Commissioning for A Better Life as People Age in Dorset 2023 to 2028

A snapshot of older people in Dorset:

• 29% of the population of Dorset are aged over 65 compared to 19% across England as a whole. Over 85's are expected to increase to 40% by 2035
• +23% The expected growth in the over 65 population in Dorset this decade
• the median age of the Dorset population is 51. This is up by 4 years since 2009 and compared to just 40 for England overall
• across England there are 295 older people for every 1,000 people of "working age". In Dorset, this figure is 527
• 83.5% of over 65s are homeowners
• 6% of the Dorset workforce in 2011 were over 65. double the national rate

With a higher over-65 population than anywhere else in the country, it’s especially important that Dorset provides the opportunity for a great quality of life for older people. We want to work with residents, communities and local service providers to continue to strengthen the supportive community networks of Dorset, develop housing and other infrastructure that supports people to make the best of their strengths and age well, and ensure that the best quality information, support and services are in place as people’s health and care needs increase.

The right support

We want older people to be able to live healthy, independent lives, in their own homes for as long as possible. We want to strengthen the role of the home care sector and its workforce locally. Reablement will become a default first intervention, offering more robust, therapy led and proactive short-term support, whether to respond to a community need or a crisis, or after hospital discharge. This will avoid or reduce long-term care needs by empowering people to regain and maintain independence following a crisis or illness.

We are committed to working with system partners, including the voluntary and community sector, to develop this approach and will support providers, where needed, to upskill the workforce. We will work to strengthen relationships across the provider market, supported by effective contracts and contract management.

We plan to work with providers, partners and agencies such as Skills for Care, to make care a career of choice and understand where we can act together to stabilise and strengthen the homecare workforce, including in targeted hard to reach areas of Dorset. We want permanent admission to a care home considered only when all other options have been exhausted. We will work to ensure there is a range of suitable, affordable, quality care home services, both now and in the future, with an emphasis on developing the range of services more appropriate to the developing needs of the population.

The right place

As part of our ambition to develop our high streets, we want to improve their accessibility for older people, and explore with local organisations and businesses (including town and parish councils) how to foster connected and supportive communities. We also want to move from fixed location day service provision to a greater emphasis on networks of community-based offers for day opportunities. Some specialist day services with care included will always be needed, where complex care and support needs can be met.

To enable people to live as independently as possible in their own home providers will promote strengths-based care and support. We will develop an area zoning system across the county, increasing provider contact time by reducing travel time. This will also enable providers to develop greater local connections with voluntary and community organisations - making the most of all resources available.

We know that we need more extra care housing over the coming years, both for rental and for ownership. Where people stay in their own homes, we also have plans to improve our offer for equipment, adaptations and care technology. This will also help to reduce the number of avoidable care home admissions by self-funders.

The right time

We want to build more opportunities for the identification of social isolation in older people, recognising Dorset’s largely rural nature. As older people consider what they need to live healthy and independent lives, we will ensure that good information and advice is there to help them make decisions. We will need to help more people be digitally connected.

To promote independence and deliver the right level of care we want to expand the Trusted Practitioner model, empowering homecare providers to make amendments to the care required by individuals, based on professional judgment, including access to care technology. 

Outcome 1 

Dorset is a great place to grow older, with a range of vibrant community activity, giving people better days whether they have support needs or not, and keeping them well connected to the people around them and where they live.

Outcome 2 

People have access to excellent care and support in their home, both responsive short-term reablement and longer-term care, which always puts independence at its heart and helps people to continue to live independently for as long as possible, utilising equipment and assistive technology where appropriate.

Outcome 3 

A good range and choice of residential care is available, in high quality, modern homes, to meet the increasingly complex needs of the local older population.

Inclusive communities, healthy communities

The COVID-19 pandemic showed us the power of supportive community. Despite many opportunities for people to keep connected and active, we know that many older people fall into social isolation, aided in parts by the county’s rural setting. Intervening early when someone is at risk of isolation will be part of improving the lives of older people in our county.

