c p c scoalition OF CARE AND SUPPORT PROVIDERS I N S C O T L A N D COALITION OF CARE AND SUPPORT PROVIDERS IN SCOTLAND Hourly rates for care and support Report into a Freedom of Information exercise by CCPS
Introduction CCPS is the Coalition of Care and support Providers in Scotland. Its membership comprises more than 70 of the most substantial providers of care and support in Scotland s voluntary sector, supporting approximately 270,000 people and their families, employing around 45,000 staff and managing a combined total income of over 1.2bn, of which an average of 73% per member organisation relates to service provision that is commissioned, purchased or otherwise funded by the public purse. CCPS members provide services right across the spectrum of care and support, including services for older people; children and families; adults with physical and learning disabilities; and people facing a range of challenges in their lives, including mental health problems, addictions and involvement in the criminal justice system. CCPS and its members are concerned at the severity of the cost pressure being placed on care and support services in the voluntary sector. This pressure is most frequently applied through competitive tendering procedures in which the currency for care provision is the hourly rate. Background In September 2011 CCPS was alerted by its membership to a procurement exercise in a Scottish council in which a cap was applied to tender prices for care at home. The cap was set at 10.43 an hour, which many voluntary sector providers felt represented a new low in hourly rates for adult care and support. Following representations made by CCPS, the council confirmed the capped figure and advised that the equivalent in-house care at home service cost was approximately 21 per hour with the staff hourly rate component paid at 7.97. This correspondence prompted CCPS to seek to identify: how this capped rate compares with rates paid by other Scottish local authorities for non-residential care and support services for adults and older people; whether the market generally is migrating towards the low rate paid by this particular council; where the voluntary sector is placed in the market, compared with both private sector providers and in-house provision; and whether the comparatively high cost of in-house provision is typical across councils. In addition, many CCPS members continue to report that in seeking to reduce the cost of care, councils frequently advise them that their rates are very high compared to other providers. This exercise was envisaged at least partly as a way in which this might be tested and, where appropriate, contested. CCPS therefore issued a Freedom of Information (FOI) request in November 2011 to all 32 Scottish local authorities asking what rates 2
they pay, per service, in 2011-12, including the comparable costs of their own in-house provision. We asked councils not to identify any individual providers by name, only the nature of the provider by sector (voluntary, private or in-house). Method/Process CCPS emailed all 32 Scottish local authorities on 11 November 2011, with an attached letter requesting the following specific information: The hourly rates paid by (name inserted) Council during this year 2011-12, per service, service type and client group, for non-residential care and support for adults and older people in their own homes or tenancies, including care at home and housing support services, and/or combinations thereof, provided by private and voluntary organisations; and the full cost (expressed as an hourly rate) of equivalent services provided by the council itself, in the format set out in the table overleaf. A sample table was also included, with the intention that councils should then insert only the relevant data requested. (A copy of the full original request letter & table can be viewed in Appendices 1 and 2). Responses were then expected to be received within the 20 working day timescale set by Freedom of Information legislation. CCPS was aware that it may be asked to pay towards the cost of gathering the required information, but that it would be notified beforehand if this was the case. Responses In its recent report on social care commissioning 1, Audit Scotland noted that councils do not have sufficient information to make informed decisions in particular they do not have a full understanding of how much social care services cost and their value for money. Audit Scotland goes on to say that councils should develop commissioning strategies that set out as a minimum the current type, quality, cost, capacity and accessibility of all services in the area, including councils in-house services, and identify how they need to change to meet future needs. Our experience of conducting this FOI exercise reinforces Audit Scotland s findings, and confirms that many councils are not in a position to identify accurate information about service type and cost. Although some councils were readily able to send the information requested, others appeared to struggle to find the details, and either asked for more time to locate all the data, or sent information which was incomplete and/or did not fully match the original FOI request. 1 Audit Scotland, Commissioning Social Care, March 2012 3
Out of thirty-two councils, only eighteen replied within the required 20 working day period with all the information requested by CCPS. A further eight councils responded within the 20 day timescale, of which: Five provided responses with missing or incomplete data Two asked for more time to gather the relevant information (although one of these sent incomplete data when it did finally arrive in January 2012) One refused to provide the requested information on the grounds that Section 33(1) of FOISA provides an exemption where we believe the information requested would substantially inhibit the ability of the Council to negotiate the best value for public money on future contracts. Although you have not requested names of the individual contracted services and providers we believe that with some local knowledge of the sector, individual services and providers would be identifiable from the information you have asked for. Section 33(1) provides an exemption to protect the commercial interests of the Council, it requires us to consider the public interest test and we do not consider it to be