Commissioning for Outcomes 27 th and 28 th September 2011

1. Commissioning for Outcomes 27th and 28th September 2011

2. Commissioning:Evidence-Informed & Outcomes Focused 09.30 Coffee and Registration 10.00 Welcome and Introduction – Claire Lightowler (IRISS) and Dee Fraser (CCPS) 10.15 Introduction to the day 10.20 Commissioning: context and framework 10.40 Commissioning for outcomes 11.30 Break 11.45 Using evidence to deliver change in commissioning: tools and case studies 12.30 Lunch 1.15 Outcome-based contracting 2.15 Evaluating outcomes & group discussion 3.00 Feedback and reflection 3.15 Close

3. Commissioning for OutcomesGlasgow & EdinburghLiz Cairncross & Juliet Bligh27th and 28th September 2011

4. Institute of Public Care,Oxford Brookes University We work for better health, social care, education, housing and welfare with the public, private and voluntary sectors Specialising in: • Service design and configuration. • Market development. • Performance management. • Managing practice quality. • Service transformation and change. Website http://ipc.brookes.ac.uk Email ipc@brookes.ac.uk

5. Institute of Public Care A range of projects on commissioning for national, regional and local government: • Yorkshire & Humber Developing Intelligence Commissioning Programme www.yhsccommissioning.org.uk/ • POPPI & PANSI online demand forecasting and capacity planning system www.poppi.org.uk • Specific activities to support the development of commissioning across local authorities • Post-graduate certificates, eg, commissioning and purchasing, managing service redesign and change.

6. Purpose of today • To give commissioners and providers a better understanding of key aspects of evidence-based and outcome-focussed commissioning. • To provide an opportunity to compare your own arrangements with best practice, and to identify what needs to be done in the future.

7. Commissioning: context and framework

8. Context for commissioning social care • Ageing population: demand and workforce implications • Policy drivers • Personalisation • Prevention and early intervention • Outcomes • Financial and economic constraints

9. Key policy documents • Changing Lives: Report of the 21st Century Social Work Review, 2006 • National Care Standards • Community Care Outcomes Framework • Public Procurement Reform Programme • Scottish Procurement Policy Handbook • Third Sector Statement • National Strategy for Self-Directed Support • Reshaping Care for Older People: a Programme for Change • Christie Commission Report

10. Why is commissioning important? Public bodies should have local commissioning strategies and/or service plans which establish strategic and individual needs and determine what type of service should be put in place to meet those needs and deliver the intended outcomes. Procurement of Care and Support Services, Scottish Government, 2010

11. Role of commissioning “Commissioning at both the strategic and the individual level, is an important tool in helping to achieve improvements. Getting it right can transform people’s lives giving more flexibility, independence and choice as well as quality and value for money. Getting it wrong can lead to uncertainty, lack of continuity, undermining the potential for people to be part of the solution – sometimes being shoe-horned into provision, just because it is there.” Commissioning for Personalisation, 2009 11

12. Commissioning is a tool for… • Understanding long term demand, giving a common perception of the world • Understanding the best approaches and methods for meeting that demand and hence improving and modernising services to achieve better outcomes • Encouraging innovative service solutions by providers • Achieving best value by better configuration of services and increased efficiencies • Managing the market in a climate of expanding independent and third sectors

13. Joint commissioning model for public care (SWIA)

14. Discussion • Do you recognise this in terms of the activities in the authority you work in? • Which parts of the cycle are strongest? • Which parts of the cycle are weakest? • What are the main barriers?

15. Barriers to effective commissioning include: • Reluctance to accept that services may have to be decommissioned • Lack of flexibility to respond to what people want, beyond specifications • Lack of information – about what people’s needs and preferences are • Lack of information – for people about possibilities and choices • Poor relationships within the public sector, with differing priorities

16. Barriers to effective commissioning include: • Rigid processes e.g. inflexible block contracts or service specifications • Adversarial relationships between commissioners and providers • Lack of focus on outcomes for people.

