Integrated Care Think Tank June 2007

1. Integrated Care Think Tank • June 2007

2. Set up in 2003 as government-community social enterprise - will be established as independent charity by the Autumn 2007 • Pioneered concepts of Self-Directed Support and Individual Budget (Phase One, 2003-2005) • Today works across all social care groups - adults & children • 95 local authorities have subscribed as members • 1560 people using Self-Directed Support (Phase Two, 2005-2007) • 10 local authorities committed to total change (Phase Three...) • Leading website on Self-Directed Support: www.in-control.org.uk • Open source community - working with over 20 franchised partners

3. Independent Living The point of it all... rights, citizenship, family... choice and control Self-Directed Support The new national support system (replacing the current Social Care) - it has many parts Individual Budget One part of the system... your money... calculated up-front... based on your needs Direct Payment Another part of the system... one way of managing your money

4. Independent Living Institution Care Citizenship

5. Social Care Today • Current system of social care doesn’t work - its ‘broken’ • Its broken because power, control and responsibility is all in the wrong place • Decisions are in the wrong hands - too far away from the person • We need a system that treats people as citizens

6. Citizenship • People needs to be in control of their own life • People flourish as part of families and communities • People are entitled to support • And should have as much control as possible over how they live

7. What is the locus of integration? Social Care NHS Education Local Services Housing Tax & Benefits Transparency of rights, service and community options... services facing the right way State provision Non-state provision Community

9. in Control’s Model of Self-Directed Support

11. “IB’s changed my thinking! It’s about getting the most out of your life. Living, instead of existing!" Disabled Person, Essex “...life is going to change for my son, my husband and I. It’s going to make a mammoth difference.” Mum, Essex “We ask individuals and families what they want and it’s our job to go and find it... and generally people don’t ask for unbelievable things...” Doreen Kelly, Partners for Inclusion “Many practitioners and Team Managers feel that this is ‘what real social work is about... it’s what I trained for…’” J. Goldingham, West Sussex

12. Opportunity Threat Older People Self-funders... extending choice to all... information for all Regulation of PAs Carers fears of burden Mental Health Recovery movementOutcome focus Risk-management... Learning Disability Transfer funds for remaining services out of NHS Workforce fears Physical Disability Training for PAs The old paradigm’s dominance Long-term Conditions Continuing Care Intermediate Care Control within Virtual-NHS-account Exploit “Payment by Results” Practice-based commissioning General Net allocations v. charging re-define high level commissioning Competing charging regimes

13. Home Hospital Intermediate Care Home Reducing risk of admission Increasing planning for admission Maximising focus on community Maximising dignity Prevent re-admission Care Home Increasing rate of return to home Reduce odds of re-admission Developing a passport Care Pathway to invert Individual Pathway Involving family and friends Making plans transparent Getting good information on health and risk recover from shock - regain confidence and prepare for return to control Overcoming - ward routine - mealtimes - patient participation relatives contributing self-medication Planning my own home environment District Nursing Virtual budget Construct a person-centred approach Information on efficacy Therapy services link to friends, neighbours environmental assessment Planning to reduce likelihood of future need NHS train my PAs working with family and housing environment crisis emergency planning MH capacity plan (IB... but only for some) Practice-based commissioning NHS State funded... payment by results... increase electives Virtual - joint - non-recur budget - s.31 Recurring stream - if necessary - IB philosophy - belief - leadership - professional - individual - family - best advice for relevant problem - talk to Wendy

14. Possibilities for Staying in Control • Pooled funding • Bed-blocking • Over-medicalised interventions • MH reform • Therapy services • People with complex needs • Continuing Health Care • GP based services, practice-based commissioning • Outcome-based commissioning • Payment by Results • Jan Keane’s research?

15. Self-Directed Support The Commission for Social Care Inspection 2004 - MORI Poll found that “most people want to choose their social care - three-quarters (73%) say a person requiring social care should be able to choose their services and be given money by the government or council to pay for them, rather than have the government or local council decide.”

16. Complicate ILF Mark 1 Too Expensive Self-Directed Support: Sensible, Legal, Affordable and Universal: Designed to put EVERYONE in control of their own life ILF Mark 2 Ilegal Over-regulate Direct Payments Just for Some Limit Eligibility European Systems Doesn’t fit Professionalise Self-determination (USA) Threatens Us

17. IndividualBudget

18. Empowerment vs.Assessment

19. Co-produced Self-Assessment

20. Support Brokerage

21. Person Representative Trust Broker Provider Care Manager Degrees of Control

22. Individual ServiceFund

23. Self-determination - Helen’s Mum • Direction - Jane’s Art Class • Money - Margaret’s new family • Home - Patrick’s Trust • Support - Keith’s personal trainer • Community Life - Gavin’s season ticket

24. Are you happy with your support?

25. Satisfaction Rates Before After Self-determination 42% 97% Planning 61% 97% Money 45% 90% Home 65% 94% support 48% 100% Community life (family-based) 67% 100% Community life (non-family) 56% 100% Community life (overall) 61% 100%

26. Desired change Number Made it Where I live 17 76% Who I live with 16 81% What I do with my time 26 69% Who supports me 18 89% Other specific changes 10 90% Total 87 79%

27. Support & Housing Before After Percent Support at home 20 22 10% Employing PAs 8 22 175% Using day centre 12 11 -8% Days in day centre 4.5 3.5 -22% Registered care home 10 0 -100% Own tenancy 1 10 900% Average household 6.2 3.6 -42% Single living 0 4 N/A Direct Payment 1 16 1500% Earned a wage 1 3 200% Using family support 21 21 0% Using community support 8 15 88% In family home 14 15 7%

28. in Control’s learning • Self-Directed Support seems to lead to better support and happier people • Self-Directed Support seems affordable • Many social workers feel that Self-Directed Support is allowing them to return to the values and skills that made them join the profession • Flexibility of funding is critical - we do not know - in advance - what good support looks like - so we must not fetter the discretion of those who know best • Self-Directed Support implies a radical re-think of roles, funding, regulations and policy... and some people are ready to try

30. Examples Old System Self-Directed Support Difference Gateshead (total residential service) 600000 525000 12% Bradford (hypothetical) 5625000 4500000 20% West Sussex (where different) 194000 107000 45% South Glos. 187305 152300 19% Newcastle 594000 397000 33% Lancashire 209079 160555 23% data excludes cases of new or changing need and compares individual costs with actual or with prevalent market costs

31. Structural inefficiency • Pre-committed resources (30% waste) • High transaction costs (25% plus) • Prices driven by providers (profit levels growing from 5% to 25%) • Enormous social costs

32. Sustainability of Self-Directed Support • The right money • To the right person • Maximum choice & flexibility • Minimum burdens and waste • Clear entitlements • Productivity • Community connections • Personalisation & satisfaction

33. Current Inequity

36. Shift to Self-Directed Support

37. Managing transformation