Transparency in outcomes: a framework for adult social care

1. Transparency in outcomes:a framework for adult social care Social Services Research Group 18 November 2010

2. The policy context This is time of transition for adult social care, with challenges and opportunities in the years ahead. There are a number of strategic issues with drive our approach and suggest the need for new thinking about the relationship between national and local government: • The Vision for Adult Social Care and Think Local, Act Personal • The Spending Review and financial challenges • Changes to the local NHS and councils: Health and Wellbeing Boards • The localism agenda

3. The impact of localism This relationship between national and local government and citizens is changing. ‘Wherever possible, we want people to call the shots over the decisions that affect their lives…We will extend transparency to every area of public life…Our government will be a much smarter one, shunning the bureaucratic levers of the past and finding intelligent ways to encourage, support and enable people to make better choices for themselves…We will end top-down government.’ This means: • An end to top-down targets and performance management: the National Indicator Set and Local Area Agreements have been abolished. • A focus on local accountability to citizens, not upwards to Departments, regulators and national bodies. • A new responsibility for the social care sector to lead its own improvement, supported but not directed by national bodies. Annual performance assessment of councils by CQC has been ended.

4. Introducing the consultation This consultation marks the start of a period of co-production, through which we want to agree a new approach with new roles for national bodies, local councils and citizens. Outcomes: Placing a focus on the results achieved. Personalisation means putting what matters to people at the heart of social care. Quality: The effectiveness, safety and efficiency of services and the experience of people who use them. Quality underpins the achievement of outcomes. Transparency: Empowering local citizens to hold services to account through sharing of information, publication of reports and a greater voice for users and carers. What we propose is an enabling framework, not a directive one.

5. The aims of this consultation Outcomes • To improve outcomes for those with care and support needs. This means putting outcomes at the heart of social care, building the evidence base on how to achieve outcomes, and ensuring this underpins service design, commissioning and delivery. Quality • To improve the quality of social care services. Understanding what ‘high quality’ means in adult social care, and how it can be delivered efficiently and effectively. Remove obstacles and enabling local organisations to focus on quality, integrate services, and innovate freely. Transparency • To empower local citizens and support transparency. The focus of accountability will be local and the means will be led by the sector not the State, with consistent evidence of improvement for local communities and support for holding organisations to account.

6. Introducing the proposals • Build the evidence base – being clear about what high quality looks like in adult social care, and building the supports for evidence-based best practice. • Demonstrate progress – a consistent data set which supports councils and communities to understand progress and to hold organisations to account. • Support transparency – reporting to local citizens on the quality of social care and outcomes achieved to support public accountability. • Reward and incentivise – promoting sector-led quality improvement and the role for stronger incentives for providers and commissioners. • Secure the foundations – ensuring that essential standards of quality and safety underpin service provision to protect the most vulnerable. This is a very broad agenda, covering elements of performance, regulation, information and improvement. The consultation proposals cover five areas:

7. Build the evidence base This is about getting a clear, evidence-based picture of what high quality looks like, to improve service provision, inform commissioning and promote choice. Expand the role of the National Institute for Health and Clinical Excellence (NICE) to cover adult social care from 2012/13. NICE to develop and publish ‘Quality Standards’ on best practice in social care. Quality Standards are guidance documents which describe high quality, cost-effective care for particular circumstances, conditions or pathways. They use accredited evidence and are developed collaboratively with care professionals.

8. Demonstrate progress This is about clear, consistent and comparable information being the bedrock for both public accountability and sector-led benchmarking. This is not about performance management or central direction – there are no targets or priorities. There are two key areas of proposal here: A single data set which captures all council information on social care shared routinely between areas in one place, informed by a “zero-based review” of data collection that will reduce burdens. A set of outcome-focused measures, derived from these data, which help councils and people judge outcomes and compare progress fairly.

