Transforming the Delivery of Public Care through Commissioning Outcome Focused Services Transforming

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Transforming the Delivery of Public Care through
Commissioning Outcome Focused ServicesTransformi
ng Social Care and Outcomes 5th December 2008
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The market facilitation papers

• Papers on Market facilitation
• Papers on contracting both by commissioners and
  by service users.
• Paper on Outputs to Outcomes, based on the IPC
  project.

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The Transformation goal

• everyone who receives social care support,
  regardless of their level of need, in any
  setting, whether from statutory services, the
  third and community or private sector or by
  funding it themselves, will have choice and
  control over how that support is delivered.
• In the future, all individuals eligible for
  publicly-funded adult social care will have a
  personal budget (other than in circumstances
  where people require emergency access to
  provision) a clear, upfront allocation of
  funding to enable them to make informed choices
  about how best to meet their needs, including
  their broader health and well-being.
• LAC Circular 1 (2008) Transforming Social Care,
  Department of Health January 2008

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The Transformation goal

• The challenge will be to translate the vision
  into practical change on the ground to make a
  real difference to the way individuals engage
  with services and support and, in so doing, make
  a real difference to their lives. It will also
  mean changes in how professionals engage and work
  to support peoples needs. Personalisation is
  about whole system change, not about change at
  the margins.
• LAC Circular 1 (2008) Transforming Social Care,
  Department of Health January 2008

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But

• Personalisation must be delivered in a cost
  effective way. It is important to recognise that
  personalisation, early intervention and
  efficiency are not contradictory but will need to
  be more strongly aligned in the future.
• LAC Circular 1 (2008) Transforming Social Care,
  Department of Health January 2008
• In a civilised society, we have a moral
  obligation to ensure that people in need are not
  left without any care or support. The existing
  care and support system is not sustainable,
  because of the impact of changing demographics
  and expectations in our society.
• The Case for Change - Why England needs a new
  care and support system HM Government 2008

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But

• For working age people with physical and/or
  sensory impairments, IBs had positive effects on
  all dimensions of social care outcomes.
• Mixed outcomes were found for people with
  learning disabilities.
• Doubts and questions about the impact of IBs on
  older people.
• Glendinning, C., Challis, D., Fernandez, J.,
  Jacobs, S., Jones, K., Knapp, M., Manthorpe, J.,
  Moran, N., Netten, A., Stevens, M., Wilberforce,
  M. (2008) Evaluation of the Individual Budgets
  Pilot Programme Final Report, Social Policy
  Research Unit, University of York, York.

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But

• Concerns raised about an unregulated care labour
  market and about adult protection.
• Not much thought seems to have been given to how
  a reduction in the cash amounts of individual
  budgets or direct payments will be managed by the
  service user.
• The desire for choice may not be between service
  providers but between care workers, for example,
  who might wash and bathe me, or who will be my
  key worker in a care home.

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But

• Means testing a direct payment or individual
  budget will mean that some people receive a
  lesser amount than they need to spend. However,
  people may then be reluctant to top this up and
  consequently may not get what they need.

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Why change the national picture
In 2003-04 people aged 65 and over accounted for
approximately 43 of total expenditure
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Why change the national picture
Expenditure in 2003-04 for each age group,
expressed as a cost per head of the population.
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Why change the national picture
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Why change the South West

• The region has the highest proportion of people
  aged 65 and over and 85 and over.
• Over 65s represent 22 of the population.
• Over the next seventeen years proportion of the
  population aged over 65 will rise by 44 and
  those over 85 by 57.
• Increase in over 85s varies across the region
  from 21 in Bristol to 81 in S.Glosc.

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Why change the national picture

• 3 overall rise in the population with a learning
  disability likely to require services.
• Over 50s population with Downs Syndrome due to
  rise by 12 of which around 25 are likely to
  have a dementia.
• In 1991-95 at 25 weeks 30 of premature births
  survived. Between 1995-2000 that figure rose to
  almost 75.
• One quarter of all infants born at 25 weeks or
  less have a disability by the time they had
  reached their first birthday. This proportion has
  not improved over the years.

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What does this mean?

• Increased pressure on existing services year on
  year.
• Need for major reconfiguration of housing, health
  and social care provision.
• Major need to refocus from care and support onto
  targeting rehabilitative and reablement
  potential.
• Need for greater diversity amongst provider
  agencies and a lessening of restrictive
  practices, particularly in health.
• Much greater need for intelligence about the
  impact of activity.

