Social Care Programme

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Social Care Programme

• Briefing Pack Sept 26th
• Work in Progress

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Glossary of Terms

• CSCI Commission for Social Care Inspection
• MH Mental Health care group
• PLD People with Learning Difficulty care group
• OP Older People care group
• PSD Physical and Sensory Disability care group
• Lever change to an existing approach that will
  have a significant impact
• Reablement service we provide to help people
  discharged from hospital return to independent
  living
• SDC Self Directed Care (principle of changing
  how we deliver care)
• IBs Individual Budgets (mechanism to change
  how we deliver care)
• RAS Resource Allocation System (tool to
  calculate the value of an Individual Budget)
• JV Joint Venture
• SCC Surrey County Council

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Rationale and Focus for the Social Care Programme
This project will address both the wider
government agenda and issues specific to Surrey
Key focus of Social Care Programme

• Address the governments white paper agenda
• Drive services orientated around the individual
• Where possible this should be outside of
  institutional / residential settings
• Deliver improved outcomes for service users and
  Carers
• Better coordination / joint working or
  integration with key Health partners
• Relieve the financial pressures on the service

Scope
Proposals
Adult Social Care Medium term strategy
Proposals to be made to the Council Executive
late October
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Guiding Principles for the Social Care Programme
There are several high level rules that this work
will abide by

• To set a pace for the journey of change this
  will be a phased but intense journey
• To made evidence based decisions
• To serve those in need in Surrey to the best of
  our ability
• To maintain and improve financial health
• To be in line with central government policy
• To inform and support local policy making
• To meet new CSCI criteria
• To be prepared for the changing needs of the
  population
• To proactively stimulate and create the supply
  market for the future
• To focus council attention on commissioning over
  provision except in cases where there is a clear
  case for provision

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Future Demand

• Demographics the Case for Change

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Case for change underlying cost pressures
volume Older People
In total the number of Older People Surrey County
Council is projecting to serve is forecast to
increase by c. 1000 p.a. until 2011/12 and
thereafter by 150-180 p.a.
Year on year growth in Older people Base case 1
Net change
Volume growth in Older People drives c. 29m
increase in cost in the next 4 years Major
drivers include Helped to live at home
commitment Demographics
Note Base numbers for growth rates are based off
just residential/nursing and homecare (i.e.
excluding people receiving other small community
care packages)
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Case for change underlying cost pressure
volume Older People OP demographics (2)
This demographic pressure means that SCC will
need to serve an extra 500 users by 2011/12
Year on year growth in Older people Base case 1

• Demographics imply an additional
• 500 people served by 2011/12
• 1,500 by 2017/18

Note Base numbers for growth rates are based off
just residential/nursing and homecare (i.e.
excluding people receiving other small community
care packages)
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Case for change underlying cost pressure
volume PLD
PLD volume growth is significant as transitions
into the service significantly outnumber exits
Year on year growth in PLD (residential
homecare) Base case (people 000s)

• Volume growth is driven as transitions and other
  entrants exceed projected exits This implies an
  additional
• 330 people served by 2011/12
• 800 by 2017/18

Net change
Note We have excluded college attendees as they
represent a relatively constant cohort and do not
add to volumes over time Volume growth is shown
to be constant over time. This is because the
data we have on future transitions entries is
not of a sufficiently long time span to deduce a
trend . We have therefore included a constant
average each year. In reality the impact of the
increased incidence of learning disabilities is
likely to cause volumes to grow towards the end
of the period examined. See annex for more
detailed methodology
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Case for change - overall cost pressure
In our base case costs are projected to grow by
c.78m (or c.9 per year) by 2011/12, and by
c.212m by 2017/18
Total SCC Adults Net Spend Projections m
Total SCC Adults Net Spend Growth Projections
(07/08 11/12)
Increase of 212m
MH
PSD
Increase of 78m
PLD
OP
Note Excludes S28a includes effect of changing
mix of services
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Fulfilling the Governments Policy Regulatory
Vision
Choice, Control, Independence are key themes in
Government Policy and should be bourn out in
local services
Whats Changing