9. Demonstrate progress (2) • The single data set: • Will bring all routine social care collections into one place, making data freely accessible and cutting out duplication between organisations. • Will significantly reduce reporting burdens on councils, through a fundamental ‘zero-based’ review of social care data being led by ADASS and the Information Centre. • The outcome-focused measures: • Are for consistent interpretation of the best available data, and helping people understand the results for those using services. • Are published with the data because the social care sector and service users agree they are useful. • Are not a management tool – no targets; no annual performance assessment.

10. Support transparency This is about reporting to local people on the priorities of councils and the outcomes achieved, and citizens being able to exercise their role in accountability effectively. The key proposals are: Councils publishing ‘local accounts’ on quality and outcomes in adult social care, as a means of reporting locally. This replaces the annual performance assessment of councils by CQC. A new role for sector-led peer review and challenge to assure these accounts and lead on quality improvement in social care. A challenge role for the local HealthWatch, and whether user and carer- led assessments of councils could encourage a stronger local voice.

11. Reward and incentivise This asks what role there could be in the future for additional systems of incentives which promote quality improvement for service providers and commissioners. There are already different incentives built into the strategy through transparent publication and reporting proposals. Some further proposals in this area are: Quality ratings for providers – work is underway to develop a new measure of ‘excellence’ in service provision to incentivise providers and inform individual choice. We also ask whether payment-by-results or other national schemes for local financial incentives could have a role to play.

12. Secure the foundations This section turns to the critical issue of safety, and ensuring basic standards for all social care services. The role of the Care Quality Commission is particularly important here. The annual assessment of councils will end immediately, with a refocused role on: Registration of social care providers and monitoring of their compliance with requirements through planned and responsive reviews. A more proportionate, triggered inspection system, whereby it can highlight risks to safety arising from council commissioning. One trigger would be a referral from HealthWatch. A new sector-led approach to improvement in which local government itself takes on peer review, challenge and assurance.

13. Managing the transition Many of the proposals could not be implemented in the immediate term and will require further development. Some, however, would come into effect from April 2011 – in particular the single data set and supporting outcome measures. Consultation and data review responses First social care quality standards? NICE assumes social care role April 2013 April 2014 April 2011 April 2012 Publication of data, outcomes and local reports First data set and outcome measures Social Care White Paper Possible further changes to data set? Start of data transition to new collections Final CQC APA publication

14. Managing the transitionThe single data set The consultation proposes specific details on how to populate these information resources to ensure transparency and consistency from 2011/12: The Quality and Outcomes Data Set would be created initially by bringing together all existing social care data collections, less reductions which have already been announced for 2010/11 and 2011/12. The ‘zero-based review’ of social care data will set out, by March 2011, a series of recommendations for the future data set agreed by the sector. These will be developed where necessary and implemented from 2012/13, replacing the existing data requirements and further reducing the reporting burdens.

15. Managing the transitionThe outcome measures The consultation proposes a set of outcome measures, based on the best available data from council, NHS and other sources which is relevant to outcomes in adult social care. The outcome measures are arranged around four themed ‘domains’: Promoting personalisation and enhancing quality of life for people with care and support needs Preventing deterioration, delaying dependency and supporting recovery Ensuring a positive experience of care and support Protecting from avoidable harm and caring in a safe environment

16. 1 Promoting personalisation and enhancing quality of life for people with care and support needs Overarching measure –Frames the outcome domain at the highest level • Social care-related quality of life Outcome measures –Describe the outcomes relevant to the domain • Enhancing independence and control over own support • The proportion of those using social care who have control over their daily life • Enhancing quality of life for carers • Carer-reported quality of life • Enhancing quality of life for people with learning disabilities • Proportion of adults with learning disabilities in employment • Enhancing quality of life for people with mental illness • Proportion of adults in contact with secondary mental health services in employment* • Ensuring people feel supported to manage their condition • Proportion of people with long-term conditions feeling supported to be independent and manage their condition* Supporting quality measures – Support commissioning and analysis of productivity of services • Promoting personalised services • Proportion of people using social care who receive self-directed support * Measures drawn from NHS or other non-council data sources

