Challenges and solutions: commissioning social care during COVID-19
Published: January 2021
Last updated: May 2022
This guide addresses the challenges faced by the social care sector during the pandemic. It describes how local authorities, providers, individuals and communities have responded with a range of solutions to ensure people have the support they need. It includes examples of practical and financial support for market continuity as well as innovative solutions benefiting individuals and communities.
Commissioners, providers and the community sector will find this useful to inform immediate responses to the crisis as well as longer term market shaping plans.
Introduction and overview
The challenges of COVID-19 are many and the impacts ongoing. The sector already faced enormous challenges prior to the pandemic - longstanding financial pressures, a precarious and narrow provider market, limited choice and control for citizens in many areas, struggles to scale innovation and engage community assets, an undervalued workforce and increasing workforce shortages. The crisis has magnified these issues and local authorities are taking a huge financial hit.
Despite that, social care has continued to function. Overall, people were not left without care (though waiting lists are now growing). Community mobilisation ensured people received vital food and medicine. Some providers responded flexibly to meet needs in creative and positive ways. The provision of care, however, came at a terrible cost for people living in care homes, their families and care workers. Those using and providing other forms of support also faced considerable challenges. People missing out on reablement or healthcare may have reduced independence or suffered damage to their mental health as a result. The same is true for the millions of people awaiting surgery and the estimated 1.9% of the population experiencing long COVID. The longer term impacts of these on people’s needs and on the workforce are still to be understood.
At the beginning of the pandemic local authorities and commissioners needed to respond quickly to a rapidly developing crisis to ensure people received vital care and support. Approaches that helped include:
- Stabilising the sector through sustainability funding and meeting extra costs
- Practical support and advice – personal protective equipment (PPE), testing, infection control and help with recruitment
- Positive communication and relationships to understand issues and to develop shared solutions – building on co-production and partnerships
- Community support and mobilisation
- Flexibility and responsiveness – particularly through more personalised arrangements such as direct payments, Shared Lives and micro-enterprises
- Strong local decision-making – often in advance of Government guidance
- Collaboration with local health partners to ensure the required health input
- Personal dedication of care staff, unpaid carers and the resilience of individuals.
Some local authorities have taken proactive steps to engage with citizens, develop innovative solutions or taken market shaping measures to ensure social care providers are able to continue operating. Future planning, though, must be based on what people actually want. If it’s propping up a market that doesn’t give real choice, it’s time to think again. Plans must address the risk of future outbreaks and the multiplying impact of winter pressures, increasing needs, limited availability of some services and dire staff shortages to avoid what may be experienced by some who use social care as a ‘permanent lockdown’.
Principles for good commissioning responses to the pandemic
- Use evidence-based commissioning approaches – understand what works and what doesn’t locally and why, as well as likely future pressures.
- Embed values – choice, control, community connections and co-production.
- Share power and maximise expertise – building collaborative approaches.
- Meet immediate needs, but don’t rush to long-term solutions.
- Support what works – invest in what delivers good outcomes.
- Support community responses – don’t get in the way, help when needed to add value.
- Align long term planning to wider agendas – employment, poverty, loneliness, health.
- Money – use it locally, use it wisely, get the best impact.
- Save lives and improve lives.
The pressures COVID-19 has caused the sector
The social care sector is complex and crucial. It involves millions of people and vast sums of money. Failures would be devastating for individuals, their networks and beyond. COVID-19 emphasised the scale and importance of the sector.
- Social care is a keystone of communities employing over 1.5 million people in England and contributing £50.3 billion to the economy in 2020/21.
- Local authorities spent £23.3 billion on social care in 2019/20 and provided long term support to 839,000 adults (King's Fund).
- People privately purchasing their own care are estimated to spend £11billion per year.
- There are an estimated 6.5 million unpaid carers with millions more taking on caring responsibilities during COVID-19.
- Around 18,500 provider organisations deliver services across 39,000 establishments, and 70,000 people employ their own staff via a direct payment.
A number of pressures which already existed in social care have been amplified by the pandemic as summarised below,
Financial uncertainty and underfunding Open
- Pandemic-related costs to local authorities and providers were predicted to far exceed the Government Emergency Funding of £3.2 billion in 2020/21. There was also extra support for social care via infection control funding, funding for rapid testing and workforce capacity. This plus transfers from CCGs was vital in shoring up the financial position for councils.
- At September 2020 ADASS reported that only 4 per cent of directors were confident that budgets would cover their statutory duties.
- COVID-19 led to a large increase in net spending on adult social care services (£933 million) and public health spending (£486 million). Gross expenditure on adult social care increased by £2.9 billion (12.8%). But there were significant variations across councils. There were lower than expected increases in costs in children’s social care in part due to reduced referrals.
- There were further pressures on some already struggling councils as income from charges and business rates reduced significantly (Health Foundation).
- Councils spent £443 million (28.2%) more on ‘commissioning, strategy and admin support’.
- Adult social care funding is still below the 2010/11 level. There are concerns that the social care white paper and promised funding do not provide enough money to move out of the crisis, meet the growing demands, address sector pressures and deliver reform.
Market pressures – the fragility of care markets Open
- Early in the pandemic it was feared that extra costs and reduced occupancy of care homes would result in a significant number of providers, or a large provider, going out of business.
- With additional funding and support, the ‘market’ fared better than feared. Despite reductions in occupancy, CQC report that the number of registered care home beds remained stable to April 2021.
