Adult Social CareCommissioning Priorities

Steven FalveySenior Commissioner

December 2015

• Support people to live their life as fully and independently as possible.

• Offer clear and helpful advice when people need it and linked up to health advice and information.

• Know where to come in ASC and health if in need of support. 

Our overall purpose is to:

• Good ASC supports people through unplanned life events and back into their independent life. We address mental wellbeing as well as physical health.

• We support carers in their caring role and recognise the importance of people's relationships and families.

• If people need care and support it is personalised and promotes health and wellbeing.

• The care we offer feels good even if someone's life is difficult at that time.

What is good ASC?

Prevention – Promoting health and wellbeing and managing avoidable demand. Good advice and information. Public Health and wider public services have a important role here.Personalisation - For the customers that means flexibility, choice and control. Recognising carers and family relationships.Integration - Joining up with health and with housing where it makes a better service for our customers. Localised services - Using the local community and its resources and networks to support people.

The top four principles that apply to all service areas of our department:

ASC Principles

Customer journey is the journey customers make when they come to us for different needs and reasons. All customers are unique and people need different things at different times in their life. ASC is there for people when they need it but avoids creating dependency.

People have told us they want a life not a service. Good advice and information is key to supporting people as early on as possible. • All journeys have stages and milestones.

What is the customer journey all about

We are now embarking on a programme to transform our current model of care . This will see us shift resources “left” into effective prevention and intervention so that we can focus more heavily on keeping people safe and well. This model means that we will deliver robust and efficient services in adult social care at the same time as furthering our relationships with our healthcare partners. In order to align with and enable the new ASC model of care, we will realign our commissioning priorities in a similar way.

The Customer Journey

Front Door

Short term support

Complex Care

First Milestone Starts The JourneyFront door for all customers giving advice and Information/self assessment for eligibility links to NHS advice and information Self assessment for those who want it Direct payments and personal budgets for those who want it

Third Milestone Short Term Support delivered in partnership with health and free of charge including:

Rapid response Reablement Hospital Inreach Community independence service Seven day services Single assessment with housing for some

Final MilestoneComplex and long term Care includes Cost effective and enabling support, continuity of care and efficient and effective reviewsJoined up with GPs if people have long term conditions or with multi professional teams if people have a disability

• Increasing demand/reducing budgets• Increasing workload/decreasing capacity• Greater responsibilities on ASC departments (Care Act/Better Care Fund) –

increased responsibility for well-being/self-funders/carers• Greater expectations from citizens (and providers)• Personalisation• Increasing expectations around quality• Devolution of control – Manchester model, health integration agenda,

localised services• Living Wage/Zero Hours Contracts/Workforce Development issues• Changing political landscape – nationally and locally• Strong policy direction towards greater integration with health

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National context

• Savings (£11m) were delivered through Tri-borough and continue to be delivered every year by Tri-borough and the sharing of services. We have also delivered £40m budget reductions.

• We are all doing a lot more with a lot less people and money and we have to continue to do so.

• We have £45m savings to deliver over the next three years. This is our new normal. Local Government will not go back to where it was.

• Political commitment to ‘triborough’ is less firm than it was – we are now three boroughs

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Three Boroughs context

The department has been through some very challenging time during the creation of a triborough shared commissioning and contracting function. This uncertainty is not over and there is clear anxiety around the forthcoming restructure. The recent peer review identified a number of challenges and opportunities, particularly around commissioning and contracting:

• There has been a notable tunrover in staff during the transition to tri-borough. This has meant both a loss of skills and knowledge and a loss of capacity which now needs to be addressed.

• There has been a lack of clarity about the overall strategy and direction for adult social care. This has had the impact of a lack of clarity around commissioning priorities and intentions.

• There has been a lack of clarity around roles and responsibilities. Different boroughs interpret the same roles, functions and terms in a different way in practice. Now that staff have been brought together into a single structure, work needs to be done to ensure we are using a common language.

• Focus has understandably been inward looking – we have been concerned with how we as a department are structured and operate to the detriment of some basic housekeeping. For example, we are lacking a clear and consistently understood pathway and process for the brokerage and placements service. We are also lacking clear and consistent business processes to ensure contractual compliance.

