IDeA case study: Integrated commissioning to improve care and dignity

Authority: Warrington Borough Council

Name of the LSP: Warrington Partnership

Other organisations significantly involved: all contracted social care providers in Warrington

Region: North West England

Date of case study: July 2008

Keywords: social care, adult social care, dignity in care, social care commissioning, older people, learning disabilities, mental health, user involvement.

National Indicators: Warrington Borough Council is promoting the dignity agenda through the Local Area Agreement. The Council believes, however, that a much broader range of NIS PIs can be used to reflect progress beyond the headline self reported measure NI 128, which is currently being developed.

Download the case study as a pdf.

For Warrington, key themes include supporting people to reach their potential and commissioning a broader range of services that are effective in supporting independence. The contribution of a thriving Third Sector to the dignity agenda is also emphasised.

Warrington’s LAA PIs include:

• NI 125 Achieving independence for older people through rehabilitation/ intermediate care
• NI 136 People supported to live independently through social services (all ages)
• NI 7 Environment for a thriving third sector
• NI 146 Adults with learning disabilities in employment
• NI 150 Adults in contact with secondary mental health services in employment

WARRINGTON BOROUGH COUNCIL

Integrated commissioning to improve care and dignity

ABSTRACT

Strengthening the commissioning function in social care is a top national and local priority. Warrington Borough Council has made a concerted effort to use commissioning to lever improvement in services by adult social care providers and to increase dignity for service users, as defined by the Department of Health’s Dignity Challenge. Evidence shows this approach is working, with a significant increase in the number of contractors meeting required standards. Key learning points include: strategic use of available data; recruiting social care staff to the commissioning team and co-locating with social care practitioners; sharing information with providers and working closely with them on improvement and training towards explicit standards of care; extensive user and carer involvement in the monitoring, planning and commissioning of services.

MAIN TEXT

The issue

When the national Dignity Challenge was issued by Health Minister, Ivan Lewis, in November 2006, Warrington Borough Council’s recently restructured community services department wanted to use its commissioning role as a lever to improve the quality of care in a way that would increase dignity for users of social services. The Council purchased a large proportion of services from the independent sector (approximately 83% in 2005) and was aware that the sector produced significantly lower standards than local authority and national provision as a whole.

The Council’s understanding of ‘Dignity in care’ is the kind of care, in any setting, which supports and promotes a person’s self respect. This includes providing an appropriate environment, and assisting people to maintain autonomy, control and a quality of life that can reasonably be expected by anyone within our society, regardless of difference. The 10 points in the Dignity Challenge are:

1. Have a zero tolerance of all forms of abuse. 
2. Support people with the same respect you would want for yourself or a member of your family. 
3. Treat each person as an individual by offering a personalised service. 
4. Enable people to maintain the maximum possible level of independence, choice and control. 
5. Listen and support people to express their needs and wants. 
6. Respect people’s right to privacy. 
7. Ensure people feel able to complain without fear of retribution. 
8. Engage with family members and carers as care partners. 
9. Assist people to maintain confidence and a positive self-esteem. 
10. Act to alleviate people’s loneliness and isolation.

Where actions described below relate to specific points in the Dignity Challenge, the number is given in brackets. However, all the actions described are believed to have contributed to addressing the Dignity Challenge which the Council saw as providing an ultimate benchmark. It focused on developing the capacity of both individuals and services to deliver care with dignity, as well as the full involvement of services users and carers in all aspects of planning and delivering care. The Council focused on five main objectives.

• Knowing that there was much untapped data including information held by social care staff that was not being effectively captured, it set out to bring together information about the quality of care from all available sources, ensuring that actions were based on robust and timely information. It wanted to share the information gathered with care providers.
• It aimed to provide both additional incentives and additional support to providers to improve care.
• It needed to build the resources to deliver the required improvements.
• It wanted greater involvement of service users and their carers in commissioning as this would contribute to several points in the Dignity Challenge (in particular 3,4,5,8,9 and 10).