17. Resources • Procurement of Care and Support Services, Scottish Government, 2010 • Changing Lives: Personalisation: A Shared Understanding: Commissioning for Personalisation: A Personalised Commissioning Approach to Support and Care Services, 2009 • Guide to Strategic Commissioning: taking a closer look at strategic commissioning in social work services, SWIA, 2009 • Key Activities in Commissioning Social Care, CSIP, 2007 (available on IPC website)

18. Commissioning for Outcomes – An IPC Perspective

19. What do we mean by “Outcomes?” “Outcomes are specific changes in behaviour, condition and satisfaction for the people that are served by a project or a service. These gains are generally signal improvements or ‘human gains’ that have been brought about by the service/intervention.” Centre for Public Innovation

20. What is meant by an outcome focused approach? “...shift the focus from activities to results, from how a programme operates to the good it accomplishes.” Plantz and Greenaway

21. National Outcomes • Defined by government that specify what is to be achieved for everyone. For example: • We have strong, resilient and supportive communities where people take responsibility for their own actions and how they affect others. • We live longer, healthier lives. • We live in well-designed, sustainable places where we are able to access the amenities and services we need. 21

22. Strategic Outcomes • Defined by local authorities and reflecting national outcome priorities, specify what is to be achieved for particular populations or by a particular plan or commissioning strategy. • For example: • More people with dementia live in their own homes to death. • More people return to live independently in the community following a stroke. 22

23. Service outcomes • Defined by local authorities or local health boards (often in conjunction with service providers) and reflecting both national and strategic outcomes, specify what the service is to achieve for its service users. • For example: • 20% people using home care will improve their mobility. • 50% people having a stroke are admitted to a specialist stroke unit. • 90% hip fracture patients have a multi-factorial falls risk assessment. 23

24. Individual outcomes • Defined by the individual • For example: • “I would like to be more independent and rely less on others to do daily activities and tasks” • “I want to feel less lonely.” • “I want to feel I have some control over how I am helped.” 24

25. Outcome based purchasing Our particular interest is in moving the focus of service purchase from buying by outputs –days, hours, treatments - and onto purchasing by a set of agreed outcomes. For IPC outcome based purchasing means… …putting in place a set of arrangements whereby a service is defined by, and paid for, on the basis of a set of agreed outcomes rather than the volume or way in which it is delivered.

26. Discussion • Where have you got to in terms of commissioning for outcomes? • Is there a difference in progress between providers and commissioners?

27. Using evidence to deliver change in commissioning: case studies and tools

28. Evidence informed commissioning ‘Taking a systematic approach to collecting and analysing evidence throughout the commissioning process. By evidence we mean research, local data and evaluations.’

29. A realistic balance of evidence sources • National and international research as well as government guidance and legislation • Population data and prevalence rates • Referral, assessment and service activity data • Illustrative care pathway/case studies • Engagement activities with patients/service users and carers, providers, professionals and other stakeholders

30. Skills for evidence-informed commissioners Able to: • Design and conduct analyses to justify commissioning plans to a range of stakeholders • Understand research methodologies and research reports and extract information • Work with a range of stakeholders to understand evidence and use as a basis for plans • Design and implement effective ongoing evaluation and feedback arrangements on an ongoing basis

31. Using local evidence – to target prevention and early intervention • Targeting early intervention and prevention in an English county. • Part of IPC partnership programme aimed at facilitating transformation of social care. • Aim to prevent or avoid unpopular and costly admissions to residential care.

32. Using local evidence – to target prevention and early intervention • Key questions: • Can we identify characteristics or points along care pathway leading to care or hospital admissions where early intervention may be preventative and beneficial? • Can we identify from the research literature, approaches to practice that when focussed on these issues/conditions, will be more effective than current practice?

33. Using local evidence – to target prevention and early intervention • If we can both identify key points that suggest appropriate interventions and interventions that offer greater cost benefits, are they likely to be used by older people?