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Commissioning and Contracting context (1)

• Lack of capacity and focus on structural challenges has meant that we have not focussed on innovation and progression. Some services are currently quite traditional and we have no clear plan or vision for how and when we will transform these services.

• Similarly, both commissioning and contracting are currently operating in a very traditional, silo-ed manner. Opportunities for more integrated, seamless and innovative services have not been capitalised on. This has a knock on effect of not allowing the realisation of efficiencies through new models of contracting, commissioning and care.

• Our efficiency plan is unachievable in many areas and takes an out of date ‘salami-slicing’ approach to services.

• Staff are not working in a multi-skilled, collaborative fashion. Opportunities for learning and development and sharing of good practice and skills is being missed because of this. It also exacerbates our capacity issues.

• The scale of the task seems overwhelming at the moment. By trying to manage the existing workload of three separate boroughs with significantly less staff in the same way it was managed when under separate commissioning teams we are dooming ourselves to fail. We need to work smarter, not harder.

All these challenges need to be addressed, but the priority is for Commissioning and Contracts to come up with a clear statement of purpose and a clear strategy that supports the newly articulated vision for One Adult Services.

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Commissioning and Contracting context (2)

• After many years of developing the commissioning and contracting model across the three boroughs, our next task is to review and revise our future commissioning intentions and prioirities to align with the emerging One Adult Social Care vision and the new operating model for One Adult Social Care (known as the Customer Journey.)

• The Customer Journey can be described in three stages, and sets out how people will interact with us, recognising that everyones journey is unique.

• Our commissioning intentions also need to take into account the four underpinning principles that will be embedded into everything that One Adult Social Care does.

The Customer Journey

• Commissioning and contracting are here to:• Support, enable and deliver good quality services which meet the

identified needs of the population• Our role is to work with operations to identify the types of services

which will meet need, deliver good outcomes and improve the lives of people who need support

• We have the challenging job of developing new models of care and ensuring that existing services are of good quality within a decreasing financial envelope

What is our purpose?

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Our commissioning vision is:

• We will support and enable the right services, in the right locations for the right cost. We will work with the people of the three boroughs to design and develop locally lead, locally delivred services wherever possible, and we will be innovative and bold in developing new models of care and support. We will work with our providers and partners to design and deliver care in a true partnership model, and will encourage proivder and user led model fo care wherever they are appropriate.

A number of overarching principles, some shared across health and social care, underpin both the vision for adult services and the vision for commisisoning.

• People will be empowered to direct their own care and support• GPs will be at the centre of organising and co-ordinating people’s care• Our system will enable and not hinder the provision of integrated care• Care and support will be co-ordinated around the individual• We will improve outcomes• We will improve people’s experience of care• We will maximise independence• We will avoid unnecessary hospital admissions and support people to regain independence through proactive and

joined up care

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Example of a vision for adult social care commissioning and contracting?

ASC commissioning prioritiesIn order to align with and enable the new ASC model of care, we will realign our commissioning priorities in a similar way. This means ‘grouping our existing and future services into four distinct blocks of care. These are set out below with some intial suggestions as to what types of services will be included in each block

Front door Short term support

Complex care - Community

Priority 1 will be the scoping, options appraisal and development of a new ‘front facing’ service. We call this ‘bundle’ of services ‘front door’, however, it will cover a wide range of other existing services including signposting, information and advice, and will explore the development of new services to give people the information they need at the earliest point they need it and empowering people to direct their own care and support.

Priority 3a will be the design and development of a new model of care to deliver community services. There are a wide range of community services offering care and support, however some of these services are both traditional and expensive, for example, buildings based day services. In order to support national policy (Putting People First, Care Act, Better Care Fund) and as supported by the recent peer review, ASC has a clear strategic aim to increase the number of people using direct payments and people who have an individual budget. This strand of work will undertake a scoping exercise and options appraisal to identify new models of care that are more personalised, less buidling based and facilitate the use of direct payments and individual budgets wherever possible.