• Council to be a strategic leader of services
• Choice Control for all
• Services to promote independence, rather than
  dependence
• Users and Carers listened to
• Individual Budgets
• Focus on Outcomes rather than Outputs
• More evidence for service quality
• Partnerships important Health / 3rd Sector

The Implications for Surrey

• Need to set the strategic direction
• Person centred approach
• Services designed to enable users and Carers
• User forums important
• Need to set up infrastructure for Individual
  Budgets
• Start measuring outcomes and managing quality

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What is already being done in Surrey - Examples
Surrey has already come some way in addressing
some of its issues
Telecare Supporting people in their homes
Extra Care Housing Increase choice, reduce costs

• 7 buildings providing 347 Extra Care units across
  Surrey
• Those using the service
• Have reduced acute admission to hospital
• Avoid residential care and dependency
• Result in potential saving on residential and
  home-based care packages
• Have increased choice and flexibility

• Safe at Home project PTG telecare and
  Community Alarms. Also fall sensors and flood
  detectors.
• 50 of users who were at risk of going into
  residential care were enabled to stay in their
  home with telecare.
• There is an opportunity to roll schemes out
  further, improve the cost effectiveness of the
  service and monitor outcomes

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What is already being done in Surrey - Examples
Surrey has already come some way in addressing
some of its issues
Direct Payments Personalisation
Day Services Personalisation, improving
employability of PLD

• 414 Direct Payments users by June 2007
• Although Surrey made good early progress on this
  agenda, there is now an opportunity to increase
  take up

• Move away from traditional leisure and social
  activities to those that promote employability
• Opportunities for users include developing their
  learning opportunities, getting trained in how to
  use public transport and developing a range of
  work schemes
• Pockets of best practice exist across Surrey, but
  there is a opportunity to roll these out
  county-wide.

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Our Challenge

• Review how we organise to deliver adult social
  care
• Addressing
• The challenges posed by demographic growth
• The funding gap we will face
• The opportunities presented by the Governments
  agenda for Independence, Choice and Control
• How we can roll out pilot programmes and best
  practice approaches already in place
• What we can learn from other Councils responses
  to similar challenges

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Key Levers for Change
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Our Key Levers for Change
We have identified four key levers to drive
change in service provision
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Re-Ablement Fundamentals
Re-ablement is a lever which helps empower people
to regain a higher level of independence and
control
Broad Re-Ablement Process
Period of Re - Ablement

• 2-12 weeks
• 1st 6 weeks funded by NHS
• Focused on re-developing ability and confidence
• Jointly delivered by health and social care
• Focused on Older People care group, more frail
  than dementia

Persons Own Home
Small package of care (potentially from the
voluntary sector)
Persons Own Home
Care Home / Nursing Home
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Re-Ablement in Surrey
There are several tools for re-ablement already
in use in Surrey
Components of Re-Ablement in Surrey

• Frequently used for step down and re-ablement
  care because they are set up for lower acuity
  patients
• Discharge from a community hospital requires
  social care attention as there is no charging as
  with Acute hospitals
• Keys to success in due to fast throughput,
  appropriate re-abling staff, not care givers, and
  a cut off for discharge decision making

Community Hospitals

• Teams deal with sudden loss of ability and
  intervene to get people back on their feet
• Includes exercises and practice cooking focus
  on confidence building, referral can come from
  community or other

Promoting Independence Teams
Intermediate Care

• On-site in NHS Trusts sourced from discharges and
  community referrals, merged with home care team
  in the East
• Requires sufficient resource and integrated and
  merged services wherever possible

IRS Rehab (Mid Surrey)

• Similar to intermediate care, but social care led
  not health led, tends to use slightly higher cost
  people

IRS Dementia

• One service at the Royal Surrey focuses on proper
  assessment, OT led

Rapid Response

• Community based care intensive for the 1st 6
  weeks can be up to 3 to 4 calls a day

Interim Beds

• Beds reserved within a care or nursing home block
  purchased by the county council, people are
  placed for 1 3 weeks to remove the pressure of
  a decision from the Acute environment

Night Service

• Enables people to stay at home instead of in
  care, allows night calls when needed, staff are
  protected

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Re-Ablement Learnings
There are several areas of potential change to
the current re-ablement programme
What More can be done in Surrey?
Lessons from Other Counties

• Recruit more staff to reable a larger number of
  people?
• Assess all frail and EMI people for re-ablement?
• Implement county wide programmes based on CSED
  best practice?
• Integrate more with the NHS?
• Look upstream at people yet to enter the system
  and begin re-ablement at an earlier stage?