Healthy Ageing is impossible to conceive without the support of strong and active communities. People staying socially connected, keeping physically active, and continuing to explore things that interest them or matter to them, is all dependent on community well-being. We want to explore all the ways in which we can continue to support our communities so that of Dorset is a place where it is easy to age well and stay healthy and active.

Programmes such as Dementia-Friendly

Communities will be important to helping people feel safe and confident to access local shops or community facilities. There are many good examples of local towns and villages in Dorset who are looking out for older residents, providing a supportive environment for them – as a council we want to be able to support and amplify those caring environments.

In our Enabling a Better Life for Adults strategy we have identified some of the opportunities for preventive interventions. Key to them all is our strong partnership work with the voluntary and community sector, as they build upon their connection to local communities to strengthen social resilience. As people develop a need for support, it is to these groups, organisations or small businesses that they naturally turn first – and in many cases who may have first spotted their emerging needs. We want to support this natural community ‘wraparound’. Likewise, regulated providers of formal care will improve and develop their local community networks to further enhance the ‘wraparound’ opportunities.

Ageing in ‘places’

Without excessive generalisation, ageing is often accompanied by a greater settled connection to local place. Whether through long-established residence, or through new arrival into Dorset as a retirement plan, often there is an investment in the very local community setting, which those of working age may sometimes not share so heavily. It is important as we think about commissioning for place, and much of the success of how we meet the early support needs of older residents may lie in how well we understand the opportunities and strengths of local communities, and support them to develop.

Changing the narrative about an older population

This emphasis on the voluntary sector as the natural first port of call for help, drawing on its embedded position with local communities, points to an increasingly urgent need to change the conversation about an ageing population. As one of the oldest populations in the UK, Dorset can lead this discussion. Too often, the emphasis is on ageing as a problem: a cost to society. But Dorset would not have the range, depth and connectedness of its voluntary sector without the time and energy contributed by very many people who are reaching the end of their formal working age, and entering retirement and older age. This is a strength.

We have committed to strengths-based commissioning approaches, and this resource of community-minded, socially connected older people is one of the greatest strengths that we should be drawing on when thinking about how we support an older population. There are opportunities – many of them as yet untapped – to foster intergenerational connections through this work. We will need to work on the exact projects that people want to explore, but we are committed to making such intergenerational programmes as part of our approach.

Long-term conditions

Men in Dorset have a healthy life expectancy of 62.6 years, and women 65.2 years. Taken together with overall life expectancy, this means people live for around 19 years on average with health conditions. Around two thirds of adults are overweight or obese, smoking rates are below UK averages, and physical activity levels stand at around the national average. In older adults physical activity is associated with increased functional capacities.

Hip fractures and frailty

Hip fractures are a debilitating condition that can leave people with reduced mobility, chronic pain and at risk of depression. Nationally, only one in three sufferers return to their former levels of independence and one in three ends up leaving their own home and moving to long-term care. The rate of hip fractures in Dorset (570 per 100,000) is better than the England average however we see variation across the county. Local workshops highlighted the risk of deconditioning and its role in falls and frailty – as people spend time being inactive, their condition decreases, and frailty increases. This leads them to being at risk of falls, which further increases inactivity, continuing the cycle of deconditioning.

Dementia

One of the most significant conditions to develop in older age is dementia. One in five people aged over 85 are estimated to have dementia in the UK. With a relatively high population aged over 85, and set to grow, dementia is a major issue for Dorset and will set to become more significant over the coming decade. Recorded prevalence in Dorset is lower than for the South West overall, and for neighbouring Bournemouth, Christchurch and Poole. Lower numbers of people die with a recorded dementia diagnosis also, however, those statistics are dependent on people coming forward for assessment and diagnosis. With the Alzheimers Society estimating a national prevalence of up to 1 million people by 2025 without further intervention, and with the South West of England having a net migration of retirees, the eventual impact of dementia on the Dorset health and care system is likely to be very significant.

Learning disability

More adults over 65 are living with a learning disability in Dorset. While life expectancy for the learning disability population is approximately 14 years lower in men and 17 years younger in females than the general population, people with a learning disability are living longer often with increasing physical and mental health needs. Nationally there is an increased prevalence of age-related dementia within the learning disability community; with 13% of 60 to 65 year olds diagnosed with the condition in contrast to 1% of the general population. Something which is also being reflected locally.

