Implementing outcome-based commissioning

Implementing outcome-based commissioning Received (in revised form): 23rd January, 2007 Chris Paley was Director of Community Wellbeing at Thurrock Unitary Council until February 2007. She joined Thurrock Council in August 1997, setting up the Social Services Department for the new unitary, which first became operational in April 1998. Thurrock s Adult Social Care has this year been judged to be Three Stars with Excellent Prospects. Chris is co-chair of ADSS (Association of Directors of Social Services) Older People s Committee and Chair of the National Homecare Council. Colin Slasberg is Head of Business Support in the Directorate of Community Wellbeing, Thurrock Council. Colin has been with Thurrock Council since 1997 and has played an integral role in the development of practice within Thurrock s Adult Social Care and has also led on the development of outcome-based commissioning in Thurrock. Abstract Arguably commissioning services at the individul service user level on the basis of outcomes rather than tasks is a way forward in increasing service user control of their services. Its potential is particularly relevant to service users who will not want, or not be able, to manage the higher levels of control of finances the Direct Payments and some forms of Individual Budgets offers. This paper shows how one Council has set about the challenges of changing the practices and culture it believes are needed to move to outcomes-based commissioning. It believes the challenges are considerable and need careful thought and management if we are to succeed. Keywords: control, all service users, flexibility, choice, responsiveness INTRODUCTION The focus on outcomes is not new. The present authors interest was stimulated by the work of Hazel Qureshi and her team at York University in the 1990s 1 when they identified two types of outcome: Colin Slasberg Community Well-being Thurrock District Council Civic Offices New Road, Grays RM17 6SL, UK Tel: +44 (0)1375 652652 E-mail: cslasberg@thurrock.gov.uk Change outcomes: which reflect the intention to achieve improvements in an older person s mental and physical condition, to a point where services could be reduced or withdrawn. Maintenance outcomes: situations in which only slightly improved stability or deterioration is expected and where continuing maintenance of an acceptable quality of life is the aim. # HENRY STEWART PUBLICATIONS 1750^1679 Journal of Care Services Management V O L. 1 N O. 4 P P 3 5 3 3 6 1 353

Paley and Slasberg Person-centred working Shifting control Outcome-based commissioning, however, is new, but gaining ground rapidly as a strategy for bringing about more responsive services. It is referenced in the recent state of social care report by Dame Denise Platt, 2 while the Care Services Improvement Partnership has a network that is dedicated to developing outcomebased working. It has recently produced a podcast that debates the issues involved. 3 The Commission for Social Care Inspection (CSCI) report on the state of home care 4 also identifies outcomebased commissioning as a way forward to bring about key and much needed improvements in the experience of home care by service users. Thurrock Council has come to the view that commissioning against outcomes is a precondition of achieving person-centred care for all service users. It involves shifting the power from commissioners to providers in a major way and empowering them to be responsive and flexible in the light of service users shifting needs and shifting views of their own needs. Whether one is talking about a change outcome or a maintenance outcome it must be driven by the service user s own expression and aspiration, and not something imposed upon them. Staff in Thurrock have been thinking about and developing their thoughts on outcome-based commissioning for several years now. There is a momentum of change in place and the pace is intensifying all the time. The change is a major one. It cannot be achieved by simply changing contracts or specifications, or even more simply by changing language and rhetoric. This paper describes this journey. In sharing their experience the authors are not saying their way is the only way of doing it, as there are many potential approaches to outcome-based commissioning. It is, however, an honest account of their journey and the lessons learned along the way. ACHIEVING CHANGE In outcome-based commissioning, the commissioner agrees with the service user the issues to be addressed and what difference the commissioned service should make to their lives by tackling those issues. The commissioner also decides on the volume of service within which the provider should work. It is then for the provider to work with the service user to agree what work will actually be done, when it will be done and how it will be done. Currently, the systems at Thurrock Council, supported within the statutory context of a cash-limited environment and, arguably, the professional dominance of social work within the care management function, put the commissioner in the driving seat. Staff at Thurrock Council came to the conclusion that this culture cannot support genuinely person-centred working, where it is the view of the service user of their own needs that should drive the service design for them. The recent Green Paper and subsequent White Paper 5 proposed working towards: 354 # HENRY STEWART PUBLICATIONS 1750^1679 Journal of Care Services Management VOL. 1 NO.4 PP 353 361