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What do people expect from supportand care
services

• Support and care is seen as needing to encompass
  both practical help and social support.
• People do not want care to be restricted to their
  home, but to have support to do things
  themselves, eg being accompanied when shopping.
• Consistency of carer is usually identified as the
  most important element of a quality service.
• People look for reliability of visits, people
  arriving when expected, but that the actual care
  given can be flexible.
• Older people want support with practical domestic
  tasks, DIY, gardening, which have often been lost
  in the tightening of eligibility criteria.

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What do people expect from support and care
services

• Younger older people have expectations that their
  preferred patterns of bathing, hair washing etc,
  should be maintained by care services.
• While friends and family are important sources of
  support, people do not want to be a burden to
  them.
• People are positive about equipment and assistive
  technology and see this as offering real
  opportunities for them to stay in their own homes
  comfortably and safely. However, usage may be
  less than availability suggests.
• People do not want to move into a care home.

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Home care as a case for change

• Monitoring of contract arrangements is not always
  good and sometimes LAs may be paying for a
  service that is not delivered, sometimes they may
  be getting services they are not paying for. The
  system mitigates against carers who do that bit
  extra.
• Care planning and assessment can be too much of a
  straitjacket when the service needs to be
  flexible and responsive to immediate need.
• Incentives are perverse
• Past, and in many instances current, contracting
  process may mean we dont use the knowledge that
  home care agencies have to their fullest
  potential.

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Home care as a case for change

• Home care services rarely have a rehabilitative
  focus and dont / cant always cater for the
  important issues that can effect peoples quality
  of life.
• In some instances the system is undermined by
  service users feeling grateful for what they
  receive and limiting their demands. This can be
  expressed through service users and carers being
  told there are strong cash limits to provision or
  through being told by care providers how short of
  staff they are.
• The current plethora of services does not make it
  easy to deliver cross cutting outcomes.

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Summary

• We know that social care needs to change for both
  positive and negative reasons.
• That what we have provided in the past is not
  necessarily what people ay they want.
• That the amount of money per head of population
  available for health and care services will
  diminish.
• Some service provision focuses too much on
  outputs rather than outcomes.
• Some services have perverse incentives.

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Conclusions

• That just changing the fiscal means of who pays
  will not necessarily drive the change needed.
• That transformation needs to shift thinking away
  from problem service via state funding.
• That we need to focus more on recovery and
  reablement in older people and less on care and
  support through focusing on what outcomes can be
  achieved rather than what outputs are delivered.

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Defining outcomes

• Much mentioned little defined
• Strategic goals phrased in terms of outcomes
  however most strategies and plans rapidly revert
  to outputs and processes.
• Measures invariably revert to provision of
  services as proxy indicators.
• In particular the currency of care remains as a
  payment for a volume of service where the test is
  was the service delivered and delivered to an
  agreed standard rather than did it achieve the
  desired goal.

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Different types of objectives and measures

• Outcomes The result or impact of a service on
  service users and/or on the population as a
  whole.
• Outputs The nature, type and volume of service
  required to deliver the outcomes.
• Processes The activities we put in place and
  the order in which they are implemented so that
  the outputs can be achieved.

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Examples of strategic outcomes

• More people with dementia living in their own
  homes to death.
• Fewer older people who have had one stroke
  suffering from further strokes.
• Fewer people coming into care homes through carer
  breakdown.
• 50 of service users with a mobility problem at
  assessment have improved mobility six months
  later.

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Examples of outputs and processes

• We will develop a new specialist dementia
  focussed home care service.
• We will integrate our home care and supporting
  people commissioning by 2009.
• We will identify key carer populations that are
  at risk through doubling our number of carer
  assessments

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Examples of individual outcomes or goals

• Able to walk at least two hundred yards further
  at the end of the year than could at the start.
• Able to meet with old friends at least once a
  fortnight.
• Able to have garden maintained to an acceptable
  standard and contribute to keeping it tidy.
• Able to choose to have a particular care worker
  to wash and bathe me.
• Able to go to bed when I choose and at different
  times each day.

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The test

• Can we
• Define the outcomes we want to achieve, then
  define and measure services by their potentiality
  to achieve those end results and marry these with
  individual aspirations.
• Give commissioners an improved knowledge of what
  outcomes might be achievable.
• Persuade providers to move away from providing
  services to a role of resolving problems.
• Offer providers incentives for doing better than
  the agreed outcomes, and disincentives if they
  dont.
• Persuade service users that the guarantee is not
  a pre-determined volume of service.

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The ultimate challenge

• To develop a currency for care based on the
  results or outcomes it can achieve rather than
  defined by the nature of its inputs.
• This in turn should encourage providers to focus
  on doing what it takes to achieve an end result.
• Which should lead to a service based on the
  things we aspire to rather than based on a
  compromise we might need to accept.