Joint Improvement

Partnership South East

South East Joint Improvement Partnership (JIP)

Financial Sustainability March 2011

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Contents Page

Executive Summary

SECTION ONE Introduction Report structure Project scope and approach

SECTION TWO Strategic Context and Literature Review

SECTION THREE Developing Practice

SECTION FOUR Conclusion and recommendations Resources and Additional Sources of Information Appendices

• Appendix one – Contributors

• Appendix two – Request for Information – Combined analysis

• Appendix three – References

• Appendix four – Case studies

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Executive Summary

Overview This report is the outcome of a project within the South East Region’s Joint Improvement Partnership (JIP) work programme. It has been produced by the JIP Manager in association with the SE ADASS Finance Leads Committee. The report:

• sets out the strategic and policy context for financial sustainability

• highlights some key issues that should be taken into account

• summarises the main findings from field work undertaken with local authorities in the region

• presents a number of examples that illustrate developing practice within the region and elsewhere

• points to sources of additional information

• identifies some areas for further consideration and development.

Despite a major programme of change to implement personalisation over the past three years, there continues to be a lack of robust evidence about the financial impact of the changes. Equally, there is little evidence that the changes have made a substantial difference to Adult Social Care budgets either way, and in particular, that they have not been the cause of additional financial pressure, other than the costs associated with making the transition from one system to another. It is of concern that the anticipated efficiencies from a more simple care pathway do not yet appear to have been achieved in many cases. Key Findings The key findings from research carried out with the participating local authorities are as follows: Understanding service costs It is important to understand costs at an individual and strategic level, and that as much of the budget available to FACS eligible service users as possible is devolved to individuals via personal budgets. This should help to address issues of inequality of allocation of resources, both within and between groups of people who use services, and double funding where under-utilised in-house services and block contracts exist. This should be addressed through strategic financial planning, and also links to the commissioning cycle. It is of concern that many authorities were unable to provide information on the total cost of extra care housing. This was both the case in unitary and two-tier authority areas. This may be for a variety of reasons, including recording systems and working relationships with housing departments.

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It was also not possible to access information to be able to compare people with the same needs in different care settings. It is, however, suggested that authorities make these comparisons themselves, comparing how much it would cost to support someone with the same needs in each of the settings. Further work could also be undertaken to collate and analyse that information at a regional level if it becomes available. IT, monitoring and Resource Allocation Systems The majority of authorities that responded in the South East did not make reference to the monitoring of personal budget costs. There is still a lack of robust evidence that personalisation, and especially self-directed support and personal budgets, can result in efficiency savings. This may be because systems for monitoring the longer-term impact of personalisation are relatively underdeveloped. Authorities are still reporting that their IT systems do not support personalisation, and therefore this is something that should be further investigated. Improvement and Efficiency South East (IESE) are involved in the National Information Framework for Adult Care Services, which will build on work already undertaken to deliver simple practical guidance on the key system and data requirements. This work in due to end in March 2011. To find out more about these, see Section four of this report on Resources and Additional Sources of Information. In addition, a lot of authorities reported that there is still a lot of work to do in further developing their RAS, particularly for Mental Health. This should be linked to financial planning, recalibrated over time and informed by developments in the market. There is a SE RAS Technical Working Group which meets quarterly to discuss these issues. There is also upcoming guidance currently under development on implementing SDS in Adult Mental Health, which will contain a section on the RAS. To find out more about these, see Section four of this report on Resources and Additional Sources of Information. Further care pathway efficiencies Business processes and supporting systems offer one of the best opportunities for making savings through personalisation, and it is clear that more can be done to create further efficiencies from the care pathway. This might include outsourcing parts of the process. In particular, authorities need to look for more efficient ways of managing direct payments and assessment times. Integrated working across departments and sectors, to pool resources and reduce duplication and handoffs, can help deliver efficiencies. Although this was referenced in relation to prevention and reablement services, this seems relatively underdeveloped. Proactive review Information collected via the TASC key milestones suggests that authorities in the South East are now offering personal budgets to people at their reviews. However, there is little evidence from the data returns to suggest that people with existing packages of care are being offered authentic personal budgets

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(i.e. the RAS is being applied, and if appropriate, a new support plan is being developed) at review stage unless there is a change in need. Although anecdotally, it is acknowledged that this is being practiced in some areas, it was only mentioned by one of the authorities completing the return, and it is not known whether, or indeed how, they have tackled the issue of applying their resource allocation policy to those situations where there is little or no change in need.. There is some evidence that work is being done to look at high cost placements. In some places, authorities are reviewing their charging policies, eligibility criteria and financial assessment processes. It is suggested that more could be done to look at reviewing historical packages of care and ‘claw back’ for under spent personal budgets. Financial Controls There were quite a lot of references to financial controls being in place to help manage budget pressures. In particular, both funding panels and building in efficiencies using the RAS were cited. This is of concern, as there still seems to be a lot of focus on authorities maintaining control in this way, rather than acting in a facilitative role to help the culture to change. Market development and commissioning The development of both existing and new services was cited by most authorities as important to achieving financial sustainability. This includes reducing spend on long-term residential care to allow for investment in other areas, such as prevention and early intervention. Whole Systems Approach Finally, the findings from both the literature review and Request for Information show that each part of the care pathway needs to be taken into account to help address financial sustainability. Areas for Further Consideration and Development A number of areas of further consideration and development are as follows:

1. Further fieldwork to investigate some of the areas of data gathered would be interesting. In particular, it would be useful to seek additional data for those questions that did not receive an adequate response to be able to draw conclusions. It would also be useful to collect additional examples of good practice, as mentioned above.

2. Additional work should be undertaken to understand the costs of delivering different models of support, in particular Support Related Housing.

3. More needs to be done to understand how Local authorities are recording and monitoring the impact of implementing Personalisation. This includes which system(s) are being used and how these are being applied, and should be referenced with the work on the National Information Framework for Adult Care Services. It is suggested that, if they haven’t already, authorities should undertake their own financial

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evaluation of the impact of implementing personal budgets. It would also be useful to have sight of any financial evaluations completed within the region, the findings from which could be collated and shared.

4. Further work could be undertaken to understand the approaches Local authorities are taking to financial planning and modeling, and what key areas are being taken into account.

5. As recommended in the original PID, it would be useful to investigate how Local authorities can maintain financial and budgetary control, and address the full range of costs that may be associated with Personalisation. This includes individuals who over or under spend their budget, the option to claw-back under spend, potential changes to budgets at review and the frequency of review. It will also consider any additional costs, such as the increase in take up and costs relating to supporting self-funders. This could be established initially through the ADASS Finance Leads Committee.

6. Further work could be considered around the impact of prevention and early intervention on financial sustainability, although it is anticipated that more work may also be undertaken on this nationally.

7. Further work could be undertaken to establish whether there is a discernable difference (increase or decrease) between commissioning costs in light of transformation, with a comparison between traditional commissioning practice and commissioning practice under a transformed system. This could look at cost implications of different forms of commissioning activity including the use of brokerage.

8. Given some of the outstanding issues regarding process inefficiencies, it may be considered whether a more robust care pathway analysis should be undertaken in the future, across local authorities.