There are also a number of adults, aged between 40 to 55years, with a learning disability living with elderly parents, who may not currently be in receipt of social care support but become known when the carer becomes unwell or is no longer able to offer support, often at a time of crisis. This is a considerable area of risk for the individual and Dorset due to the minimal information available to us around the future need for this population.

Table shows the predicted numbers of people over the age of 65 who do or will need help with at least one self-care activity by age and gender in Dorset.

Males	2020	2025	2030	2035	2040
65-69	2,096	2,320	2,688	2,688	2,480
70-74	3,066	2,751	3,066	3,549	3,591
75-79	2,996	3,808	3,444	3,864	4,480
80+	4,690	5,670	7,245	7,805	8,575
Females	2020	2025	2030	2035	2040
65-69	3,146	3,410	3,960	3,982	3,718
70-74	3,864	3,480	3,768	4,392	4,440
75-79	3,364	4,350	3,944	4,321	5,046
80+	8,820	9,898	12,201	13,230	14,259
TOTAL	32,042	35,687	40,316	43,831	46,589
% change on 2020	-	11.4%	25.8%	36.8%	45.4%
Total over 80s	13,510	15,568	19,446	21,035	22,834
% change on 2020	15.2%	43.9%	55.7%	69.0%

The table, above, shows the predicted numbers of people over the age of 65 who do or will need help with at least one self-care activity by age and gender in Dorset. The data highlights the critical importance of prevention interventions in the face of the rising demand that is predicted. It is particularly important to note the more rapid growth of people aged over 80, with greater likelihood to need on-going support.

Residential and nursing care demand

Ultimately, if we don’t get the right support to people in the community, then we risk people moving into residential care earlier than they would otherwise need to. Currently, there are 2,948 occupied care home beds in Dorset. This is out of 3,552 available beds. A range of scenarios have been evaluated, with estimates of potential reductions in demand for residential care (over other options) matched against the escalating potential numbers needing some form of care and support. These scenarios are not an exact science, but will continue to shape the work of commissioners and partners. The worst-case of the scenarios is provided by LaingBuisson, market analysts whose data suggests a higher level of occupancy than the council currently assesses as being the case.

However, it provides one scenario based on assuming that there is no further intervention in the market. By 2035 it predicts as many as 5,936 beds may be needed, an increase of 2,384 beds (67%) on current capacity levels, equivalent to 30 more 80-bed care homes. In the middle-range of the projections is that issued by the POPPI system (the Projecting Older People Population System). Their data is based on Office for National Statistics data on the older population. Again, without preventive intervention this projects a care home population of 4,727 in 2035, 1,175 (33%) more beds. This is equivalent to around 15 new 80- bed care homes. At the other end of the scale, with maximum preventive intervention and leveraging all possible care-at-home interventions, demand could be as low as 3,307 beds. This is a reduction of 245 beds on current levels, and is a significant stretch target. It relies on maximum whole-system impact, which these strategies aim to shape, including:

• improved information/advice to self-funders
• improved care at home and day opportunities
• improved and additional extra care facilities
• increased capacity and therapy-led reablement; and
• equipment and technology-enabled care

In addition, there would have to be significant intervention in the operation of the residential care market locally, shifting its emphasis away from elective provision for self funders, to a higher level of acuity. Whilst this is an ambitious target, with all commissioning intentions considered this is the scenario commissioners are keen to strive for.

Promoting independence

To enable everyone to optimise their independence, all providers are currently expected to work in a strengths-based way; Commissioners will formalise this by coproducing the approach with providers and this will be specified within future contracts. 

Dorset Council will continue to work with Providers to move away from the traditional ‘time and task’ model and implement a more ‘outcome focussed’ model. Although ultimately Providers will be paid in terms of time, the delivery of the services will be more flexible to achieve individual outcomes.