What they did

1. Making the best use of information

The Council wanted to improve the flow of information between users, regulators and providers. It brought together information from the following sources:

• feedback, compliments and complaints process
• information gained through adult protection procedures
• statutory and regulatory information, including that relating to inspections
• practitioner knowledge and experience of services
• service user feedback
• care reviews
• contract monitoring information.

The Commissioning and Contracting Team (CCT) were accessible, not only via written communication but by encouraging colleagues to drop in to share information. Complaints relating to a provider were routinely notified to the CCT and practitioners were required to make the CCT aware of any concerns. The Council also ensured it had strong working relationships with local CSCI inspectors and consistently shared information with them. It also routinely monitored inspections reports and mapped outcomes using a colour-coded system to flag up providers of concern. Important factors were:

• complaints, training and CCT functions all managed by the same Head of Service, with one senior manager overseeing both CCT and complaints.
• co-location of CCT and practitioners. 
• a dedicated team to oversee care home reviews, managed by the Adult Safeguarding Coordinator. 
• the strengthening of effective, open working relationships between all parties.
      

2. Developing resources for proactive commissioning

The Council acknowledged that more investment was needed to strengthen commissioning and relationships with providers. Two new Compliance, Monitoring and Improvement Officers, both qualified social workers, were recruited to the Commissioning and Contracting Team.

The concepts of dignity and respect underpinned much of the discussion about improved resources, including changing a number of job descriptions of support workers to make specific reference to valuing people (Dignity Challenge 2) and to inclusion (Dignity Challenge 10).

As well as measurably improved outcomes in terms of quality of care commissioned, a clearer focus on efficiency within CCT has also resulted in better value. The Council has used its relationship with providers and pricing mechanisms both to lever improvements and to keep costs down – see point 4 below.

3. Working with care providers to improve quality

Two approaches to working more closely with providers were used.

• Collectively – through homeowners’ meetings and, for domiciliary agencies, a care network meeting. These provided an opportunity to discuss quality and the Council’s expectations in relation to dignity standards; and an opportunity to share information from a wide range of sources, including the Local Authority Market Analyser (LAMA). The LAMA provides comparison with equivalent England and comparator group data. In 2005, standards in external provision, both domiciliary and residential care were below national averages. This stimulated a productive discussion with providers to address quality and improvement strategies. Time to Care (CSCI’s 2006 critique of the ‘15 minute slot’ model of domiciliary care -  Dignity Challenge 3) has also been discussed with providers, as well as CSCI’s annual report on The State of Social Care in England. Meetings also enable the discussion of specific problems and the sharing of good practice, such as the practice guidance on Dignity in Care developed by the Social Care Institute for Excellence (SCIE). The homeowners’ meeting has supported the implementation of enhanced payments for quality and has scheduled additional meetings to discuss individual issues. One priority arising from provider forums was training. A strong partnership between the Contracts and Commissioning team and training department focuses on tailoring appropriate training internally and externally. A special module on dignity has been developed as part of the training programme.
   
• Individually – through annual negotiations with providers; monitoring visits; and visits resulting from specific information. In domiciliary care, unified documentation has been developed in agreement with all providers, with particular emphasis on ensuring that the care delivery plan is truly person-centred (Dignity Challenge 3). Provider Care Plans now have a common and consistent structure, and in the small number of cases where two agencies are providing care for one service user, they now keep joint records. The Council is moving on to develop a common service-user questionnaire to be used with all domiciliary care providers for the annual survey of service users’ views (Dignity Challenge 5).
     

An integrated approach between CCT and the Training team is considered especially important by the Council, both in developing the wider social care workforce and in contributing to the Warrington Social Care Partnership. This group recently hosted a Sharing Caring conference to share the Council’s vision for the direction of future commissioning, with providers from the public, private and third sectors. This was attended by the Executive Member for Community Services, Cllr Roy Smith who is signed up as a ‘Dignity Champion’. This role began with attendance at a seminar on the Dignity Challenge, with Health Minister, Ivan Lewis. Cllr Smith sees his role as that of keeping the issue of dignity on the agenda and making a commitment to promote the issue with service providers. He meets as many service users as possible, and says that the touchstone for him about whether people are being treated with dignity is “how I would want my mother to be treated and how I would want to be treated myself”.