in the public interest to release this information as to do so would limit the ability of the Council to negotiate best price on similar contracts in the future, which would not be a good use of public funds. Six councils failed to respond within the timescale, of which: Five eventually sent the required information, when pressed to do so, in January 2012 One eventually responded, when pressed, with a refusal to provide the requested information on the grounds that [The council] does not have some of the information you have asked for and that to provide you with the information [it] does have would cost over 600 Section 12(1) of the Freedom of Information (Scotland) Act 2002 provides that Scottish public authorities are not obliged to comply with a request for information if the authority estimates that the cost of complying with the request would exceed such amount as may be prescribed in regulations made by the Scottish Ministers. The prescribed amount is currently 600. CCPS has sought leave to appeal to the Information Commissioner regarding the two councils that formally refused to provide the information requested. Our experience of conducting this exercise bears out the Information Commissioner s Special Report to the Scottish Parliament in January 2012, which states; There is still substantial evidence of poor compliance affecting information disclosure Still too many of the appeals made to the Commissioner are a result of late responses by authorities to requests, or by the failure of authorities to respond at all. 2 2 Informing the Future: the state of Freedom of Information in Scotland Scottish Information Commissioner, January 2012 4
Interpreting the information We believe that the information gathered during this FOI exercise can offer a reasonable indication of current market rates for care and support; however we are aware that some of the detail may not be entirely reliable for a variety of reasons, including the following: There is considerable disparity between councils in the way that care services are described: for example, a service providing personal care to an older person in their own home is variously described as Home Care, Home Support, Day Care, Care at Home and some of these types of service are linked in with Housing Support, so data cannot always be separated out. Similarly, some councils combine supported living and housing support within the same category, while other councils treat them separately. Some councils did not supply all the data requested e.g. some did not distinguish between Private, In-house or Voluntary providers; others chose to give the information in a different format to the one requested e.g. some councils gave weekly or monthly prices rather than the hourly ones requested by us. They told us this was because they did not hold the data in any other way. We asked councils to distinguish between basic hourly rates, ie. those that are exclusive of enhancements (such as weekend rates and Bank Holiday rates) and those that are inclusive. However, some councils gave us a mixture of these rates, or only inclusive rates, or did not identify which rates they had given. Some rates appeared artificially low (e.g. 4.32 per hour). We assumed that in these cases, councils are referring to services that they break down into 15 or 30 minute slots that are paid within a single hour as part of a block contract. We have been made aware since collecting the data that some of it may be missing or inaccurate. CCPS members who have contracts with some of the councils who responded have advised us that the rates they are paid are either not included in the information supplied, or (where they are identifiable) are for the wrong amount (e.g. the council has listed the rate as 15.62, whereas the provider has confirmed to us that it is in fact 15.84). Some rates relate to block contracts, which have been broken down by the relevant council in each case into notional hourly rates. However, we have been advised by providers that some block contract rates are missing from the data, which is likely to distort the picture of the market presented by the data, particularly where these rates are located at the upper end of the range for that council. We are aware that external providers generally do not receive any additional allowance for travel time between visits to people they support at home: some providers build this consideration into their hourly rate whilst others (particularly in the private sector) simply do not pay staff for time spent travelling. By contrast, we understand 5
that in-house council staff are generally paid for time spent travelling. Again, these disparities make comparative analysis of the data very difficult. We do not appear to have received all the rates relating to in-house service provision. Careful checking of Care Inspectorate data from April 2011-December 2011 has revealed that some councils have registered in-house service provision which was not listed in the data sent to CCPS in response to this request. We are aware that some councils have developed and re-badged their in-house home care teams as reablement services. These services are generally intensive and frequently multi-disciplinary, and their costs are likely to be higher than traditional care at home services as a result. We believe that some councils may have treated these services as outside the scope of our FOI request, even though they may be registered with the Care Inspectorate as care at home services. This may help to explain the anomaly noted above. It should be noted however that if these services were included, in-house costs may appear even more disproportionately high compared with the voluntary sector. Again, the difficulties that councils appear to have experienced in identifying and supplying the information requested suggests that there is still some way to go before councils are in a position to develop the type of commissioning strategies recommended by Audit Scotland. Analysis of the information received The key elements of our analysis of the data are as follows. Findings from this exercise provide an approximate 3 indication of current market rates for care at home, supported living, housing support and other visiting support to people in their own homes and tenancies. The range of basic rates across all providers and for all care groups starts at 9.45 and goes up