17. 2 Preventing deterioration, delaying dependency and supporting recovery Overarching measures –Frame the outcome domain at the highest level • Emergency readmissions within 28 days of discharge from hospital* • Admissions to residential care homes, per 1,000 population Outcome measures –Describe the outcomes relevant to the domain • Helping older people to recover their independence • Proportion of older people (65 and over) who were still at home after 91 days following discharge from hospital into reablement/rehabilitation services • Preventing deterioration and emergency admissions • Emergency bed days associated with multiple (two or more in a year) acute hospital admissions for over 75s* • Improving recovery from falls and falls injuries • The proportion of people suffering fragility fractures who recover to their previous levels of mobility / walking ability at 120 days* Supporting quality measures – Support commissioning and analysis of productivity of services • Supporting recovery in the most appropriate place • Delayed transfers of care* • Delivering efficient services which prevent dependency • Proportion of council spend on residential care * Measures drawn from NHS or other non-council data sources

18. 3 Ensuring a positive experience of care and support Overarching measure –Frames the outcome domain at the highest level • Overall satisfaction with local adult social care services Outcome measures –Describe the outcomes relevant to the domain • Improving access to information about care and support • The proportion of people using social care and carers who express difficulty in finding information and advice about local services • Treating carers as equal partners • The proportion of carers who report that they have been included or consulted in discussions about the person they care for Supporting quality measures – Support commissioning and analysis of productivity of services Could be supported by relevant activity and finance data related to adult social care, as identified locally through the services provided to users and carers who respond positively or negatively to their experience of care. This domain is also likely to be able to be supplemented by local survey activity and complaints information.

19. 4 Protecting from avoidable harm and caring in a safe environment Overarching measure –Frames the outcome domain at the highest level • The proportion of people using social care services who feel safe and secure Outcome measures –Describe the outcomes relevant to the domain • Protecting from avoidable falls and related injuries • Acute hospital admissions as a result of falls or falls injuries for over 65s* • Ensuring a safe environment for people with mental illness • Proportion of adults in contact with secondary mental health services in settled accommodation* • Ensuring a safe environment for people with learning disabilities • Proportion of adults with learning disabilities in settled accommodation Supporting quality measures – Support commissioning and analysis of productivity of services • Providing effective safeguarding services • The proportion of referrals to adult safeguarding services which are repeat referrals Could also be supported by relevant activity and finance data related to adult social care, including the Abuse of Vulnerable Adults (AVA) data collection. * Measures drawn from NHS or other non-council data sources

20. How the outcomes fit together ASC and NHS: Supported discharge from NHS to social care. Impact of reablement services on reducing repeat emergency admissions. Supporting carers and involving in care planning. ASC and Public Health: Preventing avoidable ill health or injury, including through reablement services and early intervention. NHS and Public Health: Preventing ill health and lifestyle diseases and tackling their determinants. ASC, NHS and Public Health: The focus of Joint Strategic Needs Assessment: shared local health and wellbeing issues for joint approaches.

21. What next? The consultation on this agenda closes on 6 February 2011. During that time, we want to work with the local government and social care sectors to co-produce a joint response, which sets out the next steps, roles and responsibilities of partners – including agreed outcome measures for local use in 2011/12. The formal consultation response will be published in March 2011. Some elements would come into effect from April 2011 (as set out in the consultation response). Further proposals for the approach will be included in the planned Social Care White Paper in late 2011.

22. Your feedback matters • This consultation closes on 6 February 2011. You can contribute to the consultation by providing written comments to: • qualityandoutcomes@dh.gsi.gov.uk • We will be hosting a series of consultation events: • London 1 December (two events) • Nottingham 3 December • Bristol 6 December • Manchester 8 December • Leeds 13 January (two events) • Details on how to sign up are on the DH website with the consultation documents. Spaces are very limited!