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Commissioning Review: Core Service Offer. Agenda Item 5. Objectives. To review core service offer across universal, targeted and specialist tiers To improve outcomes To identify efficiencies and cost reductions To pursue total place thinking

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Objectives
Objectives

To review core service offer across universal, targeted and specialist tiers

To improve outcomes

To identify efficiencies and cost reductions

To pursue total place thinking

To seek opportunities available through partnership working


Principles
Principles

Pragmatic and time-limited

Needs focused and whole system thinking

Green-field approach

Challenging – back to basics

Searching for minimum offer – to be supplemented with service add-ons where budgets allow or political priorities require


Radical efficiencies
Radical efficiencies

  • Different, better, cheaper

  • Radical efficiency turns the role of provider on its head – no longer solution ‘deliverers’, but pioneers of a new type of public service, asking difficult questions about who they are trying to serve and what they are trying to achieve

  • Services will look different in different areas

  • Radically efficient systemic reform moves from being desirable to being purposeful, pragmatic and urgent

  • Embedding radical efficiency at the heart of a new approach to public services would require a fundamental reshaping of accountability frameworks, funding sources and allocations; understanding of risk and of shared values

  • Better together – for radical efficiency to be possible, integration has to be a habit and an instinct, not a behaviour forced into being by financial reward or legislation

  • The Innovation Unit 2009


Approach
Approach

Project Scoping

Needs Analysis

Service Analysis

Policy Review

Options + Costings

Conclusions

SUM Interviews

Questionnaires

Workforce requirements

Policy review to identify statutory requirements

Service Mapping

VFM and Impact

Identification of core functions

Configuration to core functions

Scope for integration

Resources: Reshape, Recycle or Released

Universal Under 5, Early Intervention and Complex

DMT review

Political consideration

Decisions on selected transformation

JCG Workshop

Develop Approach

Project Initiation

JSNA Review

KPI Analysis

Service Specs

Agreed scope Service Transformation

Proposed Future Model

As Is Picture

Needs confirmed

3 Projects


Needs analysis conclusions
Needs analysis conclusions

  • Research from JSNA, services specifications, KPIs

  • Confirms current needs analysis still appropriate to inform service planning

  • Suggests further scope to strengthen the impact of services – particularly at the targeted tier

  • Needs analysis has been used to underpin the review of the core offer


Proposed strategic direction
Proposed Strategic Direction

Locality Model

Multi-Agency Teams

Step 2: Over next 12-36 months meet some complex needs earlier

Push Down

Step 4: Achieve Further Savings

Improve Outcomes

Step 3: Reshape early intervention services on an invest to save basis, reducing costs where possible

Pull Up

Step 1: Over next 12 months redirect efficiencies from universal tier

i.e. A Whole System Approach



Universal under 5 proposal
Universal Under 5 Proposal

Vision

  • Within 12 months an integrated partnership service will provide a core programme of advice, assessments, and development interventions for all pregnant women, children under the age of 5 and their families in Lewisham, reducing costs and improving the efficiency and effectiveness of local services.

    Objectives of Project Scoping

  • To define the core universal under 5 service offer and service model for its delivery

  • To reduce costs of service provision

  • To improve outcomes

  • To achieve significant savings across the CYP partnership


Commissioning review core service offer

‘As is’ Services by Tier: Universal

‘As is’ mapped against ‘To be’ Services by Tier: UNIVERSAL


Conclusions 1
Conclusions: 1

  • The majority of universal services for the Under 5s are health related and determined by the key elements of the CHPP, with the main exception being the early years foundation stage (i.e. free entitlement to 3 and 4 yr olds).

  • These requirements are likely to continue and are consistent with indicative Coalition policy.

  • This presents an opportunity to stop children’s centre universal offer and re-invest into targeted services (e.g. newly configured Early Intervention Service) / or continue targeted provision within 30% most deprived areas.