to 29.60 per hour, with the great majority of rates falling within the lowest half of this range (i.e. between 9.45 and 19.52). The information suggests that the capped care at home rate of 10.43 per hour which triggered this research is by no means the lowest rate paid for care. According to the data we collected, there are in fact over 50 individual rates quoted which are lower than 10 per hour, with some starting from as low as 9.45. However, virtually none of the councils paying these rates have applied a cap, so their median rate (i.e. the mid-point within the range of all rates paid) is well above the lowest. The council that triggered this research remains a significant anomaly in this respect, and a major cause for concern, because by applying a cap, it is in effect forcing all its rates down to a price point which is lower than the median (and in some cases, lower than the lowest) rate in the majority of authorities, whilst its in-house provision is more or less exactly double the capped rate. 3 As noted, we believe that some of the specific information we received may not be reliable 6
Most of the lowest rates we found are paid to private providers: the lowest rates per type of service tend to be for care at home for older people and people with a learning disability. In some areas, voluntary sector providers are also paid the very lowest rates. However, rates paid to the voluntary sector extend across the full range, including some of the highest rates. The highest rates paid to external providers per type of service tend to be for care at home services for people with mental health problems, supported living for people with a learning disability 4, and housing support for people who are homeless. Overall, the highest rates relate to in-house provision, with several councils disclosing in-house costs that are up to 100% higher than rates for equivalent services paid to external providers. As noted above, although we requested full information disclosure about the number of comparable in-house services and their costs, this was not always supplied: some councils have several relevant services registered with the Care Inspectorate, but indicated to us that they only have one in-house service or (in some cases) none. In the more remote areas of Scotland services are provided almost exclusively in-house. In the course of this exercise, CCPS was given access to the findings of a similar FOI request undertaken by Scottish Care in 2007. Comparison of the data shows that, out of the 30 Scottish councils who responded to our request, 10 appear to have significantly lower rates in 2011 for the same type of service than the rates disclosed in 2007. For example, the lowest rate for care at home for older people in one council in 2007 was 13.06; in 2011, the lowest rate disclosed by this same council is 9.53. This reinforces evidence gathered by CCPS in its Provider Optimism Survey 5 and elsewhere that the market has moved in some cases, fairly sharply downwards over the last five years, which is a clear matter of concern given Audit Scotland s conclusion in its 2012 report that councils are focusing their attention on the cost of services without sufficient attention to, or information about, quality, outcomes and value for money. Using the data provided by councils, we prepared tables for each council area setting out the range of rates paid for each service within that area, and the median rate, broken down as far as possible by client group, service type and sector of provider (private, voluntary or in-house). Councils are not individually identified in the tables. We are making these tables available to CCPS members working in these areas, so that they can see where their services are placed within the range of rates paid (bearing in mind the series of caveats about the accuracy of the data, as noted above). 4 Note the distinction between care at home and supported living, and the earlier note about different councils using these terms in different ways 5 CCPS conducts a regular survey of business and funding trends among its members: see www.ccpscotland.org for the relevant reports; see also the Local Authority Funding of Housing Support report from the Housing Support Enabling Unit - www. ccpscotland.org/hseu 7
We have opted not to publish these tables more widely, partly because (as noted in the introduction) this exercise was undertaken principally as a service to our membership, and partly (again) because of the concerns set out above regarding the accuracy and reliability of the data. Moreover, we are very much aware that without contextual information relating to the nature, location, intensity and volume of each service, comparisons between rates for ostensibly similar services will be difficult to draw: in that context, we are concerned that the Scotland-wide data provided by the tables might influence both the market and individual purchasing decisions in ways that are likely to be problematic, particularly in the current climate of severe constraints on public expenditure. In this respect, we are mindful of Audit Scotland s findings that within the public sector baselines were in place for costs, but not for activity and quality; performance measures were not routinely being used; and reporting of efficiency savings was not supported by performance information on the quantity and quality of services provided There is therefore a risk that reported efficiency savings might actually be cuts in service because it is not clear if they have resulted in fewer or poorer quality services being provided. 