Challenge 5: Creating flexible and sustainable long-term support
What is the challenge?
To maximise available resources to support people who require long-term support.
Increase the number and capacity of dementia and nursing care homes
It will be vital that we ensure that our available bed-based capacity in Gloucestershire provides care to those who most need it. This aligns with our previous MPS which stated:
“We expect that people who choose to live in care homes in future will make that choice to meet increasingly complex needs. We would like to see care homes developing creatively to provide innovative services and appropriate environments for people of all ages with a variety of more complex needs”.[1]
Our residential and nursing care home market is substantial but is not always able to provide the type and level of care for individuals with dementia. Previous sections have set out our need for over 1,000 nursing and dementia care home beds by 2043.
Enhance productivity in our care workforce
The whole health and social care system is feeling the pressure of increasing demand and limited workforce capacity. We propose to ensure that as a system we understand the impact of these changes within the short-term (intermediate care) and long-term bed-based care market and across health services. We will work in partnership across the system to ensure that every resource is used effectively.
CQC State of Care Report for 2022-23 found:
“Overall, there has been an increase in the number of full-time equivalent (FTE) staff working in NHS hospital and community health service trusts and other organisations in England (excluding primary care staff) ...
However, numbers of fully qualified GPs decreased over the same period (by 1.2%). Without intervention, the shortfall in fully qualified GPs reported in the NHS Long Term Workforce Plan[2] is projected to be around 15,000 by 2036/37.
In adult social care, latest data from Skills for Care [3]shows that, despite an increase of 1% in filled posts (roles with a person working in them) in England between 2021/22 to 2022/23, there are 45,000 fewer filled posts in 2022/23 than in 2020/21. However, the number of FTE staff in post has recovered to 2020/21 levels.”[4]
Understand the impact of private funders and out of county placements
We recognise that those people funding their own care without advice as to the appropriateness of care services may unnecessarily contribute to workforce demand.
We also recognise that the provision of support services to people with disabilities or mental health conditions funded by other local authorities which have capacity gaps in their own markets increases workforce demand.
How are we planning on addressing this challenge?
The delivery of adult social care services across the county is entirely reliant on the care workforce and the pressures in this area are well known. For this reason, we are developing a ‘Working Well’ Integrated Workforce Strategy which will include analysis of:
- Recruitment and retention across the sector
- Training and development needs (including healthcare and digital skills)
- International recruitment and how providers and overseas recruits are supported
Our engagement with providers has identified four key areas for development:
Recruitment
We will need to ensure that providers are offering the best terms and conditions to their staff in terms of pay, career progression and job security. We propose to work with providers and the care workforce to find ways to achieve this.
We recognise that as the older population is growing faster than the working age population, staff are increasingly going to be drawn from a younger age group. This may require a shift in culture to ensure that they are attracted to roles in adult social care. We propose to work with staff and young people to understand what is important to them and what might have the most impact.
Retention
We will work with providers to develop ways that will make a difference to retaining our care workforce. These might include:
- Efficient recruitment processes to onboard staff quickly
- Training opportunities
- Recognition of transferable skills
- Access to career pathways
- Job satisfaction
- Development opportunities (for example, delivery of delegated healthcare activities)
- Staff wellbeing support in the preferred style or format
We will work on developing a culture shift to recognise providers and the care workforce as an important part of the integrated care system.
Training and development
We recognise that there are skills gaps in the market as people being supported have increasingly complex health and social care needs. Training and development for staff is key to providers being able to meet these needs.
We will work with providers to further develop the training offer in Gloucestershire and to find ways to make it more accessible for staff. This will include dementia care, delegated healthcare activities, complex behaviours, and digital skills.
We are currently reviewing proposals for the delegation of healthcare activities and seeking sustainable ways to enable this to happen.
We will continue to work with providers to enhance their digital capability and increase their use of digital solutions. Support is currently available to take up the “Digital Security Protection Toolkit” (DSPT) and use of digital social care records (DSCR). More work is proposed to explore how digital developments can further increase the efficiency and productivity of care provision.
International recruitment
We are working with local authorities across the South-west region to support international recruitment practice and there is a focus in Gloucestershire on providing pastoral care to international recruits.
We are also considering what the additional or bespoke training needs are for this group to ensure that they are as effective in their new roles as possible.
We recognise that international recruitment is not and cannot be the single solution for our workforce crisis but are keen to ensure that if used it is used effectively and
forms part of a strategic approach to workforce recruitment and deployment.