Priority 2 will be the evaluation, review and further development of integrated enablement. We have made an excellent start with integrated enablement with the development of a Community Independence Service. However, this service now needs to be evaluated and the model amended if necessary. We also believe that the model can be further developed and extended to conver a wider range of services with the aim of developing a comprehensive and integrated service. This service will support the strategic aim of keeping people well in their own communities for longer and supporting people to remain independent for as long as it is safe and appropriate.

Priority 3b will be the design and development of a new coherent care pathway and models of care to support people needing accommodation based services. National policy (Putting People First, Care Act, Better Care Fund) is clear that wherever possible people should be supported to remain in their own homes and communities as long as it is safe and appropriate. However, there will always be a need for a range of accommodation based care and support solutions. At present, the three boroughs offer a limited range of very traditional accomodation based model of care (residential homes, nursing placements, limited extra care housing). There is also a lack of coherent care pathway allowing for increasing or decreasing needs to be met in a variety of settings.

Complex care - accommodation

based

1 2 3a 3b

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Ways of working

• We have 40% less staff, but kept 100% of the workload – this is not sustainable. We must commission and contract differently. Some commissioning principles for the future:

• Focus on larger, more comprehensive contracts which cover a wider range of services – how do we do this and retain a commitment to localism?

• More trust and partnership with our providers – we will need to allow providers a greater degree of autonomy to deliver services, and a higher degree of self assessment and monitoring (providers as assessors and reviewers & providers as self monitors)

• Less focus on smaller contracts, and the workload that goes with that; more focus on committing staff time to larger, more strategic contracts

• Be open to different models of delivery – these should be appropriate to the outcomes we want to achieve

• More focus on quality – including quality development, not just quality monitoring• More flexible, multi-skilled approach to areas of work – we need to work collaboratively

amongst ourselves and with operations

Commissioning priority 1 – Front Door

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Priority 1 will be the scoping, options appraisal and development of a new ‘front facing’ service. We call this ‘bundle’ of services Front Door, however, as set out below it covers a wide range of other existing services and will explore the development of new services to support the aim of giving people the information they need at the earliest point they need it and empowering people to direct their own care and support.

Front Door

• Options appraisal and scoping exercise to identify existing contracts, spend and providers delivering S,I & A.• Development of a single, consolidated model to deliver front facing services.• The model is likely to include a range of existing services such as:

• Advocacy• Information, advice and signposting• Supported self-assessment• Carers assessment and services• Peer support• Self-care and self-management• Community navigators• Empolyment support and advice• Direct payments and individual budget support, advice and management• Befriending and social isolation

• The options appraisal will also consider whether some existing services that require a full assessment to access can be shifted to the front door. For example, this may include the provision of community equipement, access to telecare and telehealth or the ability for existing packages of care to increased or decreased within a tolerance without the need for input from a social worker.

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Priority 2 will be the evaluation, review and further development of integrated enablement. We have made an excellent strart at integrated enablement with the development of a Community Independence Services However, this service now needs to be evaluated and the model amended if necessary. We also believe that the model can be further developed and extended to conver a wider range of services with the aim of developing a comprehensive and integrated service which supports the strategic aim of keeping people will in their own communities for longer and supporting people to remain independent for as long as it is safe and appropriate.

Integrated enablement

• Evaluation and review of CIS• Further development of a single, integrated model to deliver enablement services.• The model is likely to include a range of existing services such as:

• Reablement• Rehab and physio• Telecare and telehealth/other assitive technologies• Community alarms• Proactive and enhanced case management (aligned to risk stratification of populations for WSIC)• A clear care pathway with referrals to allow for referral from a wider range of agencies, including GPS,

hospital, self referral for existing customers• Falls support

• The evaluation will also consider whether other health services can and should be included in the model.

Commissioning priority 2 – Integrated enablement

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Priority 3a will be the design and development of a new model of care to deliver community services. There is a wide range and diversity of community services offering care and support. Some of these services are both traditional and expensive, for example, buildings based day services. In order to support national policy (Putting People First, Care Act, Better Care Fund) and as supported by the recent peer review, ASC has a clear strategic aim to increase the number of people using direct payments and people who have an individual budget. This strand of work will undertake a scoping exercise and options appraisal to identify new models of care that are more personalised, less buidling based and facilitate the use of direct payments and individual budgets wherever possible.