Implementing outcome-based commissioning Clear outcomes for social care derived from what people tell us they want. The outcome will be used to test and challenge how far social care is moving towards delivering the vision. Key cultural changes Thurrock Council sees outcome-based commissioning as one of the key catalysts in delivering the vision of the White Paper and is also clear that if it is to achieve genuinely person-centred working, the key relationship has to be between the service user and the provider. THE CHANGE PROCESS Two years ago, a pilot was carried out to test what outcome-based commissioning was about. 6 It involved an independent sector provider of homecare, a part of Thurrock Council s own direct services and some of its assessment and care management workforce. The key challenges it highlighted were as follows: For care management practitioners: understanding what is meant by outcomes, building plans based on them and letting go of control. For providers: moving from organisations built to carry out prescribed tasks, for agreed levels of money, to ones able to take responsibility for meeting outcomes, flexibly, within agreed resource levels. For financial managers: moving from control of spending by buying tasks, to strategic control based on cash limited spending for providers. For all: moving from a client-contractor relationship to a genuine partnership, on an adult-to-adult basis. Increased levels of satisfaction Of course, the contractual relationship cannot be ignored but, if it remains the dominant force, it is believed that the degree of trust that this working requires will not develop. Each of these challenges is significant and, if nothing else, the pilot showed it was easier said than done. The pilot was designed to show differences between a volumebased commissioning approach and an outcome-based commissioning approach. In all cases, the pilot only worked with new service users but with sufficient numbers to test the processes. The overall satisfaction of service users with the outcome-based approach was very high, with 100 per cent being either very satisfied, satisfied or quite satisfied with the process. The same measure as that used by the Performance Assessment Framework (PAF) Performance Indicator was used in order to show if there would be an increase in satisfaction, which proved to be the case. It was found that care managers, at the beginning of the pilot, did not feel comfortable with passing over a case to a provider without stipulating the tasks to be done. It is important that care managers feel confident that providers have the staff with skills to # HENRY STEWART PUBLICATIONS 1750^1679 Journal of Care Services Management V O L. 1 N O. 4 P P 3 5 3 3 6 1 355

Paley and Slasberg match activities to outcomes and provide regular feedback to them. It was found to be important for providers to have the infrastructure to enable them to construct service user plans that identify the outcomes specified by the care managers, cost them and also change the plans, as required by the service user. In order to meet the challenges, Thurrock Council went on to take a number of actions. The first of these was to respecify the contract. The contract and service level agreement now require the provider to: Changes to service specification Fair price for care Make decisions about what work will be done with service users, based on what they say about their needs. Work within an agreed budget set by the commissioner. They can vary it but not exceed it. Have the flexibility to move resources between service users, according to need, so long as they work within their total budget allocation (aggregate hours). Have systems in place to record precisely how long they are with each service user, usually through electronic monitoring. Providers are expected to be able to invoice electronically, showing how much service each service user received in the month. Work with commissioners so that service users get the minimum level of service to meet their needs. This is based on the premise that service receipt is not in itself a good thing and is contrary to the achievement of independence. Develop a workforce able to deliver this higher level of responsibility. This includes training, but principally means minimising the level of casual employment and maximising the level of secured and usually salaried staff. Linked to these requirements there are some key points to be made in relation to the contract. Achieving this specification is demanding, both of managerial skills and also resources. Thurrock Council knows that councils pay themselves very much more to do this work than it pays independent providers: in 2004/05 18.40 against 11.90 nationally. While much of this higher cost could be attributable to inefficiencies and wider council overheads, some of it is about higher levels of resources and the kinds of resources that support good quality working, which includes training and supervision. Locally, work was carried out to compare the unit cost with those of independent providers; Thurrock Council came to the view that a figure of about 15 per hour was about right. The Council cannot afford this price in Thurrock but, over the past three years, has invested growth in the independent sector to get much closer to it. It was realised that, for providers, economies of scale come into play and the more hours an agency has, the more its fixed costs are spread and the more able it will be to resource its infrastructures. It was decided, therefore, to reduce the number of agencies the 356 # HENRY STEWART PUBLICATIONS 1750^1679 Journal of Care Services Management VOL. 1 NO.4 PP 353 361

