Context

Bexley's Institute for Public Finance comparator group is Hillingdon, Redbridge, Havering, Enfield, Sutton, Merton, Hounslow, Harrow, Kingston upon Thames, Croydon, Barnet, Bromley, Richmond upon Thames, Barking & Dagenham, Waltham Forest. Bexley is a London Borough bordering Greenwich and the River Thames in the north, Kent to the east and Bromley in the south. It has a population of around 218,000, with an increasing number of older people over 85 years. Although less deprived than the English average, higher levels of deprivation exist in the north and south extremities of the borough.

Bexley local authority boundaries are coterminus with the community health commissioner and provider, Bexley Primary Care Trust. It previously shared its Health Authority with Bromley and Greenwich, but from April 2002 is part of the new South East London Strategic Health Authority, with Lambeth, Lewisham and Southwark authorities.

Over the 20-year period for 1991-2011 it is predicted that there will have been a 53% increase in the population over 85 years, although the rate of increase slows to 9.8% for the period 2001 to 2011. 10% of the population in Bexley are disabled, (21,800) 36% of which are aged 16-64 years (7,850). Approximately 870 of these adults require a high level of assistance in daily living activities. Estimates by the London Research Centre in 1999 suggested 8.7% of the Bexley population would be of the black and ethnic minority placements in 2001 (19,085 people) rising to 29,697 (13.5%) by 2011. The age structure of Bexley's population is similar to the national profile but with a 9% increase in the very elderly, 85+ group, projected during the next 10 years, there are predictable pressures on community care services.

A commissioning strategy for older people

A key driver for developing the commissioning strategy was the concurrent but separate transfer of the Council's home care and residential home service for older people to the independent sector. This was consistent with the recommendations of the Best Value reviews of these two major services - a process which involved careful projections of service demand, the impact of demographic trends, market testing, options analysis, cost/benefits and, most importantly, detailed consultations with all stakeholders.

These disciplines continued to inform the process of constructing a broader commissioning strategy around these, the two largest services, within the full range of community provision for older people.

The commissioning methodology ensures monthly monitoring of the components of the strategy, weighing up the implications of investments in specific service areas against savings in others and addressing the imperative of refining care packages to more closely match the assessed needs of older people.

Benefits

The combining of hard data (service demand trend-lines, volumes, and benchmarking/unit costs with softer data (professional opinion from multi disciplinary assessment and placement panels, user satisfaction surveys, complaints/compliments and consultation/feedback) are particularly strong features of the commissioning model.

Their systematic consideration in joint commissioning and contract monitoring meetings ensures that the strategy is a living document, an integral part of the quality assurance and performance management systems of the statutory agencies and of the business plans of the provider organisations.

Click here for full PDF version of the commissioning strategy

Context

Cambridgeshire's comparator group consists of Warwickshire, Gloucestershire, Oxfordshire, Wiltshire, Worcestershire, Leicestershire, Bedfordshire, Cheshire, Suffolk, Northamptonshire, Hampshire, Staffordshire, Shropshire, Derbyshire and Somerset.

In recent years, Cambridgeshire has experienced the highest rate of population growth of any county in the UK, and this is expected to continue. The population of 557,000 is expected to grow by about 7,000 by 2006. The largest percentage increase is projected in those aged over 85 years, where growth of 23 per cent is forecast for the 10 years up to 2006, the highest in the Country, with a significant impact on the demand for social care and healthcare.

The economy is buoyant and the County is not judged to be deprived overall. Full employment and high house prices especially in Cambridge make it hard to recruit and retain staff in social services.

The minority ethnic community is expected to be higher once the 2001 census is published. Children from minority ethnic groups now account for 10 per cent of children in need and are over represented on the Child Protection Register.

Use of commercial expertise to help shape the market

In partnership with providers, Cambridgeshire commissioned an independent consultant, Laing and Buisson, to research and advise on the cost/price structure of the local market for social care. The research was done and as a result different levels of funding were agreed that reflect local market differences within Cambridgeshire.

Benefits

Capacity has expanded or been retained where it might have declined.

Delayed transfers of care from hospital have improved.

Providers appreciated the shared approach to understanding their costs and pressures, though some tensions remain with the residential and nursing home sector, who feel that the Laing and Buisson recommendations were not fully implemented.

Home care providers are very positive about the agreement reached on the formula for annually updating rates, which recognises pay and inflation rates in the market.

Independent providers, through the Independent Service Providers Consultative Committee, worked with the Authority to develop a purchasing strategy. Providers also appreciated the time, effort and degree of consultation involved in drawing up service specifications.

