Introducing an outcomes focus to service planning and delivery in Powys Adult Services.

1. Introducing an outcomes focus to service planning and delivery in Powys Adult Services.

2. A few facts about Powys • Geographical area: 210,271 acres (25% of Welsh Landmass) • Number of sheep: 1,000,000+ • Number of residents: 131,500 (4.4% of Welsh population) • Equates to: each resident having 1.6 acres of land and 7.6 sheep!

3. The land of the three Shires • Montgomeryshire • Radnorshire • Brecknockshire

4. What we are famous for ? ·The Red Kite ·Elan Valley ·Adelina Patti ·A hiding place for Salman Rushdie ·Adult protection work – (Social Care Accolade 2005)

5. What we are not famous for: • Innovative social care services • ‘In adult services, people in Powys get help that is safe and caring, but may well prove insufficient to meet their needs…… services are not sufficiently focused on enabling users and carers to retain maximum independence and control’ Joint Review, February 2006

6. Historical decision making: Reactive, rather than strategic… Result: A ‘Hodge podge’ of disconnected services and processes Future decision making: Reflective and strategic… Result:

7. ‘A strong distinct coherent and accountable function of Powys County Council, in tune with citizens’ and communities’ needs, promoting social inclusion and the rights of individuals, concerned with outcomes and high quality support services that are provided in a joined up, flexible and efficient way in partnership with service users and carers, and where and when they are needed’. WAG 2006

8. Rising to the challenge – changing a culture Defining outcomes? ‘Outcomes’ refer the impacts or end results of services on a person’s life. Outcomes-focussed services therefore aim to achieve the aspirations, goals and priorities identified by service users’ SCIE (2007)

9. The view of ACIN (2006): ‘Outcomes …… a brilliant concept built on jelly’ ‘It was felt that there are probably “20 steps to get there” and that there are challenges of defining outcomes on different levels and for each stakeholder, due to different expectations and concepts of effectiveness’

10. Experience from Ystradgynlais ‘I don’t want that reablement service again – they expected me to do everything for my self, and at my age, I think I deserve to be looked after’ ‘She (the home carer) spends half of the time chatting to me – I don’t think she realises that under your ‘Fairer Charging’, I am paying for this service by the minute!’

11. ‘Personalising’ Social Services in Powys ‘3 steps to heaven’ - A whole system approach to ensuring better outcomes: ·Step 1: Getting and applying the national picture – broad outcomes ·Step 2: Getting and applying the local picture – shaping broad outcomes ·Step 3: Getting and applying the individual picture – personal outcomes

12. Step 1: Getting and applying the national picture – broad outcomes • Building a good life for older people in local communities (Godfrey et al 2004) ·Older people – independence and well being (Audit Commission 2004) ·Caring for the Whole Person (Patmore and McNulty 2005) ·Time to care? (CSCI 2006) ·Promoting person centred care at the front line (Innes et al 2006) ·Outcomes focussed services for older people (SCIE 2007)

13. Step 2: Getting and applying the local picture - shaping ‘broad outcomes’ Powys Service User and Carer Participation Strategy Participation – the ‘apple pie’ concept that is often ‘operationalised, before it is conceptualised’ (Sheppard 2001) We need to clarify the benefits of ‘participation’ (Burton 2006)

14. Developmental benefits ·Improved self esteem of ‘participants’ ·Increased self confidence and ability to take control over all aspects of life ·Increased awareness and understanding of own real interests, and how they relate to the needs of others An opportunity for self expression

15. Instrumental benefits ·Wider range of views brought into decision making ·Provides a useful reality check for policy makers ·Political legitimacy and accountability to citizens ·More effective services

16. Principles and standards of participation Principle 1: Equality of opportunity and people focused All service users, carers and support organisations have the right to participate. 1.1 The Involvement Standard 1.2 The Equality Standard 1.3 The Diversity Standard 1.4 The Support Standard

17. Principle 2: Openness and Integrity We will work in a person centred, clear, open and transparent way that promotes trust in Powys Social Services. • 2.1 The Choice in Participation Standard • 2.2 The Sharing Information Standard • 2.3 The Feedback Standard • 2.4 The Accountability Standard

18. Principle 3: Valued Partnerships We value the knowledge and expertise of service users and carers, recognise that they are ‘experts in their own experience’, and want to work together with individuals, groups and support organisations to develop meaningful participation. 3.1 The Culture Standard 3.2 The Working Together Standard 3.3 The Working With Others Standard 3.4 The Improving Partnerships Standard

19. Principle 4: Striving towards Excellence in Planning and Evaluation We are committed to always learning and improving 4.1 The Comprehensiveness Standard 4.2 The Planning Standard 4.3 The Methods Standard 4.4 The Monitoring and Evaluation Standard

20. Wheel of Participation

21. Information and Advocacy: Service user and carers have access to clear, and comprehensive information and advocacy support to maximise their choice in decision-making, and are also involved in information design and delivery. Joint Planning: Service users and carers involved in the planning and development of services (including acting on evidence based national research on the views of service users and carers). Consultation: Communicating with and listening to service users and carers views, including the provision of robust and consistent feedback Evaluation and shaping: Service users and carers involved in evaluation processes to ensure continuous service improvement. Training: Service users and carers trained to enhance their participation and also involved in staff training and development Self-Direction: Service users and carers in direct control of services, and able to access any support needed to achieve this.

