Introducing an outcomes focus to service planning and delivery in Powys Adult Services'

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Introducing an outcomes focus to service
planning and delivery in Powys Adult Services
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A few facts about Powys

• Geographical area 210,271 acres (25 of Welsh
  Landmass)
• Number of sheep 1,000,000
• Number of residents 131,500 (4.4 of Welsh
  population)
• Equates to each resident having 1.6 acres of
  land and 7.6 sheep!

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The land of the three Shires

• Montgomeryshire
• Radnorshire
• Brecknockshire

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What we are famous for ?

•         The Red Kite
•         Elan Valley
•         Adelina Patti
•         A hiding place for Salman Rushdie
•         Adult protection work (Social Care
• Accolade 2005)

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What we are not famous for

•     
• Innovative social care services
• In adult services, people in Powys get help that
  is safe and caring, but may well prove
  insufficient to meet their needs services are
  not sufficiently focused on enabling users and
  carers to retain maximum independence and
  control Joint Review, February 2006

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• Historical decision making Reactive, rather than
  strategic
• Result A Hodge podge of disconnected services
  and processes
•  
• Future decision making Reflective and strategic
•  
• Result

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• A strong distinct coherent and accountable
  function of Powys County Council, in tune with
  citizens and communities needs, promoting
  social inclusion and the rights of individuals,
  concerned with outcomes and high quality support
  services that are provided in a joined up,
  flexible and efficient way in partnership with
  service users and carers, and where and when they
  are needed.
• WAG 2006

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Rising to the challenge changing a culture

• Defining outcomes?
• Outcomes refer the impacts or end results of
  services on a persons life. Outcomes-focussed
  services therefore aim to achieve the
  aspirations, goals and priorities identified by
  service users
• SCIE (2007)
•  

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The view of ACIN (2006)

• Outcomes a brilliant concept built on jelly
•  
• It was felt that there are probably 20 steps to
  get there and that there are challenges of
  defining outcomes on different levels and for
  each stakeholder, due to different expectations
  and concepts of effectiveness

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Experience from Ystradgynlais

• I dont want that reablement service again
  they expected me to do everything for my self,
  and at my age, I think I deserve to be looked
  after
•  
• She (the home carer) spends half of the time
  chatting to me I dont think she realises that
  under your Fairer Charging, I am paying for
  this service by the minute!

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Personalising Social Services in Powys

• 3 steps to heaven - A whole system approach to
  ensuring better outcomes
•  
•         Step 1 Getting and applying the
  national picture broad outcomes
•  
•         Step 2 Getting and applying the local
  picture shaping broad outcomes
•  
•         Step 3 Getting and applying the
  individual picture personal outcomes

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Step 1 Getting and applying the national picture
broad outcomes

•  
• Building a good life for older people in local
  communities (Godfrey et al 2004)
•  
•     Older people independence and well being
  (Audit Commission 2004)
•  
•     Caring for the Whole Person (Patmore and
  McNulty 2005)
•  
•      Time to care? (CSCI 2006)
•  
•      Promoting person centred care at the front
  line (Innes et al 2006)
•  
•     Outcomes focussed services for older people
  (SCIE 2007)

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Step 2 Getting and applying the local picture -
shaping broad outcomes

• Powys Service User and Carer Participation
  Strategy
•  
• Participation the apple pie concept that is
  often operationalised, before it is
  conceptualised (Sheppard 2001)
•  
• We need to clarify the benefits of
  participation (Burton 2006)

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Developmental benefits

•  Improved self esteem of participants
•  Increased self confidence and ability to take
  control over all aspects of life
•  Increased awareness and understanding of own
  real interests, and how they relate to the needs
  of others
• An opportunity for self expression

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Instrumental benefits

•  Wider range of views brought into decision
  making
•  Provides a useful reality check for policy
  makers
•  Political legitimacy and accountability to
  citizens
•  More effective services

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Principles and standards of participation

• Principle 1 Equality of opportunity and people
  focused
•  
• All service users, carers and support
  organisations have the right to participate.
•  
• 1.1 The Involvement Standard
• 1.2 The Equality Standard
• 1.3 The Diversity Standard
• 1.4 The Support Standard

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Principle 2 Openness and Integrity

• We will work in a person centred, clear, open
  and transparent way that promotes trust in Powys
  Social Services.
• 2.1 The Choice in Participation Standard
• 2.2 The Sharing Information Standard
• 2.3 The Feedback Standard
• 2.4 The Accountability Standard

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Principle 3 Valued Partnerships

• We value the knowledge and expertise of service
  users and carers, recognise that they are
  experts in their own experience, and want to
  work together with individuals, groups and
  support organisations to develop meaningful
  participation.
• 3.1 The Culture Standard
• 3.2 The Working Together Standard
• 3.3 The Working With Others Standard
• 3.4 The Improving Partnerships Standard

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Principle 4 Striving towards Excellence in
Planning and Evaluation

•  
• We are committed to always learning and
  improving
•  
• 4.1 The Comprehensiveness Standard
• 4.2 The Planning Standard
• 4.3 The Methods Standard
• 4.4 The Monitoring and Evaluation Standard

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Wheel of Participation
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• Information and Advocacy Service user and
  carers have access to clear, and comprehensive
  information and advocacy support to maximise
  their choice in decision-making, and are also
  involved in information design and delivery.
•  
• Joint Planning Service users and carers
  involved in the planning and development of
  services (including acting on evidence based
  national research on the views of service users
  and carers).
•  
•   Consultation Communicating with and
  listening to service users and carers views,
  including the provision of robust and
  consistent feedback
•  
• Evaluation and shaping Service users and
  carers involved in evaluation processes to ensure
  continuous service improvement.
•  
• Training Service users and carers trained
  to enhance their participation and also involved
  in staff training and development
•  
• Self-Direction Service users and carers in
  direct control of services, and able to access
  any support needed to achieve this.

