The keys to life - Improving Quality of Life for People with Learning Disabilities

Commissioning of public services

Setting the scene

The key to delivering effective services is to ensure that people are provided with the outcomes that they need at the right time and in the right place.

The Christie Report - Commission on the Future Delivery of Public Services⁸ proposes an approach based on a thorough understanding of how public services could improve the quality of life and outcomes for the people of Scotland, while focusing relentlessly on prevention, early intervention and driving out costs.

It follows that any reform of organisational boundaries should be 'bottom up' - based on the reality of delivering front-line services - rather than 'top down', or solely motivated by the desire to make savings.

Demographics, economics, increasing care complexity and people's expectations are driving a rethink about what kind of health, wellbeing and social care services are needed, and about the way in which services are planned and co-ordinated to be effective in securing the best possible outcomes for the population, including people with learning disabilities.

A range of public bodies, including local authorities and the NHS, are involved in planning, delivering and purchasing services that affect the lives of people with learning disabilities. From social care, community transport, and leisure services, to district nursing, further education colleges and employment support, the way services are commissioned touches almost every part of our lives. If we are to meet these challenges, people who use services, their families, and their carers, need to be at the heart of the commissioning process.

Joint commissioning

Strategic commissioning is the term used for all the activities involved in assessing and forecasting needs, linking investment to agreed desired outcomes, considering options, planning the nature, range and quality of future services and working in partnership to put these in place. Joint commissioning is where these actions are undertaken by two or more agencies working together, typically health and local government, and often from a pooled or aligned budget.

Commissioning is commonly described as a cycle of strategic activities similar to that shown in Figure 1 below.

Figure 1: Joint Commissioning Model for Public Care

In this model, based on that developed by the Institute of Public Care (IPC), the Commissioning cycle (the outer circle) drives purchasing and contracting activities (the inner circle), and these in turn inform the ongoing development of Strategic Commissioning.

Joint commissioning should consider the following ten strategic outcomes which relate to statutory bodies legal obligations and national priorities, and, in doing so, will help people with learning disabilities to achieve positive outcomes:

• People have choice and control in their daily lives and are supported to live as independently as they can;
• People enjoy the best possible health and emotional wellbeing;
• People have good things to do that help them achieve their full potential;
• Carers are supported;
• People are safe, respected and included in their communities;
• People are involved in the planning, development, design and delivery of services that help them to achieve the outcomes they want;
• People are satisfied with their experience of health and social care services;
• Statutory bodies fulfil their statutory legal responsibilities, adhere to meeting quality standards, services are safe and continually improving;
• People working in services are positive about their role and supported to improve the care and treatment they provide;
• Services are efficient and responsive to local people's needs.

Integration of Adult Health and Social Care and Commissioning

The integration of adult health and social care will facilitate integration of commissioning budgets for adult services, in such a way that the source of the resources will lose its identity, for as the Cabinet Secretary has stated: "where money comes from, be it health or social care, will no longer be of consequence"⁹. This will create a single commissioning budget from which partners will commission improved outcomes for adult health and social care. For this to be effective, it will be essential that steps are taken to integrate the commissioning process.

The Integration of Adult Health and Social Care Bill is likely to place a duty on partnerships to put in place locality planning arrangements to deliver locally agreed strategic commissioning plans that have the support of the professionals and other care providers who will deliver services as well as users and carers. It is vital that these new partnership arrangements function to improve performance in the form of the delivery of outcomes for local communities, and that joint commissioning functions to ensure the specific needs of people with learning disabilities are met.

The recommendations in this chapter are designed to reorientate commissioning further towards outcomes and away from a tight focus on service volumes (e.g. hours of activities) and costs.

Recommendation 3

That by April 2015 community planning partners should ensure that local arrangements for joint commissioning are developed across relevant partner agencies and service areas to support the delivery of agreed outcomes, and that these take account of the needs of people with learning disabilities.

Reshaping Care for Older People

We know people are now living longer and this is the same for people with learning disabilities. The Reshaping Care for Older People is a Scottish Government initiative aimed at improving services for older people by shifting care towards anticipatory care and prevention.

Older people are an asset to this country and preparing for an increasingly ageing population is one of our biggest national challenges. Our older population is likely to increase by around two thirds in the next twenty years and because of this we need to change how we deliver care.

Around 90,000 older people receive some kind of care, whether in their own home, a care home or long-term hospital care. If we continue delivering care the way we do right now, an extra 23,000 people will need care by 2016. A programme for change 2011-2021¹⁰ sets out our vision and has been produced in consultation with the people of Scotland, politicians and professionals both locally and nationally.

'Older people are valued as an asset, their voices are heard and they are supported to enjoy full and positive lives in their own home or in a homely setting'.

Self-Directed Support (SDS)

The Social Care (Self-directed Support) (Scotland) Act 2013 will also provide opportunities and challenges for commissioners and providers. Self-directed support (SDS) empowers individuals to have greater choice and control over the support they receive, either through receiving a direct payment in lieu of services, or by having greater control over decisions about what types of services or supports are provided. Rather than being a passive recipient of services, citizens can become actively involved in selecting and shaping the support they receive.

