Putting the full range of services in place

Good practice examples

A different way of looking at service provision

The tiers of support

• Tier 1 The community and social inclusion
• Tier 2 Family and friends
• Tier 3 Specialist services
• Tier 4 24-hour care

Good practice examples

Reading - Development of independent tenancies

Bexley - Older people's commissioning strategy

Lincolnshire - Commissioning strategy

Surrey - User involvement in commissioning

Hull - Cost effective supported living

Kent - market mapping

A different way of looking at service provision

For some ideas about how to start looking at commissioning in a different way read the the Commissioning Module of the Making Ends Meet Toolkit which describes a scenario where an authority is trying to reduce its reliance on high cost independent sector placements. "You have in house residential services for older people that are considerably more expensive than independent provision"

Focusing only on the commissioning of what have been seen as traditional social and health care services has resulted in a top down approach with most attention spent on the high cost specialist service. Commissioning strategies for each adult service need to quantify the level of demand for low key services which will prevent breakdown and maximise independence. Failure to develop this sector will further exacerbate problems as demand for social care increases resources as more people live longer and people expect a choice of higher quality services.

Users and carers who talk to the Joint Review Team about their needs are anxious to retain the highest level of self sufficiency and independence, with some choice about the sort of services which they might use.

A 'one size fits all' sort of service is no longer acceptable, so it is important to work with users and carers in deciding the level and range of services that will be provided. Surrey have worked with users to involve them in some of the difficult choices about commissioning services, see good practice box, user involvement in Commisioning Surrey.

For most service users sustaining a life style that retains the key elements of:

• choice
• being able to participate in what is happening around you
• feeling safe in your own community
• receiving support to maximise independence

are the features which matter, not who provides it nor how much it costs.

Recent research by the Audit Commission supported by Age Concern has confirmed this. For more information about this and other recent related publications see the Audit Commission website

Traditionally social care professionals have seen their role as planning the specialist services they will provide without looking first at what is already there for everyone. It is better to start at the other end. This makes financial sense as well as meeting the aspirations of most service users. It is more helpful to consider how best to harness the low cost support potentially available in the community and reduce so far as possible the demand for high cost of care provided twenty-four hours a day and seven days a week.

Try to shift from a commissioning strategy that focuses on a series of services in isolation (exhibit 3):

To one that looks at a continuum of support, which considers needs and where they might be met first, before looking at the sort of services that might need to be provided (Exhibit 4).

Source: Joint Reviews

For more information about developing a commissioning strategy see the Commissioning Module. See also "All Our Tomorows: Inverting the Triangle of Care", ADSS and LEA 2003, where future services for older people are described in a more imaginative way.

The tiers of support (Exhibit 5)

Every authority needs to look at how by developing services at the lower tiers it can minimise the needs for high cost services at tier 4. Failure to develop services at tiers 1 and 2 may ultimately result in higher costs as more users need to be offered services at tiers 3 and 4. Many authorities are taking steps to move from a high level of institutional care to more community based services. For more on this look at the case study scenario in the Commissioning module: "You want to shift the balance of services for older people away from institutional to community based care"

Tier 1: The community and social inclusion: universal services:

Becoming old or disabled, or having a learning disability or mental health problem, should not deprive an individual from the right to access universal services in the community. So in planning social care provision in your area the first level of provision to consider is the universal services that everyone uses, shops, surgeries, leisure centres and clubs etc. How many current service users might not need more specialist provision if universal services were better prepared to understand the needs of all the local community?

Minimise the number of people using costly specialist services by making sure local community facilities are accessible and welcoming. You may be able to reduce the number of day care services you offer if local community resources can offer opportunities for social contact.

Universal services are already there funded through private enterprise, local government, charitable donations, fees and charges etc. The additional cost of making them more accessible is likely to be small and the benefits likely to have an impact on significant numbers of people. This is potentially high volume and low cost.

But once you've done all this work to develop local services you need to make sure the community and your care management staff are kept up to date with what is available and where. Users are often not accessing local services because the professionals involved in putting together their care plan do not know about them.

For more ideas on social inclusion within local authority services see 'Getting others to help- Developing the community'.

For more information about how you can use partnerships to promote community development see 'Partnership Module'

Tier 2: the Family and Friends

With an estimated 5.7 million carers in the country it is self evident that anything that contributes to supporting them in their role will reduce the need for professional support services.

If someone does require help, it is likely that they would prefer help to come from people they know and trust rather than from strangers.

Until recently most support to carers has offered little choice, mainly providing respite care, often in institutional settings, with little advice or service to carers themselves and limited recognition of the role friends and neighbours take within communities.

But patterns are changing, many carer organisations are providing services chosen by carers themselves, services to give carers a break are becoming much more flexible with a choice of options as to how this might be provided, Though there continue to be significant differences between different authorities in the numbers of respite nights they offer.

Develop your commissioning strategy to value the role of carers. Sustaining users in their own homes makes good financial sense. For example: an older person could stay in the community by supporting the carer; this may be cheaper than a residential placement.

Tier 3: Specialist Services

This refers to specific services, which may be provided at home or elsewhere on a short or long-term basis to meet identified needs. It includes occupational therapy, home care, day care, respite care, physiotherapy, district nurse, speech therapy, chiropody and of course the services of a care manager to assess and review changing needs

Social Services have traditionally seen these services as low cost high volume, but they can often be costly to run using highly trained and skilled staff. Make sure all current users are reviewed. Where needs have changed levels of service will change too, and should be focussed where universal services cannot be developed.