- ADASS however reported that one in two councils had to respond to a care home closure or bankruptcy in the six months to November 2021. They also reported increasing numbers of home care providers handing back contracts or not able to accept new work.
- Fees remain an issue. There was already a 10 per cent shortfall in care home fees paid by local authorities. Any further pressure on fees or running costs could mean care homes closing or only supplying to the higher paying self-funders. New builds tend to target self-funders and charge higher end rates.
- Quality remains an issue with nearly one in six registered services rated as requiring improvement or inadequate.
- Staff vacancies in care homes present a big risk to viability rising from 6% in April 2021 to 11.5% in December 2021. Vacancies across the sector generally have also risen and were at 9.4% in December 2021.
- New waves and variants of COVID-19 have caused additional pressures. Lack of staff plus COVID-19 related worker absence and infection rates in homes, resulted in many care homes not accepting new referrals in December 2021. This has a significant impact on hospital discharge too.
Lack of choice and unmet needs Open
- Some people are not getting, or for long periods did not get, the support they need due to temporary closure of services, providers not accepting new people and some people refusing support out of fear or the need to shield. Prior to the pandemic, Age UK estimated one in seven older people don’t get the care and support they need.
- ADASS reported in November 2021 that over 500,000 people were waiting for an assessment of their needs or waiting for a service.
- More than 2 million hours of commissioned home care could not be provided between January and March 2022 because of a lack of staff.
- Choice has been limited. Lack of appropriate assessments, rapid discharge to care homes or quickly arranged support in the community means people may be in homes they wouldn’t have chosen, have not had help to return home or are not getting support that is right for them.
- Thirty-five per cent of local authorities report fewer people presenting needs relating to domestic abuse and safeguarding since lockdown in March 2020.
- There is also insufficient access to primary, community services and mental health services to support local people’s needs.
- An additional 4.5 million carers are providing unpaid support in the crisis. Existing carers are providing more support and facing isolation, stress and financial pressures with many more having to decide between caring for someone or giving up work.
- Modelling, however, indicates that many people are over-supported. Support approaches and the way contracts operate limit opportunities to tailor support and help people gain more independence.
Workforce pressures Open
- The pandemic has highlighted the skills and dedication of many workers.
- Death rates amongst care workers are double the general population – with higher risks still for black, Asian and minority ethnic workers and for men
- Poor terms and conditions for care workers added to the spread of the virus. Many don’t have contractual sick pay, 25 per cent are on zero hours contracts working multiple shifts across sites and simply cannot afford to take time off.
- Recruitment and retention are ongoing concerns. Skills for Care estimated that vacancy rates across the sector were 10.3% in May 2022 having risen from 6% in March 2021.
- Turnover which decreased early in the pandemic is back above pre-pandemic levels at over 30 per cent and higher in some areas.
- Skills for Care also point to sickness rates increasing during COVID-19 and the number of workers leaving or ill due to burn-out.
- Recruitment and retention is a major concern especially given higher pay and shortages in other competing sectors. New immigration and Brexit rules have added more pressure (visas are currently only available for professional and more senior roles). Concerns about the loss of workers due compulsory vaccinations has led to the requirement being suspended.
Specific challenges affecting care homes Open
- During the two peak periods of COVID-19, April to September 2020 and October 2020 to March 2021, 39,350 deaths in care homes were attributed to COVID-19.
- Around 40 per cent of all care homes reported an outbreak in the first four months of the pandemic.
- Transmission was accelerated by the congregate nature of homes, residents with COVID-19 moving in, lack of testing and lack of PPE.
- Lack of specialist healthcare going in to care homes has resulted in people suffering a range of health complications – not just COVID-19.
- Providers faced rising costs of more than 30 per cent higher than usual - largely due to PPE inflated costs, sick pay, retaining higher staffing ratios and backfilling with more expensive agency staff.
- Two-thirds of providers reported delays in receiving additional funding as this took time to pass through via local authorities.
- Residents – many of whom have dementia – experienced distress, confined to their rooms with no outside visitors.
- Poor or rushed assessments made it hard for staff to understand the needs of new residents.
- Since the start of the pandemic, occupancy levels in care homes have fallen from 86% to 76% in care homes with nursing and from 87% to 81% in residential care (August 2021).
- Staff vacancies in care homes present a big risk to viability rising from 6% in April 2021 to 11.5% in December 2021. The National Care Forum reported even higher rates in the not for profit sector.
- New waves of COVID-19 have caused additional pressures. Lack of staff plus COVID-19 related worker absence and infection rates in homes, resulted in many care homes not accepting new referrals in December 2021. This has a significant impact on hospital discharge too.
Impact on community support settings Open
Community-based services have also faced issues with staff sickness, absence, costs, PPE and loss of business. The lack of regular testing for people receiving social care, home care workers, unpaid carers and personal assistants will have accelerated transmission across a range of settings.
Supported living schemes faced similar challenges to care homes, but did not get official access to testing until much later, despite supporting people facing higher risks from COVID-19, including people with learning disabilities.
Many buildings-based services – day centres and short breaks – have had to close temporarily or change their offer. Some services have still not returned to face to face support.
Support for direct payment users was variable across the country. Some areas were slow off the mark. Many direct payment users felt abandoned:
This under-estimated the challenges individuals were facing with access to and inflated costs of PPE, workers being off, contractual issues, the difficulty and cost of back-up support and contingency planning, let alone the isolation and fear that people experienced.