Using a ‘One workforce’ team approach, the Council works across the sector to support workforce development and also targets providers to address areas for improvement, including support for progression with Investors in People. This work is also supported by an emphasis on safeguarding (Dignity Challenge 1). Both training team and the Safeguarding Adults Coordinator provide training in individual establishments.
Increasingly, the Council is developing partnership approaches to commissioning, for example in implementing its Sustainable Community Strategy and Local Area Agreement. In partnership with the Primary Care Trust a Joint Commissioning Board is identifying further opportunities for improving efficiency and addressing local needs through joint commissioning.

4. Using financial incentives to improve the quality of provision

In tangible recognition that quality of care was a high priority, the Council introduced what were at first called ‘enhanced payments’ to those providers showing that they met all minimum safeguarding, care, health and management standards. Those not meeting the standards receive ‘basic payments’ and are required to develop an action plan for improvement. The Council does not make new placements with such providers while working with them on their improvement plan. As so many of its social care services are contracted out, the Council believes it cannot afford to be an ‘arms-length’ commissioner and that it has a responsibility to ‘default’ contractors (i.e. invoke the default clause in their contract) that are not performing up to standard.

At a later stage, enhanced payments were renamed ‘standard payments’, as it was felt that this made clear that this was the level generally expected from all providers.

The differential in price paid by the Council to the strongest and the weakest providers is now £20 a week per person. As it has used pricing mechanisms as a means of improving standards, it has grown more confident and believes it has got tougher on inadequate quality through differentials. Its target is now to reach 100% for all care homes rated as ‘good’ or ‘excellent’ under CSCI ratings.

 
5. Involvement of service users, carers and partners

Service user involvement is now embedded in service planning, monitoring and commissioning and is believed to be one of the greatest contributors to increasing dignity. This includes planning and delivery of training and checking services for quality, for instance through a Planning Day with users of learning disability services and carers to identify priorities and targets. The Learning Disability Partnership Board has a strong representation of service users and carers. However, members felt they had limited influence over resource allocation. It was decided that service users would be involved at the outset in deciding priorities for commissioning services. As a result of this process, the Learning Disabilities Development Fund has been distributed among the Partnership sub-groups to be spent against the priorities and targets identified. Progress is to be measured in a year’s time.

Users of learning disabilities services have also been involved in direct monitoring of providers through the Checking Out Project and mental health service users in training on mental health issues. Several people from the Council’s Older Persons Engagement Group (OPEG) have been trained to take part in monitoring older people’s services alongside the Council’s own Monitoring Officers. A member of OPEG has also been involved in assessing bids from care homes for the distribution of the care home improvement capital grant.  A carer was involved in the tender process for choosing an organisation to award the contract for personal care and support to people with Acquired Brain Injury. There are also plans to involve a service user/carer in the recruitment of staff for this service. Warrington Borough Council is also working with a local social enterprise organisation to ensure broad engagement in an LSP-wide Physical and Sensory Disability Commissioning Strategy.

Users and carers have also been involved in selecting providers after having had training (for example, in contract law). “This is a powerful process”, comments Roger Millns, Head of Service for Mental Health, Learning Disabilities and Corporate Social Services. “We don’t always agree with service users’ views but we know that our commissioning decisions are influenced by their perspective”.

6. The impact and evidence for it

The evidence strongly indicates that this approach is resulting in more consistent and improved quality of care and is, thereby, contributing to increased dignity and respect for service users, as defined through the Dignity Challenge. The impact of the approach can be seen in a range of settings, for example the Dallam Day Centre (for people with physical and/or sensory disability) which involved all stakeholders in the plans for the re-provision of this service. Outcomes included a larger meeting room and wider corridors to allow two people in wheelchairs to pass. There is also measurable evidence of a general improvement in care by external providers.