34. Using local evidence – to target prevention and early intervention • File audit of recent admissions to care homes: characteristics and predisposing conditions. • Interviews to explore pathways into care and critical incidents. • Using research literature to identify key factors that may help us to target populations: • Prevalence and incidence. • Current interventions and evidence of effectiveness. • Good practice. • Develop pilots – implement change.

35. Using local evidence – to target prevention and early intervention • What did we find in the file audit? • Most already known to social care services. • High levels of dementia and incontinence. • Two-fifths had had a fall in the last 12 months but very few had received falls services. • Men likely to go into care homes at earlier age than women and with lower levels of ill health. • Area differences also emerged.

36. Using local evidence – to target prevention and early intervention • What did we find from interviews? • Many admitted after long stay in hospital. • Confirmed falls, incontinence and dementia as key factors. • Limited use of services related to these conditions. • Carers’ need for practical support and information. • Tipping points around bereavement and disability.

37. Using national evidence – Money Matters • Shared Lives • Extra-care housing • Health in Mind – well-being cafes • Linkage Plus • Rapid response adaptations • Self-assessment for low level needs • Individual budgets • Southwark hospital discharge

38. Using evidence – Shared Lives • Formerly known as Adult Placement • Involves the provision of care and support in the homes of ordinary people • A family setting with emphasis on community links • Carers support up to three people at a time • Long-term accommodation, short breaks, intermediate support • Carers are self-employed • Placed and matched by local authority – c.15 schemes in Scotland.

39. Using evidence – Shared Lives • 79% of schemes rated good or excellent by CSCI compared with 69% of care homes • High levels of satisfaction among service users and carers • Staff, users and carers highlight positive outcomes in terms of developing independence and confidence, continuity of relationships, choice and control

40. Using evidence – Shared Lives • Cost of service for 85 service users for five years = £620,000 • Potential net savings of £12.99 million • Shared Lives - mean unit cost per week (including management costs) = £419 • Learning disability supported living - mean unit cost per week = £1,288

41. Using evidence – Self-assessment • Pilot project for older people • Linked access to assessment for older people with lower level needs to range of preventative services • Self-assessment with support from self-assessment facilitators • Facilitators researched and signposted to relevant services & also commissioned some low level services eg careline, meals

42. Using evidence – Self-assessment • Similar satisfaction levels to standard approach • Facilitators provided more advice on preventive services than care managers • Reduced costs: overall £88 per assessment with facilitator compared to £286 per assessment by a care manager.

43. Using evidence – Self-assessment • Pilot now mainstreamed across adult services • Targeted on those with low level needs.

44. Useful Websites http://www.ons.gov.uk/ons/index.html http://www.sns.gov.uk/ http://www.scotpho.org.uk/home/home.asp http://www.jrf.org.uk/ http://www.esds.ac.uk/government/resources/themeguides.asp - includes: Guide to data sources for Scotland http://www.nice.org.uk/ http://ipc.brookes.ac.uk/

45. Discussion • What types of evidence do you use? • What have you found helpful? • Where are the evidence gaps?

46. Developing an approach to outcome based contracting

47. Benefits of an outcome-based approach for commissioners It makes the authority focus on exactly what they want the provider to achieve and why, rather than volume of service provided. Achieving outcomes can be both collectively and individually more motivating than providing an amount of service. It can have a beneficial approach to both raising the quality of the service and for enhancing working relationships.

48. Why take this approach? Recent evaluation of an approach by major UK care provider Service users: • 68% - Improvements in overall health and wellbeing • 77% - Greater Independency • 78% - Feelings of greater choice and control • 93% - Recognition of the way care had been provided Staff: • Reduction in sickness levels • No staff leavers • Increase in staff satisfaction • Increase in written compliments - no complaints!

49. Developing an outcome based approach

50. Identifying the specific roles for Providers & the Local Authority Local Authority • Develop outcomes based contracts. • Ensure flexibility for providers in addressing outcomes. • Undertake person centred assessments that identify individual outcomes. • Produce outcome focused support plans that can be easily understood by providers.