Commissioners will work with Social Care Operational Teams to enable processes and procedures to reflect a more flexible way of working and to portray this within contractual performance monitoring. Where appropriate, social work practice already regularly considers whether there are alternative options available to regulated care and support to meet individuals’ outcomes. This includes support from the local voluntary and community sector organisations, as well as existing networks of support from family and friends. However, our ambition is for this to become standard practice for Providers too.

Links to voluntary and community sector

Dorset Council’s strategy for growing the voluntary and community sector will identify the support that can be offered through informal networks. There are a growing number of Micro Providers in Dorset and commissioners are working with these, including where they grow in size or collaborate in arrangements where registration with the CQC is required to allow them to deliver personal care and support. For those who do not wish to become registered and directly commissioned via brokerage, the Direct Payment Strategy will help identify the processes and procedures for Individuals to commission these providers directly.

Developing the links and relationships between registered care providers, voluntary and community sector including Micro Providers is a key to addressing the current care deficit and making a stronger sustainable Dorset Care Market.

Day opportunities

Around one third of people using day services (pre COVID-19) were mainly older adults living with dementia or other cognitive impairments or who have physical care needs. For those aged over 65, the number of people accessing long term care from the council due to memory and cognition is anticipated to rise from 535 in 2020 to 870 in 2040. The most significant increase can be seen with those who are aged over 85 requiring physical support which is anticipated to rise from 1,665 in 2020 to 3,150 in 2040.

In our strategy for improving support for all adults in Dorset, we set out a vision for day opportunities that is more community-focused, more flexible and more responsive to how people want to live their lives. We also commit to a more modern set of specialist day services for those who need that level of support. Our current service offer mixes provision for older people and for people with learning disability, and we want to work with both groups to think differently about what each wants from their support.

The Dorset market

There are approximately 70 Home Care Providers operating in Dorset, most deliver care for the council. 28 are commissioned via the Dorset Care Framework and work at the published rates. 42 are engaged on a spot contract basis, generally at rates above the published rate. Approximately 75% of all home care packages are delivered by DCF Providers.

However, due to high demand for care, and in order to mitigate risks to vulnerable people without care, the rate of spot purchases continues to rise. In Dorset, like many other areas across the country, there is not enough homecare for the number of people who need it. Increases in need and complexity, together with workforce reductions, have driven this challenging situation. The proposal to make reablement the first choice of support will reduce the need for so many high acuity packages and therefore increase the capacity in the regulated providers.

The “care deficit” (care hours needed that couldn’t be sourced) peaked in winter of 2021 at around 5,000 hours of care per week. This included 70 patients awaiting discharge from hospital. At the time of writing the deficit has reduced to approx. 3,000 hours. This equates to approx. 80 extra full-time equivalent workers, or as many as 120 part-time individual workers.

During 2021 the number of hand backs has increased significantly. From June to November there were 74 from across the Dorset footprint. Many of these have been single hand backs, but it did include 20 from a single provider. One provider has closed citing the lack of available workforce. Hand backs have an effect on the Reablement service as those workers are also used to staff the Provider of Last Resort. This then impacts on the reablement capacity and, as care and support is difficult to source, many packages remain with the service for longer than initially planned.

Workforce challenges

Workforce reductions result from issues such as COVID-19 illness and ‘burnout’, some overseas workers being unable to return due to COVID-19 travel restrictions, and more attractive terms and conditions in sectors such as hospitality and retail. Dorset is particularly challenged by having an ageing population and reducing working age population. Skills for Care predict that the Dorset care workforce will need to increase by 37% to be able to meet the needs of Individuals by 2035. This equates to an extra 3,626 workers joining the sector.

Becoming a customer of choice

Dorset is, in the main, an affluent county where many individuals can fund their own care and support. This means commissioners are in competition with self funders who tend to be able to pay more for care and support. Respondents to a recent survey of homecare providers suggested that only one provider had more that 75% of their business commissioned by Dorset Council and most had less than 50%. This evidences that the council is not a customer of choice, despite being able to guarantee a stream of business. More recently some providers have stated that the council fees affect the ability to recruit and retain enough staff for the lesser paid home care commissioned by the council.

