APPENDIX A

Social Services Inspectorate

South East Region Group

Isle of Wight

Directorate of Social Services and Housing

Inspection of Best Value Review of:

Care Management and Commissioning

September 2001

Summary

1.1 The scope of the review was complex and comprehensive. Department of Health SSI standards across a number of services had informed the review (copies of which are attached to this report). Legislative and policy requirements were used as a framework. The review clearly identified options, gaps and scope for improvement.

1.2 The review had identified that whilst care management was making a positive contribution to promoting independence, there were also significant shortfalls in performance. Our fieldwork confirmed the findings of the review and service users themselves told us that they were dissatisfied with some aspects of the care planning arrangements.

1.3 In relation to the commissioning function, there were some indications that providers found the partnership arrangements were at present immature. There were few ongoing forums in which service development and contracting issues could be debated. Hence the contribution of providers could not be maximised.

1.4 Consultation was felt to be good by staff and partner organisations. Service users and their carers had been consulted but a strong culture of consultation and listening to them within the context of service development was not evident. This was an area for development.

1.5 The review was well researched and as a result comprehensive and well presented. We formed the view that this review would be a significant driver for positive change.

1.6 For these reasons we judged the service to be a ‘Fair’ 1 – star service which will definitely improve. This judgement is based on the evidence obtained during the inspection and is explained in greater detail in subsequent sections of this report.

1.7 The lessons in completing this challenging review were to be incorporated into future Best Value reviews as they roll out.

Inspection performance matrix

Recommendations

1.8 The social services department and housing directorate should:

· Establish mechanisms for involving health and other partners in the development of new approaches to commissioning and contracting.

· Explore with Members how they might wish to be more actively involved in the fieldwork stage of Best Value reviews.

· Ensure that existing users were clear about access points, the location of their care manager etc, following reorganisation and other changes flowing from the implementation of this review.

Introduction

1.9 The care management and commissioning service for adults embraced the assessment of service users, the construction of care packages, review, and the procurement of services from the private and voluntary sectors. The service as a whole increasingly worked closely with the NHS.

1.10 The Isle of Wight has a population of about 130,000 people with a particularly high proportion of people over 65 years. The population between 18 and 64 years was lower than most comparator councils and lower than the England average. At the time of the review, the council was run by an all party executive. The council had adopted a model of cabinet/executive committee with select committees undertaking the scrutiny role.

Background

1.11 The council’s Best Value Review Programme indicated an intention to review all major social care services. However, the programme was flexible and subject to change as the council moved towards a more thematic approach to reviews. At the time of this inspection (September 2001), the review programme appeared comprehensive with the year 1 (2000/01) topics of Care Management and Commissioning and out-of-hours services reflecting, inter alia, Joint Review Action Plan commitments, service plans and also the scale of review topics, capacity and workload considerations.

1.12 The Directorate’s Best Value review programme had started with how services for adults were made available, assessed, planned for, secured and arranged; subsequent reviews would look at the care services themselves.

1.13 We believed that there was a logic to year 1 reviews focusing on access, care management and commissioning arrangements, prior to reviewing specific care services in their own right.

1.14 The scope of the review was both complex and comprehensive and influenced by Department of Health Social Services Inspectorate (SSI) standards. The services were, therefore, reviewed against:

· national priorities and strategic objectives;

· cost and efficiency;

· effectiveness of service delivery and outcomes;

· quality of services for users and carers; and

· fair access.

1.15 The review clearly took account of both legislative and policy requirements.

1.16 As the review progressed, priority was given to aspects of the review with particular scope for improvement. In particular, the review focused on improving and ensuring a more accessible and consistent care management service.

1.17 In summary, the review looked at the following areas:

· arrangements for providing access to services for adults;

· assessment of need;

· care planning;

· review and maintenance of care plans;

· commissioning arrangements;

· contracting; and

· performance and equality of access.

