IPC

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• IPC

NHC Conference Outcome Based Commissioning and
Contracting March 2007
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Institute of Public Care

• Centre of Oxford Brookes University
• A range of projects on commissioning and
  contracting for Department of Health, DCLG, DfES
  and Welsh Assembly government.
• Delivery of specific activities to support the
  development or implementation of commissioning
  strategies in more than 20 local authorities in
  Wales and England in 2005-06.
• IPC also facilitates a commissioning and
  performance network for community, primary care
  and childrens services. Over 30 members.

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Today

• To have a brief look at where we might be going
  in social care and in particular in relation to
  older people.
• To look at the distinction between outcomes,
  outputs and processes and to look at what outcome
  focussed contracting might mean in terms of
  future thinking about services.
• To apply that outcomes based approach to
  contracting for home care provision.

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The context of thinking about outcomes
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Challenges to Adult Social Care

• What are the drivers that will underpin our
  interventions?
• How will we manage demographic change.
• How should we prioritise our activities?
• How will we know if we are successful?

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What drivers will underpin our interventions?

• Choice
• Control
• Cost
• Integration
• Quality
• Outcomes

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Managing Demographic Change
Shire in 1911
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Managing Demographic Change
Shire in 2001
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Managing Demographic Change
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How do we prioritise our activities?

• How do we position our priorities?
• Services that keep people alive
• Services that care for people
• Services that improve health
• Services that rehabilitate
• Services to meet needs or desires?

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How do we know if we are successful?

• Delivered to budget
• Three stars
• Few complaints
• Successfully made the shift from managing
  services to commissioning services.
• Clarity about what goals and outcomes wanted for
  the population and why these are important.
• Capacity to effectively measure and monitor
  whether local based indicators are being
  achieved.

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Do we really need to change?

• Nationally the demographics may make us look
  sharper at whether what we provide actually
  delivers.
• Services focussed solely around outputs may not
  deliver and encourages the measurement of proxy
  indicators which may not be true.
• Increasingly as service users we may want to know
  not what am I to be given but will this work.
• Increasingly as service users we may not want to
  fit into a service but have services that fit us.

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Outcomes, outputs, processes and individual goals
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Types of objectives and measures

• Outcomes The desired result or impact of the
  service on service users and/or on the population
  as a whole, eg,
• Reduction in alcohol use.
• Improved mortality rate from heart attacks.
• Increase the number of people who remain within
  the community.
• Outputs The nature, type and volume of service
  required to deliver the outcomes, eg,
• Number of service users seen per day/week/month
• Number of beds to be provided.
• Processes The activities we put in place and
  the order in which they are implemented so that
  the outputs can be achieved, eg,
• Date for opening the new specialist unit.
• Numbers of staff employed

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Examples of strategic outcomes

• More people with dementia living in their own
  homes to death.
• Fewer older people who have had one stroke
  suffering from further strokes.
• Fewer people coming into care homes through carer
  breakdown.
• 50 of service users with a mobility problem at
  assessment have improved mobility six months
  later.

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Examples of personal outcomes

• Able to walk at least two hundred yards further
  at the end of the year than could at the start.
• Able to meet with old friends at least once a
  fortnight.
• Able to have garden maintained to an acceptable
  standard and contribute to keeping it tidy.
• Able to choose to have a particular care worker
  to wash and bathe me.
• Able to go to bed when I choose and at different
  times each day.

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Linking outcomes, outputs and individual goals
together
Strategic Outcomes
Organisational Outputs
Organisational Processes
Expert Outcomes
Knowledge of what methodology works
Business Process Engineering
Individual goals or targets
Does the service achieve the goals and targets?
Service delivered to agreed plan
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Linking outcomes, outputs and individual goals
together
Strategic Outcomes
Organisational Outputs
Organisational Processes
A higher proportion of the population aged over
80 should live within the community
We will increase the capacity of the continence
service
We will appoint a specialist joint service lead
by March 08
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Linking outcomes, outputs and individual goals
together
Strategic Outcomes
A higher proportion of the population aged over
80 should live within the community
Expert Outcomes
Fewer people admitted to care homes will have a
previously undiagnosed continence problem.
Individual goals or targets
My worry about continence and its capacity to
limit my lifestyle is no longer a problem.
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Linking outcomes, outputs and individual goals
together
Strategic Outcomes
Organisational Outputs
Organisational Processes
Expert Outcomes
Knowledge of what methodology works
Business Process Engineering
Individual goals or targets
Does the service achieve the goals and targets?
Service delivered to agreed plan
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Commissioning framework for Health and Well-being

