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Introduction to the market position statement (MPS)

State of the nation

It is six years since Gloucestershire produced a Market Position Statement (MPS). A lot has happened in that time but in many ways the messages have not changed. The adult social care market in the county is diverse and substantial but faces considerable challenges in meeting the demands for services. Our approach needs revisiting and updating in the light of demographic growth, the impact of the Covid pandemic, workforce challenges and economic pressures.

What our demographic analysis shows us now is that:

•    The number of people over 65 in Gloucestershire is increasing, particularly in the older age groups who are more likely to use social care services. There is going to be a resulting increase in demand for domiciliary, bed-based dementia and nursing care services.
•   The number of working age adults remains relatively static and therefore increase in demand for social care services will require increased staff which will result in workforce pressures worsening. This will impact the provision of care across the market. 
•   Demand for services for the working age adult population is likely to remain largely static with only 2% growth predicted over the next 20 years. However, the current pattern of migration of adults of working age with disabilities into Gloucestershire to receive support is unsustainable with a limited workforce to recruit from.  
•  Whilst demand for services to working age adults is not growing substantially there is an increasing need to focus on the diversity, sufficiency and appropriateness of provision, particularly for specific groups where issues have been identified. 

These findings mean that the key messages of this Market Position Statement are: 

•    There is an increased need to promote health and wellbeing to ensure that people enter older age in good health, and then stay in good health for as long as possible.
•    Supporting people to live as independently as possible will be crucial at every stage of their life, and, whether they are eligible for support from the council or not, providing the right support at the right time will be essential in preventing deterioration and delaying care demand.
•    Workforce capacity will be limited and there is a need to ensure that it is used effectively where it is most needed. This may mean a reduction in services that are not a necessity and investing in innovation that frees up workforce to undertake essential tasks.
•    Understanding and supporting the family and carers of people who have need of social services and NHS commissioned care is as important as supporting the individual with needs. 

The focus of our commissioning intentions in the last MPS was to: “Develop a market which can support people to live as independently as possible for as long as possible”. 
This remains the case but the urgency with which we seek to address it is more acute as we project a significant increase in the older population in Gloucestershire over the next ten years with a resulting increase in the number of people who will need social care and NHS commissioned services.

The Market Position Statement is divided into sections that can be studied separately or in sequence to enable providers, commissioners, and other partners to gain a good overview of the adult social care market. It aims to present the demographic findings for the county’s population over the next twenty years and to project the anticipated demand for adult social care services and NHS commissioned care during that time. It covers the impact of demographics on both the commissioned and self-funder markets and it identifies the growing challenges that providers and the integrated care system will face. 

Providers have been engaged with to inform the document and their responses are included in a separate section focussing on their concerns and reflected in the proposed actions. We intend to carry out further engagement with our provider market to develop any strategies that are needed as a result of the MPS and will value provider input into how they can help to tackle any upcoming challenges in the system over the next 20 years. 

We understand that the market is constantly changing, as do the pressures and demands that it faces. We want our MPS to be an agile resource that grows and develops in order that commissioners and providers can access plans, strategies, and relevant information to shape and inform a sustainable care and support market. This is why we have made it web based with a view to easy navigation to the most relevant information and to facilitate timely updates.

The following sections will be regularly updated: 

•    Demographic changes
•    Bed based care markets
•    Home based care markets

The later sections of the Market Position Statement are concerned with the challenges we face as a system. These are the same as those identified in the last MPS, as they are as relevant today as they were in 2018, although we have combined “flexible long-term support” and “sustainable long-term services” into “Creating Flexible and Sustainable Long-Term Support”.

The sections are therefore:

1.    Supporting Independence
2.    Appropriate Housing
3.    Increasing our Community Support Offer
4.    Focusing on Rehabilitation, Recovery and Reablement
5.    Creating Flexible and Sustainable Long-Term Support
6.    Working in Partnership across the System

For each core challenge we have set out our proposed approach and how we plan to work together as a system to maximise the outcomes for the people of Gloucestershire.

 

 

In the Chief Medical Officer’s annual report 2023: health in an ageing society, Professor Chris Whitty notes that: 

“The great majority of people move out of cities and large towns before older age, concentrating geographically in coastal, semi-rural or peripheral areas, often with relatively sparse services and transport links... Providing services and environments suitable for older adults in these areas is an absolute priority if we wish to maximise the period all older citizens have in independence. The provision of health and social care also needs to be concentrated in these areas.”