BVR findings:

1.18 In relation to care management, five options were proposed including maintaining the status quo. The review clearly identified gaps and areas for improvement. These were reflected in four of the five options. There appeared to be a clear link between the findings of the review and the conclusions drawn.

1.19 Each option was clearly and succinctly stated and a Chartered Institute of Public Finance and Accountancy decision tool was used to support the options appraisal.

Quality of service

Are the authority’s aims clear and challenging?

1.20 As a direct result of the review, the authority had substantially revised the aims and performance standards for the care management service. It had also established the way in which it planned to enhance the performance of the commissioning and contracting service. The review challenged existing arrangements for these services in a rigorous way and this had clearly led to a challenging change agenda.

Does the service meet these aims?

1.21 The Performance Assessment Framework data indicated that care management was making a positive contribution to promoting independence. However, the review itself identified significant shortfalls and our fieldwork confirmed these difficulties and inconsistencies in the care management process. Service users themselves told us that they were dissatisfied with some aspects of the care planning arrangements.

1.22 In relation to commissioning and contracting, there were some indications that providers found partnership arrangements immature. There were few ongoing forums in which service development options could be debated at an early stage; hence their contribution could not be maximised.

1.23 The service did not currently meet the aims and standards that had been established by the review process. However, an ambitious improvement plan had been approved by councillors, the purpose of which was to deliver significant improvements in the cost and quality of services over time.

· Consultation

1.24 The consultation phase involved a wide range of stakeholders and a variety of techniques were used. These included workshops, conferences, questionnaires and contact with service users, carers and their representative groups. Consultation was also supported by the Rural Community Council and private sector care providers.

1.25 In terms of user consultation, 275 users were contacted, resulting in a 46 per cent response rate.

1.26 Headline results included:

· 95 per cent of respondents were satisfied that they were contacted quickly (but expectations could possibly be low);

· 93 per cent of respondents felt aware of and involved in their assessment;

· Of a group of former service users asked why they had stopped their service, 50 per cent said that charges were the main factor.

1.27 Other stakeholders consulted, through a variety of means, included:

· Voluntary sector organisations;

· Independent service providers (both in relation to care management and commissioning and contracting);

· Staff ;

· Primary Care Group;

· Hospital based services;

· Community nursing;

· The views of councillors were sought; and

· The Isle of Wight Joint Registration and Inspection unit.

1.28 The views of consultees were clearly summarised and systematically recorded. There was evidence of a link between issues raised and the action plan.

1.29 Consultation needed to become embedded in the day to day business of the care management service. In particular, front line staff should be empowered to consult service users and carers on an on-going basis. This could assist with monitoring service quality; it could also provide a channel for users and carers to influence service developments.

How does its performance compare?

· Comparison

1.30 The care management service was described clearly and it was noted that while referrals to the community team were declining, care management activity is increasing, by 3.5 per cent per year between 1998-2000. The budget for the care management function was £1.25m.

1.31 Equally, the commissioning and contracting service were clearly described in terms of activity. The contracting service, which supported commissioning, cost £110k per year.

1.32 In terms of care management, the Directorate had compared itself with a number of authorities selected for a variety of reasons. For example, Torbay because it was arguably the Isle of Wight’s most comparable council; North Lincolnshire because of an exceptionally good Joint Review. Wider national comparisons were also made through the use of PAF data.

1.33 The Directorate has set Best Value objectives which would place it among the top 25 per cent of unitary council performances by 2004.

1.34 A time and work study was also undertaken with Portsmouth City Council and cost comparisons with other unitary authorities appeared favourable.

1.35 Cornwall County Council was also approached for information because they were perceived to have a different approach to care management which led to high standards and positive comments from a Joint Review inspection. Ultimately, the standards set by Cornwall strongly influenced target setting for the Isle of Wight.

1.36 The Directorate concluded that national comparators showed care management and commissioning arrangements for adult services are delivering a shift towards supporting people in their own homes. Furthermore, bench marking against high performing councils such as North Lincolnshire and Cornwall was a means of setting challenging improvement targets.

