Care Management Matters – The Future of Learning Disability Care - 8 September 2011

1. Care Management Matters – The Future of Learning Disability Care - 8 September 2011 Financial Viability - An Update and Discussion David Roe Consultant, Laing and Buisson Director, Better Care Outcomes Ltd. Better Care Outcomes Ltd.

2. Financial Viability – An Update & Discussion Topics • Laing and Buisson Cost Issue reports • Major Cost-related concerns • Housing Issues • Financing Issues • Law Commission and Dilnot Commission proposals • DWP Housing benefit reforms • Lack of Consistency in Cost Models • Personal Budgets Considerations • Cost-saving and support needs reduction initiatives • Future financial viability prospects - discussion Better Care Outcomes Ltd.

3. Major Cost-Related Concerns • Hours of Support and Hourly Fee Rates being reduced • Sufficiency of Provider Margins/ Returns • Ways in which local authority cost savings are being achieved & impact on quality/ VFM • Housing Constraints • Difficulties in obtaining sufficient Bank Financing • Barriers to Deregistration • Balancing Cost, Effectiveness and Choice • Lack of Consistency in Application of Cost Models • Inadequacies in Personal Budgets Better Care Outcomes Ltd.

4. Housing Issues LA Housing Dept. Social Housing Housing shortages Private Landlords Care Provider Housing Provider Finance insufficient Exempt Status, but new DWP proposals Local Housing Allowances inadequate for private providers (now only 30%ile) Care Manager or Broker Housing benefits may also be insufficient & not cover adaptations in full Better Care Outcomes Ltd.

5. Financing Issues – Supported Living 2) Separation / no back-up from support income • Credit squeeze & bad debts • Restricted, ‘property’ lending (no extra for earnings multiple) Care Provider Housing Provider Bank 3) Lack of security in income streams, and voids, as service user moves on LA Housing Dept. Care Manager or Broker 1) Shortfall in housing benefits Lack of social housing & reduced capital grants increase reliance on banks, but banks are reluctant to lend, especially for supported living Better Care Outcomes Ltd.

6. Balancing Cost, Effectiveness and Choice Costs, efficiency and economies of scale Dedicated support, individual flats, more choice • Many individuals prefer smaller housing, personalised staffing • But, if economics/ financing do not stack up, or budgets are constrained, then choice will not be available • Economies of scale argue for clusters of flats, larger homes, shared staffing models and some shared activities / day services (particularly with severe cost constraints) Effectiveness • Effectiveness of support seems to be determined more by skills, work methods, culture and commitment of staff, than by living arrangements • High quality environments tend to show increased efficiency, reduced key costs and improved financial viability (see Virtuous Quality Circles) • Working to maximise what individuals can do for themselves/ independence is key and can / should be pursued in any housing setting. Better Care Outcomes Ltd.

7. Law Commission Adult Social Care Report Beneficial recommendations • Single, streamlined Assessment and Eligibility Framework • Duties to carry out assessments enshrined in law • Requirement for assessment of eligibility to follow assessment of needs • Potential for this to result in national eligibility criteria • Portability of assessments between different local authorities, leading to protection of entitlements, & increased speed in ensuring needs met when changes in location occur • Those in residential care to be able to obtain direct payments Better Care Outcomes Ltd.

8. Dilnot Commission Recommendations Beneficial recommendations, though some concerns • People born with disabilities and who enter adulthood with a support need will be eligible for free lifetime care • (though concern that those with low/ moderate needs will not be eligible – as now) • Need for integration with healthcare and welfare, aligning with/ maintaining universal disability benefits • (but concern that Personal Independent Payment (PIP) to replace DLA to be directed to those with lowest needs, with those receiving local authority support losing current DLA entitlement (care, mobility, or both?), whereas government was suggesting PIP directed to those with higher needs) • Support to cover all aspects to help people flourish Better Care Outcomes Ltd.

9. Dilnot Commission Recommendations Beneficial recommendations, though some concerns • Lifetime cap on amount someone pays for their social care(£35k), tapered by age, so that those under 40 would pay only £10k, increasing £10k by decade to £35k at 65 • However, people in residential care should pay set amount towards living expenses i.e. ‘board & lodging’ (£7k -10k for older people), even if cap reached • But recognised that state welfare support for those of working age is much less, so should be set at a lower level( & eligible for means tested support if unable to afford this) • Means tested support to increase from assets of £23.25k to £100k, tapered for those with greatest need • Support for national eligibility criteria • Separate assessment for carers Better Care Outcomes Ltd.

10. Dilnot Commission Recommendations Conclusions – beneficial aspects and concerns • Those with substantial and critical needs are likely to get free care for life and not have this reduced if they happen to obtain some modest inheritance or employment • But concern that those with low/ moderate needs will still not receive any social care support, with low welfare benefits • Whilst this addresses funding entitlement, in principle, for some, the major issues relating to how much local authorities pay for care/ support and housing benefits are not addressed – so this may still be too low to cover the actual, full costs of provision,for high quality support Better Care Outcomes Ltd.

11. Housing Benefit Reforms – DWP Proposals Need for Reform – DWP acknowledge: • Current system no longer works • Excessive complexity • Poor fit with individual choice in commissioning own care • Unfairness • Unnecessary risk to specialist housing providers • High cost to local authorities These issues have resulted in uncertainty, threatened financial viability and reduced much needed investment in new housing Better Care Outcomes Ltd.