Implementing outcome-based commissioning Change of providers Road map of change Council worked with from nine to four. Staff were aware that in doing this they would be seen to be bucking the market-led trend and reducing choice. They consulted service users about their plans and were told that choosing the agency that provided the service was not important, choosing and not changing the carer was important. In March 2006, new contracts were let with four providers who were committed to come on this journey of change with Thurrock Council. The contracts were handed over in July. Perhaps the biggest lesson learned was that a major change of this sort should never be attempted during the key summer holiday period, because it unleashed significant problems for a few weeks. The providers stuck together and worked cooperatively and in partnership with each other during this nightmare time and, importantly, they stuck with the Council and the vision. Thurrock Council had built in additional support during this key period but a smooth handover meant the old providers, who had been working with it but no longer had contracts, were required to be cooperative with the new providers. Perhaps not surprisingly there were some major problems with the information the old providers handed on to the new providers. The new agencies were not expected to start working to the new outcome requirements straight away. They were expected to move into this over a period of 12 months while work developed to ensure the changes required to support it were firmly in place. Thurrock Council has developed a roadmap which sets out the range of key and interrelated tasks that all have to be accomplished if its vision is to be achieved. It has been developed with providers, both independent and direct Council, with commissioners and with key NHS staff. A consultant has been engaged, funded by the Government Training Grant, to support the Council throughout the implementation work required in developing (Council and agency) staff. The consultant has significant experience as a senior manager in health and social care and as an executive in the independent sector. He has been closely involved in the Outcomes Network, now linked to the Department of Health. He has high levels of credibility across all sectors and carries the respect to challenge everybody involved. The roadmap identifies three streams of change: changing systems and practices; changing staff behaviour; changing service user behaviour. To start with the third of these, changing service user behaviour and giving back control is key but, as other studies have found, 7 the service user s attention is often focused on the problems of service provision, and the change from looking at services to looking at outcomes is not necessarily easy for them. While in many respects what is being done is giving them back the control # HENRY STEWART PUBLICATIONS 1750^1679 Journal of Care Services Management V O L. 1 N O. 4 P P 3 5 3 3 6 1 357

Paley and Slasberg Self-assessment Responsibility of service users that should never have been taken away in the first place, it would be wrong to assume that it will happen naturally and with no need to support them through what it means for them. Thurrock Council wants to move to a model of delivering its commissioning work within the Community Care Act based on a model of self-assessment. This is based on an assumption that people can carry out their own assessments, but recognises that there will need to be graduations of support for those people for whom self-assessment is more challenging. This concept of selfassessment goes beyond providing basic information for the assessor to use, or a simple list of service demands. It asks service users to identify their issues and outcomes within a prioritised context. Of course, very few people will be able to respond to the challenge expressed that way; however, the Council s believes that once the task has been dejargonised it can be applied. The Council is working with service users to create a Do it yourself pack to help them to know what information and what thinking are required to satisfy a Community Care Assessment. If people self-assess and these assessments drive resource allocations, both the requirements of equal access to services and the legal requirements will need to be adhered to. Service users need to understand that outcomes are what the provider has to achieve, and it is their role to drive what needs to be done to meet that outcome. Service users will also be key sources of information for the purpose of monitoring the performance of providers and commissioning staff. There are some real challenges here. Changing systems and practices is obviously essential. The assessment and care management function has to deliver and deliver well. Thurrock Council has gone back to square one to ask questions about the business functions of assessment and care management (what is thought of as operational commissioning). The Council is starting with the assumption that assessing needs and risks, setting outcomes and deciding priorities is something people will be able to do for themselves. The task is to give them the support they need to do so and the framework for them to understand how their priorities fit within a wider context of the equitable deployment of public funds. The Council is looking at what skills are needed for this job and is thinking through what the right contribution of social work will be in this process. Social work is a skilled and valued job, but the Council is questioning whether the assumption that social work is the lead profession for the work is right. It may be the case that social work has a different contribution to make, perhaps as a service provider to meet outcomes in relation to behavioural or relationship changes and as a specialist assessment function. The Council will be redesigning the assessment and care planning process during the year ahead and developing the means of supporting it with redesigned quality assurance processes. 358 # HENRY STEWART PUBLICATIONS 1750^1679 Journal of Care Services Management VOL. 1 NO.4 PP 353 361

