Adult Social Care Risk Assessment

1. Adult Social Care Risk Assessment • Insights and intelligence from facilitated workshops 2017-2019 Liz.greer@local.gov.uk 07717720729 June 2019 www.local.gov.uk

2. Insights and intelligence from facilitated workshops April 2017- March 2019 • This slide-deck summarises the insights and intelligence gained from 45 facilitated risk assessment workshops using the Adult Social Care Risk Self-Assessment Tool between April 2017 and March 2019 • The workshops were fully funded by the LGA’s Care and Health Improvement Programme (CHIP) - the offer to Directors is summarised on slide 7 • Funding for these workshops was devolved to the ADASS regions in April 2019; requests for workshops should now be made via the regional Care and Health Improvement Advisor (CHIA) or Sector Led Improvement (SLI) Lead; CHIP can still advise on sourcing facilitators and developing a tailored specification if required. Contact liz.greer@local.gov.uk • The objective of the facilitated workshop offer was to support Directors to develop a deeper understanding of their strategic risks and to develop mitigating actions, thereby reducing the likelihood of system failure; feedback suggests there was a high level of satisfaction with the workshops and that they met or exceeded participants’ expectations • There was a significant degree of consistency in the 3 main risks identified through this process over two years: 1.market sustainability 2. Adult Social Care (ASC) workforce – with serious shortages and skill gaps in particular roles and 3.managing demand www.local.gov.uk

3. Context & background to the facilitated workshop offer • In 2015 the TEASC (Towards Excellence in Adult Social Care) partnership developed a voluntary self-assessment tool for use by Directors of Adult Social Care (DASSs) • The original tool was developed with ADASS regional chairs & piloted in each ADASS region • It has been widely adopted with most councils using it in some form, usually as part of local and/or regional peer-led improvement arrangements, and regions continue to adapt and refine the tool to meet local need • In 2016 the LGA’s Care and Health Improvement Programme commissioned a refresh of the risk self-assessment tool • For 2017-18 CHIP developed a new offer to councils of fully-funded external, independent support to undertake the self-assessment, providing analysis, constructive challenge and brokering additional support to councils in managing and mitigating risk in the short and medium term • This offer complemented the support on offer from Care & Health Improvement Advisers (CHIAs) and Principal Advisers • This new offer wasalso open to DASSs to facilitate discussions with chief executives, chief finance officers, elected members and other system leaders about risk and to support the development of shared risk mitigation actions • The anticipated benefits of the facilitated workshop offer: deeper understanding of strategic risks and development of mitigating actions, reducing likelihood of system failure www.local.gov.uk

4. The self-assessment model : a 360‎° look at risk Performance and outcomes (including safeguarding) Leadership and governance Commissioning and quality Risk Areas National priorities and partnerships Culture and challenge Resource and workforce management www.local.gov.uk

5. Entry to the facilitated risk workshop : a two way process Performance and outcomes (including safeguarding) Leadership and governance Commissioning and quality Councils could take up the risk workshop via their Sector Led Improvement (SLI) lead, CHIA or Principal Adviser ,or having identified the need via another route/diagnostic eg MSP, iCBO, Use of resources, peer review etc Risk Areas National priorities and partnerships Culture and challenge Resource and workforce management www.local.gov.uk

6. 2 Brokerage to other specialist support offers Once the workshop was complete, CHIP could then broker further specialist/ bespoke support in any of the 6 domains as needed Performance and outcomes (including safeguarding) Leadership and governance Commissioning and quality Risk Areas National priorities and partnerships Culture and challenge Resource and workforce management www.local.gov.uk

7. The offer to DASSs • free full-day facilitated workshop on site plus a half day action planning/ review follow-up meeting if required • choice of highly skilled and experienced facilitators with credibility and senior level experience in local government, health and adult social care • pre-workshop discussion with local stakeholders/ sponsors (eg CHIA, DASS, SLI lead) to agree scope & ensure offer was tailored to local need • Synthesis and analysis of both qualitative and quantitative data to inform the workshop discussion under ‘Chatham House rules’ • an active, engaging peer-led conversation to prompt open and honest group discussion and challenge in a safe and confidential environment • an agreed, locally owned action plan including optional brokerage for other free, specialist support from the LGA/CHIP on specific risk domains • a confidential summary of learning points and action agreed at the workshop • a half-day follow up action planning/review session (if required). www.local.gov.uk