Rurality

The large majority of Dorset is rural with some areas where it is very challenging to commission care and support due to travel times and mileage needed to reach individuals. There are also towns in Dorset where it is particularly difficult to source care, such as Swanage and Lyme Regis. These areas have higher older populations with few working age adults willing and able to work in the care sector. During the summer period the time it takes to reach these areas is increased due to the number of visitors coming to Dorset. 

We concluded our Market Sustainability Plan for homecare (provided to adults of all ages) in early 2023. This forms the basis of an ambitious set of plans to improve the stability of the market, and support providers to deliver high quality services for people who need them. We will work with providers, through the Provider Association, to continue to strengthen and build upon this ambition.

To proactively and strategically work to improve relationships with providers

• collaborate with market leaders on establishing a more active provider association, and jointly agreed plan for the future, aligned to commissioning strategies

To work with the market to tackle workforce challenges

• develop joint workforce plan with provider market, including promotional activity, to address recruitment and retention challenges, paving way for developing more specialisms
• work with providers on round optimisation, with ‘zoned’ approach to improve retention
• develop housing plans that support keyworker housing for areas where targeted support is needed to build the local workforce

To continue to develop understanding of the ‘Fair Cost of Care’ and refine implementation

• strengthen dialogue on FCoC, leading to early repeat of exercise to improve engagement

To develop new reablement and other short-term interventions for independence

• develop new reablement model with Care Dorset, as community preventive intervention, supporting ICS strategy and developments

To improve contracting processes to better drive innovation and responsiveness

• implement Dorset Care Framework 2 as vehicle for reforming homecare and reablement system
• design new contracts, emphasising recovery and independence and stronger links to VCSE
• implement e-brokerage system and PAMMS provider quality management system to strengthen brokerage activity, with linked council workforce development plan
• establish strategic provider relationships, for more consolidated and transformational purchasing, and to develop more trusted assessor and trusted practitioner models

To build on strengths-based approaches to better support individuals; choice, control and independence

• improve information/advice provision, to support good decision-making including self-funders and promote alternatives to contracted homecare (PAs/DP, etc.)
• develop strategy around delivery of extra care and other accommodation with support, and associated market development plan
• development programme around personal assistants and other micro-provider activity
• new extra care housing developments in order to support effective care delivery in people’s homes for longer

To harness technology to better deliver care outcomes for individuals and improve access

• implement plans to develop and promote technology-enabled care options, improve efficiency of care delivery, incl. training providers and expanding trusted assessors
• new technology will allow for some assessment self-service, linked to other strands of the reform programme

The Fair Cost of Care

We have undertaken detailed research with providers on the costs that drive their delivery of social care services. On this basis we have established a “fair cost” for care delivery, in line with Government guidance issued in mid 2022. We remain committed to the journey towards paying the fair cost of care, particularly prioritising the homecare market, but we always have to balance our ambition with the resources the council has available within a ‘balanced budget’.

Like other areas, Dorset has experienced significant pressure on health and care services over the past three years. In addition to the challenges of an ageing demographic and recruitment and retention difficulties, the COVID-19 pandemic has created difficulties logistically, restricting capacity and adding to workforce pressures, all of which have further negatively impacted on people’s mental and physical health. The current cost of living crisis is exacerbating this position and presents more challenge both in workforce stability and business costs.

Across the system, partners are working to mitigate the risks and impact for individuals and their families; and for the staff who deliver this care and support. There has been short term investment in additional home and bedded care to provide extra community capacity, underpinned by continuous improvement work across hospital and community teams to refine and improve the processes that support successful discharge/prevention of admission. Our care company, Care Dorset, is working to further develop their Reablement Service to support Hospital Discharge Policy and the ethos of ‘Home First’. The future direction is to build this more formally into the future whole Dorset system intermediate care offer.

Our current offer for supporting people back to independence is strongly focused on helping people to come out of hospital and return home, driven in large part by the significance of the ‘out of hospital’ pathway to the stability of the local health and social care system. The transfer of these services to Care Dorset in 2022 is an opportunity to address a significant gap in reablement provision in Dorset, and build a stronger therapeutic element into the service model.