6 Discussion and conclusions Complexity of the market for care at home services The provision of non-residential care and support is a complex area. For the purposes of this report, it is important to remember that not all care at home services are the same; some are time-and-task services focusing almost entirely on personal care and practical assistance, whilst others are designed to support people to become or to remain more independent and in control of their lives. Further, care at home can range from relatively low-level support to, in some cases, 24/7 support for people with complex care needs. The existence of these different types and levels of support - and the workforce skills required to deliver them at least partly explains the wide range of rates paid for services which are described in largely similar terms. The cost of services will also be influenced by local delivery infrastructure arrangements and the volume of service provided in each contract. One of our chief concerns in looking at the data gathered during this exercise is the tendency for rates to be clustered at the lower end of the range. This would suggest a number of possibilities, for example: that councils are purchasing significant volumes of care and support from the same providers, who are thus able to achieve economies of scale; that these large volumes of care predominantly relate to time-and-task services; or indeed that councils are only prepared to pay time-and-task rates for more complex types of support. In either case, we would have concerns about how this picture of the market relates to the agenda for more personalised support to promote independent living, and to the workforce development agenda for care and support. 6 Improving public sector efficiency, Audit Scotland, February 2010 8
Low rates, the workforce and quality This FOI exercise confirms that many rates paid to providers for care and support are worryingly low. Rates of 9.45, 9.53 and 9.85 found in data disclosed by three separate councils highlight that the capped rate of 10.43, which triggered this exercise, is by no means the lowest rate paid for care at home services (although, as noted above, these rates are generally well below the median rate paid by each of the councils concerned). In our view, the lowest rates (and in some authorities, even the median rate) paid by councils are highly unlikely to cover all the costs necessary for providers to successfully offer good quality support, especially for people with complex support needs, and in particular, will seriously affect providers ability to attract and retain appropriately skilled and experienced staff. Given that such a significant proportion of the cost of support services relates to workforce costs (in a voluntary organisation, this is typically between 80 and 90 per cent) rates of 9.45, 9.53 and so on cannot, in our view, be sufficient to cover (for example) a minimum staff hourly rate of 7.97 7, plus employers costs of NI and pension provision, and in addition, all the necessary additional costs of successful complex support provision including management and supervision; workforce development, training and qualifications; compliance and regulatory fees, administration of the service, management, back office costs, and so on. The potential impact of low rates on the quality of care and support is a matter of considerable concern to CCPS. The most recent report on quality gradings produced by the Care Commission 8 (prior to the creation of SCSWIS/Care Inspectorate) demonstrates that the voluntary sector has the best overall track record for quality of care and support at home compared with the private sector and council in-house provision, with a significantly greater proportion of gradings at 5 and 6 ( very good and excellent ) for housing support and care at home services. This FOI exercise tells us that hourly rates paid to the voluntary sector are, in general, higher than those paid to the private sector, but lower than the cost of in-house provision. Linking this to the gradings information published by the regulator, it seems reasonable to conclude that whilst high cost does not automatically translate into high quality, there may be a price point at which low hourly rates mitigate against the successful delivery of support that is deemed very good and excellent. This is a matter of particular concern because of the evidence that hourly rates are now under increasing downward pressure. In our view, this FOI exercise suggests that more detailed research is required into the connection between low cost and poor quality or, to put it another way (and from a voluntary sector perspective) the connection between reasonable cost and high quality. We believe that this is all the more urgent given the view of Audit Scotland, again in its recent report on social care commissioning, that 7 The rate paid to in-house care at home staff by the council whose capped rate triggered this exercise 8 Quality of Care Review, produced in 2011, Care Commission 9
with reducing budgets across the public sector, there is a risk that councils focus too much on reducing costs when procuring services and give insufficient regard to the range and quality of services and their impact on individuals. 9 The cost of in-house care This FOI exercise confirms once again that the cost of in-house services is very significantly higher in most cases than services purchased from external providers, although evidence from Care Commission gradings shows that they are generally of comparatively poorer quality relative to the voluntary sector. In the current climate of public spending contraction, it seems to us increasingly difficult to account for the fact that councils under a duty of best value continue to sustain such highcost in-house services whilst simultaneously placing severe cost pressure on external services. It has been noted on a number of occasions that councils find it difficult to disaggregate their service costs and in particular, to identify overheads with any accuracy. This would seem to be borne out by this FOI exercise, as the data submitted by some councils is clearly inaccurate: for example, one council told us that the cost of its in-house care at home service is 13.17 per hour which, taking into account public sector workforce and employer costs, seems extremely unlikely. In its report on social care commissioning, Audit Scotland reported that it did not find any examples of commissioning strategies that included information about the quality and costs of both in-house and external provision; noted the need for more consistent data and much greater transparency in this respect; and recommended that commissioning strategies set out an analysis of costs and budgets for services, both inhouse and externally provided. This exercise bears out Audit Scotland s findings and serves to support its recommendations. Future directions As noted above, Audit Scotland has recently published its audit of social care commissioning which found, inter alia, that councils do not have sufficient information to make informed decisions and in particular, they do not have a full understanding of how much social care services cost and their value for money; councils focus too much on reducing the cost of care, and not enough on its quality; councils do not base their commissioning decisions on the difference that care and support services make to people s lives; and councils need to compare the value of their own directly-provided services with those provided by voluntary organisations. Following the publication of the Audit Scotland report, a number of initiatives have been set up to improve commissioning and in particular, partnership with providers. CCPS is actively engaged in these initiatives and will highlight the key elements of this report in its work with them. 9 Commissioning social care, Audit Scotland, March 2012 10