The only communication from my council was very general and addressed to “Dear DP user”.
Shared Lives carers experienced varied responses from local authorities. Some council-run schemes saw co-ordinators redeployed leaving households with limited support. Shared Lives schemes were missed from early government guidance so had inconsistent messages, and Shared Lives carers were not initially recognised as keyworkers. Some experienced difficulties accessing PPE (though some local authorities provided this). Households locking down together faced extra costs and added pressures when other usually essential supports were not available.
Digital barriers are a significant issue. As more services moved online, despite real efforts by many providers to keep people connected, exclusion and isolation were compounded for those without digital access. Lack of digital skills for staff was also an issue.
Solutions to commissioning challenges during COVID-19
There have been varied solutions to the issues faced. Commissioners will want to ensure the positive community and innovative solutions become embedded in ongoing approaches. The ADASS budget survey and Coronavirus survey from June 2020 showed how councils rapidly adapted and enhanced provision of information and advice, re-trained council staff and partnered with volunteers to enhance support. There has been a range of measures of practical and financial support for providers throughout the pandemic. Importantly, providers, communities, carers and individuals have adapted to respond positively to the challenges.
Local authorities provided funding (including via emergency funding from the government) to local providers to support cash flow, sustainability, cover excess costs and extend services. Examples include:
- payments in advance and immediate payments to support cash flow
- sustainability payments for providers with reduced business or unable to operate – paying for commissioned capacity rather than occupancy in care homes, home care and day services
- increased rates for home care and care homes, contingency funds for direct payments and financial support for unpaid carers
- guarantees to micro-providers in receipt of direct payment income
- emergency funds for providers to claim back excess COVID-19-related costs
- funds to support and sustain voluntary and community sector organisations
- funding expansion of some voluntary and community sector (VCS) activity such as adding capacity to mental health teams to broaden their support offer and reach
- funding crisis accommodation for people with learning disabilities and mental health needs.
Local authorities also provided practical support including:
- procurement and delivery of PPE at no cost to providers, unpaid carers and people receiving direct payments
- a local seven-day public health support and advice line on COVID-19 for care providers
- expert training and advice, e.g. weekly webinar training sessions on infection prevention and control for providers
- early arrangements for testing and, importantly, re-testing for people in all care and support facilities (e.g. by Bexley with Queen Elizabeth pathology lab)
- supporting clinical links such as ‘virtual’ GP and pharmacy appointments for care and nursing home residents through supplying iPads to care homes
- recruitment: local campaigns, undertaking recruitment for providers
- leverage and leadership to change local behaviour – for example, a local DASS intervened when blanket DNR notices were being sent.
CQC has been documenting innovative and inspiring examples of how providers are responding to COVID-19. Examples include supporting people to stay in touch with family and friends, use of technology, virtual exercise classes, enhanced infection control, supporting people and their families with information and advice, plus practical ways of supporting staff such as with safe travel arrangements as well as emotional support.
Providers themselves have adapted rapidly and many have implemented changes to ensure safety whilst promoting wellbeing.
Practice example: Collaborative working and maintaining quality
Princess Homecare Open
Summary and purpose
Princess Homecare is a small domiciliary care agency in a rural part of Wiltshire Council with less than ten clients (older people). Since the start of the COVID-19 crisis, the Council has been proactive, supportive, as well as approachable and responsive to questions. They have acted as a sounding board for questions or signposted Princess Homecare to further information, which has been crucial particularly at the break of the crisis.
Wiltshire Council have supported us providers by agreeing to pay all invoices sent to us, ensuring we are financially stable to continue the service during the crisis. They have also offered to pay for additional costs such as training new staff, extra travel incurred due to emergency service provision and the purchase of tablets for the use of video calling service users’ families during the lock down. These have enabled our company to continue providing services safely and without financial concern, particularly with the cost of personal protective equipment (PPE).
We have kept a log of actions and activities taken due to COVID-19 to ensure we know what happened and when. We have also been able to keep in touch with the service users’ families with regular updates on top of their video calls. Because of this, we are able to easily reference resources we have found, reasons we have taken actions and provide accurate information to families for peace of mind.
Examples of actions taken below:
- Providing video calls between clients and families.
- Recruiting volunteers to phone clients weekly.
- Working collaboratively with other providers, sharing resources and involving them in contingency plans.
- Working with Wiltshire Care Partnership (WCP) to connect with other providers.
- Sharing our insights and experiences with SCIE.
- Engaging with webinars provided by organisations such as Skills for Care and SCIE.
- Providing technology to ensure those who can work from home are able to, boosting motivation and support.
- Continually checking latest guidance and best practice to ensure we are working as safely as possibly.
- Making sure staff never run out of PPE.
- Regular checks on staff health and mental wellbeing.
- Working with staff to develop working schedules rather than just handing them their weekly rota.
- Providing regular updates to staff (weekly videos in a format they all wanted) and clients/families (website updates and email communication).
- Separating staff from care service and other services to ensure minimal cross-over and risk of transfer.
- Use of technology to enable call diverts away from land-based office to remote working.
Challenges and learning points
The key challenge has been to keep up to date with the amount of information being released daily, and being able to translate it in a practical way to staff, service users and families. The fact that the information is not organised in one same place has added to the difficulty, as some days we received several emails from different sources with similar information.
To help combat this, we have been recording weekly video updates for staff with the key information they needed to do their jobs. We also forwarded some information for them to read, but provided a video summary to facilitate accessibility to the key messages and give staff the opportunity to listen to them when suitable.