• Sees there as being a shift from a focus on
  inputs and processes to a focus on outputs and
  outcomes and payment linked to work done, based
  on outcomes.
• However, guidance says little about how this is
  to be achieved.

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Developing an outcome based approach to
contracting
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An outcome based approach to purchasing services

• The aim of an outcome based approach is to
• "...shift the focus from activities to results,
  from how a programme operates to the good it
  accomplishes."
• Plantz, Greenway and Hendricks 1999
• Outcome Measurement Showing Results in the
  Non-profit Sector. United Way of America Online
  Resource Library

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Antecedents

• Background chiefly in USA and Australia
• Initially focussed on drug and alcohol treatment
  programmes.
• More recently the approach embraced in a major
  way by the Federal government in the USA with
  performance based contracting.
• Much discussion in this country although little
  used in practice. Where development has occurred
  it has been chiefly in relation to the voluntary
  sector.

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The IPC experience

• Development of an outcomes based contract for
  young carers service.
• Work with two authorities on developing an
  approach to outcomes for home care services.
• Learning from Thurrock.

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Common issues in home care that an outcomes
approach may look to resolve

• Monitoring of contract arrangements is not always
  good and sometimes LAs may be paying for a
  service that is not delivered, sometimes they may
  be getting services they are not paying for.
• Care planning and assessment can be too much of a
  straitjacket when the service needs to be
  flexible and responsive to immediate need.
• Some services do not always see themselves in
  partnership with family carers.
• The contracting process may mean we dont use the
  knowledge that home care agencies have to their
  fullest potential.

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Common issues in home care that an outcomes
approach may look to resolve

• Home care services are rarely rehabilitative and
  dont / cant always cater for the important
  issues that can effect peoples quality of life.
• In some instances the system is undermined by
  service users feeling grateful for what they
  receive and limiting their demands. This can be
  expressed through service users and carers being
  told there are strong cash limits to provision or
  through being told by care providers how short of
  staff they are.

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Thurrock Home Care Lessons

• Issues in getting care mangers to write care
  plans on the basis of outcomes. Care managers did
  not feel happy initially with handing over work
  without specifying the tasks required.
• Provider agencies need more information to be
  passed to them if they are going to complete
  service user plans.
• Flexible care plans dont fit well with existing
  financial procedures or with current approaches
  to charging.

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Thurrock Home Care Lessons

• Electronic recording needs to be in place, cant
  work well in a paper forms based environment.
• Contracts had to change.
• Improved training for provider staff.
• Need to establish the current base line of
  service provision if the intention is to measure
  improvement through outcomes.

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The IPC model for outcome based contracting
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The overall contracting process

• Assuming this is for the award of a whole service
  and
• contracts with more than one provider
• Identify an indicative existing area of service
  provision and the boundaries around this.
• Get key stakeholders on board
• Identify preferred providers and discuss approach
  to be adopted, timescales, approximate value of
  contract etc.
• Outline outcomes to be achieved and the rationale
  that underpins these.
• Negotiate and modify outcomes after discussion
  with potential providers.

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The overall contracting process

• Providers to respond with approaches to be
  adopted to deliver outcomes and the evidence that
  supports their applicability.
• Confirm preferred provider(s).
• Identify agreed approaches for measuring and
  monitoring, frequency that measurement and
  monitoring is to be applied, break clauses.
• Test the final proposal.
• Agree funding.
• Award contract.
• Commence service provision.