CCPS has also been active in pursuing improvements to social care procurement. We were instrumental in the decision by Scottish Government to publish specific guidance in this area and we have made strong representations to the Scottish Procurement Directorate and the European Commission, urging them to introduce procurement regimes that are more appropriate for social care services. Our contention that competitive tendering is dominated by considerations of cost over quality has been borne out by Audit Scotland and we would expect to see a shift in councils approach as a result of its report. Again, we will be highlighting the relevant sections of this report in our ongoing work in this area, as we believe that the findings of this FOI exercise offer strong reinforcement of Audit Scotland s conclusions and recommendations and add further evidence to support the growing momentum for change and improvement in social care commissioning and procurement. We believe that change is now becoming urgent, particularly with respect to our shared ambitions for high quality public services that have a positive impact and deliver better outcomes for people. We believe that this is even more important now that legislation for self-directed support has been introduced to parliament and implementation of the relevant strategy is under way. In this respect, we believe that there is a serious debate still to be had about why the hourly rate remains the currency of care and support; and why, despite encouraging developments relating to commissioning for outcomes, councils appear determined to continue paying for care and support only in terms of inputs. Above all, we hope that this report will provide a wake-up call for commissioners and providers alike, and that it can help to prevent any further movement towards a minimum-wage, low-cost, poor quality market for social care and support. 11
Appendix 1 11 November 2011 Dear Sir or Madam FREEDOM OF INFORMATION REQUEST: SOCIAL CARE I request the following recorded information from Council under the terms of the Freedom of Information (Scotland) Act 2002: The hourly rates paid by Council during this year 2011-12, per service, service type and client group, for non-residential care and support for adults and older people in their own homes or tenancies, including care at home and housing support services, and/or combinations thereof, provided by private and voluntary organisations; and the full cost (expressed as an hourly rate) of equivalent services provided by the council itself, in the format set out in the table overleaf. Please note the following points in relation to this request: In responding to the request, we would ask the council NOT to identify by name any individual contracted services or providers: these should be referred to as Service 1, Service 2, etc, as shown in the table. The hourly rate(s) shown should be, as applicable and as indicated in the table format overleaf (a) the hourly rate exclusive of any enhancements for weekends/bank holidays, sleepovers etc and (b) the rate inclusive of any such enhancements. Hourly rates for council in-house services should accurately reflect revenue and overhead costs: where the council is not able to accurately calculate or show these, this should be clearly indicated. I look forward to receiving the information. Yours sincerely DAVINA ADAMSON Information & Communications Officer Enc 12
Appendix 2 Name of Council: Service 1 Service 2 Service 3 etc Client group Specify principal client group for the service, for example older people; learning disability; dementia; mental health; addictions; physical disability;homeless; women fleeing domestic violence; etc Service type Specify principal service category or descriptor, for example care at home; housing support; supported living; supported accommodation; etc Hourly rate Hourly rate paid by the council* for the service where this is exclusive of any enhancements for weekends or bank holidays, sleepovers, etc *or, in the case of in-house services, equivalent cost expressed as an hourly rate Hourly rate Hourly rate paid by the council* for the service where this is inclusive of any enhancements for weekends or bank holidays, sleepovers, etc *or, in the case of in-house services, equivalent cost expressed as an hourly rate Provider sector Specify whether the service is provided by a voluntary sector organisation, a private sector organisation, or delivered directly by the council ( inhouse ) 13
c p c scoalition OF CARE AND SUPPORT PROVIDERS I N S C O T L A N D About CCPS CCPS exists to identify, represent, promote and safeguard the interests of third sector and notfor-profit social care and support providers in Scotland, so that they can maximise the impact they have on meeting social need. CCPS aims to: Champion quality care and support provided by the third sector Challenge policy and practice that inhibits or undermines the sector s ability to provide quality care and support Prepare providers for future challenges and opportunities Support providers to understand, negotiate and influence the complex policy and practice environment in which they operate. CCPS Norton Park 57 Albion Road Edinburgh EH7 5QY T. 0131 475 2676 www.ccpscotland.org CCPS is a company limited by guarantee registered in Scotland No. 279913, registered with the Office of the Scottish Charity Regulator as Charity No.SCO29199. The company s registered office is at Norton Park, 57 Albion Road, Edinburgh. EH7 5QY. CCPS is a registered Scottish charity: No. SC029199. June 2012. This document is copyright protected and may not be reproduced, in part or in whole, without the permission of CCPS