One key lesson is how much more we can achieve and how much further can we reach working collaboratively. We have been linking to other small providers in the area and supporting each other emotionally and professionally. The level of collaboration between small companies has been incredible.
Contact Charlie Marillier, Registered Manager
Support with hospital discharge and to reduce admissions
With urgent pressure to free up NHS beds, local authorities quickly established routes to support hospital discharge. Some pre-empted the devastating consequences of rapid discharge and quickly closed care homes to all new admissions. Examples to support and avoid hospital admissions include:
- Re-deploying occupational therapists (OTs) from hospitals to support home-based reablement so people did not lose skills and independence
- Moving OTs to front-line calls to understand needs and advise accordingly
- Block booking care home beds and capacity for environments with enhanced infection control and separate infection-free areas
- Securing extra capacity with home care providers
- Using hotel facilities for hospital discharge and respite
- Modelling how to maximise admission avoidance by increasing ‘safety net’ and interventions at home
- Re-deploying council, Clinical Commissioning Groups (CCG) staff and nurses to staff new accommodation with support for people who have been infected, but no longer need hospital
- Use of Shared Lives to provide enhanced support at home
- Quickly mobilising a COVID-19 step down unit
- Direct payments – promoting their flexible use and supporting people to pay family members as appropriate.
Flexible support approaches
People achieve better outcomes when they make their own decisions about support, rather than receiving services scripted by commissioners or assessors. Innovative services also help attract new people into social care, plus experienced staff wanting more creative, quality and sustainable jobs. Commissioners can help by promoting direct payments, innovation and flexible support.
Support for direct payment (DP) users
Direct payments (DPs) offer choice and control, and are designed to be used flexibly and innovatively. Commissioners should support and promote their use.
There are positive reports of pro-active support, advice and practical help by local authorities and by DP support services. Areas with strong co-production were closer to understanding what was working for people and ensuring citizens shaped the response. Some areas have seen shifts towards DPs for people wanting more flexibility than their commissioned arrangements allowed, including for hospital discharge support.
In regular meetings with the social care minister, members of the National Co-production Advisory Group and other self-advocates have fed through patterns of experience. This has been complemented with registers of people’s experience such as the Be-Human register.
Actions reported as helpful by people using direct payments include the following:
Early and regular supportive communication and advice Open
One of our earliest actions was to redirect a reviewing team. A real asset – called all people with a DP to see how they were doing, contingency plans, any advice needed or additional funding. This really settled folks down a lot early on.Barnsley
Letters were posted to all DP users. This gave assurance and ideas for using budgets flexibly and who to contact for help and advice: council numbers, DP support service, insurance numbers – rather than just online resources.Hammersmith & Fulham
- Information about employment, sick-pay and contractual issues. Some insurance and payroll companies, and their legal helplines, have been providing clear advice and regular updates to individuals and groups.
- Help to recruit new personal assistants safely.
Peer support Open
- Some DP support services quickly set up online, phone or social media groups (e.g. Facebook) for people to stay in touch, share solutions and enjoy socials.
- Webinars arranged by inControl/Be-Human have been sharing fantastic ideas and advice including on contingency planning, rights and legal issues.
- Regional groups such as the London SDS Forum are connecting people using DPs along with workers and allies to share support and advice.
Flexibility in the use of DPs and support to do this Open
- Pro-actively supporting flexible use of funds. Helping people explore ways to meet their outcomes if workers aren’t available, activities have stopped or to negotiate a different offer from a service.
- Support and advice on employing family or household members.
- Use of DPs to stay in touch e.g. purchase of dongles to get online for shopping, or to stay connected with family and friends.
- Reducing process, permissions and keeping monitoring to the minimum.
- Training for social care workers so they can support the above.
- Some areas used government funding to cover additional costs to DP users.
- Contingency funding for DP users (with quick decision-making/ authorisations) e.g. Tower Hamlets provided an upfront 10 per cent contingency to all DP users with permission for flexible spend.
- Supporting DP users to continue paying personal assistants (PAs) to sustain contracts (if furlough not possible) or funding alternative support if PAs can’t work.
- Some local authorities handled sustainability arrangements e.g. with day services so DP users did not have to pay for services they weren’t using.
- However, some DP users are worried about building up excess funds so clarity and reassurance has been helpful.
Practical support Open
- Some areas quickly arranged regular PPE supplies to DP users. This also gives people a knock on the door and follow up calls can be made as needed.
- Training and advice for DP users and PAs in use of PPE.
- Mutual aid support with food, medicines and regular phone calls, etc.
- Issuing ID letters and access to free parking for PAs.
We contacted all our DP recipients at the start to make sure people had plans, give support and we continued contact where this was requested. Our PAs have access to PPE, Infection control training and swab testing. We also have a back-up pool of PAs.Nottinghamshire
Flexibility of community support has proven key in providing meaningful connections. A number of services extended their offer to reach people in new ways. Whilst many centre-based services closed, some rapidly responded by contacting people, making regular phone calls, dropping off supplies, offering in-reach and activities.
Practice example: Provider responsiveness
Mencap in Kirklees Open
Summary and purpose
Dawn is an operations manager in Mencap in Kirklees. She works with day care services, domiciliary care and three residential homes for adults with learning disabilities (30 residents across the three residential homes).
When COVID-19 lockdown began, the day care services closed, the domiciliary care services reduced enormously due to shielding, and staff numbers in residential homes were reduced due to being ill or symptomatic.