It will be important to reorient reablement away from being solely an out-of-hospital intervention, and build its community-facing capacities, so that it can respond to community crisis and return people to stability prior to needing hospitalisation, other medical interventions, or long-term care.

Reablement and other short-term interventions as preventive intervention: a model of empowerment

Commissioners propose that a future response to individuals who are being assessed for the first time, should be short term strengths based ‘empowerment’ support that focusses on regaining or maintaining of independence, considering the individual’s assets rather than just the deficit that is presenting at that time. This is consistent with the strengths based approach to social work that is integral to how adult social care works in Dorset. It will be piloted with providers, enabled through the new Dorset Care Framework 2

The Dorset Home First programme Dorset ICS has commissioned a Home First programme to mobilise an integrated and sustainable intermediate care model for the Dorset population which provides both step-up and step-down support to people in the community (ideally in their own homes).

The Home First Board has agreed an outline service model for a pan-Dorset integrated intermediate care service which is premised on bringing together the current service offer across health and care, and ensuring it has the right capacity, therapeutic capabilities, and resilience to meet local need. Key to this will be a strong commissioning and financial framework that enables a true ‘discharge to assess’ approach.

An outline business case has been developed that is focused on delivering these outcomes:

• reduction in bed days through increased prevention of admission and reduction in acute and COHO LOS
• improved health and care outcomes as a result of timely and effective intermediate care with more people able to return/remain living independently at home

Whilst full delivery of the integrated intermediate care model is likely to take 2 years, the Home First Board has committed to accelerating key components where this can support improved system flow and resilience.

In Dorset, a scheme is defined as extra care accommodation if it contains self-contained apartments and communal facilities, offers hot meals on site, and has an on-site care team available 24/7. The schemes are designed to accommodate people with a wide range of care needs, up to and including end of life care, and should be at the cutting edge of Technology-Enabled Care and digital technology to help people to live as independently as possible.

In Dorset we see Extra Care Housing as an accommodation with support model and environment that could be appropriate and beneficial to people of all ages, rather than just the traditional over-55s model.

We would like Extra Care Housing to form a key part of our support offer for people with non-complex support needs and health conditions. Two main factors that lead to people entering Residential Care are Night Support needs and Social Isolation. With the right environmental design and support, Extra Care Housing can support people with these needs and others, while keeping people as independent as possible within a home of their own.

The Housing Learning Improvement Network (Housing LIN) have produced a toolkit for estimating demand for Extra Care Housing, based on research into how the market has developed across the Country. The toolkit finds that to meet demand for Extra Care Housing there should be 22.5 units for every 1,000 people aged 75 and over. In Dorset this conversion rate suggests that 1,206 units of Extra Care housing are needed in 2020, and 1,960 units will be needed by 2040.

Dorset Council area currently has 4 affordable Extra Care Housing schemes, and a further two schemes are currently in the development pipeline. A third new scheme is in the process of being commissioned, which will be located in Wareham.

The council is actively facilitating the development of affordable Extra Care housing, primarily through the Building Better Lives development programme, but also through partnerships with Registered Providers. This needs to continue if estimated demand will be met.

We also know that older housing stock is often not well-suited to increasing frailty, and the concept of ‘houses for life’ – in which people can live with significantly growing care needs for the whole of life should they choose – will become ever more important as the population ages and demand for housing.

Developing a more comprehensive extra care strategy

We are working to develop a more detailed set of plans for providing extra care housing and other supported living options for people in Dorset. We expect to develop some options at the start of 2023, and be able to invite people’s comments and contributions to the plans. We are aiming to finalise our strategy by the summer of 2023.

• 1,036 people funded by Dorset Council for their care home placement
• 75% in residential care vs. 25% in nursing care
• 84% are resident in Dorset Council area with 16% placed out of county
• Dorset Council purchases 30% of occupied beds in the county
• 16 homes out of 100 in the county, accept rates on the Dorset Care Framework

Approximately, 100 care homes in the Dorset Council area provide care for older people, with a total of 3,552 beds. There is also a total of 159 registered care homes in the neighbouring Bournemouth, Christchurch and Poole area.