There has long been a focus in Gloucestershire on supporting people to maintain their health and wellbeing and remain at home as long as possible through our ‘Make the Difference’ approach.

Since our last MPS we have supported more people to live at home for longer (over 8% increase in packages between 2022 and 2023) and fewer people to enter residential care, the expected growth in the older population, particularly in the older age brackets, will increase the demand for care services significantly over the next 10 years. Already we can see there is a rising demand for domiciliary care and an increased need for bed-based nursing and dementia care.

In the Chief Medical Officer’s annual report 2023: health in an ageing society, Professor Chris Whitty notes that: 

“The great majority of people move out of cities and large towns before older age, concentrating geographically in coastal, semi-rural or peripheral areas, often with relatively sparse services and transport links... Providing services and environments suitable for older adults in these areas is an absolute priority if we wish to maximise the period all older citizens have in independence. The provision of health and social care also needs to be concentrated in these areas.”

There has long been a focus in Gloucestershire on supporting people to maintain their health and wellbeing and remain at home as long as possible through our ‘Make the Difference’ approach.

Since our last MPS we have supported more people to live at home for longer (over 8% increase in packages between 2022 and 2023) and fewer people to enter residential care, the expected growth in the older population, particularly in the older age brackets, will increase the demand for care services significantly over the next 10 years. Already we can see there is a rising demand for domiciliary care and an increased need for bed-based nursing and dementia care.

The Covid pandemic increased the pressure and stresses on all elements of the health and social care system. The Care Quality Commission (CQC) State of Care Report 2019/20 noted:

“As the pandemic gathered pace, health and care staff across all roles and services showed huge resilience in the face of unprecedented pressures and adapted quickly to work in different ways to keep people safe.

It took a substantial emotional toll on care staff, concerned as they were not only for the wellbeing of their patients and residents but also for their own families and loved ones, as they worked to understand the nature of the disease and protect people to the best of their ability.”

 

The emotional legacy of Covid has been the depletion of people prepared to work in the industry. The difficulties faced saw many leave the profession and recruitment and retention of staff has become a major concern ever since.

The Covid pandemic increased the pressure and stresses on all elements of the health and social care system. The Care Quality Commission (CQC) State of Care Report 2019/20 noted:

“As the pandemic gathered pace, health and care staff across all roles and services showed huge resilience in the face of unprecedented pressures and adapted quickly to work in different ways to keep people safe.

It took a substantial emotional toll on care staff, concerned as they were not only for the wellbeing of their patients and residents but also for their own families and loved ones, as they worked to understand the nature of the disease and protect people to the best of their ability.”

 

The emotional legacy of Covid has been the depletion of people prepared to work in the industry. The difficulties faced saw many leave the profession and recruitment and retention of staff has become a major concern ever since.

Workforce availability is increasingly the dominating factor for the provision of any care services and demography determines that this will continue to be the case. In Gloucestershire whilst the older population is growing rapidly the working age population growth rate is much slower. This means that demand is increasing but the number of potential staff available to meet it is not. Added to that the experience of Covid for staff working in health and care was extremely challenging and, in some instances, traumatic. The industry has lost staff who might have stayed in the profession for longer at a time when they are needed most.

There is a need to replace them and a limited number of people willing to step forward. The NIHR Policy research unit conducted six online surveys with health and social care workforce from 2020 to 2023 and found that, of the social care worker respondents, 44.2% considered changing their occupation during the pandemic and 53.7% were “overwhelmed by increased pressures”. (Analysis: Health and Social Care Workforce Research Study).

Recently the gap in workforce capacity has reduced significantly, largely due to changes in Home Office policy which have enabled the recruitment of overseas staff to fill social care roles. This opportunity has addressed some of the strain being felt by the industry in recruiting and retaining staff, however, it cannot be seen as a universal solution and comes with risks of its own, including capacity challenges if licenses are revoked, and abuse of the system by unscrupulous organisations leading to instances of modern slavery.

The need to prioritise how we recruit, support, and retain care staff has never been more keenly felt.

