Challenges and solutions: commissioning social care during COVID-19
Published: July 2020
This guide addresses the challenges faced by the social care sector during the pandemic. It describes how local authorities, providers 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 benefitting individuals and communities.
Commissioners, providers and the community sector will find this useful to inform immediate responses to the crisis as well longer term market shaping plans.
Introduction and overview
The challenges of COVID-19 are many and 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 the 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. Community mobilisation ensured people received vital food, medicine and calls. 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. There’s also an as yet unknown impact on people who survived the virus.
Local authorities and commissioners have needed to respond quickly to a rapidly developing crisis to ensure people received vital care and support. Approaches that have helped so far include:
- Stabilising the sector through sustainability funding and meeting extra costs.
- Practical support and advice – personal protective equipment (PPE), testing, infection control, 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, 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 are taking proactive steps to engage with citizens, develop innovative solutions and take market shaping measures to ensure social care providers are able to continue operating. However, planning 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, potential lockdowns and the multiplying impact of winter pressures.
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.
- Align long term planning to wider agendas – employment, loneliness, health.
- Money – use it locally, use it wisely.
- Save lives and improve lives.
The pressures COVID-19 has caused the sector
The social care sector is a keystone of communities employing 1.5 million people in England and contributing £40.5 billion to the economy. Failures would have devastating consequences on individuals, their networks and beyond. Local authorities spent £22.2 billion on social care in 2018/19 supporting 841,850 adults. People privately purchasing their own care spend £11billion. There are an estimated 8 million unpaid carers with millions more during COVID-19. Around 18,500 provider organisations deliver services across 39,000 establishments and 70,000 individuals employ their own staff via a direct payment. The pressures, summarised below, have been amplified by the pandemic.
Financial uncertainty and underfunding Open
- Costs to local authorities and providers of the pandemic will far exceed the Emergency Funding from the Government of £3.2 billion – half has been made available to date (June 2020) – to support local government’s response to the pandemic, plus a £600 million Infection Control Fund.
- The sector estimates £6.6 billion in extra costs, such as PPE, staffing and deep cleans due to COVID-19 by the end of September 2020. There is an £800 million deficit in 2020/21 based on the first three months alone.
- Only 4 per cent of directors are confident that budgets will cover their statutory duties this year. Without extra funding, this will impact on the ability to meet needs.
- This adds to the uncertainty of future funding and social care reform. Adult social care is still below the 2010/11 level but facing rising costs of provision and growing demographic demand.
Market pressures – the fragility of care markets Open
- The likelihood of a significant number of providers, or a large provider, going out of business has significantly increased largely due to extra costs and reduced occupancy of care homes in most areas.
- Two out of three care providers report they fear going out of business due to the impact of the pandemic.
- There is already a 10 per cent shortfall in care home fees paid by local authorities. Reducing fees would mean care homes closing or only supplying to the higher paying self-funders. Quality remains an issue with nearly one in six registered services rated as requiring improvement or inadequate.
Lack of choice and unmet needs Open
- Some people are not getting 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.
- 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 on 23 March 2020.
- There is also insufficient access to primary, community services and mental health services to support local people’s needs.
- An additional 4 million carers are providing unpaid support in the crisis. Existing carers are providing more support and facing isolation, stress and financial pressures.
- 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 (BAME) 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 with an estimated 7.8 per cent of roles vacant at any given time. Turnover is at 30.8 per cent and higher in some areas. Average care worker pay is below that for shop-workers and cleaners.
Specific challenges affecting care homes Open
- Up to 12 June 2020 there were over 29,000 excess deaths in care homes.
- Over 40 per cent of all care homes reported an outbreak up to 7 June 2020.
- Transmission has been 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 face rising costs of more than 30 per cent higher than usual. This is largely due to PPE inflated costs, sick pay and backfilling with more expensive agency staff.
- Two-thirds of providers reported they haven’t received additional funding.
- Residents – many of whom have dementia – experienced distress, confined to their rooms with no outside visitors.
- Poor or rushed assessments have made it hard for staff to understand the needs of new residents.
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 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 or change their offer.
Support for direct payment users was variable across the country. Some areas were slow off the mark. Many direct payment users felt abandoned: ‘The only communication from my council was very general and addressed to “Dear DP user”’. 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 fear that people experienced.
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 with 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.
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 show 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. Importantly, providers, communities, carers and individuals have adapted to respond positively to the challenges.
Ninety-five per cent of local authorities provided funding 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-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 session 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. Bexley & Queen Elizabeth pathology lab)
- clinical links e.g. established ‘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 being sent.
CQC is 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, enhanced infection control, supporting people and their families with information and advice, plus practical ways of supporting staff such as with travel arrangements as well as emotional support.
Providers themselves have adapted rapidly and many have implemented changes to ensure safety whilst promoting wellbeing.
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 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 discharge and respite.
- Modelled how to maximise admission avoidance by increasing ‘safety net’ and interventions at home.
- Re-deployed 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 enhanced support at home.
- Quickly mobilised 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 is working for people and ensuring citizens shape 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 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 workers 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 are 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 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 and advised DP users not to pay for services they weren’t using.
- However, some DP users are worried about building up excess funds.
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 is proving 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.
One short break service continued its support 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.
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. Several micro-enterprises have collaborated to set up The Buzz – online sessions of dance, art and activities for people 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.
TLAP is documenting how innovative community-centred organisations are working differently during the pandemic and still offering good person-centred support.
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. What’s helped:
- 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 risks.
- 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 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 also broadens the concept of providers e.g. local businesses such as food suppliers, handypersons, takeaways, pubs and restaurants, hotels and 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.
Supporting community mobilisation
Commissioners need to find the right relationship balance to ensure that non-statutory effort remains mobilised. 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 a working with community business and user led groups and doing together to the develop 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 can 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 economy organisations and supporting whatever the response they develop through coproduction and openness and trusting that.
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
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 as well as reassure providers they won’t be penalised for sensible changes or 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.
- 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?
- Most importantly, what is the feedback from citizens?
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. Second or localised spikes are likely. 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 keep citizens and workers safe but plan for contingencies too.
Increase choice and promote equalities. Begin to scale things that are working well – innovative and more personalised approaches, such as Shared Lives and community enterprises have shown to deliver good outcomes throughout. Support 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 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.
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.