At the time of writing, 6 of the 100 care homes providing care for older people in the Dorset Council area were rated by the Care Quality Commission as ‘outstanding’, 86 were rated as ‘good’ and 6 ‘required improvement. Two care homes were awaiting assessment. Two-thirds of these care homes offer residential care without nursing, and the remaining third offer residential care with nursing. Five companies have over 100 beds each across the Dorset Council area and own 38% of all care home beds.

The majority of care homes in the Dorset Council area tend to be small, with 14 (14%) homes have less than 20 beds, 61 (61%) homes have 20-49 beds, 25 (25%) have 50+ beds. There is a need to develop our understanding of the buildings occupied by care homes in Dorset and to assess the implications for meeting the various needs of both state and self funded residents. Being more ‘efficient’ is only one part of the story in delivering quality residential care, however, and many people appreciate a smaller home. How the physical building stock of Dorset care homes supports effective delivery of care, including where they are located, is something we need to do more work to understand.

Four care homes in the Dorset Council area closed during the period August 2020 to August 2021. The reasons for the closures included the Care Quality Commission’s decision to withdraw registration (following ‘inadequate’ ratings), the provider’s decision to close the home for refurbishment, and the owner’s view that the care home was no longer commercially viable. The majority (59) of care homes state that they provide services for people with dementia. However, this market is underdeveloped and often presents a challenge in finding suitable placements for people who use services, particularly where their dementia is advanced and / or the person may exhibit behaviours that others may find challenging.

More work is needed to develop and agree a shared definition as to what constitutes different types and levels of residential care - to make it easier for all stakeholders, including people who fund their own care, to understand which service user groups and needs are catered for by individual care homes.

The council faces several challenges in responding to the scale of forecast demand.

Systemic pressures and demands

The COVID-19 pandemic has placed enormous pressures on an already stretched health and social care system, and care homes have undoubtedly been hit hard. However, the pandemic has also highlighted care homes’ key role in helping the wider system, including our acute and community hospitals, to function throughout the crisis.

We therefore need to develop our ability to respond quickly and proactively to systemic pressures and demands, with better market intelligence, over-sight and more efficient brokerage processes, including e-brokerage.

Developing alternatives to permanent care home placements

Key to achieving our aim of helping older people to remain at home for longer, is the need to develop realistic, robust and appealing options for housing with care in later life. This includes the provision of flexible and holistic options to support people at home, as well as alternative housing options such as Extra Care Housing.

Substantial, coordinated efforts and investment will be needed to shape and deliver the range of later life housing options that will be needed to enable people to stay at home for longer.

Using reablement as a first choice of care and support will be another key factor in keeping people in their own homes for longer so reducing the need for care home placements.

Focus of the Dorset care homes market

Dorset has a large and growing population of older people, 83.5% of whom own their own home. The Dorset care homes market is predominantly geared towards more affluent, asset-rich individuals who fund their own care. Collectively, it is private or self-funders who have the market power in Dorset. Our current reliance on one-off ‘spot’ purchasing further dilutes our ability to negotiate good long-term access to residential care at reasonable rates.

However, people who pay for their own care and support often lack the comprehensive information required to make an informed choice about how their care needs will be met. Self-funders’ purchasing decisions have a major impact on Dorset Council’s ability to access suitable, affordable, quality care for the people whose care it funds.

Care homes that predominantly target people who pay for their own care are less likely to cater for the type and level of care need that the council brings to the market, to have the capabilities needed to do so or to be able to offer an affordable price.

Additionally, people who choose to go into permanent residential care may do so at a far earlier stage than would be typical for someone whose care is funded by a local authority. In 2020/21 the council spent £2.3m on the care fees of 64 individuals who had run out of their own funds.

Gaps in service provision

Despite needing to source, on a daily basis, care home placements for older people with dementia and complex care or nursing needs, the council struggles to do so, leading to delays in sourcing appropriate care for individuals including those ready to leave hospital.