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Section one

1. Introduction

This report on financial sustainability forms part of the South East Region’s Joint Improvement Partnership (JIP) agreed work programme for supporting delivery of transforming adult social care (TASC). In 2010, the SE ADASS Finance Leads Committee raised concerns that there were potentially some ‘hidden’ costs relating to Transformation and the project was identified as an area that Local authorities would welcome regional level support for. The project focuses on the need to examine opportunities for financial sustainability particularly within the context of increasingly constrained budgets, demographic pressures and funding uncertainty. Individual Budget pilots and early implementation of Transforming Adult Social Care has provided some supporting evidence that personalisation can be implemented without additional cost. However there is little evidence to support Transformation’s financial sustainability in the context of increasing demand and constrained budgets. Furthermore, the economic climate along with the demographic context have been identified as a long-term risk to the full and successful implementation of Transforming Adult Social Care by ADASS, and requires further exploration at a regional level In November 2010, the refresh of Putting People First (PPF), Think Local, Act Personal was launched, which was then confirmed in January 2011. This partnership agreement sets out areas where further action is required to transform adult social care services whilst taking into account the financial context. In addition, a number of other papers have recently been published addressing the issue of personalisation and efficiency, including ADASS’s How to make the best use of reducing resources: a whole system approach. This encourages Directors to review the opportunities presented to see if they are using their resources in the most effective way. Section two further explores the key messages from the most relevant publications.

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2. Report Structure

The report is structured in the following way:

• Project Scope and Methodology - A short overview of the key areas of the project and on how it was carried out.

• Strategic Context and Literature Review - The issues and implications for financial sustainability made as part of The Vision for Adult Social Care, Think Local, Act Personal and other publications.

• Developing Practice - including examples from the region.

• Conclusion and recommendations - Setting out key themes from the work and highlighting areas for further development and consideration

• Useful resources and sources of further information

• Appendices

3. Project Scope and Approach

Scope

This project aimed to ensure a regional dialogue over the issues of financial sustainability and enable Local authorities to prioritise financial sustainability activity. The objectives of this piece of work were as follows:

• There is greater clarity over the financial implications, benefits and costs relating to delivering Adult Social Care within the principles of personalisation and transformation.

• Local authorities are enabled to make informed decisions relating to process re-design to implement transformation.

The first element of the project was to undertake an analysis of financial models and service delivery costs in the light of TASC, with the aim to ensure any savings, and potential hidden or increased costs, as a result of transformation are transparent. This looked at a comparison between the costs of delivering services through traditional methods and through personal budgets. Detailed financial modeling information was not requested, as this was felt to not be available. A review of gross actual spend by councils on different types of service and client group was requested, although many councils fed back that their recording systems restricted the information they could provide, and therefore responses were limited. Please note that information about nursing costs was not collected as part of this exercise. The second element of the project was to look at the most effective and streamline means of developing processes to transform Adult Social Care – in particular the core operating model. Transformation is being implemented in a range of ways across the region, but it is common across all local authorities that a degree of process re-engineering is taking place to incorporate new activities such as calculating personal budgets.

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Detailed work relating to Resource Allocation Systems (RAS), prevention, market development and IT systems were not addressed as part of this project as they were being addressed by other projects, both within the region and nationally. In addition, it was decided not to investigate charging policies, and therefore, council’s were asked to provide information on gross costs.

Approach The primary approach for this project was to draw on existing information, data and knowledge, and through a consensus with the relevant finance leads, draw conclusions relating to recommendations and future steps needed. The scope was developed by ADASS Finance Leads Committee with representation from SE region local authorities. Details of contributors are given at Appendix one. A Request for Information (RfI) was developed and agreed by the ADASS Finance Leads Committee. This was then submitted to authorities for completion, via Finance Leads and Directors. The RfI was completed by 11 out of 19 SE region local authorities. A further return was received towards the end of the project, and therefore was not included in the data analysis. The RfI can be found, populated with the combined analysis from the returns, in Appendix two. A literature review was then undertaken of the key policies and publications (Section two), the references for which can be found in Appendix three. It is worth noting that additional, relevant documents have been published during the course of the project, and these have been included. The RfI was analysed to draw out key issues, findings and developing practice. The analysis can be found in Section three of this report. Finally, the RfI findings were compared with the key messages from the literature review to draw conclusions and make recommendations about the direction of travel in the SE region for financial sustainability. These can be found in Section four.

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Section two 4. Strategic Context and Literature Review

The following publications set the strategic context within which this report has been written. A number of strategies are currently being implemented, all of which emphasise the importance of efficiency and productivity to enable sustainability. Relevant extracts from these strategies are shown below. An important caveat is that these are subject to change and development as the Coalition Government sets its vision and direction for health and social care reform and in other related areas of public policy. A Vision for Adult Social Care The vision states that “the Spending Review settlement gives local authorities the resources they need to maintain vital services and meet growing demands”. However, there is an expectation that councils can make this money go further, “redouble their efforts”, and that “efficiencies can be achieved through a joined-up approach between social care, housing, employment and other sectors”. The vision sets out “a framework that councils should use when looking at delivering efficiencies and getting value for money from social care without reducing services”. This includes:

• “Helping people to stay independent for as long as possible”

• “Reducing spending on long term residential care for reinvestment in other services”, and

• “Maximising spend on front-line services”. There is an expectation that councils will review and potentially “reduce the proportion of spending on residential”, nursing and in-house services through improvements to community-based provision, such as extra care and supported housing, as these “can provide better outcomes at lower costs”. In order to divulge as much of the power to individuals as possible, “We want people to have the freedom to choose the services that are right for them from a vibrant plural market. That is why this vision challenges councils to provide personal budgets, preferably as direct payments, to everyone eligible within the next two years.” Telecare provides the “potential to save resources as well as promote independence”, although “Robust evidence on how to target telecare and telehealth to ensure both cost-effectiveness and successful outcomes is lacking”. “Councils must examine how they use their resources and reform their services to ensure the very best quality outcomes for those who need social care”. This will require “rigorous prioritising of expenditure”, and “minimise spend on back office administration and replace poor value services”.

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“It is vital that councils deliver lasting reforms and redesign their services to deliver efficiencies and transform how social care is delivered”. This includes a thorough review of “unnecessary processes”. Councils are expected “to show that they have reduced unnecessary management costs in their assessment and care management processes and redirected it to funding more care and support”. Think Local, Act Personal (Putting People First) The Partnership Agreement, published in November 2010 and finalised in January 2011, outlines next steps that local authorities should take for Transforming Adult Social Care, taking into account, “The current financial context and consequent reductions in public expenditure”. Emphasis is placed upon, “efficient, effective and integrated service delivery alongside partnership working to support the contribution of individuals, their families, carers and the wider community – reducing the need for acute health and care support”. Following on from Putting People First (PPF), there continues to be a focus on prevention and early intervention, “shifting of resources from crisis and acute interventions”. “The most significant efficiencies are likely to come through reducing people’s reliance on paid support and changing the way that support is provided.” Councils should support people “to make the best use of their own resources to support their independence and reduce their need for long-term care”, and “helping individuals to secure support more efficiently than through councils (or the NHS)”. Community-based services, co-design and delivery and partnership working are all enablers for maintaining and improving service delivery within the current financial envelope. This includes a robust review of “processes, systems and resources to avoid duplication”. Finally, “At an individual level, choice, control and greater efficiency will be achieved when workers in social care are able to help people decide and pursue their goals and stay connected to their community”. Use of Resources in Adult Social Care This guide for local authorities, published in October 2009, explores the key issues for delivering improved outcomes in a more cost-effective way. The key message is that financial sustainability will only be achieved through whole system reform. The report states that increasing demand for Adults Social Care should be managed by reducing the number of people needing ongoing services, through targeted prevention and early intervention. More flexible approaches to procurement and commissioning should be introduced to help to “develop more cost-effective interventions”. There should be changes to in house services and a move away from block contracts to help to reduce double running costs. In addition, resources should be shifted from