12. Housing Benefit Reforms – DWP Proposals Main Proposals: • Private landlords able to obtain same level of housing benefits (HB) as ‘not for profit’ non registered housing providers • No longer a need for housing providers to provide both housing and support, to meet exempt requirements • For non-registered providers, level of benefits to be categorised in two groups: a) People in conventional supported housing b) People with more specific housing needs • System for registered providers to continue largely as is Better Care Outcomes Ltd.

13. Housing Benefit Reforms – DWP Proposals a) People in conventional supported housing • For more communal housing, possibly short-term, such as hostels, refuges and foyers, plus sheltered accommodation • Pay local housing allowance (LHA) plus top-up to meet costs of security systems/ staff, higher levels of wear and tear and additional housing management • Possibly a single flat rate top-up or several by type of support? • Providing a reasonable amount, with extra needing to be through alternative funding streams Better Care Outcomes Ltd.

14. Housing Benefit Reforms – DWP Proposals b) People with more specific housing needs • For people with more intensive levels of care/ support, requiring specially adapted, higher cost housing • Also receive LHA, but with specific extra budget on top, based on needs, agreed by local authority commissioning (rather than HB department) • Commissioning of housing better integrated with care and support, though still part of HB (or possibly added in with personal budgets, with discretion as to how spent?) Better Care Outcomes Ltd.

15. Housing Benefit Reforms – DWP Proposals Registered Providers • Continue under existing system, with rent (which is normally below market rents) and eligible service charges paid in full; treat in same way as mainstream social housing • However, as now, rents could be referred to a rent officer, if considered high; but, make comparison with similar supported living housing (rather than general housing) • Commitment to support service charges adequate to meet needs Better Care Outcomes Ltd.

16. Housing Benefit Reforms – Issues a) People in conventional supported housing • Many people in hostels and refuges have high support needs (e.g. domestic violence, substance abuse), though those in sheltered accommodation have low needs • A single top-up will therefore not work; a series of flat-rate top-ups will also cause problems as actual costs vary depending on size of house/ numbers of occupants and resultant economies of scale • LHAs often insufficient to cover basic rent in supported living and do not align with all types of housing (e.g. refuges with multiple occupancy rooms) Better Care Outcomes Ltd.

17. Housing Benefit Reforms – Issues b) People with more specific housing needs • LHAs as a base level are deficient similarly to a) above, in covering basic rent, multiple occupancy etc. • No consistent guidelines, criteria or benchmarks currently exist to determine levels of extra housing costs justifiable • Moving assessment away from HB teams risks losing their expertise in relation to detailed housing cost review • In the adverse financial climate, there is a serious danger that local authorities simply fail to set extra budgets at levels sufficient to cover actual justified costs, with no other funding streams to draw on • Difficult to see how proposals would be cost neutral Better Care Outcomes Ltd.

18. Lack of Consistency in Application of Cost Models Care Funding Calculator - Independent Living version In Control – RAS,for Personal Budgets • Detailed needs matrix provides hours support required • Support fees directly based on cost of hours support + other associated costs • Assessment results in points based on broad level of need • £ per point calculated using average costs of supporting others with similar needs currently, adjusted based on what is affordable • No direct link to hours or to actual costs for mix of of support provided RAS is not transparent or reliable, particularly in calibrating support/ costs for those with high needs Better Care Outcomes Ltd.

19. Personal Budgets ConsiderationsA simplified ‘hybrid’ approach is suggested: Significance of need Hours per day Support requirement Proposed Support Resource cost Daily Cost PERSONAL CARE A% B hrs. A x B hrs. Ratio / % £ per hr £ per day INDEPENDENT LIVING EDUCATION, ACTIVITIES COMMUNITY/ SOCIAL WORK PHYSICAL HEALTH KEEPING SAFE Totals See Cost and Cost-Effectiveness Issues Report Appendix 3 for explanation Better Care Outcomes Ltd.

20. ‘Viable’ Cost Saving Initiatives Without sacrificing quality? • Increasing supervision management spans of control • Prioritising/ cutting head office overheads based on value • Improving staff scheduling & management (e.g. reducing agency, sickness, overtime), plus effectiveness/ efficiency • Improving service user risk management • More economic activity programmes, shared costs, reduced travel cost options etc. • Use of assistive technologies • Increased use of personal assistants and voluntary community support • Reducing support needs e.g. increasing independence & ‘All Together Now’ report Better Care Outcomes Ltd.

21. Laing and Buisson Cost Issue Reports Illustrative Cost Models in Learning Disabilities Social Care Provision • Commissioned by Valuing People Now, Department of Health • Highlights relative unit costs of different types of provision and impact of changes in key variables affecting margins • Reviews staffing and housing models and comments on economies of scale/ efficiencies • Highlights the increasing roles of Assistive Technology and Community Support Cost and Cost-Effectiveness Issues in Learning Disabilities Social Care Provision • Reviews impact of/ potential for cost savings and efficiency improvement • Identifies Housing and Finance constraints • Describes Effectiveness, Quality Improvement, Outcomes and Value for Money considerations • Debates further Development/ Deployment of Costing/ Entitlement Models and Personal Budgets Better Care Outcomes Ltd.

22. Contacts David Roe 01306 731311 mobile: 07860 163796 Consultant, Laing and Buisson david.roe@laingbuisson.co.uk Director, Better Care Outcomes Ltd.Supporting the social care community in business development,marketing, improving effectiveness, efficiency, service quality and outcomes, as well as financial management and overall value for money. david.roe@btconnect.com www.bettercareoutcomes.co.uk Reports www.laingbuisson.co.uk/MarketReports/FreeReports.aspx Better Care Outcomes Ltd.