The senior management team created a ‘backup workforce’ from these affected staff to work across different services – most of whom agreed to take part. Staff previously working in day services or domiciliary care started working in residential homes to fill the gaps and keep the service safe.
One of the care homes had several people ill and three individuals had died, which created a staffing problem in terms of numbers. It was also hard on those who were still working or in the care home and affected by the illness/death of people close to them.
Staff suggested and implemented very innovative and engaging activities for people to thrive. For example:
- Being inspired by the quote ‘you can’t go to the world so we bring the world to you’, staff dedicated one day each week to a specific country so staff and residents experienced food, films, songs, etc. from that country.
- Residents ran a walk in shop, so others could buy those little things that they missed such as sweets, magazines and toiletries.
- Residents used social media platforms to video call people important to them and to maintain relationships. They also wrote letters to the local school children to maintain community links and much more.
One of the great achievements has been the increase in knowledge, skills and sense of one big team. The relationships between staff at a personal and professional level have developed in a very positive way, which allows them to work better together.
Challenges and learning points
The challenge will be to build members' confidence to return and engage in the new normal; some people and family carers are very fearful.
One key lesson Dawn learnt is that it would have been better to centralise calls to reduce the amount of them, rather than relying on different service managers to deal with the calls to their individual service.
Contact Dawn Wood, Operations Manager
One short break service continued its support to adults to with learning disabilities and their families and moved its community choir online. Some services distributed digital devices and helped people get online - something commissioners could support post-COVID-19.
We offered evening and weekends online - evening and quizzes- they do virtual walks - really essential. More informal 24/7 as online so extend reach.Day service provider
There has been positive feedback on individual service fund (ISF) arrangements as providers used person-centred approaches to quickly re-shape support in line with people’s wishes and changing circumstances.
Shared Lives Open
Shared Lives arrangements are high quality, flexible and adaptable by nature. There were many positive stories of supportive households and resourceful Shared Lives carers building on their networks. Shared Lives Plus and local schemes provided support, guidance and connections to enable households to cope and often thrive. There are examples of Shared Lives carers who provide short breaks and day support being paid (Portsmouth) in the absence of their usual ‘business’ to retain their skills and flexibility.
Shared Lives offers fantastic local options and is strongly placed to respond rapidly to add local capacity (Growing Shared Lives) including for hospital discharge.
Lots of evidence of how it works really well for hospital discharge and back to independence but also builds relationships and connection that is sustained even when people move back home. Lots of schemes taking referrals, fast tracking new carers assessments, using tech to make matches etc. Now that testing is more widely available it should make things easier too. We want to scale this solution up in response to the crisis.Shared Lives Plus
Community micro-enterprises Open
Community micro-enterprises have been offering a wealth of support through tailored local provision and have flexed rapidly to deploy creative solutions. In Somerset micro-enterprises successfully support significant numbers of people with network co-ordination by Community Catalysts. Micro-enterprises collaborated to set up The Buzz – online sessions of dance, art and activities for people around the country to connect and have fun during the crisis.
Self-managed teams Open
Self-managed teams have performed well offering a responsive alternative to traditional home care centred around an individual and their natural networks. They are already highly responsive, solution focussed and maximise people’s skills and relationships. They also offer decent pay and conditions for workers, shared decision making and flexibility. Radical-home-care.
The TLAP ‘Directory of innovations in community centred support’ has documented how groups and organisations are working differently during the pandemic and offering great person-centred support. Their stories of promise also charts the multitude of creative responses that have evolved in communities across England. Themes include: keeping people connected; digital innovation; information and advice; self-directed support; and workforce.
Practice example: Sustaining intergenerational initiatives
Liverpool City Council Open
Summary and purpose
The Inter-generational Sustainable Skills Exchange is funded by Liverpool City Council and is delivered by IIIN Community, a Community Interest Company.
The sessions bring together socially isolated older adults and allow them to teach their life skills to parents and children in their community. These skills include, but is not limited to:
- card making
- wood work
- bike repairs.
The older adults would plan the session in advance amongst themselves, with IIIN Community providing a little guidance or steer as needed. These sessions empower the older adults and enhance their feelings of self-worth and value. Older adults feel valued and respected in society once again and begin to realise they have a wealth of skills and experiences that are incredibly valuable and we mustn’t lose. As sessions progress the younger generations share skills, often digital skills, supporting the older adults to become proficient in any areas they wish to be.
These sessions also:
- help parents and children reduce, reuse and recycle items/clothing that many would normally throw away
- allow parents to devote a large amount of time and attention to their children which improves the relationship between parent and child
- help older adults make and maintain friendships with members of their community, which they can call upon in a time of to help reduce feelings of social isolation and loneliness.
When the COVID-19 pandemic hit Liverpool, all intergenerational sessions were halted as the majority of the older adult participants were required to shield, unable to spend time with anyone or leave their homes.
Initially, significant support was given around meeting essential needs, such as food shopping. ‘Hello’ bundles were established from donations with some essential items, including a range of toiletries when items were hard to obtain. However, it became apparent that the older adults were missing the contact they had with the children and parents.
The IIIN Community devised ‘VIRTUALITEA’ where older adults would eat a meal with each other via FaceTime/WhatsApp video. This alleviated some of the isolation the older adults were feeling. IIIN Community decided to attempt to bring the groups together virtually and ‘Virtual knit and natter/Crochet and Chat’ was born.
