoples aspirations for their later life, better planning and the availability of some housing alternatives.

The CCG intends to continue this strategy and build upon it with the delivery of 300 Extra Care Housing units across NEL by the end of 2018.

(See Extra Care Market Statement)

As a result of this, we believe that the overall population supported by the local authority will plateau or rise shallowly between 2014/18.

The effects of Care Bill Implementation remain to be modeled.

The CCG has asked the local care home association to nominate local reps to engage with the CCG on its implementation.

Strategic direction

The Adult Social Craare Strategy (2013-2016) clearly sets out strategy and actions in relation to the older peoples standard residential and nursing sector and can be described in broad terms as follows;

• to shrink the current over supplied market in order to increase average occupancy from 70% occupancy to nearer 85% occupancy to deliver better stability and sustainability,

• to encourage and reward better quality through the introduction of a new quality framework,

• to offer the public a tool for comparing care (quality framework standards)

• To build a positive relationship with providers within the sector and to work together through the introduction of changes to procedure associated with the introduction of the Care Bill (once enacted).

• To commission specialist enhanced long term care beds for people with Dementia that display behavior that challenges.

This strategy has started to deliver during 2013/14 with a reduction in over 80 beds and an increase in overall average occupancy from 70% to nearer 75%.

At the beginning of 2013 the CCG offered the sector an inflationary linked fee uplift of 1% which brought the standard fee up to £394 per week. This represents a standard residential fee that is very competitive with the other Y&H local authorities and puts us above the average level, especially when added to the already agreed quality premium payments that are due to commence this year.

There was no inflationary linked uplift on the basic fee for 2014/15 however the CCG has stated its intention to implement Quality Payments from 1st April 2014. (see quality section)

Commissioning principles and aims, including timings for any significant developments in commissioning

Provider implications – how the CCG expects the market to respond

Advice for new providers.

The CCG would want to continually refresh the local residential offering to ensure the most up to date and modern facilities are available for the people of NEL.

New providers who believe they have something to offer the locally are encouraged to start a dialogue with the CCG at the earlier opportunity in order we can talk about local opportunities and the state of the local market.

Any new provider would need to operate under a license for an initial period while sufficient numbers of people justified the initiation of the Quality Inspection.

We would expect all new providers to be able to meet our Bronze Standards before a full contract is let.

Quality and performance monitoring

Advice for existing providers

All provider will be written to in May 2014. The letter will set out the findings and outcome of the Quality Inspection. A rating of Gold, Silver, Bronze or Standard will be issued. Homes that are judged to be offering care at sub-standard levels will be given notice under the current contract. Homes that are deemed to be offering standard care will have LA funded placements suspended while improvement to bronze standard if evidenced.

Enhanced payments will apply per person per week from 1st April 2014 for invoice purposes.

Tendering procedures
There are no plans to run a tender at this moment in time.

Technology & Equipment - Telecare/ Equipment/ AHP

Telecare is a system of sensors in an individual’s home which detect household dangers e.g. fire, flood and/ or detect risks to vulnerable people e.g. falls, failing to take medication. On detecting a danger/ risk, sensors alert a 24/7 monitoring centre; the centre responds to alerts through a triage system, which may result in a call to family members, friends, neighbours etc. or to the emergency services.

In 2011, a Department of Health (DoH) funded control trial found that Telecare can (if properly delivered) substantially reduce mortality and decrease the time spent in hospital/ in A&E.  In 2012 a Concordat between DoH and the UK Telecare industry established a 5-year enabling framework to accelerate the adoption of Telecare, to increase quality of care for 3 million people living with long term conditions/ social care needs.  Not all research demonstrates a conclusive causal link between Telecare and reductions in health and social care budgets, but the significant benefit to users and carers is consistently acknowledged.  Reservations about the cost savings generated by investment in Telecare are not reflected in the findings of many providers.

Local Telecare services are delivered by Carelink.  The service is exceptionally well reviewed by users and is respected amongst professionals. As part of the recent contract review process, a Telecare Stakeholder Summit was hosted by North East Lincolnshire Clinical Commissioning Group (NELCCG) and Carelink, and attended by local providers and community representatives.  Agreement was reached to continue the current service for a further three years, with some modification. These changes included improvements to the way the service interacts with other key provider services, a more responsive service (rather than a purely reactive one), to include welfare and courtesy calls to support wellbeing and prevention, and a new link between Carelink and Care @ Home agencies to ensure effective support of vulnerable people in crisis.  It was also agreed that the service should expand to reach more funded users across the health and social care system and more self-funded users through the preventative services market.  The service specification now in place reflects the refined vision for Telecare services in North East Lincolnshire.

Allied Health Professional Services (AHP)
There are almost 700,000 Allied Health Professionals employed in the English NHS (HSJ 2008); Allied Health Professionals (AHPs) work in health and social care teams but are distinct from nurses, doctors, and social workers. They vitally support the health and social care system function by providing a range of diagnostic, technical, therapeutic and direct client care and support services that are critical to the health and social professionals they work with, and to the clients, client families and carers they serve. Their role in the delivery of improved outcomes for people and their families directly supports the sustainability of the health and social care system. AHPs include physiotherapists, occupational therapists, speech and language therapists and podiatrists, to name but a few. 

AHPs can make an immediate impact on the lives of older people and those with long term conditions, and they ensure resources are used to best effect by preventing unnecessary admissions to hospital or care, enabling people to live at home for longer, and supporting people to return home quicker; overall this encourages a reduction in the dependency on care services, due to a focus of re-ablement and self-management. “Enabling” approaches, including re-ablement, rehabilitation, prevention & wellbeing and supported self-management, will therefore play a central role in underpinning the transformation required, to support individuals and communities to be strong and resilient.