• It takes a long time to Implement (4 yrs when 1
  was budgeted in one case)
• The goal is confidence more than specific skills
• Can also be done for other user groups
• Periodic re-assessment is key to preserve
  ablement
• Small team around each user and carer
  consistency continuity
• Invest time and money up front it pays
  dividends
• Social care led not health
• Identify and measure outcomes

Source Coventry, Pilkington, Leicester, Wirral,
Poole
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Our Key Levers for Change
We need to consider options for change to address
financial, outcome and performance challenges
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Residential Shift Framework for
understandingConcept
SCC currently provides a relatively high
proportion of care in a residential setting
Spend1 Analysis user group by care service
(2005-2006)
National Average
Surrey
Note 1 net total cost (after client
contributions), excludes other user groups
including asylum seekers and substance abuse.
S28a the only impact included here will be any
difference between funding and cost. 2 Other
includes Direct Payments, Day care, Home care,
Supported living, assessment and care management.
Source PSSEX
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Residential Shift Framework for
understandingExtra Care
Extra-Care refers to accommodation for older
people which is self-contained (unlike
residential care) and where flexible 24-hour care
is provided (unlike ordinary sheltered housing)
Typical models of development Typically 40 units
on a single site in order to achieve economies of
scale 3 Models
Leasehold
Rented
Mixed Tenure
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Residential Shift Framework for
understandingExtra Care
Theoretically, extra-care could be an alternative
form of care for all residential users thus SCC
could theoretically require 1200 units. The
fastest that a shift of this magnitude could be
effected is 4-5 years

• SCC could utilise c. 1200 Extra-Care places and
  reduce to a minimal level of residential frail
  usage (although retaining EMI/nursing beds)
• Private market demand is of a similar scale
• This shift could be effected over 4-5 years
• Average length of stay in residential is c.2 years

• Theoretically, extra-care could be an alternative
  form of care for all residential users except
• Extremely frail and in need of significant
  nursing care
• Disruptively confused / a danger if not
  constantly monitored
• Any shift would need to be as the result of
  diverting new admissions rather than moving out
  existing residents

As-Is flow
Homecare
Nursing / residential
CRISIS
80 of residential admissions happen after a
hospital stay. Most of these users have
previously been receiving homecare but this has
not been sufficient to prevent a crisis
Extra-Care flow
Homecare
Extra-Care
Nursing/ residential
As homecare users begin to struggle on their
homecare packages a controlled move to Extra-Care
is possible. In Extra-Care the more supportive
environment and more flexible care mean that
crisis/residential admission is avoided/delayed
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Residential Shift Framework for
understandingSupported Living
People living in Supported Living refers to
people with learning or physical disabilities who
meet SCC eligibility criteria and who are
supported to live in the community with their own
front door
Typical models of development Typically a small
number of units on a single site to facilitate
community integration 4 Models
Own flat
Small block of flats with office
Shared house
Family placement
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Residential Shift Financial Model Extra-Care
(1/x) Maximum possible demand
High level estimates suggest a theoretical SCC
requirement for 730-880 units of Supported Living

• Basic premise No-one has too high a level of
  need that they should not be given the option of
  leaving residential care
• There are currently c. 1850 residential users in
  PLD/PD.
• Additionally, numbers are currently projected to
  grow at c.5 per year. E.g. there are c.60 new
  PLD residential users projected each year through
  the effect of transitions
• However, many of the current residential users
  have been in residential care for a long time and
  moving would not be practical
• We need to proactively enable people entering the
  service to live independently
• We need to offer the opportunity to people
  already in residential care who have the
  potential and desire to live independently
• Potentially increasing our number of supported
  living clients by up to 150 people a year

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Our Key Levers for Change
We need to consider options for change to address
financial, outcome and performance challenges
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Self Directed Care - Principles
There are seven principles underlying self
directed support as articulated by the in control
programme
Source In Control
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Self Directed Care - Seven Steps for being In
Control
Source In Control