The work is being led by our Integrated Commissioning and will involve providers and their representative body. We will aim to publish in autumn 2024.
The delivery of adult social care services across the county is entirely reliant on the care workforce and the pressures in this area are well known. For this reason, we are developing a ‘Working Well’ Integrated Workforce Strategy which will include analysis of:
- Recruitment and retention across the sector
- Training and development needs (including healthcare and digital skills)
- International recruitment and how providers and overseas recruits are supported
Our engagement with providers has identified four key areas for development:
Recruitment
We will need to ensure that providers are offering the best terms and conditions to their staff in terms of pay, career progression and job security. We propose to work with providers and the care workforce to find ways to achieve this.
We recognise that as the older population is growing faster than the working age population, staff are increasingly going to be drawn from a younger age group. This may require a shift in culture to ensure that they are attracted to roles in adult social care. We propose to work with staff and young people to understand what is important to them and what might have the most impact.
Retention
We will work with providers to develop ways that will make a difference to retaining our care workforce. These might include:
- Efficient recruitment processes to onboard staff quickly
- Training opportunities
- Recognition of transferable skills
- Access to career pathways
- Job satisfaction
- Development opportunities (for example, delivery of delegated healthcare activities)
- Staff wellbeing support in the preferred style or format
We will work on developing a culture shift to recognise providers and the care workforce as an important part of the integrated care system.
Training and development
We recognise that there are skills gaps in the market as people being supported have increasingly complex health and social care needs. Training and development for staff is key to providers being able to meet these needs.
We will work with providers to further develop the training offer in Gloucestershire and to find ways to make it more accessible for staff. This will include dementia care, delegated healthcare activities, complex behaviours, and digital skills.
We are currently reviewing proposals for the delegation of healthcare activities and seeking sustainable ways to enable this to happen.
We will continue to work with providers to enhance their digital capability and increase their use of digital solutions. Support is currently available to take up the “Digital Security Protection Toolkit” (DSPT) and use of digital social care records (DSCR). More work is proposed to explore how digital developments can further increase the efficiency and productivity of care provision.
International recruitment
We are working with local authorities across the South-west region to support international recruitment practice and there is a focus in Gloucestershire on providing pastoral care to international recruits.
We are also considering what the additional or bespoke training needs are for this group to ensure that they are as effective in their new roles as possible.
We recognise that international recruitment is not and cannot be the single solution for our workforce crisis but are keen to ensure that if used it is used effectively and
forms part of a strategic approach to workforce recruitment and deployment.
The work is being led by our Integrated Commissioning and will involve providers and their representative body. We will aim to publish in autumn 2024.
Many of the areas we need to address depend on how we respond to our increasing older population. For this reason, we will continue to develop an ‘ageing well’ system-wide approach which will include:
- Refreshing our ageing well programme (including Proactive Care, Enhanced Health in Care Homes (EHCH) and End of Life care)
- Developing a strategy for older people
We are also proposing that we work together as a system to develop and deliver a way of training care staff to undertake some delegated healthcare tasks. This would enhance and expand the wrap-around approach to health and care services for people in their own homes. This could be done by working with closely with community health services to ensure that all care providers are supported in the way which care homes are through the Network Contract Direct Enhanced Service (DES) for 2023-24 “Enhanced Health in Care Homes” Framework.[1]
This work will be led by Integrated Commissioning and we aim to publish the refreshed ageing well programme in February 2025.
Many of the areas we need to address depend on how we respond to our increasing older population. For this reason, we will continue to develop an ‘ageing well’ system-wide approach which will include:
- Refreshing our ageing well programme (including Proactive Care, Enhanced Health in Care Homes (EHCH) and End of Life care)
- Developing a strategy for older people
We are also proposing that we work together as a system to develop and deliver a way of training care staff to undertake some delegated healthcare tasks. This would enhance and expand the wrap-around approach to health and care services for people in their own homes. This could be done by working with closely with community health services to ensure that all care providers are supported in the way which care homes are through the Network Contract Direct Enhanced Service (DES) for 2023-24 “Enhanced Health in Care Homes” Framework.[1]
This work will be led by Integrated Commissioning and we aim to publish the refreshed ageing well programme in February 2025.
The provision of support services for adults of working age will benefit from further in-depth analysis, including transitions from children’s services to understand potential future demand from this age group.
In addition, there is work to be done with providers and other local authorities to manage the growth of demand from outside of Gloucestershire in this sector, especially considering our limited workforce capacity. The unpaid care workforce and voluntary sector organisations will also have key roles to play.