North East Lincolnshire CCG has conducted a review of AHP services and has established a vision of a ‘one system model’, which has been implemented over the last year.  Care Plus Group and Northern Lincolnshire & Goole Hospitals NHS Foundation Trust are now working together under a formal partnership arrangement with commissioners to deliver AHP services in North East Lincolnshire. The services aims to operate in the community, feeding into the acute services delivered at the hospital. The service includes a single point of access which provides advice, information & signposting. Where appropriate, a referral can be made into a multi-disciplinary assessment function, and subsequent therapy services delivered to meet a client’s needs.  . The service ensures a continuum of care, based on the right support at the right time and tailored to the client. An emphasis is placed on promoting people’s independence & wellbeing. Clients, their families’ and carers are encouraged to be in control of their own care & support, and to give feedback that informs overall service design, implementation & monitoring.

Assisted Living Centre
National Context
There are over 11 million people with a limiting long term illness, impairment or disability (2012). At least 7 million people in the UK are disabled and the prevalence of disability is rising across all age groups. It is estimated that there are 1.2 million wheelchair users in England– circa 2% of the population.

The Audit Commission has issued several reports, including ‘Fully Equipped’ in 2000 and a further update in 2002, which highlighted poor equipment and wheelchair provision across England and made recommendations for change.  The most significant suggestion was to develop regionally integrated services that would be funded under the Health Act Section 31 Partnership Arrangements, including pooled budgets.  These changes became mandatory for all authorities by April 2004 as part of the Government’s NHS Plan. 

More recently, a comprehensive review of existing community equipment services in England by the Department of Health (DH) (2009) identified that community equipment, i.e. Simple Aids for Daily Living (SA4DL) such as eating and drinking utensils, grab rails and raised toilet seats or more complex equipment such as beds, hoists and lifts, help millions of people to be independent. Yet there are real and growing problems with the existing way equipment services are provided to clients; for example, services are already struggling to meet need, without taking into account budgetary pressures, increasing demand due to demographic change, and the intersection with other services which may not promote the same agenda, i.e. independence, choice and control for all. The solution identified by the DH was a new service delivery model, which will move SA4DLs into the retail marketplace and redesign provision for those with complex needs.

The estimated total UK cost for what is termed ‘equipment for disabled’ stood at £1.6 Billion in 2008, up from £1.43 Billion in 2004 (Keynote 2012). There are approximately 138 community equipment and 151 wheelchair services in England.  Many of these are run by local authorities and/ or NHS bodies and the remainder have become outsourced to private contractors.

According to DH figures, the annual spend on community equipment (including approximately £82 million on equipment refurbishment and reuse) is over £318 million.  Approximately 60% of this value is for complex equipment such as hoists, beds, etc.  The remaining 40% of current state spending is on simple equipment such as bath boards, raised toilet seats and bath lifts, etc. These figures do not include state expenditure on wheelchair services, of which £54 Million was spent on wheelchair equipment and associated items (2008).

The updated Care Act, recently launched in 2014, clearly sets out a new vision for health and social care services from April 2015 onwards. The Act places a greater emphasis on the need to provide advice, information and support to the wider community, not just to those requiring formal services.  The Act emphasises prevention and wellbeing as being significant concepts, as well as including and involving individuals in decision making, assessment and care planning. The Act also focuses on the wider outcomes and goals to be delivered, looking at whole family approaches. Overall, the Act strives to support the community to remain as independent as possible for as long as possible. The CCG specification for this service supports the aims of the Care Act 2014.

Local Strategic Context
The Integrated Community Equipment and Wheelchair services in North East Lincolnshire are under significant pressure as a result of growing demand; this is due to changing demographics, the change in national and local policy regarding personalisation and, in particular, the promotion of client choice and control. It is estimated that around 20% of the population of North East Lincolnshire have a disability (Annual population survey 2012).

Equipment services are vital for the residents of North East Lincolnshire, and, as such, have been reviewed in detail over recent years, with extensive community and stakeholder engagement to:
• Explore the potential for relocating the current service, as the current buildings were not fit for purpose
• Identify ways to make the service more efficient, fit for purpose and able to meet future demand
• Identify the changes required by legislation
• Identify and collate concerns raised by clients and professionals
• Explore whether the service was operating in a way that represented best value for money.

As a result, the Transforming Community Equipment Services Steering Group was established to pull together the information from the review and to develop a vision for a new model of community equipment services in North East Lincolnshire.  In addition to this, the wheelchair service was undergoing review due to concerns raised via clients and professionals regarding waiting times.

Potential improvements were identified in both the equipment and wheelchair service, which led to the development and subsequent approval of business cases to support the changes required. These included increasing staffing capacity to reduce waiting times for the assessment, delivery, collection, cleaning and repair of equipment and wheelchairs. Revised service specifications were developed and launched in April 2014 to reflect the changes. Although the services have historically been separate, a much wider vision was articulated for an ‘Assisted Living Service’ delivered through an ‘Assisted Living Centre’, which would utilise all of the changes emerging as part of the specifications and further enhance the service by combining the two services to share functions, develop a multi-skilled workforce and generate economies of scale. This will improve client access, improve service quality and enhance client and carer outcomes. In addition, the service will provide a robust front facing service to clients, their carers, health and social care professionals and the wider community. The service is planned to offer specialist advice, information, signposting, demonstration facilities, assessments and the provision of equipment/ wheelchairs to support independence, via self-purchase, signposting or provision of items through a loan facility.