"They really are partners."

home care provider

Context

Leicestershire's Institute for Public Finance comparator group is Bedfordshire, Cambridgeshire, Cheshire, Derbyshire, Gloucestershire, Hampshire, Northamptonshire, Nottinghamshire, Oxfordshire, Shropshire, Staffordshire, Suffolk, Warwickshire, Wiltshire and Worcestershire.

In April 1997 Leicester City and Rutland were made unitary councils leaving Leicestershire County Council to control the remaining seven district councils in the County. The population of over 600,000 live in what is, overall, an affluent area. There are, however, areas of considerable variation. Within Leicestershire there are ex-mining areas undergoing regeneration; Rural Development Areas; urban areas with sizeable ethnic minorities; traditional university and market towns; as well as suburban overspills from the City of Leicester. Local deprivation is considered to be low in comparison with similar authorities.

Leicestershire Residential Childcare Commissioning Strategy

Over the last 3 years, Leicestershire County Council Social Services Department has let contracts to 3 separate providers to provide both mainstream and respite residential children's provision.

It was essential to ensure that any external providers were prepared to take children and young people with the same degree of challenging behaviour as the authority's in house-units.

This was achieved by:

• Building in a penalty clause so that if any admissions were refused, the price of a bed per week would be deducted.
• Writing into the contract that it could be ended by either party by giving 12 months notice, even if there was no breach of contract.
• Ensuring that potential providers were fully aware of the types of young people we would be seeking to place.

Benefits

• Fixed Costs. The only additional annual cost to the contract is inflation.
• Any other additional costs have to be borne by the provider.
• The property is owned by the provider not the Council so neighbourhood issues become one step removed from the Council.
• The contracted units are part of a wider network of provision which is beneficial when negotiating spot purchases.
• The providers' ideas about how the service can be provided have enhanced the quality of the service to young people.
• Average occupancy in Leicestershire's 7-bedded units is around 70 - 80%. In the smaller units it has been in the high 90s.
• Small units did mean higher unit costs but the gap between the two sizes of provision has narrowed over the duration of the contract.
• If the contract hits difficulties the Authority will only have to live with the contract for 12 months at the most.

Context

Leicestershire's Institute for Public Finance comparator group is Bedfordshire, Cambridgeshire, Cheshire, Derbyshire, Gloucestershire, Hampshire, Northamptonshire, Nottinghamshire, Oxfordshire, Shropshire, Staffordshire, Suffolk, Warwickshire, Wiltshire and Worcestershire.

In April 1997 Leicester City and Rutland were made unitary councils leaving Leicestershire County Council to control the remaining seven district councils in the County. The population of over 600,000 live in what is, overall, an affluent area. There are, however, areas of considerable variation. Within Leicestershire there are ex-mining areas undergoing regeneration; Rural Development Areas; urban areas with sizeable ethnic minorities; traditional university and market towns; as well as suburban overspills from the City of Leicester. Local deprivation is considered to be low in comparison with similar authorities

Commissioning agency placements

Leicestershire is relatively well provided for in terms of children's residential beds. With regard to disabled children, however, the Authority has only residential respite provision, so full-time looked after children who need residential care have to be placed in agency placements.

The process for agency placements:

• Leicestershire has a dedicated Placements Officer who is responsible for making all residential placements (with contracted providers, in house and on a spot purchase basis).
• Agency placements can only be made following the agreement of a multi-agency Placements Review Group, which includes representation from Health and Education.
• Following that agreement, the Placements Officer will identify a placement.
• No children are placed before the proposed placement has been checked by the Placements Officer. This includes a visit, contacting the local National Care Standards office and obtaining references from other social workers who have children placed there (our checking procedure for the visit can be supplied). The Authority also has an agreement with Leicester City Council for reciprocal checking.
• Leicestershire has a standard contract which is negotiated and agreed by the Placements Officer prior to a placement. 'Extras' can only be agreed by the Placements Officer.
• The Placements Officer will liaise with the providers throughout the length of the placement (this additional support has avoided unplanned placement breakdowns, thereby reducing further costs).
• Contract compliance is monitored by the Placements Officer via the allocated social worker and/or directly with the provider.

Benefits

The emphasis on developing protocols relating to commissioning agency placements has been to focus on safeguarding children while at the same time ensuring value for money

Context

Lincolnshire's Institute for Public Finance comparator group is Cornwall, Cumbria, Derbyshire, Devon, Gloucestershire, Norfolk, North Yorkshire, Northumberland, Nottinghamshire, Shropshire, Somerset, Suffolk, Warwickshire, Wiltshire, and Worcestershire.