1.37 The review report noted that the contracting team had a set of service standards based on ensuring a prompt response to stakeholders with regard to contract management; monitoring demonstrated a high level of compliance.

1.38 We concluded that in relation to care management, the comparison phase of the review highlighted both areas of strength and development and that stretching improvement objectives have been set as a result. However, targets lacked associated performance measures - a weakness of the improvement plan.

The review process

BVR Methodology:

1.39 The Best Value Review report evidenced a comprehensive and recognisable approach which followed the 4 C’s (challenge, compare, compete and consult) in an iterative way. The review made use of a wide range of appropriate methods (examples; surveys, benchmarking, case work audit etc), considered a number of improvement options, and the final report reflected both the rigor and clarity of thinking and evidenced internal consistency and sound use of data.

Terms of reference/objectives:

1.40 As already noted, the scope of the review was broad and comprehensive, account was taken of legislative requirements and the rationale for including care management and commissioning in the year 1 programme was well made. The council also made use of relevant SSI inspection standards (standards that are deemed to represent ‘Best Practice’). The limits of the review were also clear.

1.41 In our view, the objectives of the review could have been expressed in more explicit and measurable terms; we understood that this observation will be taken on board with respect to future reviews.

Review team:

1.42 A project team supported and advised the review. The membership of this team included a range of representatives of the directorate, the health authority and the community health council. There was also an appraisal group comprising councillors and trade union representatives.

1.43 The skill mix of the review team appeared reasonable and there was a mix of genders. Improvement options were taken to the project team for consideration.

1.44 A corporate Best Value facilitator contributed to the review process.

Other resources:

1.45 The European Foundation of Quality Management (EFQM) model was used as a supplementary resource. It appeared that the council had collaborated appropriately with Portsmouth City Council who undertook a review of care management at the same time.

Joint working arrangements:

1.46 Representation from health appeared to be strong and this should ensure ownership of the recommendations for change.

Sampling:

1.47 275 users were sent questionnaires and 111 case files were audited. Questionnaires were sent to a structured sample selected on the basis of the population profile. However, consultation also included contact with a range of representative organisations and other stakeholders.

1.48 Elsewhere in this report we have commented on the need to build consultation into the day-to-day business of the care management process. In this context, it will it be important to ensure that disempowered and socially excluded groups, such as members of minority ethnic communities and people with sensory impairments, are not overlooked because they are small in number or hard to reach.

Will the service improve?

Does the BVR drive improvement?

· Challenge

1.49 The review established that both care management and commissioning and contracting were core strategic activities. On that basis, the challenge phase concentrated on how well these functions were operating and the scope for improvement. In relation to care management, SSI standards were used to ensure a focus on improvement.

1.50 In terms of mapping need, and how this translated into demand for care management services, the review demonstrated that key influences, such as demographics, had been appropriately taken into account.

1.51 An audit of care management practice was undertaken in 1999, and the Best Value review followed this up with a new audit of recording based on 111 case files. This process revealed that many basic weaknesses identified in the 1999 audit were still in evidence.

1.52 The challenge phase resulted in a comprehensive gap analysis, both in relation to care management and commissioning and contracting.

1.53 The potential for integration of care management with health had been considered but deferred and will be re-evaluated in 2001 as the more specialised adult services teams developed. It will be important to revisit this periodically, given the NHS Plan, health act flexibilites and the Health and Social Care Act 2001.

1.54 The report identified many areas of weakness revealed by the challenge phase and these are picked up in the action/improvement plan.

1.55 We concluded that the challenge phase of the review had been conducted with rigor and candour and had resulted in the identification of a number of areas for improvement.

· Compete

1.56 The review noted the potential to transfer commissioning to health partners and such changes were already taking place on the Isle of Wight in respect of mental health services. Care management for mental health had also been transferred to Isle of Wight Healthcare NHS Trust.

