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Commissioning for Outcomes
27th and 28th September 2011
Commissioning:Evidence-Informed & Outcomes Focused09.30 Coffee and Registration10.00 Welcome and Introduction – Claire Lightowler (IRISS) and
Dee Fraser (CCPS)10.15 Introduction to the day10.20 Commissioning: context and framework10.40 Commissioning for outcomes11.30 Break11.45 Using evidence to deliver change in commissioning: tools and
case studies12.30 Lunch1.15 Outcome-based contracting2.15 Evaluating outcomes & group discussion3.00 Feedback and reflection3.15 Close
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Commissioning for Outcomes
Glasgow & Edinburgh
Liz Cairncross & Juliet Bligh
27th and 28th September 2011
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.ukEmail [email protected]
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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.
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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.
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Commissioning: context and framework
Context for commissioning social care
Ageing population: demand and workforce implications
Policy drivers− Personalisation− Prevention and early intervention− Outcomes− Financial and economic constraints
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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
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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
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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
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
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Joint commissioning model for public care (SWIA)
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?
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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
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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.
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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)
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Commissioning for Outcomes – An IPC Perspective
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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
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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
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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.
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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.
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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.
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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.”
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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.
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Discussion
Where have you got to in terms of commissioning for outcomes?
Is there a difference in progress between providers and commissioners?
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Using evidence to deliver change in commissioning: case studies and tools
Evidence informed commissioning
‘Taking a systematic approach to collectingand analysing evidence throughout thecommissioning process. By evidence wemean research, local data and evaluations.’
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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
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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
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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.
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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?
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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?
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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.34
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.
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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.
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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
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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.
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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
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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
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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
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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.
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Using evidence – Self-assessment
Pilot now mainstreamed across adult services
Targeted on those with low level needs.
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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/
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Discussion
What types of evidence do you use? What have you found helpful? Where are the evidence gaps?
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Developing an approach to outcome
based contracting
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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.
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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
providedStaff: Reduction in sickness levels No staff leavers Increase in staff satisfaction Increase in written compliments - no complaints!
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Developing an outcome based approach
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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.
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Identifying the specific roles for Providers & the Local Authority
Providers
Design services and support that will achieve outcomes.
Effectively monitor the achievement of outcomes.
Be able to provide evidence to commissioners that service is meeting outcomes.
Regularly evaluate and assess individuals outcomes.
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Some issues....
Care planning process does not readily encourage flexibility.
Some services are rarely rehabilitative or “Quality of Life” focused.
Care staff limited in the time they can spend with service users.
Balancing health and safety concerns and ‘risk’.
Service users reluctant to give up unneeded care.
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More issues...
Some services do not always see themselves in partnership.
Monitoring of contract arrangements is not always good.
Skill of care workers often unrecognised by contracts.
Contractual arrangements provide few incentives to providers.
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Developing an outcomes based
specification
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Developing an outcome based specification
“Outcomes-focused services … aim to achieve the aspirations, goals and priorities identified by service users – in contrast to services whose content and/or forms of delivery are standardised or are determined solely by those who deliver them.”
Social Care Institute for Excellence, 2007
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Outcome based contracting – the process
Process
1. Agree the desired outcomes.2. Describe why these outcomes are desirable.3. Define other required parameters, e.g.
timescales, limitations or boundaries of service, estimate of funding available etc.
4. Decide what methods will be used to deliver outcomes and determine what evidence is there that the methods will achieve them.
5. Describe measures for monitoring.6. Determine what resources required7. Write action plan.
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Issues to be tackled
It takes time and thought; people are used to defining services by quantity and content.
Who should be involved and at what stage in the process? What is the role of the commissioner?
New versus existing services. Making outcomes desired, achievable and
measurable (DAM outcomes). Payment by outcomes?
Hartlepool case study
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Hartfields Experience – Creating the Environment
Strong partnership. Early engagement on principles of
outcomes based contract. Starting with a ‘clean slate’. Care management ‘buy in’.
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Hartlepool Borough CouncilHartfields Experience - The Rationale for the Specification
Evidenced improvements in physical symptoms and behaviour and recovery from illness.
Evidenced improvements in physical functioning and mobility (rehabilitation) skill and confidence, and the prevention of unnecessary dependency.
Evidenced prolong periods of improved morale.
Feeling safe, secure and comfortable in their own home.
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Hartfields Specification – Service Level Outcomes
A service that can:
1. Contribute to the initial reduction of the levels of care and/or support previously received by the resident before entering the scheme.
2. Support the on-going care and support needs of its residents and reduce the likelihood of admission to long term care.
3. Contribute to the prevention hospital admission re-admission and enable early discharge.
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Hartfields Specification - Example Individual Outcomes
Support the on-going care and support needs of its residents and reduce the likelihood of admission to long term care.
