Current arrangements for commissioning older people’s care-home placements are failing to address some long-standing issues

Current arrangements for commissioning older people’s care-home placements are failing to address some long-standing issues
Elderly person holding a carers hand.

Specific challenges relate to funding regimes which are overly complex and cause division amongst partners, and an overall system which is difficult to navigate.

The Welsh Government must assure itself that proposed policy reforms address these issues and achieve the aim of putting quality and outcomes at the heart of the commissioning process.

Across Wales, the costs of care-home commissioning for older people run into several hundreds of millions of pounds each year and many thousands of people are affected.

After recently completing a review of commissioning care-home placements for older people in North Wales, this report draws together issues of wider national significance and makes recommendations for the Welsh Government to consider as it looks to take forward actions in response to its Rebalancing Care and Support White Paper [opens in new window].

We highlight challenges that should be considered as part of planned policy reform, to secure meaningful change and better outcomes for people across Wales.

Some key facts on care-home commissioning:

  • There are 677 care homes in Wales, 263 of these provide nursing care.
  • 96 of these are local authority run care homes.
  • 16,144 over 65s were receiving adult care-home services from local authorities in 2018-19.
  • In 2019-20, local authorities spent £297 million on nursing and residential placements for over 65s in Wales.

From our regional report and our all-Wales analysis, we’ve found that:

  • Access to care homes for older people is complex and hard to navigate.
  • Public-sector funding approaches for different aspects of care can create division among partners.
  • Performance information relating to health and social-care commissioning is patchy and does not provide a good indicator of whether policy aims are being achieved, well-being goals delivered and there is no evidence of change to service-user outcomes.
  • Minimum technical compliance with the pooled-fund requirement fails to deliver any tangible benefit.
  • The governance and operation of Regional Partnership Boards is maturing but structures are extensive and complex and their accountability needs to be strengthened. 
  • There is inexplicable variation in expenditure on residential care and continuing healthcare costs, suggesting inequitable application of policy across Wales.
  • The charging cap on service user contributions is different for care-home placements compared to people supported in the community, providing a potential perverse incentive for commissioners of care.

We recommend that Welsh Government considers our findings from our work in North Wales, and in particular that it:

  1. should reduce the complexity of the funding responsibilities across partners,
  2. clearly describe and communicate how it expects pooled funds to operate across partners,
  3. take measures to require strengthened scrutiny arrangements and accountability of Regional Partnership Boards, and
  4. develop a framework for outcome-based performance reporting, which links to policy ambition and the seven well-being goals for Wales.

Although most of the issues now faced in care services were there before, the COVID-19 pandemic has exposed both the importance and the fragility of these services across Wales.

The Welsh Government needs to ensure that its planned reforms resolve long-standing and challenging issues around care-home commissioning and integrated care. Now is the chance to build consensus about the changes necessary to deliver improved services for those in need.

Adrian Crompton, Auditor General
Care Home Commissioning for Older People
North Wales Councils and Betsi Cadwaladr University Health Board – Commissioning Older People’s Care Home Placements