The same as you? was instrumental in bringing about a focus on individuals having more control over the care and support that they receive and highlighted the role of direct payments, as one SDS option, in achieving this. People with learning disabilities have been well represented in pilots of SDS both in Scotland and elsewhere and have indicated that they welcome the strengthened opportunity that this new legislation will offer - not to be shoe-horned into existing models of service provision. The roll-out of SDS will mean that the person receiving services will become the lead commissioner - they will work with professionals to co-produce a support plan and will make joint decisions about the type of support to be commissioned. In some cases the individual will also be the purchaser, and may even employ support staff directly.

Case study

Jane received a support service that really didn't work for her. As a young woman with learning disabilities and lots of interests and aspirations she did not accept that she had to fit her life around the support that she received. With the help of her family Jane advised the local council that she needed something different and they agreed and suggested that she and her family look at other possible options. On Jane's behalf her dad set about meeting and interviewing local support providers. It was decided to link with C-Change Scotland who offered to manage her support using an Individual Service Fund. From the beginning they negotiated with her what aspects of her support she would manage and what the organisation would do on her behalf. For example Jane paid less from her budget for service management as she agreed to take on some aspects of this role.

Jane has achieved many of her ambitions, furthering her education with a course at University of the West of Scotland; obtaining employment and developing her political interests.

Jane was keen to take greater control over her individual budget and in April 2010 successfully applied for and received her Individual budget in the form of a direct payment. She says 'I have my money so I have more say over my support.'

The SDS Act will place statutory obligations upon social work services and funding arrangements. It will provide an opportunity to further personalise the commissioning process to link to individual outcomes. Commissioners will increasingly have to develop and influence their local markets to encourage greater choice and control for service users from a more diverse range of providers; develop financial flexibility to enable resources to be re-directed from less popular services; and develop systems which provide clarity about purchasing options for SDS clients, eligibility criteria and individual pricing mechanisms for in-house and external services. This will be a challenge for commissioners and providers alike as it heralds a move towards a co-production approach and away from long-term block contracts.

People with learning disabilities and carers have said that involvement in the decision making process leads to better outcomes and better decisions about services; they can provide information based on life experience that will help support commissioners and planners to make sure that support services are targeted and that planning leads to the most efficient use of available resources, therefore leading to better outcomes.

Recommendation 4

That the Learning Disability Strategy Implementation Group will set up a training sub group to take forward health and social care workforce development. The sub groups remit will be to work in partnership with NHS Boards, local authorities, relevant statutory bodies and third sector to support workforce development to:

• Ensure the ongoing learning and sharing of best practice is available and accessible to all health and social care professionals to address the healthcare needs of people with learning disabilities
• Ensure that NHS staff, as part of their mandatory and induction training, receive training in the suite of legislation relevant to supporting people with learning disabilities in mainstream health settings
• Ensure that staff in high volume acute pathways for people with learning disabilities are given relevant learning disability training
• Ensure that health and social care staff working with people with learning disabilities are trained on use of 6D cards and Talking Mats

Recommendation 5

That in preparation for the legal duties imposed by the Social Care (Self-directed Support) (Scotland) Act 2013, local authorities and their NHS partners should work with private, voluntary and third sector agencies to ensure that people with learning disabilities have access to a creative variety of providers and supports and are assisted to think creatively about how outcomes can be met and what assistance they may need to develop control.

Under this recommendation, health and social care partnerships should:

• gather robust information on unmet eligible need;
• ensure that future joint commissioning plans and strategies seek to shape the range of choices available to people with learning disabilities;
• combine demographic and care management information to project future eligible need;
• improve the links between the information recorded in individual assessments and the major strategic decisions about what services to commission, what type and variety of services and where;
• work in co-production with providers to stimulate the development of new services and new service models in response to what people with learning disabilities say they want; and
• build the capacity of people with learning disabilities so that they can collaborate with the Health and Social Care Partnership to design, deliver and commission a greater variety of services and supports.

An overarching requirement will be that any new provision should not be large scale and/or one which attempts to replicate long stay hospital provision of the past. Joint commissioning is a key mechanism by which integrated health, wellbeing and social care will be expected to deliver the Government agenda for better outcomes for older people, including those with learning disabilities.

The Joint Strategic Commissioning Learning and Development Framework¹¹ and the Guidance on the Procurement of Care and Support Services¹² will help those responsible for improving joint commissioning capacity in local partnership to achieve joint commissioning.

Recommendation 6

That by June 2014 COSLA, ADSW and NHS partners work with Scotland Excel to improve the quality and consistency of support for people with learning disabilities who have a long-term need for specialist residential care, by developing a national framework agreement for procurement. This should include a core service specification which focuses on outcomes for residents, the rates that will apply, and the arrangements that will be put in place to monitor and manage performance.

Recommendation 7

That by April 2015 local authorities and NHS Boards should ensure that joint commissioning plans take account of the needs of people with learning disabilities of all ages. Plans should have regard to relevant guidance, scope current and future need, identify the total resources available to meet those needs, and set out how they will be invested to secure sustainable, high quality services and supports that can deliver outcomes for individuals, including those agreed as part of person-centred care planning and self-directed support (SDS). Plans should make reference to early interventions, maximising independence and control.

Recommendation 8

That by June 2015 the Care Inspectorate and Healthcare Improvement Scotland should ensure that strategic commissioning plans, processes and implementation are examined as part of on-going scrutiny work that impacts on services for people with learning disabilities.