Workforce availability is increasingly the dominating factor for the provision of any care services and demography determines that this will continue to be the case. In Gloucestershire whilst the older population is growing rapidly the working age population growth rate is much slower. This means that demand is increasing but the number of potential staff available to meet it is not. Added to that the experience of Covid for staff working in health and care was extremely challenging and, in some instances, traumatic. The industry has lost staff who might have stayed in the profession for longer at a time when they are needed most.

There is a need to replace them and a limited number of people willing to step forward. The NIHR Policy research unit conducted six online surveys with health and social care workforce from 2020 to 2023 and found that, of the social care worker respondents, 44.2% considered changing their occupation during the pandemic and 53.7% were “overwhelmed by increased pressures”. (Analysis: Health and Social Care Workforce Research Study).

Recently the gap in workforce capacity has reduced significantly, largely due to changes in Home Office policy which have enabled the recruitment of overseas staff to fill social care roles. This opportunity has addressed some of the strain being felt by the industry in recruiting and retaining staff, however, it cannot be seen as a universal solution and comes with risks of its own, including capacity challenges if licenses are revoked, and abuse of the system by unscrupulous organisations leading to instances of modern slavery.

The need to prioritise how we recruit, support, and retain care staff has never been more keenly felt.

During Covid financial pressures for the independent provider market increased:

  • Care homes felt an economic impact as they lost residents and admissions stopped for a period causing a loss in earnings
  • Workforce pressures were felt across the system with rising staff sickness and the need for people to isolate challenging capacity. The cost of staffing increased rapidly fuelled by soaring agency costs and wage rises to match other sectors such as retail.
  • The cost of providing personal protective equipment (PPE) before national funding and supply became available was an unexpected burden, particularly as supply issues saw prices escalate

Since then, the cost of living has significantly increased, and providers reported the impact of this in response to the 'Cost of Care' exercise undertaken in 2022. Locally the cost of care identified by bed-based care providers was higher than the average price paid by the local authority, domiciliary care saw less difference. In 2023 Home Farm Trust (HFT) and Care England (CE) reported that, nationally, on average, providers saw energy costs rise by 72% but some saw increases of up to 350%. (Hft Sector Pulse Check 2023 - Digital Singles).

Local Authorities are equally impacted by the cost of living increases and despite Government investment, such as the Market Sustainability and Improvement Fund (MSIF) demand for services continues to grow more rapidly than budgets meaning the overall impact of these funds on wages for instance are minimal. HFT and CE report that, nationally, 84% of adult social care providers said that government funding initiatives implemented over the past year have had no impact upon their financial sustainability.

The impact of the increased cost of living is also felt by citizens. We know that the conditions in which we are born, grow, live, work and age can impact our health and wellbeing. These 'wider determinants of health' mean that people living in deprived areas are more susceptible to ill health and more likely to use social care services than those in wealthier circumstances. It is likely that the rise in the cost of living will have increased demand.

The biggest expenditure, and therefore the biggest economic concern, for providers continues to be the workforce. In Gloucestershire, the provider representative organisation has highlighted this and the HFT and CE report indicates that 81% of providers flag workforce as the most significant pressure.

The cost of care exercise undertaken in 2022 revealed that in Gloucestershire care homes there are a large proportion of people funding their own care. People who fund their own care only do so until their capital drops below the threshold over which they are fully chargeable. After this point providers turn to the local authority to pick up the cost at the but with an increase in the older population putting maximum strain on council budgets councils are unlikely to pay anything above their usual rates. If social care reforms are implemented, and the threshold for local authority funded care is lowered, less people will be self-funding in the first instance and those providers whose business models rely on higher private fees will feel a significant impact.

During Covid financial pressures for the independent provider market increased:

  • Care homes felt an economic impact as they lost residents and admissions stopped for a period causing a loss in earnings
  • Workforce pressures were felt across the system with rising staff sickness and the need for people to isolate challenging capacity. The cost of staffing increased rapidly fuelled by soaring agency costs and wage rises to match other sectors such as retail.
  • The cost of providing personal protective equipment (PPE) before national funding and supply became available was an unexpected burden, particularly as supply issues saw prices escalate

Since then, the cost of living has significantly increased, and providers reported the impact of this in response to the 'Cost of Care' exercise undertaken in 2022. Locally the cost of care identified by bed-based care providers was higher than the average price paid by the local authority, domiciliary care saw less difference. In 2023 Home Farm Trust (HFT) and Care England (CE) reported that, nationally, on average, providers saw energy costs rise by 72% but some saw increases of up to 350%. (Hft Sector Pulse Check 2023 - Digital Singles).