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supporting traditional models of delivery, such as residential and nursing, to community based provision. Increasing use of mainstream (universal) services should also be encouraged, including leisure and transport. Business processes should be streamlined; in particular assessment and care management, and external capacity should be sought for support planning. In addition, there should be further investment in information and advice. The report also raises a lot of questions about how money is spent and whether this achieves good value and improved outcomes. Finally, there are a series of best practice case studies and references to useful information sources throughout the document. Financial Management of Personal Budgets This Audit Commission document describes the challenges and opportunities for councils of introducing personal budgets. In describing the commissioning implications, it states, “Personal Budgets are unlikely to result in significant cost savings for councils. Self-directed support can lead to savings in cases where councils have high-cost care packages resulting from poor commissioning”. It goes on to recommend that block contracts and in-house services should be reviewed. Medium term financial planning should be undertaken to “show the likely demand and costs of personal budgets and the implications for future budgets”. It also states “the resource allocation system (RAS) needs to be affordable”, and that “The RAS and agreed support plans must result in sustainable, affordable allocations and not over-commit the council”. In the research undertaken as part of this report, some participants “forecast small savings [from personal budgets] but none expected savings to be significant”. In addition, there was “no consensus about whether assessment and care management would be more or less costly”. Savings were thought to be been possible through better commissioning, and that “it was the introduction of personal budgets that challenged previous arrangements and costs”. Finance Systems and Putting People First This document explores some of the requirements for finance and IT systems under Putting People First. It states that councils should use IT systems to enable them “to effectively manage use of resource under the Putting People First Framework (e.g. tracking shift to prevention/early intervention and associated efficiency gains)”. “PPF encourages councils to shift resources to early intervention and prevention, with the aim that many more people are helped to recover their independence”.

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Making RAS work in a Financial Environment This document offers practical suggestions and good practice for Resource Allocation Systems, including how finances should be allocated for existing service users. The report states “whichever method is chosen it should continue to offer an upfront indicative financial resource, whilst enabling councils to manage budgets, gain financial stability and maintain long-term sustainability. It continues “bureaucratic and prolonged processes that are neither flexible nor financially sustainable should be avoided”. Another area addressed is how a RAS should be recalibrated over time, and that initially, this should happen every three months, increasing to nine, and eventually, if needed, every 12 months. This will help with financial planning. “All elements of Putting People First (including enablement and wider prevention, information and advice, universal services and social capital) need to be deployed to create a financially sustainable system – not just the internal self-directed choice and control systems of councils”. Finally, in linking efficiency savings and the RAS, it states “that the RAS should not be used to promote or justify efficiency savings”, and “It should be taking financial inputs from the system, not driving efficiency improvements or targets”. How to make best use of reducing resources: a whole system approach The first draft of this live document, published by ADASS in December 2010, draws together some of the Adult Social Care findings of the Local Government Group’s Place-Based Productivity Review that can deliver both efficiency savings and improved outcomes. The document looks at 6 key areas from across the social care journey; “the first three address what should be offered to people and the remaining three address how this should be delivered”; prevention, recovery, continued support, efficient process, partnership and contributions. The document is laid out in tabular form, featuring different components from within each of the 6 areas, the metrics that can be used and any relevant guidance or evidence. It “draws together learning from various products and initiatives already in existence to provide a whole system view”. The document can be used by others to review the evidence and best practice, to benchmark themselves against, and “to look at whether they are taking all the opportunities to use their resources in the most effective way possible”. Further evidence of best practice examples is expected to be collated in the coming months and added to the ADASS website.

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Practical approaches to improving productivity through personalisation in adult social care This document, produced by the Putting People First (PPF) consortium alongside the following SCIE publication, reviews the evidence to date on the cost effectiveness of personal budgets and highlights emerging initiatives through a series of short case studies. Like the SCIE report, it states that much of the evidence available is piecemeal and therefore it is not possible to draw conclusions across the board. It concludes that whilst further, strategic analysis is needed, confidence that personalisation can deliver efficiencies should remain, and that it should be seen as “the key building block in a transformed system”. The paper highlights the importance of understanding costs at both a strategic and individual level, and where possible, “disaggregating budgets to individuals”. In some cases this has not been possible due to the fact that, where partnership working is in place, efficiencies are likely to be shared across agencies and therefore difficult to measure. Councils are also struggling to reach “conclusions about how the costs of new types of support packages compare with more traditional solutions” due to the lack of appropriate financial systems in order to monitor this. It also emphasises the importance of simplifying business processes and developing efficient supporting systems. It states that early implementation of self directed support resulted in inefficiencies as a result of often being an add on to existing processes and systems. “Mainstreaming of personal budgets now offers an opportunity for a more thorough overhaul, including the introduction of new operating models that address the whole customer journey from the point where people first ask for support”. Specifically, information and advice, resource allocation and monitoring and making best use of community resources are cited. The report features several case studies in this area, including the use of online systems for arranging support. Among the case studies included in the report, there are two from the South East region. Kent County Council has been using a lean approach to review business processes, and one project has resulted in 15 practical suggestions on how to improve the first response to telephone callers. Oxfordshire County Council has introduced self-directed support for people who already have high cost home support packages. 36 of the 241 people who took up self-directed support now have direct payments, and the council estimate this will save £485,000 per year. The paper addresses some of the issues regarding lack of understanding of unit costs and how to ensure value for money for people with ongoing support needs. “The introduction of personalisation has enabled many councils to review some people’s support packages, and to work with them to find solutions that offer better value for money.” Alongside this, new commissioning and procurement arrangements are needed in order to ensure that good value, quality, personalised services are available that people want to buy.

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Finally, it should be noted that “Work is currently being undertaken within the Putting People First consortium to model how a council’s budget might typically be deployed within the new, transformed financial environment”. This work is due for completion in April 2011. Further detail can be found in the Joint National Delivery Support Plan on the Putting People First website. Personalisation, productivity and efficiency This overview report by SCIE investigates “the potential for personalisation…to result in cost-efficiencies and improved productivity”, and “provides an overview of some emerging evidence on efficiency from the implementation of personalisation so far”. It examines similar areas to its companion report by the PPF consortium, explored above, including the potential for savings to be made by streamlining business processes. In particular, there is evidence to show that single points of access, improved use of IT systems and proportionate auditing of direct payments are all areas of developing practice. In addition, it is stated that personalisation is “stimulating review and change in business processes” and that external support planning and brokerage could bring about further efficiencies. SCIE also draw attention to the fact that setting up personal budgets has initial costs, which need to be reviewed and recovered over time. Another of the key themes explored in the paper are the changes in the market, and SCIE report that “local authority commissioning practice is not yet facilitating the type of market development and diversification needed for personal budgets to be used effectively and efficiently”. They go on state that “Outcome-based, user-directed, flexible approaches to commissioning services, rather than rigid ‘time and task’ delivery models, could result in greater efficiency”. Building community capacity is another key theme, with “smaller community hubs providing personalised activities and learning opportunities…reported as delivering efficiency savings.” In addition, “savings could come from wider strategic and efficient integrated working, focusing on prevention and early intervention”. It has already been widely discussed that investment in prevention, including well being services and involvement in the community, can generate savings. “Support Related Housing for people with different support needs can result in efficiencies, if commissioned on an integrated service model between housing, health and social care.” In addition, savings should be considered more widely across the system, as “cost savings to health are not necessarily registered by, or shared with, social care.” Direct payments are still seen as the most efficient way of deploying personal budgets if they are “administered effectively and efficiently”. “The potential for efficiency gains through increased choice and control can only begin to be realised if the changes are supported by improved information, market development and choice in care and support provision”.