We will develop a Living Well Strategy that will provide an in-depth analysis of the provision across all service types and to meet a full range of needs including costs, capacity and usage to help us develop a clear and coherent strategic approach for individuals with:
- Physical disabilities
- Learning disabilities
- Mental health conditions
- Specific complex conditions such as acquired brain injury or neurological illness
- Autism
This work will be led by Integrated Commissioning, and we aim to publish a 'living well strategy' in summer 2025.
The provision of support services for adults of working age will benefit from further in-depth analysis, including transitions from children’s services to understand potential future demand from this age group.
In addition, there is work to be done with providers and other local authorities to manage the growth of demand from outside of Gloucestershire in this sector, especially considering our limited workforce capacity. The unpaid care workforce and voluntary sector organisations will also have key roles to play.
We will develop a Living Well Strategy that will provide an in-depth analysis of the provision across all service types and to meet a full range of needs including costs, capacity and usage to help us develop a clear and coherent strategic approach for individuals with:
- Physical disabilities
- Learning disabilities
- Mental health conditions
- Specific complex conditions such as acquired brain injury or neurological illness
- Autism
This work will be led by Integrated Commissioning, and we aim to publish a 'living well strategy' in summer 2025.
In order to achieve a personalised approach that encourages and enables independence, reduces care need and avoids people receiving community care earlier or for longer than they need, we recognise that we need to encourage the development of services that avoid or delay the need for statutory care.
We aim to increase opportunities for people to use direct payments which will involve increasing the choice of support offers available, including:
- Personal assistants (PAs)
- Micro-providers
- Voluntary sector community support
- Shared Lives
This work will be led by Integrated Commissioning working with Public Health, the voluntary sector, the social care market and the wider system.
In order to achieve a personalised approach that encourages and enables independence, reduces care need and avoids people receiving community care earlier or for longer than they need, we recognise that we need to encourage the development of services that avoid or delay the need for statutory care.
We aim to increase opportunities for people to use direct payments which will involve increasing the choice of support offers available, including:
- Personal assistants (PAs)
- Micro-providers
- Voluntary sector community support
- Shared Lives
This work will be led by Integrated Commissioning working with Public Health, the voluntary sector, the social care market and the wider system.
We want to work with residential care homes to increase their capacity for dementia care where the buildings and facilities are or can be made, appropriate.
We recognise the need for an increase in staffing to facilitate the enhanced level of care for people with dementia and we will explore how we might facilitate this through strategic partnerships.
There is also a need to ensure staff have access to appropriate training to provide quality dementia care. We want to ensure the training and development offer for all care staff in Gloucestershire is fit for purpose and this will be addressed through the development of the ‘Working Well’ Integrated Workforce Strategy.
In some areas there may be potential for the development of a 'shared care' model where care staff might work both in care homes and in the community. A locality-based outreach service from a care home might have advantages by creating a business opportunity to provide additional capacity in areas where there are limitations.
This work will be led by Integrated Commissioning working with care home providers and the wider system.
We want to work with residential care homes to increase their capacity for dementia care where the buildings and facilities are or can be made, appropriate.
We recognise the need for an increase in staffing to facilitate the enhanced level of care for people with dementia and we will explore how we might facilitate this through strategic partnerships.
There is also a need to ensure staff have access to appropriate training to provide quality dementia care. We want to ensure the training and development offer for all care staff in Gloucestershire is fit for purpose and this will be addressed through the development of the ‘Working Well’ Integrated Workforce Strategy.
In some areas there may be potential for the development of a 'shared care' model where care staff might work both in care homes and in the community. A locality-based outreach service from a care home might have advantages by creating a business opportunity to provide additional capacity in areas where there are limitations.
This work will be led by Integrated Commissioning working with care home providers and the wider system.
We will work with nursing care homes to increase their capacity where appropriate and possible. This will sometimes require increasing staffing levels and enhancing staff training. In other cases, it might involve the provision of additional equipment or the adaptation of accommodation.
Ensuring a robust support offer to care homes from Community Health services will be key in facilitating nursing homes to support more people with more complex health needs for longer and more frequently to end of life.
The Enhanced Health in care homes framework is managed in Gloucestershire as part of the ageing well programme.