Support planning

• Evaluation and review of existing spend and contracts for community services• Further development of an options appraisal to identify new models of care to deliver more coherent and consistent

community services.• The model is likely to include a range of existing services such as:

• Day services (buidling based)• Day opportunities• Employment support• New models of respite• Short breaks• Individual budget and direct payment support and management• Carers services• Outreach and peer support• Befriending and floating support• Community hubs

• The evaluation will also consider whether other/existing health services can and should be included in the model.

Commissioning priority 3a – Complex care, community services

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Priority 3b will be the design and development of a new coherent care pathway and models of care to support people needing accommodation based services. National policy (Putting People First, Care Act, Better Care Fund) is clear that wherever possible people should be supported to remain in their own homes and communities as long as it is safe and appropriate. However, there will always be a need for a range of accommodation based care and support solutions. At present, the three boroughs offer a limited range of very traditional accomodation based model of care (residential homes, nursing placements, limited extra care housing). There is also a lack of coherent care pathway allowing for increasing or decreasing needs to be met in a variety of settings.

Support planning

• Evaluation and review of existing spend and contracts for accommodation based services• Further development of an options appraisal to identify new models of care to deliver more coherent and consistent accommodation

based services.• Desing and development of accommodation based care pathway(s). This is likely to include options to support short term and long term

accommodation based needs, needs across all care groups and to support the aim of decreasing the use of residential care over time.• The model is likely to include a range of existing services such as:

• Residential homes• Nursing homes• Respite placements• Extra care housing• Bed based reablement

• The options appraisal will also consider how new models of accommodation based care can be developed. This might include:• Discharge to asesses beds• Assessment and support units to support transitions and repatriation of out of area placements• Supported living• Shared lives

• The options appraisal will also consider opportunities for more integrated services/ jointly commissioned services with health.

Commissioning priority 3b – Accommodation based services

2017/18-18/19

Our approach to transforming commissioning

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Phase 2: Developing new models of care to support

priorities and new operating model

Phase 1: consolidation (our work so far)

Phase 3: Delivering new models of care and efficiencies

• Define a clear vision that supports the identified priorities for adult social care

• Revise and agree an efficiency plan and timescales

• Restructure of department to align with new operating model

• Stocktake of existing contracts and spend

• Agree demand profile• Develop commissioning

intentions aligned to new structre and operating model

• Define and agree new models of care aligned to new operating model

• Develop project plans and full commissioning strategy for new models of care

£45m savings (£39.8m recurring to 2015, £16.2m savings in 15/16)

• Commissioning project teams for new models of care agreed and in place (to include operational, procurement, finance and L&D)

• Revised departmental structure in place

• Agreement to new models of care at political, management and operational levels

• Options appraisal for less well defined commissioning model

• Detailed design for more well defined models

• Identification and testing of savings assumptions attached to new models of care

• Co-production with market, providers, VCS, health partners and service users

Savings identified as part of this work

• Implementation of best developed new models of care

• Detailed design of less well developed new models of care

• Testing and review of new models of care, including co-production methods of feedback

• Further market development with providers

• Development of more integrated models of care for next phase with health (link to BCF).

Initial savings projections will be identified following discussion about the direction of travel

2015/16 2016/17-17/18

Next steps

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This document has been prepared to initiate a discussion about the future direction of adult social care commissioning and contracting. It has also been prepared to provide important context to the budget setting process and to inform the debate we need to have with healthcare commissioners and providers locally about the value that adult social care and local government can add operating in a whole care context.

Key steps in the process include:

• Engagement with the Cabinet Member for Adults and Public Health

• Engagement with senior managers in the department and with our partners

• Initial testing of budget requirements for the remainder of 15/16 and 16/17

• Developing outline budget requirements for the ASC service to 2018/19 (to be developed further)

• Engagement with partners, including health commissioners and the provider market locally.