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The report states that there is not yet enough robust evidence to conclude that personalisation can or has delivered significant savings; however there are individual examples of best practice. In addition, it concludes that whilst “many local authorities are not yet routinely monitoring personal budget costs and outcomes”, providing this robust evidence will remain difficult. Value for money in adult social care In addition to the above publications, the Audit Commission are undertaking a study into value for money in adult social care. The fieldwork is due for completion in April 2011, to be reported by July 2011. For more information, please visit the Audit Commission website. Summary The following key themes can be drawn from the publications cited above:

• It is clear that a whole system approach needs to be taken to addressing financial sustainability, as the introduction of personal budgets alone will not deliver significant savings.

• There is still a lack of robust evidence that personalisation, and especially self-directed support and personal budgets, can result in efficiency savings.

• An investment in prevention and early intervention services, to help people stay independent for as long as possible, is key to reducing spend on long-term support.

• Business processes and supporting systems offer one of the best opportunities for making savings through personalisation, although it is clear that there is still some way to go in the development of these areas. In particular, opportunities should be sought to minimise back office and management costs to help to maximise spend on front line services.

• Systems for monitoring the longer-term impact of personalisation are relatively underdeveloped.

• It is important to understand costs at an individual and strategic level, and that as much of the budget available to FACS eligible service users as possible is devolved to individuals via personal budgets. This should help to address issues of inequality of allocation of resources, both within and between groups of people who use services, and double funding where under-utilised in-house services and block contracts exist.

• Resource Allocation Systems should be sustainable and affordable, linked to financial planning and recalibrated over time. These should also be informed by developments in the market.

• Emerging evidence suggests that some council’s are being more proactive in reviewing existing packages of support, although it is not known whether, or indeed how, they have tackled the issue of applying their resource allocation policy to those situations where there is little or no change in need.

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• The development of more flexible procurement and commissioning strategies that support personalisation are needed. This includes reducing spend on long-term residential care to allow for investment in other areas.

• Market development, building community capacity and the development of social capital in particular, is paramount in supporting efficiencies through personalisation.

• Integrated working across departments and sectors, to pool resources and reduce duplication and handoffs, will help deliver efficiencies.

• There are a number of case studies throughout the documents, and it is recommended that these are reviewed as examples of good practice that may be taken up more widely.

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Section three

5. Developing Practice

This section sets out key issues on various aspects of financial sustainability, summarises the findings from the Request for Information, and presents examples of developing practice. Firstly, it is worth noting that there was a variety in response levels across the questions asked, with some achieving as many as 10 out of 11 responses, and others only one. Therefore, some responses have not been felt viable for analysis, and those are highlighted below.

Sustainability of Personal Budgets This section covers questions one to seven of the Request for Information (see Appendix two). It sought to establish how sustainable the introduction of self directed support through personal budgets is, compared with the traditional care management model, and any means by which authorities are making this sustainable. Key Issues Policy driven Much like the SCIE report findings, the authorities that responded in the South East did not make reference to the monitoring of personal budget costs. This may be due to the restraints of current IT systems, which is mentioned. This suggests that authorities have implemented a policy rather than understanding the financial implications of implementing personal budgets. In addition, as none of the authorities returned their separate financial evaluation of implementing personal budgets, it is not known whether these have been carried out. More work to do A lot of authorities reported that there is still a lot of work to do in this area, for instance, in further developing their RAS, particularly for Mental Health, and in the development of the market, and therefore current cost of provision. Therefore, these areas should be considered as priorities in order for personal budgets to become financially sustainable. Financial Controls There were quite a lot of references to financial controls being in place to help manage the budget. In particular, both funding panels and building in efficiencies using the RAS were cited. This is of concern, as there still seems to be a lot of focus on authorities maintaining control in this way, rather than acting in a facilitative role to help the culture to change.

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Key findings Firstly, it is encouraging to see that quite a high percentage of people with a package of care have a personal budget. At the time of submission, in most cases, this was either approaching or exceeding the 30% target for April 2011. However, it should be noted that there is reportedly still some confusion about the definition of what should and should not be included in that figure. There continues to be a wide range of figures, both in terms of value of actual personal budgets, and for costs of services (see below). It is encouraging to see that there also continues to be outliers, where people with particularly high or low needs are receiving personal budgets, in some cases ten times higher or lower than the average. This demonstrates that the models being applied are not necessarily ‘one size fits all’, and that exceptions can still exist within the new system. Please see appendix two for the data. There is little evidence in the information submitted that authorities are monitoring the difference between costs under the traditional system and those under personalisation. Therefore, only the narrative answers have been analysed below. Two authorities stated that personal budgets were calculated on the basis of the services the person would have received under the old system, although one reported that they are developing a new resource allocation system. One authority who completed the return stated that, before SDS went live, they collected estimates from Care Managers about what clients might have received prior to SDS. This indicated that there was some efficiency for new clients as opposed to no change for clients who had a previous care package. However, they no longer keep this information as it was felt to be too unreliable. One authority said they were not seeing any significant difference in spend since Self Directed Support was implemented, although it is not known how this conclusion was reached. All other authorities stated that this information was not available. The majority of authorities reported that there is no change in spend or income, with only one reporting decreased spend. It would be interesting to know how this correlates to the number of people with a package of care. Four authorities specifically stated that they were using financial controls, such as funding panels or reducing the amount allocated by the RAS, to help manage the budget pressures. Two authorities stated that they are starting to see a trend of reduced spend, partly due to more creative care packages, whilst another noted early signs that costs seem to be increasing for people with mental health problems, due to them accessing mainstream day care services. Other responses referenced changes to eligibility and deteriorating need.

Of the 10 authorities who responded to the question, all of them reported an improvement in outcomes, whether it be during the pilot, or once SDS has been mainstreamed. This included more personalised services and having more choice and flexibility. Examples can be found below.

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Of the authorities that responded, there seemed to be more accuracy in the RAS for older people than other groups. None stated that they had a universal RAS. For learning and physical disability, there still seems to be quite a lot of disparity, with the correlation between indicative and actual personal budget being as much as between 19% and 24% out for some authorities. This may be due to the range and complexity of need for these groups. Mental Health seems to be presenting the biggest challenge, with three authorities reporting they do not yet have a RAS for Mental Health. There is come upcoming guidance currently under development on implementing SDS in Adult Mental Health, which will contain a section on the RAS. To find out more, see Section four of this report on Resources and Additional Sources of Information. Finally, one authority concluded that, over time, and with increasing numbers going through the process, the RAS is becoming more accurate, although there continue to be outliers. Five authorities reported that it is their panel or moderation process which helps to ensure personal budgets are financially sustainable, by controlling expenditure and ensure it is kept within budget. Two authorities reported having built contingency into their RAS, one at 20% and one at 10%. It is unknown whether this is actual contingency or efficiency savings. A further authority reported that a saving is built into their RAS model, but did not state how much. Finally, only one authority stated they had no plans to build savings into the application of RAS, as they see this simply as a resource calculation tool. Developing Practice Six of the authorities that responded to question seven reported that they had either made refinements to the RAS following review, and/or their plans to recalibrate the RAS in the future. This included looking at alternative weightings and the intention to move towards one RAS for all client groups. One stated that their RAS has been modeled around the available budget for clients within the community and therefore included any % saving. Three authorities explained their different approaches to allow for changes in the market and services people will use. One stated their RAS is based on notional costs, which are in line with market prices, e.g. cost of employing personal assistants, which is less than the cost of contracted or internal services. Another stated their RAS has been based not on current costs, but on the target costs after planned efficiency savings have been achieved. The other cited the expansion of choice in non-statutory services as an enabler and stated they will also continue to support preventative approaches and the maximisation of social capital. Three authorities referenced that it is the cultural changes that are helping to make personalisation sustainable. Another stated that they see efficiencies being generated through innovative and creative support packages.