The idea was for older adults to attempt to continue teaching their skills to parents and children virtually.
Challenges and learning points
Internet access was a huge obstacle. Many older adults who were able to use smart phones/iPads etc. would use communal WiFi areas (e.g. in sheltered accommodation) to access the internet. These areas were placed out of bounds by housing providers, which then resulted in their internet access being suspended. Many older adults who used their own internet had low data plans which would not allow them long periods on FaceTime/WhatsApp. IIIN Community spent many hours talking participants through how to increase data plans or access WiFi outside of communal areas.
Most of the older adult participants could not use or had no access to smart phones/iPads and only three of our 50 older adult participants had the necessary skills and knowledge to be classed as proficient. Social housing providers/community organisations loaned equipment to those without the necessary technology to get involved. IIIN Community then began to devise a teaching programme to enable all participants to take part in online sessions. Additionally, we assigned one of our local high schools to design lesson cards to teach older adults how to use a mobile phone and load FaceTime and WhatsApp.
The online sessions drastically reduced the older adults’ feelings of social isolation and loneliness. They began finding activities for the parent and child to do during the week based on their skill i.e. sewing or knitting task and the sessions gave them a focus, a purpose. Older adults continued to plan these sessions between them, identifying the focus for the session, any resources required etc. to which IIIN Community would then facilitate.
All resources were delivered to participants by IIIN Community.
Parents reported children were thrilled to maintain contact with their older adult. Children found the activities a nice break from the online homework tasks. Children also maintained some form of routine by virtually meeting with their older adult, which gave them some stability in extremely uncertain times.
Older adults have reported their relationships and friendships with parents and children have become deeper. They were able to call upon them for shopping, prescription collection, as they were unable to go out due to shielding. Many reported feeling well supported and classed them as family/friends rather than being supported by the state/local government. Many older adults returned/stopped government food parcels as they had food support from their parent/child partner. Parents have gone above and beyond to support the older adults involved in our intergenerational sessions – cooking meals, purchasing shopping, delivering books and magazines to alleviate boredom. Children have surpassed all expectations by writing letters, drawing pictures and designing cards to send to their older adult partner to show how much they value them and the role they play in their life.
Contact Gemma Black, Commissioning and Contracts Manager
Support for unpaid carers
Commissioners must ensure effective support for all carers during the crisis and beyond. Areas that know their communities and carers well have been able to respond quickly and flexibly to get the right support to carers. The following approaches have been shown to be effective:
- Linking social care and mutual aid networks to connect known carers and identify ‘new’ ones.
- Getting digital devices to people, running Zoom training sessions so carers can join coffee mornings, do online shopping, etc.
- Coordination by carers’ organisations so people don’t have to navigate multiple systems. Linking carers to expert advice such as on housing, employment, money, legal issues and health conditions.
- Support to shift to direct payments to employ family members to reduce transmission.
- Practical support such as the supply of PPE and food.
- Support for carers’ mental health.
- Peer support that is emotionally beneficial and offers practical support as carers share advice, tips and resources.
We were very keen to support family carers and wanted to support our commissioned organisation to continue and develop their support offers, including calling regularly.Barnsley
Community mobilisation - a reminder of community strength
The amazing community mobilisation response through the pandemic serves as a reminder to commissioners that strong communities are essential to providing solutions. Grassroots organisations and community anchors have a deep local understanding of what’s needed and have real strength in organising. It broadens the concept of which organisations can provide support. There are fantastic examples of local businesses such as food suppliers, handypersons, takeaways, pubs, restaurants and hotels responding to provide great practical solutions. Such an approach also benefits the local economy.
Many groups came together harnessing the energy, commitment, goodwill and knowledge of local people. They add value and connect people using social care with community offers to enhance support or provide back-up and tackle loneliness. Examples of community coordination in local areas include:
- An alliance of 13 voluntary and community sector (VCS) organisations, coordinated by an infrastructure organisation, set up a collaborative response within two weeks with one central support line number.
- A community hub system was established with a volunteer platform, supportive local infrastructure and teams deployed (including from council roles) to fill gaps of capacity and expertise.
- A VCS infrastructure organisation coordinates the community/village agent network and volunteer network of ‘coronahelpers’. This avoids dilution or overlap of community offers.
- Commissioned providers are encouraged to make use of and contribute to community led activity.
Practice example: Community responses
Midlands Partnership NHS Foundation Trust Open
Summary and purpose
David worked in mental health day services until they started to be decommissioned in 2016. As a consequence, he looked into what was the best way to redesign the service, providing support to the community and maintaining people’s jobs. They created the personalisation and social inclusion (PSI) team and the role of the navigator, which is core to the PSI team.
David manages a team of ten people who cover the entirety of South Staffordshire. He also manages eight community managed libraries for Midlands Partnership NHS Foundation Trust (the Trust) in partnership with Staffordshire County Council (LA), with one paid for member of staff, whose salary is generated from the libraries income, and a group of 200 volunteers. The community managed libraries won the HSJ Health and Local Government Partnership Award last year.
The vision is to bring together the volunteers, the member of staff and the navigators:
Our vision is to spread a 'Staffordshire Together' ethos across statutory and voluntary, community and social enterprise sectors with robust coordination focused on prevention and early intervention.
The impact of COVID-19 has been enormous, as the libraries are now temporarily closed and the PSI team have had to adapt service delivery.