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Defining outcomes and their response

• Developing knowledge driven outcomes and
  defining the providers response to those
  outcomes. For example
• A service that facilitates social relationships.
• A service that is rehabilitative and prevents
  unnecessary dependence and maximises
  independence.
• A service that aids recovery from illness.
• A service that ensures that users feel, and are,
  safe, clean, warm and comfortable.
• A service that specifically works in partnership
  with and enhances the role of family carers.

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Changing boundaries

• Re-defining the boundaries of the service so
  that it may include
• Home care
• Supporting people
• Assistive technology
• Care and repair
• Some elements of health care provision.
• Some control over voluntary sector funding.

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The contracting process

• A different type of legal contract.
• Greater emphasis on partnership between provider
  and commissioner rather than arms length.
• Forces commissioners to pool resources.
• Forces providers to take on a wider range of
  services and responsibilities. Stepping outside
  the practice and financial comfort zone.
• Takes time and may require a third party
  negotiator.

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Funding and finance

• Naming the value of the contract up front on the
  basis of a number of people, at a total price,
  for whom outcomes will be delivered. This means
  moving to what's the best we can get for this
  price rather than what is the cheapest price.
  Initially the value may be determined by the
  current cost of services in the pot plus
  inflation.
• The new currency moves away from price per hour
  to value per outcome. Charging makes a similar
  shift.
• There may incentives for providers to better
  outcomes than the contract minimum.

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Agreeing outcomes Level 1

• The overall award of a contract or preferred
  supplier status.
• This involves the commissioner(s) and one or more
  providers agreeing the overall outcomes to be
  delivered and the approach by which these will be
  achieved. At this point it is likely a preferred
  supplier will be identified.
• From then on the details of the specification
  will be agreed and the measures that will be put
  in place for monitoring the delivery of outcomes.

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Agreeing outcomes Level 2

• Involves the individual determination with
  service users and carers of the types of
  provision to be offered, its frequency and the
  potentiality for flexibility.
• There would need to be agreement that the
  outcomes were desired, accessible and achievable.
  This level would involve changing the care
  planning and assessment process for care managers
  and developing new skills in tripartite
  negotiation. and developing a charging policy
  based around the key outcomes to be achieved
  rather than around the services to be delivered.

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Measuring and monitoring

• How will the outcomes be measured how will you
  know if service users are better off?
  Distinguish between effort and achievement.
• Are the measures attributable?
• How can providers show evidence of reaching
  outcomes?
• What are the consequences of non-achievement?
  Which measures are mission critical?
• Is there a need for an element of output or
  process measures to remain and does doing this
  destroy the validity of a new approach?

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Additional issues

• Identify sufficient providers who will be
  prepared to work with a new approach.
• Fund the risk element in shifting the basis of
  contracts.
• Takes time to achieve the required cultural shift
  not just from providers but also from care
  managers.
• Need to gain widespread commitment get elected
  members to agree to the shift, legal services to
  draft contracts accordingly and take services
  users and carers with you in a new approach.
• Level of commitment and trust needed.

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Outcome Based Contracting requires

• Commissioner to be smarter in knowing exactly
  what outcomes they want providers to achieve and
  the rationale that underpins those outcomes.
• Providers to be much sharper about what they will
  do to achieve the outcomes.
• Both sides to be tighter on measuring and
  monitoring in order to know whether the outcomes
  are being achieved and whether they are
  attributable to the intervention.
• Both sides to talk to each other, and service
  users, and mutually agree feasible outcomes.

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Benefits of an outcome based approach

• It makes the purchasing agency focus on exactly
  what they want the provider to achieve and why,
  rather than just the cost/volume of service to be
  provided.
• In both purchaser and provider it can encourage a
  knowledge driven approach to practice. Both sides
  need to know and understand the rationale behind
  each outcome and to identify methods of practice
  that can achieve demonstrable results.
• Achieving outcomes can be both collectively and
  individually more motivating than providing an
  amount of service.

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Benefits of an outcome based approach

• It can have a beneficial approach to both raising
  the quality of the service and for enhancing
  working relationships.
• It should make user and carer involvement easier.