Commissioning for Outcomes
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Commissioning for Outcomes 27 th and 28 th September 2011. Commissioning: Evidence-Informed & Outcomes Focused. 09.30Coffee and Registration 10.00Welcome and Introduction – Claire Lightowler (IRISS) and Dee Fraser (CCPS) 10.15Introduction to the day

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Commissioning for outcomes 27 th and 28 th september 2011

Commissioning for Outcomes

27th and 28th September 2011


Commissioning evidence informed outcomes focused

Commissioning:Evidence-Informed & Outcomes Focused

09.30Coffee and Registration

10.00Welcome and Introduction – Claire Lightowler (IRISS) and Dee Fraser (CCPS)

10.15Introduction to the day

10.20Commissioning: context and framework

10.40Commissioning for outcomes

11.30Break

11.45Using evidence to deliver change in commissioning: tools and case studies

12.30Lunch

1.15Outcome-based contracting

2.15Evaluating outcomes & group discussion

3.00 Feedback and reflection

3.15 Close


Commissioning for outcomes 27 th and 28 th september 2011

Commissioning for OutcomesGlasgow & EdinburghLiz Cairncross & Juliet Bligh27th and 28th September 2011


Institute of public care oxford brookes university

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.uk

    Email [email protected]


Institute of public care

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.


Purpose of today

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.


Commissioning context and framework

Commissioning: context and framework


Context for commissioning social care

Context for commissioning social care

  • Ageing population: demand and workforce implications

  • Policy drivers

    • Personalisation

    • Prevention and early intervention

    • Outcomes

    • Financial and economic constraints


Key policy documents

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


Why is commissioning important

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


Commissioning for outcomes 27 th and 28 th september 2011

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

11


Commissioning is a tool for

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


Commissioning for outcomes 27 th and 28 th september 2011

Joint commissioning model for public care (SWIA)


Discussion

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?


Barriers to effective commissioning include

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


Barriers to effective commissioning include1

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.


Resources

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)


Commissioning for outcomes an ipc perspective

Commissioning for Outcomes – An IPC Perspective


What do we mean by outcomes

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


What is meant by an outcome focused approach

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


National outcomes

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.

21


Strategic outcomes

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.

22


Service outcomes

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.

23


Individual outcomes

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.”

24


Outcome based purchasing

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.


Discussion1

Discussion

  • Where have you got to in terms of commissioning for outcomes?

  • Is there a difference in progress between providers and commissioners?


Using evidence to deliver change in commissioning case studies and tools

Using evidence to deliver change in commissioning: case studies and tools


Evidence informed commissioning

Evidence informed commissioning

‘Taking a systematic approach to collecting

and analysing evidence throughout the

commissioning process. By evidence we

mean research, local data and evaluations.’


A realistic balance of evidence sources

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


Skills for evidence informed commissioners

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


Using local evidence to target prevention and early intervention

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.


Using local evidence to target prevention and early intervention1

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?


Using local evidence to target prevention and early intervention2

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?


Using local evidence to target prevention and early intervention3

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.


Using local evidence to target prevention and early intervention4

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.


Using local evidence to target prevention and early intervention5

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.


Using national evidence money matters

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


Using evidence shared lives

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.


Using evidence shared lives1

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


Using evidence shared lives2

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


Using evidence self assessment

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


Using evidence self assessment1

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.


Using evidence self assessment2

Using evidence – Self-assessment

  • Pilot now mainstreamed across adult services

  • Targeted on those with low level needs.


Useful websites

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/


Discussion2

Discussion

  • What types of evidence do you use?

  • What have you found helpful?

  • Where are the evidence gaps?


Developing an approach to outcome based contracting

Developing an approach to outcome based contracting


Benefits of an outcome based approach for commissioners

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.


Why take this approach

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 provided

    Staff:

  • Reduction in sickness levels

  • No staff leavers

  • Increase in staff satisfaction

  • Increase in written compliments - no complaints!


Developing an outcome based approach

Developing an outcome based approach


Identifying the specific roles for providers the local authority

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.


Identifying the specific roles for providers the local authority1

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.


Some issues

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.


More issues

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.


Developing an outcomes based specification

Developing an outcomes based specification


Developing an outcome based specification

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


Outcome based contracting the process

Outcome based contracting – the process

Process

  • Agree the desired outcomes.

  • Describe why these outcomes are desirable.

  • Define other required parameters, e.g. timescales, limitations or boundaries of service, estimate of funding available etc.

  • Decide what methods will be used to deliver outcomes and determine what evidence is there that the methods will achieve them.

  • Describe measures for monitoring.

  • Determine what resources required

  • Write action plan.


Issues to be tackled

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

Hartlepool case study


Hartfields experience creating the environment

Hartfields Experience – Creating the Environment

Strong partnership.

Early engagement on principles of outcomes based contract.

Starting with a ‘clean slate’.

Care management ‘buy in’.


Hartlepool borough council hartfields experience the rationale for the specification

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.


Hartfields specification service level outcomes

Hartfields Specification – Service Level Outcomes

A service that can:

  • Contribute to the initial reduction of the levels of care and/or support previously received by the resident before entering the scheme.

  • Support the on-going care and support needs of its residents and reduce the likelihood of admission to long term care.

  • Contribute to the prevention hospital admission re-admission and enable early discharge.


Hartfields specification example individual outcomes

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”.


Hartfields experience a reflection

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.


Evaluating outcomes

Evaluating outcomes


Evaluating outcomes1

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


Methods and categories of evidence

Methods and Categories of Evidence


Verifying outcomes

Verifying Outcomes


Measuring outcomes example from hartfields

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 controlled


Example from hartfields

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


Evaluating outcomes adult social care outcomes toolkit ascot

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


Evaluating outcomes adult social care outcomes toolkit ascot1

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.


Evaluating outcomes adult social care outcomes toolkit ascot2

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


Evaluating outcomes adult social care outcomes toolkit ascot3

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


Evaluating outcomes adult social care outcomes toolkit ascot4

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


Discussions

Discussions


Group 1

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?


Group 2

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?

Process

Agree the desired outcomes.

Describe why these outcomes are desirable.

Define other required parameters, e.g. timescales, limitations or boundaries of service, estimate of funding available etc.

Decide what methods will be used to deliver outcomes and determine what evidence is there that the methods will achieve them.

Describe measures for monitoring.

Determine what resources required

Write action plan.


Group 3

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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