Conclusions 2
Conclusions: 2

Need to review the minimum role of LA i.e. in regulating PVI nursery sector, academy schools and in the provision of information to children and families

Further opportunities exist to review the universal youth offer, and reapply similar strategic principles. For example refocusing service to targeted provision within 30% most deprived areas – potential to income generate or leave to the 3rd sector

Need to challenge some strategic programmes i.e. NCMP, Healthy Schools Programme, TP Prevention, SRE commissioned through Health, Public Health programmes – should we reallocate investment to core health services and enable them to undertake activity in these areas

Impact of reduced universal provision could be significant for the third sector


Universal under 5 proposal1
Universal Under 5 Proposal

  • The majority of universal services for the Under 5s are health related and determined by the key elements of the Child Health Promotion Programme (CHPP), with the main exception being the early years foundation stage.

  • The local authority is the main beneficiary of savings which could be achieved through this proposal i.e. the reduction of non essential universal activity such as children’s centre programmes, and the increased targeting of services and interventions.

Key Conclusion: There is limited need to develop an integrated Universal Service (whether for Under 5s or 0-19s). Activity is best left to the health sector with discrete areas of educational input.




Vision for an early intervention service
Vision for an Early Intervention Service

The partnership will provide targeted provision for children, young people age 0-19, and their families, across Lewisham’s four children’s services areas and all settings.

Services will interface seamlessly with universal services based on robust and holistic assessments of need, ensuring no wrong door, and providing interventions as a team around the child/family.

This will improve outcomes and prevent needs escalating to a specialist level. Improved needs assessment and targeting of resources will both improve the efficiency and effectiveness of local services and reduce costs.

Analysis to date suggests significant support amongst professionals for a model of this kind, providing a core offer of skills and interventions within each of the Children’s Services Areas


Commissioning review core service offer

‘As is’ mapped against ‘To be’ Services by Tier: TARGETED

‘As is’ Services by Tier: Targeted


Conclusions 11
Conclusions: 1

  • There are a number of areas where services overlap, with similar activities or functions being delivered by different services

  • Family support, outreach, mentoring and youth key work and welfare services have the potential to be consolidated

  • Support for children with additional needs can be improved through developing expert multi-disciplinary teams, pathways and processes with potential to improve

  • Targeted support for children Under 5 has further potential for consolidation, and to shift the focus to CYP and families in a range of settings

  • We should make better use of our core health services in delivering targeted support

Initial analysis suggests there is real potential to both reduce costs, extend the penetration of our targeted offer and improve outcomes


Conclusions 21
Conclusions: 2

  • Many services remain too ‘settings’ focused – e.g. Clinics, CCs, Schools or PVI nurseries, with CYP benefiting further down the value chain

  • Outcomes can be improved with a radical rethink of pathways across the piece

  • Many services are suffering from ‘scope creep’ – the partnership needs to agree its function and remit and those areas which can be left to the market

  • Opportunity to review strategic programmes and services – where evidence of impact can be identified

Clarity of role and evidence based pathways are needed


Family support outreach an example
Family support & outreach: An Example

Family

Child / Young Person

Key Worker

Family Support Worker

Attendance and Welfare Officer

Health Professional HV/School Nurse

Mentor

?

?

?

?

?

Parent Involvement Officer

Outreach Officer

8 professionals, 1 family, 1 core objective: to support the family to become self sufficient and cope with challenging circumstances

Parenting Trainer

Conclusion: There is significant scope to be smarter in how we pursue our shared goals and outcomes


Teenage pregnancy an example
Teenage Pregnancy : An Example

School

Family Nurse Partnership

Pharmacies

SRH Service in Schools

YOS Officer

School Nurse

Connexions

Sure Start Plus

GP

?

?

?

Youth Service

Social Worker

?

TP Officer

LAC Nurse

Young Girl

Family

Girl’s Partner

Many different professionals providing advice and support before, during and after pregnancy

VCS Services

Can we both simplify and strengthen our interventions?


What should be provided
What should be provided?

An Early Intervention Service should provide a core offer of:

A multi-agency locality panel allocating:

Lead on co-ordination of TAC

Targeted health visiting provision

Targeted family support including parenting assessments, parental support, family group conferencing and family mediation, challenging non-school attendance

Youth key work sessions and diversionary programmes

Targeted mental health support to both CYP and their families

Targeted school age nursing

Targeted support for children with disabilities and their families (including those with ASD) – in school, home & community settings

Targeted substance misuse support

Targeted support to those at risk of becoming pregnant and teenage parents


Total place croydon child family place
Total Place Croydon: child, family, place

Croydon’s case for Early Intervention:

  • very early experiences set the scene for later life

  • we can identify early signs of difficulty

  • the costs of getting the early years wrong are high

  • it makes good economic sense to intervene early

  • the cost-benefit evidence base in the UK is not yet sufficiently robust BUT there is a growing understanding of what works, including:

    • Support for both fathers and mothers in the earliest weeks and months is very important - especially for mothers experiencing postnatal depression

    • Parenting programmes can significantly improve parent-child relationships, build parental skill and capacity, and significantly change child behaviour and outcomes

    • Families with high levels of need require intensive, tenacious interventions addressing multiple issues

    • The quality of the practitioner (in engaging parents, building relationships, responding to the needs of the group) has an enormous impact on the outcomes an intervention can secure


Total place croydon child family place1
Total Place Croydon: child, family, place

Croydon Total Place Proposals

  • Total Place Proposal: Family Partnership teams in localities

  • The Family Partnership Team will have a devolved budget, including health visiting, children’s centre revenue, parts of the social care and Special Educational Need (SEN) budgets, speech and language etc.

  • Proposal to have some flexibility over use of Dedicated Schools Grant (DSG) in a locality and also some use of Job Centre Plus funding

  • The team will own outcomes for all families in their geographical area.

    Family Partnership teams will focus on:

  • Attachment, including fathers

  • Mothers and fathers responsive, authoritative parenting skills

  • Family emotional wellbeing, especially maternal mental health and parental relationships

  • Supportive social connections

  • Responding to specific needs e.g. learning difficulties

  • Affordable, clean, warm housing


Current work and next steps
Current Work and Next Steps

  • Developing configuration options and workforce profile

  • Costings of service models

  • Considering implications of changing grant context – and any need to reinvest from savings released elsewhere

  • Further consultation with key stakeholders



Complex needs and resource allocation
Complex Needs and Resource Allocation

Vision

  • Within 36 months the partnership will support those children and young people with the most complex needs through integrated planning, resource allocation and seamless delivery of care and support, meeting needs in borough wherever possible.

    Through:

  • Improved resource allocation

  • Alternative models of specialist provision to placements

  • Remodelling specialist provision in borough

  • Redesign core pathways

  • Transition to adult services



Key lines of enquiry
Key Lines Of Enquiry

Understanding use of services at the top of the triangle by different cohorts of children and young people, and the movement between services for some of our children

The processes informing resource allocation

Exploring reasons why our children are becoming looked after and potential of specialist family support services to prevent this

Evidence of impact of services supporting CYP to reduce risk of placements or residential service interventions – i.e. Invest to save

Case Studies to understand more about pathways and experiences of children and young people within this tier, and use of resources throughout their journey

Exploration of business development opportunities with partners or neighbouring areas e.g. Psychiatric Intensive Care Unit for CYP, Rehabilitation Care


Conclusions 12
Conclusions:1

Resource Allocation

Budget pressures within: CAMHS Tier 4, CAMHS independent sector, SEN, Continuing Care, LAC

Rising demand/need for specialist interventions

Access to resources such as LAC placements or CAMHS Tier 4 inpatient provision is not currently through a panel system

The most complex cases are often supported by more than one service area and budgets – leading to inefficiencies and wasted resources as different pathways cross over


Conclusions 22
Conclusions:2

Resource Allocation

Scope to increase budget control through implementation of panel process for decisions to accommodate, or provide Tier 4 CAMHS treatment

Holistic planning of care and intervention could lead to reduced spend

Further potential to commission services, introduce Preferred Provider Frameworks across partnership (and wider i.e. with neighbouring boroughs) to achieve better rates and cost volume discounts


Conclusions 3
Conclusions: 3

Preventative services being explored

Extension of the CAMHS Dialectical Behaviour Therapy (DBT) outpatient service for emerging personality disorders

Development of an Eating Disorder outpatient provision

Assertive outreach service and day-care provision

Specialist Family Support and Intervention

Crisis intervention service to respond to cases at the point of family breakdown and divert children from care



Next steps1
Next Steps

To consult with DMT on proposed service reconfiguration options

Continued review of central government policy and implications as this changes

To model service costs and savings, and impact of changing grant context

To continue assessing strength of business case for any invest to save proposals – particularly at the targeted/specialist tier

To consider impact of proposals on service users and wider community