22. INPUTS INPUTS INPUTS OUTPUTS OUTCOMES – IMPACT Activities Participation Short Medium Longer term Short term changes we expect Medium term changes we expect Long term changes we expect What we invest What we do Who is reached Measurement of process indicators - measurement of outcome Evaluating participation –the outcomes based Logic Model

23. Step 3: Getting and applying the individual picture - personal outcomes The individual picture and the 4 ‘C’s of local government Culture of commissioning and contracting Culture of assessment and care management Culture of service provision Culture of performance management

24. 1. Culture of commissioning and contracting Barriers to outcomes focus: ·Lack of commitment to service user and carer participation ·Task based service specifications and contracts ·Purchaser/provider split

25. ·Lack of trust (of both service users and providers) ·Services seen as distinct and unrelated (e.g. reablement/ homecare or day service/carer respite service) ·Budget overspend ·Silo working – different teams with different priorities (policy, contracts, operations, business support)

26. Possible solutions being applied: ·Vision sharing across the Department ·Outcomes based service specifications (CSCI) ·Service user and carer involvement in shaping service specification outcomes   ·Rethinking homecare - What’s in a name? ·Home based support – an integrated approach to service provision

27. 2. Culture of assessment and care management NHS and Community Care Act 1990: Needs led assessment and care management were to become ‘the cornerstone of high quality care’.

28. Who defines need? ‘Needs are the requirements of individuals to enable them to achieve, maintain or restore an acceptable level of social independence or quality of life as defined by the particular care agency or authority’ (SSI 1991p12) ‘Ultimately, having weighed the views of all parties including his/her own observation, the assessing practitioner is responsible for defining the user’s needs’ (SSI 1991 p53)

29. Is it surprising that in a review of the implementation of the NHS and Community Care Act 1990 after a decade of being implemented in Wales, Parry-Jones and Soulsby (2001) found that care managers: ‘ … were still rationing out a limited range of standard services’ ?

30. Barriers to outcomes focus: ŸService driven referrals: Mrs Jones needs assessment for the day centre Mr Smith needs assessment for meals on wheels ŸService focussed care plans with no room for preferences/values ŸUnder-developed networking and community development skills

31. Lack of care manager awareness of the ‘modernisation’ agenda • Large case loads • Deficits based assessment tools

32. Possible solutions being applied: • Regular policy briefings with area teams • Terminating service led referral • Assessor Nurses and CPNs in adult teams, and regular ‘team’ meetings with DNs • Training in: Person centred assessment/care planning Community development/networking • More patch based care managers (e.g. GP practices)

33. Strengths’ based assessment, taking into account preferences and values (e.g. quality time or smallest bill?) • Outcomes focussed care plans • Creative care planning within existing resources - applying ‘Eligible need’ • Outcomes focussed reviews • Intelligent outcomes based evaluation and feedback to commissioning/contracts monitoring

34. 3.Culture of service provision Barriers to outcomes focus: • Bland task based Service Delivery Plans • Provider risk assessor’s overriding Physiotherapists and OTs • Frontline staff who are: Poorly qualified Poorly paid Poorly briefed Poorly trained Overworked

35. Lack of joined up working (e.g. with wardens and DNs) • The need to refer back to care managers for everything

36. Possible solutions being applied: ŸMore rigorous outcomes focussed service specifications ŸBetter service delivery plans (e.g. dementia day services) ŸPositive Risk Taking Policy ŸJoint working protocols with the LHB Ÿ‘Vision sharing’ with provider managers

37. Briefing processes for frontline staff on: Personal outcomes Individual preferences other local contacts (e.g handyman) • Joint training in person centred service provision (e.g dementia day service)

38. Exploring different approaches to delivery: • Making the best use of ‘set time’ (Patmore) • Direct Payments • Supporting flexible working (that doesn’t allow preferential treatment) – Rhayader home support • Allocating hours which can be banked (Oldham) • ‘Team working’ with patch based care managers • Making better use of AT and ‘careline’ (Durham) • Integrated support (including rapid response) • Opportunity to purchase extra hours for ‘non-eligible’ need

39. 4. Culture of performance management Barriers to outcomes focus: • PIs that measure quantity not quality • PIs that measure ‘standard’ service delivery not creativity • Data inputting that takes up valuable care manager time

40. Possible solutions being applied: • Data inputting clerks • The work of CSCI …… and WAG? • The Four Countries Adult Care Information Network (ACIN)