8. Flexibilities within the offer • Up to 1.5 days per council – could be scaled up for sub regional or regional delivery* • Councils could mix and match components of the offer : • on site/off site • real time completion/post completion • data analysis and synthesis • qualitative analysis and synthesis • action planning/ review • participants: ASC/corporate/wider system eg health • brokerage to other sources of support • ‘Bottom line’ ask from councils taking up the offer: • participation in an on-site facilitated workshop, considering all risks identified using the Risk Assessment model and individual self-assessments • work with an external, independent facilitator commissioned by the LGA, offering a fresh look and constructive challenge • a new offer, not to replace or duplicate other regionally funded activity on risk • *In 2017-8 two ADASS regions took up the offer for all of their councils www.local.gov.uk

9. ‘Bottom lines’- our ask from councils taking up the offer • participation in an on-site bespoke, facilitated workshop, considering all risks identified using individual Risk Self-Assessments • use of an external, independent facilitator* jointly commissioned by CHIP and the DASS, offering a fresh look and constructive challenge in a confidential setting • DASS (and CHIA in some cases) actively involved in selection of a supplier (usually from 3) and scoping the workshop objectives and outputs • feedback about the process and the selected supplier to CHIP so we can continue to improve and develop our offer • willingness to share key learning headlines from the process with the sector, anonymised where necessary, in line with the principles of sector led improvement • * This was a new offer, not available to fund suppliers previously commissioned locally or to replace or duplicate other regionally funded activity on risk www.local.gov.uk

10. Take-up of fully funded facilitated workshop offer between April 2017 and March 2019* • NB the south west workshop was facilitated by another CHIA from outside the region • * From 2019-20 funding for facilitated risk assessments was devolved to the ADASS regions 45 councils benefitted from a fully-funded facilitated risk-assessment workshop between April 2017 & March 2019 6 24 11 3 1 www.local.gov.uk

11. Take-up of fully funded workshop offer between April 2017 and March 2019 NB funding in 18/19 was significantly reduced, meaning priority was given to those councils who had not benefitted in 17/18 * one led by local CHIA www.local.gov.uk

12. Take-up of fully funded workshop offer between April 2017 and March 2019 • For the 2019-2020 financial year, funding to support facilitated risk assessments was devolved to the ADASS regions • The following slides summarise the key insights and intelligence collected during the centrally funded workshops between April 2017 and March 2019 www.local.gov.uk

13. Insights gained- top 3 risks 2017-18 • Although the need to make ever more savings formed the backdrop to all of the facilitated risk workshops, the top three risks to continued, sustainable delivery of ASC services emerged as: • market sustainability • ASC workforce – serious shortages and skill gaps in particular roles • managing demand • These risks are all linked; workforce shortages are not just in the provider market. For councils they include Approved Mental Health professionals, Best Interests Assessors, level 3 social workers and commissioning specialists with the analytical, modelling & predictive capability needed to design, commission and deliver new and diverse models of outcome-based care for whole populations • Councils know they need to significantly reshape their markets to deliver new models of care to meet future demand, but had real concerns about their ability to continue meeting need in the short term; they also highlighted that where levels of self-funding are high, their ability to shape or influence markets is limited • Key workforce groups are ageing (both assessors in the Local Authority (LA) and among providers) however analysis and workshops found little evidence of strategic succession planning or planning and commissioning the workforce needed to deliver new models of care and integration • Corporate barriers to addressing ASC workforce challenges speedily (eg in response to winter pressures) were cited frequently; this was a particular issue where the DASS was not member of Corporate Management Team and therefore it was less easy to influence corporate HR/unions

14. Insights gained- top 3 risks 2017-18 • Managing demand • Managing demand within current and reducing resources going forward was the third priority; workshop discussions centred on: • investing in prevention to reduce demand for care and health services • reducing reliance on expensive building-based care • developing the workforce (in-house and provider) to deliver new models of asset-based and place-based care • market development/redesign to support a ‘home first’ culture • need to deliver transformed and integrated care and support at pace - scale of culture change needed is significant www.local.gov.uk

15. Insights gained- other risks 2017-18 • Leadership challenges: corporate willingness to share and understand risk in relation to ASC is adversely affected where the DASS is not part of the corporate management team and unable to easily shape corporate/elected member narrative • Progress on integration has been much slower than anticipated; issues included: • Unrealistic timelines for integration; can be easily derailed by eg CCG restructures • Significant financial risk where systems had agreed to BCF targets they knew were undeliverable • Discussion with health partners is frequently health-dominated, with little shared ownership/leadership for joint delivery of new models of care or risk sharing • Has been overtaken (and in some cases undermined) by the national debate on DTOC and the perceived ‘naming and shaming’ of systems the centre see as underperforming • Too many competing system approaches to integration eg place; STPs • Role of HWBs in driving integration remains unclear • There are still too many untested assumptions about where savings are to be found • Little or no progress with integrated commissioning or workforce strategies • HICM generally perceived as valuable system improvement tool (but not for performance management) • Delayed transfers of care (DTOC) –interestingly, DTOC did not feature strongly as a risk; if anything it was regarded as a distraction from the main business of ASC