• You get your own individual budget
• You can do your own support plan
• You may need an agent to represent you
• You can have as much control as you want using 6
  options
• You can use a full range of support from
  traditional services to DIY
• You get real flexibility over your funding
• You tell people how youve done and whats next -
  accountability

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Self Directed Care - Micro-economies of scale

• Ability to mix paid and natural support
• Ability to use funding flexibly
• Ability to vary price paid
• Ability to reduce management transaction costs
• Ability to focus on one person at a time
• Best understanding of relevant outcomes

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Self Directed Care - Process
The overall process under Individual Budgets need
not vary greatly from today, but new aspects will
take work to develop
Current Process
New Process Under Individual Budgets
Eligibility
Eligibility
Assessment RAS
Assessment
Care/Support Plan
Care Plan Development Sign Off
Validation
Placement
Brokerage Support / Placement
Review Monitor
User Reporting
Review Safeguard
Process steps that are new or vary significantly
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Self Directed Care Potential Cost Savings
There is a possibility of cost savings through
Self Directed Care both through improved
organisational efficiency and through more
efficient allocation of funds in care packages
County Council Running Costs
Costs of Service

• Greater use of personal assistants procured by
  individuals at lower than market rates
• Growth in depth of provision increasing
  competition and helping pricing
• Appropriate care packages developed often at less
  cost than the standard / limited packages of
  care formerly assigned by the county
• More objective resource allocation system

• Slimmed down back office costs
• Improved systems and processes
• Less responsibility on the County Council
  individuals in charge of creating care and
  support plans
• Change in the role of social workers to support
  enable individuals to live independently

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Surrey Self Directed Care
The Financial benefit is unproven, but Self
Directed Care is a key driver for outcomes and
performance
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Our Key Levers for Change
We need to consider options for change to address
financial, outcome and performance challenges
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Framework of understanding Market Marking -
Concept
As Is Market
SCC
PCTs
Users
SCC In-House Provision
Small specialist Providers
Agency Providers

• Large number of providers across each care
  sector. Polarised market between those dependent
  upon SCC and those focused on self funders
• Care predominately spot purchased but some block
  contracts in place, including PFIs
• Limited representation through the Surrey Care
  Association and Networks
• Some retained care home and home care capacity

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Framework of Understanding - Market Making -
Options
There are a number of future commissioning models
which the council will need to investigate to
realise its future vision
What the solution may look like

• Outsourcing some of our remaining internal
  provision in residential and other forms of care
  as part of stimulating major change in the market
  and becoming a purer Commissioner
• Creating new markets to support re-ablement and
  person centred care
• The Council creates preferred supplier
  frameworks, made available through easily
  accessible brokerage portals, to service users
  and carers in support of the shift to Individual
  Budgets
• The Councils helps to structure a world class
  social care supply chain network, focused on
  quality, value for money and flexibility
• The Council invests in developing the skills and
  capacity to manage the market, to take leadership
  in market development and collaboration across
  Health and other government departments

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How could Brokerage work?
Surrey has the opportunity to develop a model
that meets users needs for flexibility and value
for money
Level of support increasing
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We have evaluated 3 core options and are working
up proposals to take forward User Led
Transformation
We have aggregated the levers into three
potential options
County Control
Dual Running / Individual Budget Led
User Led Transformation / Individual Budget Max

• Introduce Individual Budgets as an option for all
  care groups
• Construct the options to enable a progressive
  transition from council managed services with
  strong controls
• Manage the role out within current organisational
  structures
• Implement in parallel the county control
  initiatives

• Focus activities on diverting presenting people
  away from residential care
• Move of existing PLD / PSD people to supported
  living
• Maximise utilisation / value from current
  contracts
• Internal process efficiencies

• Adopt the full philosophy of Individual Budgets
  and design a clean sheet organisation,
  challenging
• Our purpose role
• How we interact with our users and carers
• What activities we need to resource, what skills
  we need
• What market capacity is required and how we can
  shape it
• How we can serve all surrey residents
• Develop a staged transition plan