21

Cost of different models of support This section covers questions eight to 12 of the Request for Information (see Appendix two). Certain models of support are considered more appropriate for different levels of need. This section sought to challenge that theory by comparing the gross costs of supporting people with the same needs in residential, extra care and living at home. Please note that information about nursing costs was not collected as part of this exercise. Key Issues Unfortunately we were unable to compare like with like as there was a considerable amount of work involved in collecting that information, and therefore authorities were asked to submit a profile of people living in different settings to see if they differ. It is, however, suggested that authorities make these comparisons themselves, comparing how much it would cost to support someone with the same needs in each of the settings. Further work could also be undertaken to collate and analyse that information at a regional level if it becomes available. It was not possible to draw conclusions from the data submitted for questions 11 and 12 due to the low number of responses to those questions. However, the narrative response to question 11 showed that where there is high spend on learning disability and mental health, this is due to higher complex needs in certain areas. Authorities reported that work is currently being undertaken to change this into extra care and supported housing. In one authority, for learning disability, the high relative spend on residential care is due to the transfer of some £6m of residential care placements from the NHS. They reported that they are working hard to recommission as appropriate. Two authorities commented that they were not able to include extra care spend as the information was not available to them. As the information was not available for this report, it is suggested that further work is undertaken to collate and compare the total cost of extra care to the public purse. Key Findings

A number of conclusions can be drawn from the data returns for questions eight to ten. Costs Firstly, and unsurprisingly, the cost of residential is considerably more than the cost of supporting someone to live in their own home. It is worth noting, however, that in some cases, for older people and learning disabilities, the most

22

expensive packages supporting people to live at home exceed the most expensive residential costs. For older people, as expected, the cost of extra care was in between that of residential and supporting someone in their own home. However, surprisingly the most expensive extra care packages are nearly three times cheaper than supporting someone at home. There were not enough data returns for other client groups to draw conclusions from comparisons between extra care and the other settings. It is suggested that this be investigated in a further piece of work. However, the low number of returns showed similar findings to that for older people, with average costs being in between that for residential and supporting someone at home. Profile Residential Care The majority of authorities reported that people in residential care tend to be those with the highest and most complex needs. Three authorities reported that residential care tends to be for those with highest support needs, or complex needs, although a long-term reduction is being seen. One other authority reported that people in residential care can no longer live within their own home or supported accommodation within the community and have critical needs. One authority stated that, for all client groups but older people, they do not distinguish between residential and nursing care. Two authorities stated that numbers of OP requiring residential care is decreasing, with the exception of people with dementia. One authority reported that, for physical disabilities, the lack of properties suitable for adaptation is one element in placement in residential, albeit temporary wherever possible. For people with learning disabilities, one authority stated that the increasing number of school leavers with complex needs is leading to increasing pressure for residential accommodation. Finally, whilst one authority reported minimal use of residential care, they stated that those who remain in residential care do so through personal choice, or where other personal preferences (e.g. location) are an overriding factor. Extra Care The information submitted was mainly for older people and some figures provided are based on a small number of schemes, or estimated figures for planned schemes. Two authorities reported that the development of extra care has enabled people to move out of residential care in some cases. One authority stated that they only have one extra care service that has inherited a number of high dependency cases following the closure of a residential home. Two authorities stated that their profile of needs for people in extra care are 1/3 high need, including dementia, 1/3 medium need, including physical disability and some cognitive impairment such as forgetfulness and 1/3 low need, mainly

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people with social housing needs. One reported that they anticipate a move towards more people with high and medium need and another stated that, following consultation with people with PD, future developments will include properties able to be easily adapted for people with significant PD needs. Of the three authorities that did not answer this question, one authority stated they do not have any extra care provision. Supporting people to live at home There was little additional information provided about those being supported at home, however it was reported by one authority that the figures submitted were based on the current costs of domiciliary care. One authority reported that the lower costs of supporting someone in their own home was due to provisions such as Telecare or Home Security. Finally, two authorities stated that increasing levels of people are being supported to live at home and live independently. one stated that this includes people from all client groups with moderate needs, as well as older people with increasing levels of need. Developing Practice

It seems that, where authorities are utilising residential care, this is for people with higher, complex needs, and that there is a conscious move away from residential care as a default option. Four authorities described steps that are helping to reduce the number of people in residential care, including the use of a well-developed intermediate care and re-ablement service, followed by long-term, non-residential support. two also reported that the development of Extra Care, supported living and Shared Lives schemes are considered as real alternatives, and where possible, a first choice option. Provision of respite or short-stay also enables people to remain within their own homes for longer. Extra care in the region seem to be very much ‘work in progress’ with authorities reporting about lack of schemes, or schemes that they are developing. It does, however, appear to be seen as a real alternative for residential care for some people, with authorities anticipating a move towards use of extra care for people with higher needs, and are developing schemes to this end.

It was reported that an increasing number of people are being supported to live at home, including those with increasing needs, with lower costs being due to provisions such as Telecare or Home Security.

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Care Pathway Developments

This section covers questions 13 to 16 of the Request for Information (see Appendix two). It sought to understand the impact of the changes made to authority’s care pathways, compared to their previous, traditional care pathway, whether this is now more or less efficient as a result and what particular developments are helpful in achieving sustainability. Key Issues

This section attracted the highest number of responses, although it should be noted that some authorities stressed that the information provided was anecdotal and subjective. Therefore, it may be considered whether a more robust care pathway analysis should be undertaken in the future. Six authorities stated support planning appears to take longer, most stating this allows time for people to develop meaningful support plans, and one stating they plan to outsource this to brokers. Two authorities also reported that, with more people opting for Direct Payments, they are looking for more efficient ways of managing direct payments. One went on to note that it is taking longer to recruit Personal Assistants and negotiate rates. Two respondents reported their assessment time had remained the same, despite national intentions to streamline this. Two authorities said it was difficult to compare old and new processes, as they were so different whilst another two authorities said they were undergoing system redesign. Other findings included difficulty in recording personalisation in their current IT system. One authority reported that some teams have added additional steps to the intended pathway, and a high numbers of hand-offs have occurred as a result. Key Findings It is interesting to note that five authorities reported that their new care pathway is slower than that previously in place, with only one stating their new process is quicker. Four authorities reported parts or the whole process taking longer whilst staff adjust to new ways of working and changes are embedded. Four authorities reported that their new care pathway has more steps and only one reported less steps. Three reported no change, of which one stated that, whilst the number of steps remains the same, particular steps now have more focus, in a personalised way. Another commented on their new pathway focusing on tailoring a response to a person’s need on a “rule of minimum intervention”. Most authorities are reporting better outcomes for individuals, including those care pathways with more steps. The additional steps are associated with calculating the indicative personal budget and the development of support

25

plans, including working with independent support brokers. Some improvements are thought to be as a result of proportionate responses. Several authorities stated plans for further streamlining of the process, whether through finance or IT systems, or a general review of the entire process once embedded. Developing Practice Early intervention and Prevention (including Reablement) Reablement was cited by most as a service in place or in development. This was mainly because it enables people to maximise their independence, reducing the number of people with ongoing needs, resulting in cashable efficiencies, as it helps reduce ‘throughput’. One authority quoted a 40% reduction of people with ongoing needs. One authority also described how they are working with independent providers to bed down the philosophy of reabling approaches. There were many examples of preventative interventions provided, as follows:

• Telecare is reportedly being developed to prevent crisis interventions and promote independence in the community.

