Workforce reforms feature heavily in Lord Carter of Coles’ recent hospital efficiency recommendations, and the NHS is facing huge pressure to reduce spending. So what are the options, asks Mark Hunter.

Northern Devon Healthcare NHS Trust (NDHT) has become the first NHS trust to enter the homecare market. It follows a successful bid to run Devon Cares – a new homecare service contract for Devon County Council and two Clinical Commissioning Groups (CCGs).

The trust has been appointed as ‘prime provider’ – which means it will not deliver care directly but manage homecare companies caring for around 1,500 people a year to ensure continually improving quality and consistency of service.

The deal means staff will receive improved pay and support arrangements as well as opportunities for training and a clearer career path which could lead to jobs as registered nurses. Crucially, staff will be paid for their time to travel between clients.

“Care workers do a really important job and we are investing more into these contracts to ensure that they will be paid for all the hours they work and that they receive at least the national living wage,” says Devon County Councillor Stuart Barker, cabinet member with responsibility for adult social care.

The NDHT says the move will allow it to influence the quality of care given outside hospitals and ensure providers are working to support patients’ ability to live independently. It is also hoped that Devon Cares will boost recruitment and retention in the local homecare market and give providers greater certainty, so they can plan for the future.

DAC Beachcroft Partner Hamza Drabu, who specialises in advising health commissioners and providers on commercial and contractual issues, says that models such as Devon Cares will be of great interest to others across the country.

“This is a model that involves both the integration of commissioning between the two CCGs and the local authority, as well as integration between an NHS trust and a range of homecare providers. This allows for a more joined-up approach to homecare commissioning as well as the organisation of homecare provision. The Trust has set up a process allowing for homecare providers to periodically apply to join a framework that it can sub-contract services to.”

Drabu adds that it would be possible for this kind of service to be provided through an outcomes-based accountable care model, if NHS and local authority commissioners agreed to join forces as commissioners and include homecare services within the scope.

Councillor Izzi Seccombe speaks on community wellbeing for the Local Government Association and is the leader of Warwickshire County Council. She says the idea of acute trusts managing homecare is a good one. “This is a complex area but there are a number of models of acute trusts and councils coming together to improve homecare,” she says. “And better trained staff will be able to keep people out of hospital which is cheaper, plus people are far happier and get better sooner at home.”

Cllr Seccombe says issues such as CQC inspection and registration, new pay and terms and conditions issues need to be worked out on an individual basis.

She is happy that the government is encouraging flexibility and localism but feels that while this flexibility is useful “it doesn’t concentrate people’s minds on doing some things – so you do need a little push from the top down”.

She says Sustainability and Transformation Plans (STPs) are an attempt to get people to work together “but they are a little too acute focused at the moment”.

In Warwickshire, the Discharge to Assessment model is helping to reduce the burden on acute beds. Under the scheme, multi-disciplinary community teams provide a detailed assessment of a patient’s immediate needs in the hospital, and any on-going needs are assessed on the day of discharge at home. The model brings benefits for the patient, removes many barriers that have delayed discharge in the past and forges closer links between hospital and community colleagues.

Colin Angel, the policy and campaigns director of the UK Home Care Association, says joined-up commissioning by social care and health makes sense, particularly given the growth of delayed transfers of care from hospital.

“A ‘prime provider’ relationship could have positive benefits in making the best use of the available capacity in the homecare sector. However, understanding what terms and conditions will attract an effective workforce in sufficient numbers is key.

“This means more than just organisational structures; it includes setting sustainable fees and avoiding unnecessary overheads to maximise efficiency.”

Devon Cares has a legal contract in place which passes down to providers the requirements of the service specification, quality and activity.

NDHT director of strategy and transformation Andy Ibbs feels Devon Cares is a completely new approach to homecare. Ibbs says his Trust “co-produced the tender bid with three providers and hourly rates of pay reflects the modelling we did”. The contracts are standard NHS contracts and regulation and inspection responsibilities remain unchanged, with the homecare companies still registered as personal/domiciliary care providers with the CQC.

“The training is all at each provider’s discretion and as per CQC registration requirements; however, we know that as an NHS provider we can offer support in specific areas such as medicines, safeguarding and manual handling which will enhance the care that providers are able to offer,” says Ibbs.

In terms of Devon Cares customers, Ibbs says organisations’ strong contractual links with providers will “ensure the consistency and capacity of the care offered.

“As we go forward, the areas of focus are on the benefit to patients of getting out of hospital on time, avoiding admissions where possible and receiving care from trained, well-motivated and compassionate carers.”