“Maintain adequate diet that meets my nutritional needs and takes into account my diabetes”.
“To be able to access help if I need it”. “To have peace of mind during the day and
night that trained staff are nearby to help me if I am unwell, which will promote my physical and mental wellbeing”.
“To promote my physical wellbeing, mobility and independence”.
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Hartfields Experience – A Reflection
Be prepared to pilot the approach. Outcomes based contract no good without
outcome care/support planning. Plan time for transition from traditional practice
but ............... be prepared to take the plunge. Be sure to have all the ‘right’ people on board. Communication is key – care managers, provider
mangers, care staff and service user! Train and re-train all staff. Culture change doesn’t happen overnight. It might be hard but is worth doing. Contracting for outcomes is not a way of saving
money.
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Evaluating outcomes
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Evaluating outcomes
Allows outcome-based commissioning (potential contrast to needs based approach)
Supports monitoring and regulation of service performance
Allows better assessment of cost effectiveness
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Methods and Categories of Evidence
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Verifying Outcomes
Desired outcome Example measure
Reduction in medication Medication Records
Increase in exercise Activity charts
Reduction in challenging behaviour Incident forms
Access to new social / householdactivity
3rd party verification
Improved contact with family Self report or 3rd party verification
Increased involvement in running their home
Self report or observation by staff
Increased engagement in preferredactivities
Support plan, shift plans, diaries
Improved daily living skills Observation by staff, skillschecklist
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Measuring Outcomes – Example from Hartfields
Service Outcome – − Support the on-going care and support
needs of its residents and reduce the likelihood of admission to long term care –
Individual Outcome− “Maintain adequate diet that meets my
nutritional needs and takes into account my diabetes”
Baseline − Current meals, sugar content etc− Perception of how well their diabetes is
being controlled68
Example from Hartfields
Individual Outcome− “Maintain adequate diet that meets my
nutritional needs and takes into account my diabetes”
Evidence− Meal plans− Shopping lists− The clients view on how their diabetes
is being controlled− Where appropriate a GP view – directly
or indirectly− Carer perception and contact sheets
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Evaluating outcomes - Adult Social
Care Outcomes Toolkit (ASCOT)
Developed by PSSRU Breaks quality of life/well-being into 9 key
domains:− Personal cleanliness− Safety− Meals and nutrition− Activities/occupation− Control over daily life− Social participation− Home cleanliness and comfort− Anxiety− Dignity and respect
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Evaluating outcomes - Adult Social
Care Outcomes Toolkit (ASCOT)
Wellbeing is measured by asking people to rate their experiences using either interview or self-completion questionnaires.
An overall score is calculated by adding up the ratings in the 9 domains.
The effect of service use is measured by asking people to rate the quality of life they experience both currently with services, and expected quality of life in the absence of services.
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Evaluating outcomes - Adult Social
Care Outcomes Toolkit (ASCOT)
Thinking about keeping clean and presentable in appearance, which of the following statements best describes your present situation? − I feel clean and am able to present myself
the way I like− I feel adequately clean and presentable− I feel less than adequately clean or
presentable− I don’t feel at all clean or presentable
Do the support and services that you get from Social Services/provider help you to stay clean and presentable? − Yes, No, Don’t know
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Evaluating outcomes - Adult Social
Care Outcomes Toolkit (ASCOT)
Imagine that you didn’t have the support and services from Social Services/provider that you do now and no other help stepped in. Which of the following would then best describe your situation with regard to keeping clean and presentable in appearance?− I would feel clean and would be able to
present myself the way I like− I would feel adequately clean and
presentable− I would feel less than adequately clean or
presentable− I wouldn’t feel at all clean or presentable
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Evaluating outcomes - Adult Social
Care Outcomes Toolkit (ASCOT)
Pilot study of day care centres concluded that day care for older people is cost-effective.
Approach should be applicable to other social care services such as home care, residential care.
http://www.pssru.ac.uk/ascot/index.php
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Discussions
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Group 1
Reflect on your own organisations’ current arrangements for outcome based contracting across the “whole system”.
Where do you have the right conditions in place, where would you like to see more attention?
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Group 2
Discuss the issues and challenges that the IPC process for developing an outcome specification raises for you.
How may you address some of these?
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Process
1. Agree the desired outcomes.2. Describe why these outcomes are
desirable.3. Define other required parameters, e.g.
timescales, limitations or boundaries of service, estimate of funding available etc.
4. Decide what methods will be used to deliver outcomes and determine what evidence is there that the methods will achieve them.
5. Describe measures for monitoring.6. Determine what resources required7. Write action plan.
Group 3
Reflect on your experience of collecting evidence of service user outcomes.
What works, where have you found it difficult?
What would help you in this task?
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