• One authority reported that their spend on wider prevention services has helped them manage demand for FACS critical services.

• One authority was developing a Turnaround service, for people expected to go into care homes, to help them remain independent.

• One authority reported that carers assessment and support plans are enabling carers to maintain their caring role for longer, although this is likely to be the case in all authorities.

• One authority mentioned their new joint continence service.

• One authority reported it is developing a homeshare scheme, because there is some evidence that this can prevent entry to residential care, and therefore save money.

Proportionate response Several authorities reported having proportionate or flexible processes, one of which streamlined the issue of simple equipment and another which offered ‘simple personal budgets’. Review One authority stated their intent to gain benefits from invested time at the point of review. Information and signposting Three authorities reported having an Information hub or online resource directory, whilst two others stated they were improving the information on their website to enable self service and accessibility. One authority described their Hub, where social care contact and assessment staff based together in customer contact centre to help screen and resolve queries. Support with confidence, for self-funders and those receiving social care funding, has been implemented by two authorities. One authority reported they had an 'In touch'

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service, which helps to target information where needed and reduce demand on services Financial assessment and charging One authority reported that they had revised their charging policy to make it more fair and consistent whilst another stated they had integrated their financial assessment and benefits team. Two authorities described the changes to make their financial assessments earlier in the process, to ensure service users knew their contribution at the same time as their indicative personal budget. Market development One authority had implemented Timebank. Two authorities reported that they were working with micro providers to help increase choice and develop the market. One authority mentioned the work they were undertaking building social capital and community capacity through grants to third sector. Workforce One authority had mapped required workforce against their customer journey to ensure it was fit for purpose. Others reported the development of staff guidance and training. One authority had streamlined their administrative support, aligning this to support fewer, more integrated teams. Another reported they were developing personal budget workforce expertise across client groups and will restructure into new teams and roles to deliver the new pathway. Development of IT systems Upgrading IT systems to better track outcomes was reported by three respondents, with one citing involvement of includes finance and performance. Partnership working Independent support brokerage was cited by two authorities, one stating clear benefits in terms of outcomes and costs. Two authorities reported developing integrated teams, whilst others mentioned co-location of teams to aid joint working.

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Section four

6. Conclusions and recommendations

This report pulls together a range of information and resources to assist local authorities in considering financial sustainability. Despite a major programme of change to implement personalisation over the past three years, there continues to be a lack of robust evidence about the financial impact of the changes. Equally, there is little evidence that the changes have made a substantial difference to Adult Social Care budgets either way, and in particular, that they have not been the cause of additional financial pressure, other than the costs associated with making the transition from one system to another. It is of concern that the anticipated efficiencies from a more simple care pathway do not yet appear to have been achieved in many cases. Notwithstanding the above, there are an encouraging number of areas of developing practice within the region. It is anticipated that this report merely scratches the surface of those, and therefore, it is suggested that further work could be undertaken to collate further examples, both within the region and beyond. The ongoing ADASS work on best use of reducing resources should feed into this. Key Findings The key challenges highlighted through the research are as follows: Understanding service costs It is important to understand costs at an individual and strategic level, and that as much of the budget available to FACS eligible service users as possible is devolved to individuals via personal budgets. This should help to address issues of inequality of allocation of resources, both within and between groups of people who use services, and double funding where under-utilised in-house services and block contracts exist. This should be addressed through strategic financial planning, and also links to the commissioning cycle. It is of concern that many authorities were unable to provide information on the total cost of extra care housing. This was both the case in unitary and two-tier authority areas. This may be for a variety of reasons, including recording systems and working relationships with housing departments. It was also not possible to access information to be able to compare people with the same needs in different care settings. It is, however, suggested that authorities make these comparisons themselves, comparing how much it would cost to support someone with the same needs in each of the settings. Further

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work could also be undertaken to collate and analyse that information at a regional level if it becomes available. IT, monitoring and Resource Allocation Systems The majority of authorities that responded in the South East did not make reference to the monitoring of personal budget costs. There is still a lack of robust evidence that personalisation, and especially self-directed support and personal budgets, can result in efficiency savings. This may be because systems for monitoring the longer-term impact of personalisation are relatively underdeveloped. Authorities are still reporting that their IT systems do not support personalisation, and therefore this is something that should be further investigated. Improvement and Efficiency South East (IESE) are involved in the National Information Framework for Adult Care Services, which will build on work already undertaken to deliver simple practical guidance on the key system and data requirements. This work in due to end in March 2011. To find out more about these, see Resources and Additional Sources of Information. In addition, a lot of authorities reported that there is still a lot of work to do in further developing their RAS, particularly for Mental Health. This should be linked to financial planning, recalibrated over time and informed by developments in the market. There is a SE RAS Technical Working Group which meets quarterly to discuss these issues. There is also upcoming guidance currently under development on implementing SDS in Adult Mental Health, which will contain a section on the RAS. To find out more about these, see Section four of this report on Resources and Additional Sources of Information. Further care pathway efficiencies Business processes and supporting systems offer one of the best opportunities for making savings through personalisation, and it is clear that more can be done to create further efficiencies from the care pathway. This might include outsourcing parts of the process. In particular, authorities need to look for more efficient ways of managing direct payments and assessment times. Integrated working across departments and sectors, to pool resources and reduce duplication and handoffs, can help deliver efficiencies. Although this was referenced in relation to prevention and reablement services, this seems relatively underdeveloped. Proactive review Information collected via the TASC key milestones suggests that authorities in the South East are now offering personal budgets to people at their reviews. However, there is little evidence from the data returns to suggest that people with existing packages of care are being offered authentic personal budgets (i.e. the RAS is being applied, and if appropriate, a new support plan is being developed) at review stage unless there is a change in need. Although anecdotally, it is acknowledged that this is being practiced in some areas, it was only mentioned by one of the authorities completing the return, and it is not

29

known whether, or indeed how, they have tackled the issue of applying their resource allocation policy to those situations where there is little or no change in need.. There is some evidence that work is being done to look at high cost placements. In some places, authorities are reviewing their charging policies, eligibility criteria and financial assessment processes. It is suggested that more could be done to look at reviewing historical packages of care and ‘claw back’ for under spent personal budgets. Financial Controls There were quite a lot of references to financial controls being in place to help manage budget pressures. In particular, both funding panels and building in efficiencies using the RAS were cited. This is of concern, as there still seems to be a lot of focus on authorities maintaining control in this way, rather than acting in a facilitative role to help the culture to change. Market development and commissioning The development of both existing and new services was cited by most authorities as important to achieving financial sustainability. This includes reducing spend on long-term residential care to allow for investment in other areas, such as prevention and early intervention. Whole Systems Approach Finally, the findings from both the literature review and Request for Information show that each part of the care pathway needs to be taken into account to help address financial sustainability. Areas for Further Consideration and Development A number of areas of further consideration and development are as follows:

1. Further fieldwork to investigate some of the areas of data gathered would be interesting. In particular, it would be useful to seek additional data for those questions that did not receive an adequate response to be able to draw conclusions. It would also be useful to collect additional examples of good practice, as mentioned above.