• Within care homes, the enhanced payment for quality care was paid to just 14 percent of homes when launched in October 2006. Renamed  the ‘standard payment’, it is now paid to over 62% of care home providers, despite the fact that the Council believes its own assessments are tougher than they were. 
• There has also been a noticeable change in the annual Local Authority Market Analyser for the area, since 2005-6. Quality of provision has increased markedly across domiciliary and residential care, as it has nationally. The rate of improvement has been faster in Warrington and standards were above the national average for residential care and similar to the national average in other areas at the end of 2006-7.  During the last year standards have increased further, with 90% providers rated good or excellent.

Warrington/England Trend Analysis (from Local Authority Market Analyser)

• The incentivised financial regime along with systematic information-sharing has made providers aware of the robust monitoring systems now in place. There is evidence that providers are not only working with the Council to drive up the quality of care, but are also engaging in other council initiatives, such as the iCAN consumer alert network, which broadcasts warnings in relation to local consumer fraud and rogue traders (12 external providers were signed up to iCAN at the last count) and is itself a contributor to the Dignity Challenge (1,4,9 and 10). The domiciliary care network is now seen as the quickest way of distributing such information to some of the most vulnerable Warrington residents. 
• There has been a significant decrease in complaints about external providers of service (a reduction of over 60% from 91 in 05/06 to 36 in 07/08) at the same time as a publicity campaign to make service users aware how to raise complaints (Dignity Challenge 7). 
• In the most recent survey of home care users, 98.3% strongly agreed that they had been treated with respect (Dignity Challenge 2). 
• There has been a significant increase in uptake of training by providers and their staff.  
    

• In addition to the lead councillor for adult social services registering as a Dignity Champion, 10 staff and one service user are also registered, indicating that they have made a commitment to promote the Dignity Challenge in their work.
  

7. Barriers, challenges and lessons

Introducing staff with a social care background and qualifications into the contracts team, including the term ‘improvement’ into the job titles of monitoring and improvement officers, and co-locating with social care staff has made a big difference to the working culture, says Terry Charnock, principal officer for commissioning at Warrington. “Another driver for culture change has been a much more systematic use of the information available, such as the Local Area Market Analyser, from which we and contractors can get a very good idea of what providers are doing and whether they are improving”.

Senior staff also believe that their twin approach to improvement through financial incentives but also much greater inclusion of service providers in understanding the standards and outcomes expected, what dignity means from the perspective of service users and joint training of council and provider staff, is beginning to pay dividends.

Head of Service, Roger Millns, says, “In Warrington, historically, we had a thorough-going approach to assessment and care management but we did not have a tradition of sharing best practice with partner organisations. Now we have a whole programme of sharing”, says Roger. “Using commissioning as a force for moving service users to the centre of design and delivery of services is something we all feel passionately about. We have also learned that this approach imparts a human face to processes that might traditionally have been thought to have a dry legal and technical flavour”.

8. Next steps

The PCT is committed to sharing the Council’s good practice in this area to improve dignity in health. Areas for development include care planning that effectively combines and costs health and social care elements. Currently documentation is being adapted to give service users more control over the health component of care plans.

A joint approach to commissioning from the Third Sector is another focus for development, closely aligned to priorities in the LAA. The Council is keen to encourage the development of social enterprises in particular. Supporting social enterprises to work as co-operatives in providing services is seen as a way of increasing dignity, as it enables users to be involved in providing as well as using services (Dignity Challenge 4 and 9).

“We don’t think we have fully cracked the Dignity in Care agenda through our approach to commissioning, but we now believe we are in the right direction of travel”, says Roger Millns. 

9. Further information

Web site links

Department of Health information on Dignity in Care campaign

DH web area from which the 10-point Dignity Challenge can be downloaded

Dignity in Care Champions Network (online network set up to help Dignity Champions take forward the Dignity in Care Campaign)

Social Care Institute for Excellence Practice guide 09: Dignity in care (practice examples, tools and resources)

Commission for Social Care Inspection’s response to Dignity in Care campaign

Commissioning area of website on joint reviews in Wales (useful introduction to commissioning for social care)

Last updated 26/02/2010 12:11:52

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