1.57 With respect to contracting, the review report indicated that the Primary Care Group (PCG) and the council considered, and rejected, the notion of the council’s contracting function joining that of the PCG. It was felt that few efficiencies were likely to result from such a move in the immediate future.

1.58 The potential for new partnership arrangements under the Health and Social Care Act 2001 was noted.

1.59 In summary, competitiveness had been considered only in the context of partnership approaches with health. There had not been any form of market testing which might, for example, interest voluntary organisations.

How good is the improvement plan?

Improvement plan:

1.60 The plan set ambitious targets for improvement which were much needed and were practical.

1.61 In summary, the improvement plan was organised under the following themes;

1) Improvements in access to services, information and care;

2) Improvements in arranging and purchasing care;

3) Development of more consistent care management and working;

4) Timely and responsive services through differentiation between complex and less complex assessment and services;

5) Improvements in eligibility criteria and other key information;

6) Development of performance management and service standards;

7) Improvements in job satisfaction and workload management; and

8) Development of links with key healthcare providers.

1.62 The plan contained 42 action points; there was evidence of a degree of prioritisation. In our view, the plan addressed the vast majority of issues raised in the review.

1.63 The plan also clearly identified responsibility for action and set time frames. However, a weakness was that performance measures were not clearly spelt out.

1.64 We noted that while most of the plan was to be financed from within existing resources, a substantial investment in information technology, equipment and systems was required. The need to consider the ways systems interface with health information systems should be pursued as new systems are developed.

Monitoring:

1.65 The council had established a monitoring process to check and monitor progress of Improvement Plans. The Social Services and Housing Select Committee would require regular update and reports of the conduct of each Best Value Improvement Plan. This had been noted in the public record of the Select Committee.

1.66 Regular monitoring and update on progress would ensure that momentum was maintained and that any necessary changes would be introduced in the light of changed circumstances.

Will the authority deliver the improvements?

1.67 There was an urgent need to feedback to users and their carers the results of the review. This was key to ensuring support for the improvement plan and would also encourage participation in future Best Value reviews.

1.68 We considered the plan had the potential to drive improvement. Councillors had approved the report and were committed to the proposed changes.

1.69 Leadership, commitment, innovation and energy were needed to implement the plan successfully. Given the financial pressures faced by the Directorate at the time of this inspection, there were concerns about management capacity to drive change. This was especially so as Directorate lacked the infrastructure typically found in larger authorities.

1.70 Overall, we felt that the improvement plan would be delivered and that the service would change and improve.

1.71 The production quality of management information to provide evidence of performance is increasingly important. This will enable the council to demonstrate its ability to deliver services, whilst providing the ability to improve options for service delivery. An IT system designed for this purpose was essential.

STANDARDS AND CRITERIA

STANDARD 1: COMMISSIONING STRAGEGY

The SSD understands the market and has prepared a strategy for commissioning services to meet anticipated need.

Criteria:

1. The SSD and its partners collect and analyse information about social care needs, services, providers and resource allocation, both current and projected.

2. The SSD is mapping the market and using information on demand and supply.

3. The SSD has prepared a written commissioning strategy – which deals with de-commissioning.

4. The strategy applies equally to all sectors of provision, including in-house services.

5. The SSD has a strategy for providing the information required for commissioning decisions.

STANDARD 2: WORKING WITH OTHERS

The SSD’s commissioning arrangements are part of a multi-agency approach to the purchase and provision of social and health care.

Criteria:

1. Commissioning arrangements are integrated with community care planning processes.

2. The commissioning strategy was prepared with partners and existing and potential stakeholders, including users and carers.