Lincolnshire is a large, mainly rural, county with a widely dispersed population. Services for Older People are lead by the Head of Strategic Modernisation, who has responsibility for the integration of health and social care services delivered through the three area offices and coterminus primary care trusts.

Developing a commissioning strategy

Lincolnshire began to produce annual service plans for their 3 older people's areas about 3 years ago, which set out their priorities and purchasing intentions. These plans were produced in consultation with key stakeholders and widely distributed. In 2002/3 the Authority produced its first county-wide commissioning strategy for older people.

Lincolnshire have learned from the process of developing their commissioning strategy:

"it's not rocket science; you just need to begin and you will find it all starts to come together."

"Don't wait until you think you have got all of the information that ought to be in it and don't be tempted to keep putting it off! We know that there are gaps in ours but that doesn't mean that it's not a valuable document that people can and do use."

The Authority has asked for feedback on what is helpful and how they can improve it. These suggestions will be built into the next document.

Benefits

Producing the strategy helped to:

• make sense of the plethora of national and local priorities and guidance for older people
• bring together the key information that service providers and staff need to understand the direction of travel for older people's services over a 3-year period
• instil discipline into the planning process
• enable the Authority to plan for the present and future and how their market management strategy needs to change to ensure that they can secure those services without destabilising a fragile care market

Contact: Sharon Cuffs, Strategic Commissioning Manager, Sharon.cuff@lincolnshire.gov.uk

Context

Flintshire is located in the north eastern corner of Wales bordered by the counties of Wrexham, Denbighshire and Cheshire, and sharing a river boundary with Wirral along the River Dee. It is the most populous and densely populated county in North Wales with around 148,594 (2001 Census) people living in an area of 438 square kilometres. Flintshire was traditionally an industrial economy with coal, steel and textiles forming the mainstay. Agriculture and tourism are the other main sources of employment. The decline of these industries in the early 1980s led to unemployment levels of up to 20 per cent. There has, however, been a dramatic recovery in the last 15 years with the development of indigenous, small- and medium-sized businesses alongside inward investment. Flintshire's economic profile now has more in common with the North West region of England than the rest of Wales. Unemployment levels are below the average for both Wales and the UK, and the average wage is higher than the Welsh average. This makes it one of the least deprived counties in Wales although there are a number of small pockets of deprivation at ward and sub-ward level

Flintshire Home Care Brokerage

Flintshire employs two Community Care Brokers who act as a link between social workers/ care managers and domiciliary care providers (both in house and independent sector). The two brokers arrange all Flintshire's spot contracts for domiciliary care. Care managers requiring domiciliary care to fulfill a care plan contact the brokers with their request and the brokers then use their database to determine which provider has capacity to meet the request in that locality. The database has information about provider activity across the County so can also identify which providers are operating in particular areas. Providers regularly provide information to the brokers to ensure that the database is always up-to-date. The scheme started as a six month pilot in early 2002 and has now been adopted as the method by which Flintshire spot contracts domiciliary care.

The brokerage model was already in use in the London Borough of Camden and it was agreed that a similar system of working could be tailored to meet the needs of Flintshire County. Consultation meetings were held with both independent and in-house providers of domiciliary care. The meetings were used to gather vital information about how agencies worked and where they wanted to see improvements or changes in the way that care is purchased.

Additionally, areas and locations of care packages were also mapped to create a database of the location and general spread of the agencies and where they were currently working. This information was transferred to a large map that gave a very clear indication that there was no underlying logic to how the market had developed and where providers were operating. For example, in one sheltered housing block there were five different agencies operating.

Benefits

From a care management point of view, the amount of time spent arranging packages of care with agencies has been considerably reduced and this in turn has assisted staff to work more actively on increased assessments and providing added support to service users.

From a provider point of view, the management of domiciliary care has been more organised and systematic, traveling time and mileage costs have been reduced. Positive comments have included that the brokers have been a constant point of contact that have assisted agencies to resolve issues quickly or to alert more senior SSD staff to particular difficulties thereby assuring a speedy response. The time saved by Operations Managers has allowed them to work more productively with their core business and, for most, this has increased productivity. The scheme also led to an increased provision of half hour units of service by independent sector providers.

The scheme enabled collation as essential statistical information to assist the authority to manage the market better. The brokers maintain an activity database to monitor and report on the number and source of requests for care and monitor the type of requests such as new packages, increases in existing packages, decreases in existing packages and transfers of care, hospital admissions etc. This information is shared not only with Commissioners, managers in Social Service Department but also with providers to assist in their business planning process.

The scheme has recently been expanded to include bed mapping of residential/nursing and day care placements.