“The Enhanced health in care homes (EHCH) framework is for primary care networks (PCNs) and providers and commissioners of community health and social care services. It guides the commissioning of and delivery arrangements for health and social care services in collaboration with care homes, so that the entire system works together to provide personalised care, improve outcomes and promote independence for people living in care. It recognises the life course of people who live in a care home and promotes the ethos of living, ageing and dying well.”[1]
We also recognise that community hospitals also have a part to play in supporting older people with their health care needs. The relationship between acute and community hospitals and nursing care homes will need further consideration to ensure that people can have their needs met in the right place at the right time.
The work will be led by Integrated Commissioning working with care home providers and the wider system.
We will work with nursing care homes to increase their capacity where appropriate and possible. This will sometimes require increasing staffing levels and enhancing staff training. In other cases, it might involve the provision of additional equipment or the adaptation of accommodation.
Ensuring a robust support offer to care homes from Community Health services will be key in facilitating nursing homes to support more people with more complex health needs for longer and more frequently to end of life.
The Enhanced Health in care homes framework is managed in Gloucestershire as part of the ageing well programme.
“The Enhanced health in care homes (EHCH) framework is for primary care networks (PCNs) and providers and commissioners of community health and social care services. It guides the commissioning of and delivery arrangements for health and social care services in collaboration with care homes, so that the entire system works together to provide personalised care, improve outcomes and promote independence for people living in care. It recognises the life course of people who live in a care home and promotes the ethos of living, ageing and dying well.”[1]
We also recognise that community hospitals also have a part to play in supporting older people with their health care needs. The relationship between acute and community hospitals and nursing care homes will need further consideration to ensure that people can have their needs met in the right place at the right time.
The work will be led by Integrated Commissioning working with care home providers and the wider system.
We will work on a regional basis with other local authorities to understand the demand for out of county placements into Gloucestershire to ensure that they are aware of the impacts on our resource and that any protocols agreed are mutually followed.
We will work with the providers that other local authorities commission with t better understand the drivers for accepting out of county placements and how that impacts on our resource and capacity, as well as compatibility within shared care settings.
This work will be led by Integrated Commissioning, working with Adult Social Care providers and neighbouring local authorities.
We will work on a regional basis with other local authorities to understand the demand for out of county placements into Gloucestershire to ensure that they are aware of the impacts on our resource and that any protocols agreed are mutually followed.
We will work with the providers that other local authorities commission with t better understand the drivers for accepting out of county placements and how that impacts on our resource and capacity, as well as compatibility within shared care settings.
This work will be led by Integrated Commissioning, working with Adult Social Care providers and neighbouring local authorities.
Gloucestershire County Council is currently developing plans for three new care homes in Gloucestershire which we hope will meet some of this additional demand. The model for commissioning the care provision within these new care homes has yet to be determined but the likely options are:
- The care homes being managed by Gloucestershire County Council employing their own staff teams
- Commissioning a single care home provider to provide the staff teams
- Developing a partnership with a care home provider (via a selection process) and working with them to design the care homes which they will manage and provide the staff teams
There are advantages and risks associated with each of these options which will need to be considered and a strategic decision made as to how to proceed.
Given the increasing limitations on our care workforce, we want to ensure that the option selected will maximise the productivity of these resources. This will include the provision being of a size and in a location that enables quality care to be easily delivered and a business model that invests in care staff as the primary asset.
This work will be led by Integrated Commissioning working with stakeholders across the system.
Gloucestershire County Council is currently developing plans for three new care homes in Gloucestershire which we hope will meet some of this additional demand. The model for commissioning the care provision within these new care homes has yet to be determined but the likely options are:
- The care homes being managed by Gloucestershire County Council employing their own staff teams
- Commissioning a single care home provider to provide the staff teams
- Developing a partnership with a care home provider (via a selection process) and working with them to design the care homes which they will manage and provide the staff teams
There are advantages and risks associated with each of these options which will need to be considered and a strategic decision made as to how to proceed.
Given the increasing limitations on our care workforce, we want to ensure that the option selected will maximise the productivity of these resources. This will include the provision being of a size and in a location that enables quality care to be easily delivered and a business model that invests in care staff as the primary asset.
This work will be led by Integrated Commissioning working with stakeholders across the system.
How can providers support us to meet this challenge?
- Continue to engage with us at provider forums and other opportunities so your views and ideas are heard as we develop our various strategies
- Involve us at the outset of any capital or development projects so that we can share our insights on demand and capacity for provision across our county
- Help us to better understand the picture of provision for adults of working age, particularly in relation to placements by other Local Authorities
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