2. Additional work should be undertaken to understand the costs of delivering different models of support, in particular Support Related Housing.

3. More needs to be done to understand how Local authorities are recording and monitoring the impact of implementing Personalisation. This includes which system(s) are being used and how these are being applied, and should be referenced with the work on the National Information Framework for Adult Care Services. It is suggested that, if they haven’t already, authorities should undertake their own financial evaluation of the impact of implementing personal budgets. It would also be useful to have sight of any financial evaluations completed within the region, the findings from which could be collated and shared.

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4. Further work could be undertaken to understand the approaches Local authorities are taking to financial planning and modeling, and what key areas are being taken into account.

5. As recommended in the original PID, it would be useful to investigate how Local authorities can maintain financial and budgetary control, and address the full range of costs that may be associated with Personalisation. This includes individuals who over or under spend their budget, the option to claw-back under spend, potential changes to budgets at review and the frequency of review. It will also consider any additional costs, such as the increase in take up and costs relating to supporting self-funders. This could be established initially through the ADASS Finance Leads Committee.

6. Further work could be considered around the impact of prevention and early intervention on financial sustainability, although it is anticipated that more work may also be undertaken on this nationally.

7. Further work could be undertaken to establish whether there is a discernable difference (increase or decrease) between commissioning costs in light of transformation, with a comparison between traditional commissioning practice and commissioning practice under a transformed system. This could look at cost implications of different forms of commissioning activity including the use of brokerage.

8. Given some of the outstanding issues regarding process inefficiencies, it may be considered whether a more robust care pathway analysis should be undertaken in the future, across local authorities.

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7. Resources and Sources of Additional Information

This section includes reference to various resources used to develop this report. Please note that inclusion in this guidance does not does not constitute endorsement of the service or organisation concerned. Community of Practice

If you wish to join the Community of Practice mentioned earlier in the report you can do so in the following way. Sign up with the Local Government and Improvement website www.communities.idea.gov.uk/welcome.do You can then join the South East Region RAS Technical Working Group at http://www.communities.idea.gov.uk/comm/landing-home.do?id=2323424 Please contact Fiona Hague at Department of Health South East if your require

assistance. 01483 882272/ Fiona.Hague@dh.gsi.gov.uk

Websites

The Association of Directors of Adults Social Services (ADASS): www.adass.org.uk Audit Commission: www.audit-commission.gov.uk CSED: www.csed.dh.gov.uk Department of Health: www.dh.gov.uk In Control: www.in-control.org.uk Local Government Improvement and Development: www.idea.gov.uk Putting People First: www.puttingpeoplefirst.org.uk Social Care Institute for Excellence: www.scie.org.uk NB: A number of other websites are referenced in the reports Practical approaches to improving productivity through personalisation in adult social care and Personalisation, productivity and efficiency, which you may also wish to refer to. Related work

Implementation of SDS in Adult Mental Health. Contact Tim Parkin. 01483

882376 / Tim.Parkin@dh.gsi.gov.uk

Prevention and Early Intervention Learning Packs. Contact: Jeanette Longhurst. 01483 882313 / Jeanette.Longhurst@dh.gsi.gov.uk National Information Framework for Adult Care Services. Contact: Mike Crisp, IESE. 07711 928026 / mike.crisp@southeastiep.gov.uk

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8. Appendices

Appendix one – Contributors Members of the SE ADASS Finance Leads Committee

Stuart Rowbotham: Wokingham (Chair) Alan Abrahamson and David Trim: RBWM Alison Egerton and Erica Meadus: Hampshire Anne Silley and Manvell Manvell: Brighton & Hove Caroline Chandler: Milton Keynes Chris Salt and Richard Perry: West Sussex David Cuerden: Southampton Ian Gutsell and Rita Stone: East Sussex John Huskinson: Buckinghamshire June Graves, Roz Haines and Sevil Rush: West Berkshire Kerry Hubbleday and Simon Gerfen: IOW Les Horsley : Bracknell Forest Michelle Goldsmith: Kent Nancy Kurisa, Elizabeth Norman and Simon Kearey: Oxfordshire Paula Chowdhury and Phil Mitchell: Surrey Peter Pennekett: Portsmouth Phil Watts: Medway Rob Stubbs: Wokingham Robert Poole: Reading

Acknowledgement and many thanks for the contribution from all members of the SE ADASS Finance Leads Committee.

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SE Local authorities who completed the Request for Information Bracknell Forest Brighton and Hove City Council Buckinghamshire County Council East Sussex County Council Hampshire County Council Oxfordshire County Council Portsmouth City Council Reading Slough West Berkshire Wokingham A further return was received from Medway towards the end of the project, and therefore was not included in the data analysis. The information has been retained for future use.

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Appendix two - Request for Information - Combined analysis

Questions Combined analysis

Section 1

Service user group Average number

of people with a

PB

Average total

number of people

with PoC

%

Older People 862 4565 18

Physical Disability 288 753 34

Learning Disabilities 215 690 29

Mental Health Needs 47 377 17

1. Number of people

with a personal budget

(including direct

payments) / total

number of people with

a package of care in

place

e.g. 650 / 18,565

(to understand

statistical

significance). Personal

budget figure should

include people with

ongoing support (i.e.

not one-offs),

including direct

payments, and should

not include carers.

TOTAL 1413 6384 22

Average Average Upper

Limit

Average Lower

Limit

Actual Upper

Limit

Actual Lower

Limit

2. Value of actual

(allocated) Personal

Budget (per service

user group)

- Average

Older People 212 1434 20 3360 1

35

Physical Disability 261 1992 30 4450 3

Learning

Disabilities

413 2118 56 3853 3

Mental Health

Needs

181 671 21 1731 3

- Upper and lower limit

e.g. Older people

average £250, Upper

limit £450, lower limit

£50.

Please add any

additional comments

about methodology for

reaching the figures

and any assumptions

made.

Additional commentary provided to confirm from where data has been drawn over what period.

Older People

Physical Disability

Learning Disabiliy

Mental Health

Needs

3. Gross cost of

previous services in

place (if existing

service user with no

change in need) or

estimated value of

services would have

been in place (if new

or existing with

change in need)

- Average

- Upper and lower limit

Please add any

additional comments

about methodology for

reaching the figures

and any assumptions

made.

1 authority stated that, before SDS went live, they collected estimates from Care managers about what clients might have

received prior to SDS. This indicated that there was some efficiency for new clients as opposed to no change for clients who

had a previous care package. They no longer keep this information as it was felt to be too unreliable.

1 authority said they were not seeing any significant difference in spend since Self Directed Support was implemented.

2 authorities stated that personal budgets were calculated on the basis of the services the person would have received under

the old system.

All others stated this information was not available.

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Increased spend x0 No change x7 Decreased spend x1

Increased income x0 No change x7 Decreased income x1

4. Based on above,

please provide

commentary on

whether the

introduction of

personal budgets has

increased or

decreased spend and

income.

2 authorities noted that a panel process has helped introduce a level on financial control, meaning spend has remained cost

neutral. Another stated that they are likely to have tighter financial controls, regardless of SDS, to help to manage the financial

pressures.

There is still little difference in the provisions being agreed, with few receiving direct payments for all or part of their support.

2 authorities noted a reduction in spend / increase in income as a result of changes to eligibility, however this is not specifically

a result of SDS.

1 authority noted some early evidence that care providers are willing to see if they can meet outcomes within the PB rather

than loose business.