16. Insights gained- top 3 risks 2018-19 • As in the previous year, concerns about financial sustainability, and the need to make even further savings, was a consistent thread running through all of the workshops • The top three risks sustainable delivery of ASC services based on feedback from the 7 workshops in 2018-19 were: • market sustainability • workforce • financial sustainability: the need to make further savings and the need to meet growing demand • Market sustainability issues: a fragile market; too many older people admitted to residential care because not enough community provision; difficult to reshape market to deliver new models of care, especially if high levels of self-funders; home care (low fee levels) & supported living/extra care a particular challenge; as with last year, capability within commissioning teams to plan strategically, develop markets, model demand and jointly commission is limited, with over-emphasis on contract compliance and procurement; lack of suitable Learning Disability community support a growing risk • Workforce issues: internal (LA) skill gaps, as well as in the provider market, especially nurses; issues recruiting and training staff, and high turnover levels, combine to make succession planning and service redesign problematic • Financial sustainability: these are risks faced by all councils which are deepening; the immediate need to reduce budgets in the face of growing demand makes investing in programmes of transformation and prevention which have long lead in times before delivering medium/long term savings extremely challenging, especially when combined with the market and workforce risks

17. Insights gained- other risks 2018-9 • Leadership issues: challenges highlighted included need to have stronger future-focused vision/narrative which can be shared with staff and partners alike instead of fire-fighting in the here and now; shifting ASC focus from performance and paternalism to embedding new models of care and strengths-based approaches • Progress on integration – remains much slower than anticipated which also poses a risk if integration may be part of the solution to other highlighted risks; complexities of CCG and ICS changes/restructuring are getting in the way of progress in realising the benefits of integration • New risks emerging in 2018-19 • Transforming Care & Learning Disability strategy –also a market development issue • Embedding Adult Safeguarding and MSP across local systems • DTOC – as with the previous year, DTOC did not feature strongly as a risk

18. Summary –main risks • The main risks highlighted through these workshops have been fairly consistent: • Major financial sustainability risks – reducing budgets, increasing demand, fire-fighting makes medium/long term planning difficult • Major risks are posed by market fragility, making reshaping markets extremely difficult; this is exacerbated by workforce challenges/skill gaps in the provider market, in professional roles in Local Authority ASC, and in commissioning teams • There are major ASC recruitment, retention and succession planning problems, with acute shortages in key roles in both LA and provider services • Integration which could provide some solutions is being hampered by internal restructuring/mergers etc in CCGs, ICSs • Necessary culture and behaviour change eg to strengths/outcome based approaches/new models of care/prevention is slow to embed; the recent Kings Fund report (June 2019) describes how it has taken Wigan (‘the Wigan Deal’) 6 years to embed an asset-based approach to its relationship with local people, with further work still to do • ASC Leaders are finding it hard to communicate and build ownership for a clear, positive future vision/narrative for ASC- both within their own council as well as with their NHS partners, providers and other stakeholders -while they are constantly fire- fighting and/or are perceived as impacting negatively on overall LA budgets

19. Did the workshop offer deliver the intended benefits? • The anticipated benefits of the facilitated workshop offer were that participant councils would develop a deeper understanding of their strategic risks and could then develop mitigating actions, thereby reducing the likelihood of system failure • The unique aspects of the offer were : • A fresh look at risk using an external, independent facilitator commissioned by the LGA to provide constructive challenge • The flexibility to mix and match components of the offer • The flexibility to scale up (two regions took advantage of this for all of their councils) • Signposting to other sources of support once particular risks highlighted • Feedback from participants suggests that this offer was highly effective and added considerable value beyond simply completing the self-assessment; the independent analysis of the self-assessment and the challenge workshops, coupled with the careful matching of skilled and experienced facilitators to each commission, were particularly valued. A number of councils have gone on to benefit from further support on specific risk domains and some have commissioned the same process for a second year.

20. Feedback from Directors participating in the workshops:

21. Where Next? Funding for facilitated risk-assessment workshops has been devolved to the ADASS regions for 2019-20 Requests for workshops should now be made via the regional Care and Health Improvement Advisor (CHIA) or Sector Led Improvement (SLI) Lead; CHIP can still advise on sourcing facilitators and developing a tailored specification if required. Contact liz.greer@local.gov.uk Further information: Liz.greer@local.gov.uk 07717720729