The LA and the Trust have built a pool of volunteers ready for COVID-19 support, so David, alongside them, is looking into how best to deploy these volunteers going forward. For example, using them for running the libraries, enhancing the resilience of community groups, and supporting people to go back to their lives and communities as the lockdown eases and circumstances change. There is a workshop to elicit ideas from various stakeholders and parties.
Due to a reasonable volume of the library volunteers being over 70 and currently either shielding or under the ‘vulnerable’ category, this is being considered in the recovery plan.
The aim is to spread this model across the entire county, and David is already in conversations with the North Staffordshire teams.
- Identify ‘small initiatives’ that have emerged and link them together.
- Identify opportunities for volunteer deployment across the service delivery model.
- Interview existing volunteers to identify skills and interests ready for flexible deployment.
- Recruit more volunteers.
- Identify funding streams.
- Undertake research across the Trust and social care on what needs to go back to how it was and what does not.
Challenges and learning points
The main challenge has been the fact that South Staffordshire is a very rural area, and maintaining communication and linking to different parties or delivering training has been challenging. They have, however, overcome this challenge and are using Microsoft Teams and OneConsultation software successfully.
Another challenge is the lack of equipment, set up or knowledge of some individuals to enable them to communicate through technology (i.e. broadband, phone, teams, etc.).
The key learning point is 'that for years we have been doing things in one particular way of thinking that it was the only way. Under crisis, we have found different ways of working.’
Contact Dave Bradbury, Social Inclusion and Community Capacity Lead (Staffordshire)
Supporting community mobilisation
Commissioners need to find the right relationship balance to ensure that non-statutory effort remains mobilised. The TLAP report, Towards resilience: making community matter in social care highlights how community focused initiatives are key to a more resilient future for all those that draw on, provide or commission adult social care support. Mutual Aid groups, neighbourhood support and peer networks can also play a key role in sharing information and reaching people. Commissioners can help facilitate links with the statutory sector and fill the gaps where council activity can make most difference. This, however, should not replace, restrict or slow down non-statutory efforts.
Blend the mutual aid, council and national offers. Using Cormac Russell’s term, be ‘Alongsiders’.Barnsley
Accelerating investment in community anchors enabled working with community business and user led groups and doing together to develop the response to COVID and beyond.Local authority commissioner
Mutual aid emerged very quickly – now 5k involved on Facebook. As DASS, I check in every day, as do members of our Area Council Teams – spotting issues, offering support and guidance, filling gaps.Barnsley
Practice example: Weathering the storm: Community & Council Collaboration in Kirklees
Collaborative approaches – communication is key!
Relationships, communication and trust are pillars of good commissioning and have been vital in responding rapidly and effectively to the crisis. Areas that already had strong relationships in place quickly built on these. Respective knowledge and expertise was maximised for a ‘sum is greater than the parts’ effect in these examples:
- Existing trusting relationship enabled a council to give money to a community business to manage the mutual aid response knowing they could do it better and without the restrictions of KPIs on the money.
- Professionals being redeployed has shown how skills can be utilised in different settings and helped increase their understanding and support for skills across the system.
- ASC department investing in community neighbourhoods to understand and gather live research on the needs of social enterprise organisations and supporting their responsive developments through co-production, openness and trust.
Early, frequent, and supportive communication with providers has been highly valued. The examples below are just a few of many demonstrating the benefits and practical steps to support this – some commissioner-led, some provider-led.
We started with communication with providers to understand their situation. We rang all providers, not just commissioned ones and then set up a website to collate all issues and information. People really appreciated being asked. It went a long way to getting a good partnership set up.Somerset
- The integrated commissioning function was re-focused to ensure daily contact with main providers.
- Weekly virtual provider forum meetings to build peer support, share good practice, resolve issues such as staff absence and wellbeing.
Forum run by a regional care association with over 100 local stakeholders and close working with CCG and the local authority.
A place to come to share grievances and work through solutions. It has been good then to have a place where the local authority and CCG want to come in and talk about things that are important to providers as normally commissioners invite providers in.CEO of national not-for-profit provider
- Open-book accounting gave transparency on cost-pressures and helped to build trust and really understand what’s needed.
- Commissioning and public health out of hours on call arrangements for advice and support including on infection control.
- Links with unions and workforce representatives to hear about and respond to issues of shared concern.
We celebrate on social media the wonderful examples we get sent of how people are coping.Nottinghamshire
Practice example: Information and advice hub
North Tees and Hartlepool NHS Foundation Trust Open
Summary and purpose
North Tees and Hartlepool NHS Foundation Trust set up a coordinated staff psychology support hub at the end of March to ensure internal coordination of support for staff, patients and carers in terms of information, toolkits, advice, risk assessment and onward support where needed.
The hub was created following the basics of the major incident policy already existent in the Trust; it held and organised collated information from outside sources to reduce the burden of information gathering to the wider Trust and individuals. We also coordinated and planned in the early stages with neighbouring, acute, mental health and IAPT service providers to ensure there were no gaps or duplication in this process.
We reached a 'saturation' point in terms of any novel and useful new information after approximately two weeks.
The service offered:
- A hot line for senior managers and clinicians who needed support individually or asking for team support.
- Reflective spaces for individuals and groups.
- Physical space near to the hospital, but in a different space that is not a COVID-19 red zone.
Individuals seeking support were asked for agreement to provide some data, though no demographic or identifiable data was collected – the majority of them had no issues with this. Information has been collected and processed in relation to the use of the hub and an end of month report has been produced for April and May.