Have a look at some of your unit costs for things like day care and occupational therapy assessment. Are you having difficulties recruiting qualified staff for some of your services? With a national shortage of qualified and experienced staff in social care this is not a problem that is going to go away easily for many authorities, so imaginative solutions that focus these skills where they are needed have to be the way forward (See Exhibit 6)

Modernising existing day services is not necessarily cheap, so councils need to maximise opportunities to use resources that are there already. Less building based services will release capital assets, so maximum use should be made of the council's buildings which offer universal services and other buildings in the community. See "Getting others to help" in this module.

We all need things to occupy our day, which for most of us involves opportunities to earn a living, opportunities for social contact and opportunities to develop our interests in the community and in the home. Most users of social care services want to participate in their local communities in exactly the same way and some need more specialist facilities to enable them to do so.

Moving those people who can out of more dependant specialist services closer to mainstream leisure activities and employment will in the long term be the most cost effective route as well as satisfying the needs of users to live as normal a life as possible.

Day care is often now referred to as day services, reflecting a change, begun in learning disability services, away from building based 9 to 5 "day care" which once entered became a lifetime service which provided containment, social contact and some stimulation, into a concept of offering a range of services on different days of the week in different venues that maximise independence and offer tailor made activities to meet the needs of individuals.

This modernisation in day care is not always greeted with enthusiasm. For users and carers there are anxieties about loss of links with familiar people, fears about a reduction in the number of hours a user is away from home, levels of supervision off site, etc. For staff there are fears about working alone with users in the community, and about changes to working hours.

And providing customised services is not necessarily cheaper because;

• Smaller groups in the community still need adequate support and supervision.
• Care plans based on need and not service require staff who are able to be flexible and imaginative.

So

• focus on universal and community based services and make them accessible to your users,
• develop your employment services to make sure everyone who has or will have the capacity can get into employment,
• work with education to develop programmes that maximise independence and promote daily living skills
• focus your day services on those areas which others cannot offer
• review packages for those receiving day care regularly
• remember, day care does not have to be a service for life for everyone who receives it

A number of authorities have externalised their day services to specialist providers or to voluntary groups. For younger people with physical disabilities and mental health users, it is worth considering the possibility of user run services.

Tier 4: 24/7 Care

This refers to services that are high cost and low volume - hospital, nursing home, residential care or live-in carers - and should only be needed when 24 hour support is the only option. No amount of improvement at the lower tiers will avoid the need for some full time care.

Rethinking how you provide High Cost and /Higher Dependency Services

Not all users can be accommodated in the community and for some residential or nursing care as a temporary or a long term option is appropriate. Good commissioning strategies for residential and nursing provision which are used to underpin properly monitored contracts with service providers can keep costs down, ensure accessibility and maintain quality.

For more information see the commissioning module.

For an example of a commissioning strategy for older people see the Bexley Good Practice Box.

Lincolnshire have developed a commissioning strategy for older people which focuses on managing and growing a fragile market.

But make sure that in developing block contracts for residential provision you are not tying yourself into a commitment which you may not need in the long term as you develop your community based services.

If you are interested in developing joint commissioning arrangements look at the partnership module which gives you some dos and don'ts about how to make sure you start off on the right foot in setting up partnership discussions.

The joint review team regularly come across of examples of people who were placed in residential care at a time of crisis in their lives when 24 hour care was necessary, but who have made progress whilst there and are now ready for more independent living. Inadequate care management processes have means that the mechanisms to plan moves on into more suitable accommodation are not in place

The numbers of private residential and nursing care homes, particularly for older people, in some parts of the country is diminishing, and a number of authorities are finding this is presenting challenges in enabling them to meet their hospital discharge targets. Some authorities are working in a situation of home closures where available beds are reducing and, as with all scarce commodities, unit costs are rising. Kent County Council have done an analysis of the supply of residential and nursing homes locally to inform the council's strategy around the commissioning of new services to meet identified gaps.

Focusing on the short term solution of getting more beds without quantifying the level and nature of demand is an expensive solution. Consider whether disinvestment from this sector with good community based alternatives with a lower unit cost may enable you to provide services for more people by maintaining higher numbers in the community. For help in making such changes look at the case scenario in the commissioning module: "You want to shift the balance of services for older people away from institutional to community based care"

However shifting the balance may take time, and officers and members will need to recognise that there may be some double running of costs as new community-based services get off the ground.

In thinking about the numbers that will need this sort of service consider your population profile; the numbers of significantly older people who are likely to need specialist care; the numbers of severely disabled young people who will need 24 hour care. You also need to look at the numbers you currently have in very specialist placements a long way from their families (and quantify the costs, for you, in care managing this, and for the family, in maintaining contact).

How to reduce demand for 24 hour care, through developing a wider range of housing options

Failure to develop a range of supportive housing options puts pressure on your expensive residential and nursing care services. So focus first on making sure you are not providing 24 hour care to people who could become more independent.

Housing options for social care service users range between low levels of support at low cost, and high levels of support at very high cost (see Exhibit 7).

If social services can promote an increasing range of supported housing options it benefits both the customer and the service. It is worth considering options to support owner occupation, and private landlords as well as the traditional public housing sector

The Supporting People initiative is one way in which the government is trying to help local authorities achieve suitable housing provision.

Supported living has given some impetus to authorities to think more widely about the options and choices for people who need significant care and as a result a number of innovative projects like independent tenancies in Reading and Hull have developed.

See Getting others to help for some ideas about what authorities have done to better map housing needs and develop resources to meet these