We need to work with the market and our healthcare partners to develop both capacity and capabilities within the care home market to meet the needs of people with dementia, complex care and support needs, including behaviours that challenge, nursing care needs, along with greater demand for short term services that will help older people to remain independent for longer.

Budget pressures

The financial climate facing the public sector is difficult and unlikely to improve in the foreseeable future. In all of our commissioning arrangements, value for money, quality and the sustainability of services, need to be taken into account.

We concluded our Market Sustainability Plan for residential and nursing care for those over 65 in early 2023. This forms the basis of an ambitious set of plans to improve the stability of the market, and support providers to deliver high quality services for people who need them. We will work with providers, through the Provider Association, to continue to develop these plans and build upon this ambition.

To proactively and strategically work to improve relationships with providers

• collaborate with market leaders on establishing a more active provider association, and jointly agree plan for the future, aligned to our emerging commissioning strategies

To further develop understanding of ‘Fair Cost of Care’ and refine implementation

• continue to develop dialogue around financial issues in residential care delivery
• establish agreed set of definitions on the levels of complexity in care contracting, which will include understanding of the number of care hours typically required and allow us to address the higher care hours found in the FCoC analysis
• repeat FCoC exercise to inform 2024/25 budget setting

To improve contracting processes to better drive innovation and responsiveness

• establish new contract types to match definitions of care complexity and options for intermediate, other flexible provision
• Dorset Care Framework 2 commissioning to formalise new elements in care delivery, including NHS as partner to create opportunities to make DCF2 a more powerful instrument in supporting ICS ambitions
• develop strategy for delivery of extra care and other accommodation with support, and associated market development plan
• implement e-brokerage system and PAMMS provider quality management system to strengthen brokerage activity (more efficient, more commercial), with council workforce development plan (to include stronger contract management, option for NHS offer) 
• establish strategic provider relationships on which to base more consolidated and transformational purchasing, and allowing for the development of more trusted assessor/trusted practitioner models

To work with the market to tackle workforce challenges

• shared workforce plan with providers
• develop housing plans that support keyworker housing for areas where targeted support is needed to build local workforce

To build on strengths-based approaches to better support individuals; choice, control and independence

• develop information and advice provision, proactive and targeted to those making decisions about their care and costs under new financial rules – especially issues around what counts to the cap, etc
• new online assessment self-service, harnessing opportunities for more tailored and targeted information and advice

To develop new forms of provision that can better meet residents’ needs

• council-initiated development of new residential provision for higher-level needs
• new extra care housing developments to support people staying in homes for longer

The Fair Cost of Care

We have undertaken detailed research with providers on the costs that drive their delivery of social care services. On this basis we have established a “fair cost” for care delivery, in line with Government guidance issued in mid 2022. For residential and nursing care, the journey to paying ‘fair cost’ is a complex picture, with many providers paid above ‘fair cost’, and some others below. We remain committed to the journey towards paying ‘fair cost’ in more cases, and raising our floor rates accordingly, but always in the context of the duty on the council to remain within a ‘balanced budget’.

Better ageing

• major extra care scheme developments to be completed, and further proposed developments to be scoped and initiated

Care and support in the home

• embedding the new Dorset Care Framework, new zoning system, and new arrangements for out-of-hospital and community prevention services, including new reablement services.
• strong focus on workforce development, targeted at areas of greatest need, and including the development of Micro Providers, PA support, through direct payment.
• development of greater links between regulated care and voluntary and community sector support.

Residential and nursing care

• implementation of Care Cap

Reduce demand

• predictive analytics to identify risk
• more extra care and technology
• short-term crisis interventions
• holistic support-at-home options

Prepare the market for future need

• new care home development in Bridport
• establish joint workforce support programme
• promote use of technology in care homes

Consolidate purchasing

• care homes that have signed up to Dorset Care Framework 2 invited to participate in further competitions for block contracts to be let under the various Framework Lots

Changing what and how we buy

• implement e-brokerage system

Work with stakeholders to enhance care homes’ capacity and capability

• establish joint improvement programme

This strategy was last reviewed in 2023. 

The next expected review date is 2027.