1 authority noted that, whilst personal budgets were originally designed to be cost neutral, a decision was taken to reduce the

amounts allocated by the RAS, which should lead to a reduction in spend. The degree to which this is translated into actual

reductions in personal budgets is yet to be seen.

2 authorities commented that there has been no significant change in spend or income, although 1 went on to state early signs

in Mental Health show increases in costs, especially around day care services with clients being able to access more

mainstream services.

2 authorities stated that there is a trend that the the introduction of Personal Budgets has reduced spend, partly due to more

creative care packages.

1 authority noted that individual spend has increased because it has corresponded to a deteriorating condition and a

requirement for more complex services although the level of spend has actually decreased compared to the traditional

services that would have been put in place to meet deteriorating need.

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5. Commentary on

whether outcomes

have improved. Please

give examples. Note,

this may not be

provided by Finance

staff.

Of the 10 authorities who responded, all of them reported an improvement in outcomes, whether it be during the pilot, or once

SDS has been mainstreamed. Examples include:

- Supporting planning in more person centered way

- A more personalised experience in general

- Changes in practice and more creative practice

- People feeling safer

- Improved quality of life

- Having more choice in general and control over their lives

- Spending more time with people / improved relationships

- Flexibility in how budget can be used, e.g. banking time/money or spending up front, choice of daytime activities such as

adult education

- People choosing to take respite in different way.

Older People 2 authorities stated their OP models had good correlation, within 10% tolerance, at

5% and 7% variation.2 authorities noted that budgets are being agreed above RAS

calculation, one slightly above, and the other above average before SDS.1

authority stated that their average Personal Budget for OP is 18% lower than the

average RAS.1 authority stated the correlation as OK.

6. Commentary about

correlation between

indicative and actual

personal budget, i.e.

how accurate is RAS

Physical Disability 2 authorities stated that budgets are being agreed below RAS calculation, but only

slightly for 1 of the authorities.

1 authority stated their PD model still undergoing recalibration due to inaccuracies

in original model.

1 authority stated the correlation 24% out, whilst another said that their average

Personal Budget was 19% lower than the average RAS.

1 authority stated the correlation as OK.

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Learning Disabilities 2 authorities stated that, whilst there is a reasonable correlation, the final budgets

are often in excess of indicative allocations. This may be where there are

significant support needs.

2 authorities also stated that budgets are being agreed marginally above RAS

amounts, 1% for 1 of the authorities.

1 authority stated the correlation 22% out.

Of the authorities that responded, 1 authority reported no RAS for LD.

Mental Health Needs Of the authorities that responded, 3 authorities reported no RAS for MH and 1

stated that too few had an allocation to confirm any correlation.

2 others stated poor correlation at present, one reporting that the Indicative

allocation is often too high.

2 authorities stated that they had a reasonably accurate RAS for Older People, and 1 of those said they did for and Physical

Disabilities too. Both authorities stated their main area of weakness as people with more complex conditions, and that for

Learning Disabilities, there is variation. They added that there is a wide disparity still between cost of provisions and the RAS,

especially for adult disability groups.

2 authorities commented on the role of funding/resource panels, one stating its role has expanded to support front line staff to

increase the numbers of direct payments taken up and in how the personal budget is deployed.

6 authorities stated their intention to continue to monitor their RAS and make refinements where necessary to improve

accuracy. 1 stated they are looking at what other authorities are doing to solve these issues, and another that they are moving

to a new RAS in the new year to help address inaccuracies in the current model.

1 authority reported that over time, and with increasing numbers going through the process, the average RAS is becoming

more accurate, although there continue to be outliers.

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7. Please explain any

steps you are taking to

ensure implementing

personal budgets is

financially

sustainable, e.g.%

saving built into RAS,

cultural change, etc.

6 of the authorities who responded reported that they had either made refinements to the RAS following review, and/or their

plans to recalibrate the RAS in the future. This included looking at alternative weightings and the intention to move towards

one RAS for all client groups. 1 stated that their RAS has been modeled around the available budget for clients within the

community therefore included any % saving. 5 authorities reported that it is their panel or moderation process which helps to

ensure personal budgets are financially sustainable, by controlling expenditure and ensure it is kept within budget. One stated

that the RAS is analysed to ensure that the moderation process reflects current financial pressures.3 authorities explained

their different approaches to allow for changes in the market and services people will use. 1 stated their RAS is based on

notional costs which are in line with Market prices, e.g. cost of employing personal assistants, which is less than the cost of

contracted or internal services. Another stated their RAS has been based not on current costs, but on the target costs after

planned efficiency savings have been achieved. The other cited the expansion of choice in non statutory services as an

enabler and stated they will also continue to support preventative approaches and the maximisation of social capital. 3

authorities explained how the cultural changes are helping to make personalisation sustainable, including Social workers’

perception that personal budgets are a lower cost than previous support packages. Another stated that they see efficiencies

being generated through innovative and creative support packages. 2 authorities reported having built contingency into their

RAS, one at 20% and one at 10%. It is unknown whether this is actual contingency or efficiency savings. A further authority

reported that a saving is built into their RAS model, but did not state how much.Finally, 1 authority stated they had no plans to

build savings into the application of RAS, as they see this simply as a resource calculation tool.

Section 2

Average Average Upper

Limit

Average Lower

Limit

Actual Upper

Limit

Actual Lower

Limit

Older People 527 1242 263 2242 61

8. Per service user

group, what is the

gross cost for

residential care?

- Average

- Upper and lower limit

Please add additional

comments about the

profile of people in

this setting including Physical Disability 853 1804 445 3206 210

40

Learning

Disabilities

1210 3663 259 5043 45

Mental Health

Needs

747 2282 275 5649 74

needs.

3 authorities reported that residential care tends to be for those with highest support needs, or complex needs, although a long

term reduction is being seen. 1 other authority reported that people in residential care can no longer live within their own home

or supported accommodation within the community and have critical needs. 1 authority stated that, for all client groups but

older people, they do not distinguish between residential and nursing care.

4 authorities described steps that are helping to reduce the number of people in residential care, including the use of a well

developed intermediate care and reablement service, followed by long-term, non-residential support. 2 also reported that the

development of Extra Care, supported living and Shared Lives schemes are considered as real alternatives, and where

possible, a first choice option. Provision of respite or short-stay also enables people to remain within their own homes for

longer.

2 authorities stated that numbers of OP requiring residential care is decreasing, with the exception of people with dementia. 1

authority reported that, for physical disabilities, the lack of properties suitable for adaptation is one element in placement in

residential, albeit temporary wherever possible. For people with learning disabilities, 1 authority stated that the increasing

number of school leavers with complex needs is leading to increasing pressure for residential accommodation.

Finally, whilst 1 authority reported minimal use of residential care, they stated that those who remain in residential care do so

through personal choice, or where other personal preferences (e.g. location) are an overriding factor.

Average Average Upper

Limit

Average Lower

Limit

Actual Upper

Limit

Actual Lower

Limit

Older People 304 440 252 897 9

Physical Disability 323 451 250 500 146

9. Per service user

group, what is the LA

cost for extra care, i.e.

not including housing

benefit etc?- Average-

Upper and lower

limitPlease add

additional comments

about the profile of

people in this setting

Learning

Disabilities

982 2934 20 2934 20

41

Mental Health

Needs

89 89 89 89 89 including needs.

The data provided is mainly for Older People.

Some figures provided are based on a small number of schemes, or estimated figures for planned schemes.

Of the 3 authorities that did not answer this question, 1 authority stated they do not have any extra care provision.

2