Implementing outcome-based commissioning In addition to these changes, there are a range of key operational processes that are also being reviewed and redeveloped: Developing key operational processes Risk management: this is looking at how providers will work on the management of risk with service users who exercise high levels of choice on a day-to-day basis. It is providers who will make decisions and it is expected that service users will push them to take risky decisions. A framework needs to be agreed within which to make these decisions. Fair access to care services: some people believe that outcomebased working is about higher levels of service and meeting lower levels of need. Thurrock Council is clear that it is not; however, what it does is to expose the complexity of the way in which risks are understood and assessed. Most councils, including Thurrock, now limit their eligibility criteria to critical and substantial. Thurrock Council needs to think through what this really means in practice when the service user is pressing for a lower level of needs to be met. Mental capacity: this way of working requires a high level of input from service users. People need to be very clear about how they behave when service users do not have mental capacity. The new act will provide the framework. How to cost outcomes: the basic task of the operational commissioning function is to agree outcomes and to set a price for meeting them. Current practice based on the commissioning task makes this easy. How should outcomes be costed though? The in-control process of allocating a level of resources according to dependency models is crude and very imprecise. It does not allow precise matching of resource allocation to budgets. There are some key issues to think through. How to construct the providers service user plan: these plans will need to set out how the outcomes will be met, but also allow the flexibility that is required. It requires considerable skill. A performance management system: systems will need to be agreed with the agencies that capture the key elements of performance. The performance needs to be monitored in quantitative terms, not just for resource accountability purposes, but also the extent to which service user outcomes are being met. The Council needs to be sure that providers are using the new flexibilities in response to the needs and wishes of service users and not in response to their own needs and circumstances. The Council plans to use the PAF Performance Indicator (based on the survey question) To what extent did the service respond to your wishes? as a key indicator. This has been built into the Local Area Agreement as it seems to be a good indicator of responsive person-centred services. It has the advantage of giving a benchmark against national performance and the Council s own performance. # HENRY STEWART PUBLICATIONS 1750^1679 Journal of Care Services Management V O L. 1 N O. 4 P P 3 5 3 3 6 1 359

Paley and Slasberg The third change stream is changing staff behaviour. This paper has already touched on these issues but the roadmap also highlights the following key points: Training Ownership of these changes: the Council has had and plans a number of ownership days; one was with council commissioning staff (strategic and operational), another was with providers and their chief executives. These days give the opportunity to share understanding and vision and give a common understanding of the challenges and the work that needs to be done to meet them. Similar days are being held with field staff. Participative workshops are also being held to do a lot of the redesign work. Member engagement: the Council s portfolio holder has been fully briefed and supports the work it is doing. The Council staff will be spending time with both the main political groups in Thurrock, to ensure that all members have an understanding of what is involved. Communication strategies: newsletters are used that go to staff in all agencies, not just the Council. Training: a great deal of specific training is required for both commissioning staff and provider staff. Commissioning staff need help in constructing and costing outcome-based care plans. Provider staff will need help in how to construct and deliver flexible service user plans. The intention is to ensure that the key managerial and supervisory staff, within each agency, have this training. It will be their task to ensure their teams develop the competencies to meet the requirements. This is based on the view that development takes place best within the working environment. CONCLUSION To conclude, Thurrock Council does not have outcome-based commissioning in place yet. It is part way through a major change agenda which requires all the components to be in place before the cultural shift can be made that allows it to say that it has. Staff at the Council do not believe that there are shortcuts. They have learned some important lessons so far and have plans in place to address them. They have set a direction that will come to fruition in 2008/09 and, meanwhile, are enjoying the challenges of the journey and the debates it brings, as they redefine what they believe good practice is all about. References 1. Qureshi, H., Patmore, C., Nicholas, E. and Bamford, C. (1998) Outcomes in Community Care Practice, Social Policy Research Unit, The University of York, York. 2. Commission for Social Care Inspection (2007) The State of Social Care, CSCI, London. 3. Care Services Improvement Partnership, available at: www.cat.csip.org.uk/ commissioningebook. 360 # HENRY STEWART PUBLICATIONS 1750^1679 Journal of Care Services Management VOL. 1 NO.4 PP 353 361

Implementing outcome-based commissioning 4. Commission for Social Care Inspection (2006) Time to Care, CSCI, London, October. 5. Department of Health (2006) Your Health, Your Care, Your Say, Department of Health, London. 6. Thurrock Council (2005) Outcome Based Commissioning of Home Care, Report of Pilot, Thurrock Council, Grays, April. 7. Turner, M. (1998) Shaping Our Lives Project Report, National Institute of Socal Work, October. # HENRY STEWART PUBLICATIONS 1750^1679 Journal of Care Services Management V O L. 1 N O. 4 P P 3 5 3 3 6 1 361