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Evaluating participation the outcomes based
Logic Model
INPUTS
INPUTS
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Step 3 Getting and applying the individual
picture - personal outcomes

• The individual picture and the 4 Cs of local
  government
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• Culture of commissioning and contracting
• Culture of assessment and care management
• Culture of service provision
• Culture of performance management

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1. Culture of commissioning and contracting

• Barriers to outcomes focus
•  Lack of commitment to service user and carer
  participation
•  
•    Task based service specifications and
  contracts
•  
•    Purchaser/provider split
•  

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•    Lack of trust (of both service users and
  providers)
•  
•    Services seen as distinct and unrelated (e.g.
  reablement/ homecare or day service/carer respite
  service)
•  
•    Budget overspend
•  
•    Silo working different teams with different
  priorities (policy, contracts, operations,
  business support)

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Possible solutions being applied

•  Vision sharing across the Department
•  
•   Outcomes based service specifications (CSCI)
•  
•   Service user and carer involvement in shaping
  service specification outcomes  
•   Rethinking homecare - Whats in a name?
•   Home based support an integrated approach to
  service provision

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2. Culture of assessment and care management

• NHS and Community Care Act 1990 Needs led
  assessment and care management were to become
  the cornerstone of high quality care.

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Who defines need?

• Needs are the requirements of individuals to
  enable them to achieve, maintain or restore an
  acceptable level of social independence or
  quality of life as defined by the particular care
  agency or authority (SSI 1991p12)
•  
• Ultimately, having weighed the views of all
  parties including his/her own observation, the
  assessing practitioner is responsible for
  defining the users needs (SSI 1991 p53)
•  

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• Is it surprising that in a review of the
  implementation of the NHS and Community Care Act
  1990 after a decade of being implemented in
  Wales, Parry-Jones and Soulsby (2001) found that
  care managers
• were still rationing out a limited
  range of standard services ?

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Barriers to outcomes focus

• ?   Service driven referrals
• Mrs Jones needs assessment for the day
  centre
• Mr Smith needs assessment for meals on
  wheels
•  
• ?   Service focussed care plans with no room for
  preferences/values
•  
• ?   Under-developed networking and community
  development skills
•  

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• Lack of care manager awareness of the
• modernisation agenda
• Large case loads
•  
• Deficits based assessment tools

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Possible solutions being applied

• Regular policy briefings with area teams
• Terminating service led referral
• Assessor Nurses and CPNs in adult teams, and
  regular team meetings with DNs
• Training in
• Person centred assessment/care planning
• Community development/networking
• More patch based care managers (e.g. GP
  practices)

 
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• Strengths based assessment, taking into account
  
• preferences and values (e.g. quality time or
• smallest bill?)
• Outcomes focussed care plans
• Creative care planning within existing resources
  -
• applying Eligible need
• Outcomes focussed reviews
• Intelligent outcomes based evaluation and
• feedback to commissioning/contracts
  monitoring

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3. Culture of service provision

• Barriers to outcomes focus
•  Bland task based Service Delivery Plans
•  Provider risk assessors overriding
  Physiotherapists and OTs
•  
• Frontline staff who are
• Poorly qualified
• Poorly paid
• Poorly briefed
• Poorly trained
• Overworked

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• Lack of joined up working (e.g. with wardens and
  DNs)
• The need to refer back to care managers for
  everything

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Possible solutions being applied

• ?    More rigorous outcomes focussed service
• specifications
•  
• ?     Better service delivery plans (e.g.
  dementia day
• services)
•  
• ?     Positive Risk Taking Policy
•  
• ?      Joint working protocols with the LHB
•  
• ?      Vision sharing with provider managers
•   

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• Briefing processes for frontline staff on
• Personal outcomes
• Individual preferences
• other local contacts (e.g handyman)
• Joint training in person centred service
  provision (e.g dementia day service)
•  

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Exploring different approaches to delivery

• Making the best use of set time (Patmore)
• Direct Payments
• Supporting flexible working (that doesnt allow
  preferential treatment) Rhayader home support
• Allocating hours which can be banked (Oldham)
• Team working with patch based care managers
• Making better use of AT and careline (Durham)
• Integrated support (including rapid response)
• Opportunity to purchase extra hours for
  non-eligible need

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4. Culture of performance management

• Barriers to outcomes focus
•  
• PIs that measure quantity not quality
•  
• PIs that measure standard service delivery not
  creativity
•  
• Data inputting that takes up valuable care
  manager time
•  

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• Possible solutions being applied
•  
• Data inputting clerks
•  
• The work of CSCI and WAG?
•  
• The Four Countries Adult Care Information Network
  (ACIN)