Local Authorities are equally impacted by the cost of living increases and despite Government investment, such as the Market Sustainability and Improvement Fund (MSIF) demand for services continues to grow more rapidly than budgets meaning the overall impact of these funds on wages for instance are minimal. HFT and CE report that, nationally, 84% of adult social care providers said that government funding initiatives implemented over the past year have had no impact upon their financial sustainability.

The impact of the increased cost of living is also felt by citizens. We know that the conditions in which we are born, grow, live, work and age can impact our health and wellbeing. These 'wider determinants of health' mean that people living in deprived areas are more susceptible to ill health and more likely to use social care services than those in wealthier circumstances. It is likely that the rise in the cost of living will have increased demand.

The biggest expenditure, and therefore the biggest economic concern, for providers continues to be the workforce. In Gloucestershire, the provider representative organisation has highlighted this and the HFT and CE report indicates that 81% of providers flag workforce as the most significant pressure.

The cost of care exercise undertaken in 2022 revealed that in Gloucestershire care homes there are a large proportion of people funding their own care. People who fund their own care only do so until their capital drops below the threshold over which they are fully chargeable. After this point providers turn to the local authority to pick up the cost at the but with an increase in the older population putting maximum strain on council budgets councils are unlikely to pay anything above their usual rates. If social care reforms are implemented, and the threshold for local authority funded care is lowered, less people will be self-funding in the first instance and those providers whose business models rely on higher private fees will feel a significant impact.

The focus of our commissioning intentions in the last MPS were to 'develop a market which can support people to live as independently as possible for as long as possible.'

This remains our aim but the urgency with which we seek to address it is more acute as we project a significant increase in the ageing population in Gloucestershire in the next ten years and an accompanying increase in the number of people who will need social care services. Demographic data shows us that demand for services for the working age adult population in the same period is likely to remain largely static with only 2% growth over the next 20 years but, the current pattern of migration of adults of working age with disabilities into Gloucestershire to receive care provision is unsustainable with a limited workforce to call upon. 

This MPS aims to consider how we can address the rise in demand for older people services in particular and how the social care market will need to adapt to respond to changing need over the next 10 years and beyond. Gloucestershire has a substantial external care market with some excellent examples of innovation and flexibility of response that illustrate the degree of engagement and dedication from providers. However, like the rest of the country, the ability to recruit and retain adequate workforce to deliver sustainable quality services is hampered by demographic limitations and competition for staff.

Gloucestershire County Council and Gloucestershire Integrated Care Board wish to work with the provider market to develop sufficient capacity of good quality provision to meet all identified future needs. We will prioritise investment on developing capacity in the domiciliary care market and in bed-based provision of nursing and dementia specific care because that is where the biggest demand lies but it is our intention to work with the whole market to ensure a robust and sustainable social care offer to the people of Gloucestershire.

The focus of our commissioning intentions in the last MPS were to 'develop a market which can support people to live as independently as possible for as long as possible.'

This remains our aim but the urgency with which we seek to address it is more acute as we project a significant increase in the ageing population in Gloucestershire in the next ten years and an accompanying increase in the number of people who will need social care services. Demographic data shows us that demand for services for the working age adult population in the same period is likely to remain largely static with only 2% growth over the next 20 years but, the current pattern of migration of adults of working age with disabilities into Gloucestershire to receive care provision is unsustainable with a limited workforce to call upon. 

This MPS aims to consider how we can address the rise in demand for older people services in particular and how the social care market will need to adapt to respond to changing need over the next 10 years and beyond. Gloucestershire has a substantial external care market with some excellent examples of innovation and flexibility of response that illustrate the degree of engagement and dedication from providers. However, like the rest of the country, the ability to recruit and retain adequate workforce to deliver sustainable quality services is hampered by demographic limitations and competition for staff.

Gloucestershire County Council and Gloucestershire Integrated Care Board wish to work with the provider market to develop sufficient capacity of good quality provision to meet all identified future needs. We will prioritise investment on developing capacity in the domiciliary care market and in bed-based provision of nursing and dementia specific care because that is where the biggest demand lies but it is our intention to work with the whole market to ensure a robust and sustainable social care offer to the people of Gloucestershire.