A risk assessment was carried out and a series of protocols were developed to support the local helplines, such as toolkits for staff, toolkit for patients, child friendly booklets, etc.
It has a real example of collaboration where all staff were caring and showing a clear understanding of roles and working together.
Challenges and learning points
The main challenge will now be going back to normal, as this threatens the continuation of what is still needed. The Trust has no capacity to fulfil this, even with support from partners and stakeholders received during the COVID-19 crisis.
This 'command and control' style of setting up and continuing to run coordinated support services for our staff has worked well and has strengthened internal support services cooperation, learning and planning to continue to meet this needs for the future.
Contact Dr Elaine McWilliams, Consultant Clinical Psychologist, Head of Medical Psychology Department
Moving to digital
The Performance tracker 2021 sets out how public services responded to the pandemic. One key area is the fundamental shift in how technology is used. For example use of the Capacity Tracker app has provided central government, local authorities, NHS trusts and providers with useful data on capacity in care homes and its potential could be expanded.
Greater use of technology has also improved communication between local authorities, providers and the families and friends of people using services. But this shift has not benefitted everyone and some people have been further excluded as many services moved online.
Members of the SCIE Co-production Network talked about how digital meetings had made it easier for them to be involved without the effort of travelling and balancing other commitments. Action on Disability (a disabled people’s organisation) has provided a safe and supported venue that people can choose to come to join other virtual meetings.
It’s important that commissioners work with local people to take stock of digital shifts. Digital should not be the only channel but there must be capacity building within communities to increase digital inclusion. Don’t leave people behind.
Key takeaways for commissioners
Know and support what makes a difference Open
Commissioners need to be clear about measures of success. People’s efforts must result in positive impacts with citizens. Working well together may show great endeavour, but if people themselves have little say, choice or control, then effort needs to be refocused. Numbers are important but it is outcomes and the impact as defined by people themselves that matter.
Many commissioned services are required to report key performance indicators (KPIs), but this can lead to a narrow focus limiting pragmatism and flexibility. Commissioners should agree delivery and reporting expectations with providers during the pandemic and beyond to unlock flexibility and target support where it is most needed. Providers need reassurance that they won’t be penalised for sensible changes or be intrusively monitored. Providers and local authorities have faced a huge burden of reporting with multiple data requests from different places. Good commissioning only collects information for a purpose.
- Be clear what information you are requesting and why – what difference will it make?
- How does this relate to outcomes – the impact on people and communities?
- Be clear about any contract reporting flexibilities – change them if you need to.
- Coordinate data requests and make it easy to submit the data e.g. portals to input data in one place.
- Feedback what the information has told us – what’s useful for providers, community sector, for local authorities as a whole, for health?
- How can the information be used to empower co-production and increase decision making with citizens?
- How do we know if citizens have co-produced approaches?
- Most importantly, what is the feedback from citizens and the impact on their lives?
Address the immediate issues and extend choice Open
Perfection is the enemy of the good – commissioners should do the best thing possible, quickly. This includes developing costed market response plans to minimise risks to individuals and risks of business failure. We have seen further waves of infection and there could be more or different crises in the future.
Reach out and stay in touch so you know which services are struggling, why and who is facing the highest risks. Are standards OK, are you getting feedback from people using services? Provide the practical support to reduce risks to citizens and workers but plan for moving forward to empower people and extend choice based on what’s important to people.
- Increase choice and promote equalities. Be clear about the purpose of support. How will it help people live in the way they want to?
- Begin to scale things that are working well. Innovative and more personalised approaches, such as Shared Lives and community enterprises have delivered good outcomes throughout.
- Co-produce a new vision for mental health support ensuring a clear focus here too on innovation and good practice.
- Focus on local impacts and recovery that builds personal and community resilience; improving mental and physical health. Addressing digital barriers and exclusion must be part of this too.
- Support and invest in alternatives to congregate settings. Ensure there is good support for direct payments. There must be good support for unpaid carers too.
- Proactively engage with plans to sustain community networks as more people return to work. How can people’s efforts be sustained in varied and creative ways?
Be human Open
People have faced significant trauma. It’s important to enable human reflection and connections – ensure people’s relationships are restored, that carers are supported, that citizens are valued. The wellbeing of the workforce is vital and workers may need support to sustain their commitment and energy.
Co-produce – you can’t commission without the voice of citizens. How are things for them? What will improve things for them now and in the longer term? How can you do more of what helps? Co-produce a shared vision of what good looks like. The TLAP I Statements could be a good starting point for discussion along with the vision of Social Care Future.
The message is learn together - don’t rush to back to business as usual. Celebrate what people do for each other – tell stories of community, reciprocity and resilience. Give people a strong sense of being ‘larger than self’. Use this moment to bank and build social capital. Celebrate providers that have really focused on quality of life. Reflect on what you as a commissioner have done.
- Collaborative working and maintaining quality - Princess Homecare
- Provider responsiveness - Mencap in Kirklees
- Sustaining intergenerational initiatives - Liverpool City Council
- Community responses - Midlands Partnership NHS Foundation Trust
- Weathering the storm: Community & Council Collaboration in Kirklees
- Information and advice hub - North Tees and Hartlepool NHS Foundation Trust
Support from SCIE
SCIE's COVID-19 hub contains more relevant information including safeguarding, Mental Capacity Act and infection control. It can be used when working and supporting people who are isolated or vulnerable through COVID-19, and can also be shared with community groups.