3. Formal protocols exist which delineate the individual and joint responsibilities of each agency.

4. Multi-agency forums and processes influence the commissioning of social and health care.

5. The SSD engages all providers in determining its commissioning strategy with an open and even-handed approach.

6. The SSD encourages and sustains providers who develop innovative and creative services to meet identified need.

7. Community Care Plans demonstrate that services are commissioned and adapted to meet identified need.

STANDARD 3: RESPONSIVE COMMISSIONING

Care plans are implemented to meet assessed needs and changes to care needs are identified and responded to.

Criteria:

1. Care plans specify objectives to meet individual assessed needs.

2. Service users and carers are sufficiently well informed and supported to influence both their assessment and subsequent care.

3. The SSD promotes user choice through its contract agreements.

4. Care managers have the flexibility to purchase innovative care packages.

5. The SSD has considered arrangements for making direct payments.

6. Arrangements are in place to monitor changing individual care needs.

7. Arrangements are in place to review care packages at appropriate intervals.

8. Required changes to care packages identified through monitoring and review are implemented without unnecessary delay.

STANDARD 4: RESPONSIVE SERVICES

Commissioning arrangements result in responsive services for users and carers.

Criteria:

1. The combination of services provided to individuals meets the needs agreed through assessment, monitoring and review.

2. Commissioning decisions to not inhibit the responsiveness or flexibility of services provided.

3. Choice of provider is determined by need and informed user preference rather than unreasonable organisational constraints.

4. Service users and carers experience a co-ordinated approach to the provision of their care.

5. Services provided meet the SSD’s specified quality standards.

6. Services are available ‘out-of-hours’ where the need is identified.

7. Services provided encourage independence and seek to reduce dependency.

STANDARD 5: EQUITABLE PROVISION

All sections of the community have access to services appropriate to their specific needs.

Criteria:

1. A range of services is available to meet the diverse needs of service users and their carers.

2. Monitoring arrangements are in place to ensure that services are reaching all potential user groups.

3. Where appropriate, the SSD encourages and supports the involvement of community user-led organisations in the social care market.

4. The SSD works with neighbouring authorities to develop viable and appropriate services for particular groups of service users and carers whose numbers are small.

5. The SSD ensure that service users and carers are treated fairly and with respect by all providers.

6. The SSD takes responsibility for progressing equality issues in both in-house services and those it commissions.

7. The SSD has a clear strategy and approach to ensure racial equality in the commissioning of community care services.

8. A range of service users and carers participate in community care service planning and monitoring.

9. The SSD has identified the responses it needs to make to the Disability Discrimination Act.

STANDARD 6: ORGANISATION ARRANGEMENTS

The SSD’s organisational arrangements support the implementation of the commissioning strategy.

Criteria:

1. The SSD’s organisational structure can deliver the commissioning strategy.

2. Contracting arrangements are effective and efficient.

3. The SSD’s payment processes are reliable and timely.

4. There is effective communication between the staff relevant to the commissioning processes, including those with responsibility for inspection.

5. There is clear management accountability for budgets, with financial and managerial responsibility aligned as closely as practicable and supported by robust systems.

6. Commissioning staff are trained and resourced to undertake the tasks they are expected to perform.

7. Commissioning staff understand and consistently apply SSD policies and procedures governing financial transactions.

8. Commissioning staff’s decision making is informed by the use of relevant and timely information.

STANDARD 7: BEST VALUE

The SSD strives for Best Value in the social care services it purchases and provides.

Criteria:

1. Choices offered to service users and the choices made, and identified gaps in service are recorded in order to influence future service development.

2. The SSD collects a range of appropriate management information to evaluate whether services are value for money.

3. Commissioning services are evaluated against the achievement of desired outcomes and customer satisfaction.

4. Quality of service is ensured through inspection and contract monitoring.

5. Service development plans are informed by measures of best value.

6. Identifiable changes to services have resulted from user and carer consultation.

7. Commissioning decisions are informed by the results of contract monitoring, care planning, inspections and complaints procedure.

8. The respective roles of contract staff, care managers, inspectors, service users and providers in service improvement are clear.