NWJIP

Lancashire County Council and Care UK, a national domiciliary care provider, are undertaking an outcome-based domiciliary care pilot project for around 30 older people.

Service users on the pilot scheme previously received a traditional input based service, whereby the commissioning authority specified care inputs in terms of times and tasks. This approach can create a rigid service model, resulting in providers putting too much focus on sticking to the authority's set care plan, rather than providing a service which is responsive to the service user's changing choices and preferences.

It is hoped that by moving towards an outcome-based approach, flexible, personalised services, which give service users real choice and control, can be provided.

What prompted the organisation to develop this approach?

• A desire to commission domiciliary care in a person-centred way, giving service users choice and control, in line with the White Paper Our health, our care, our say
• An opportunity to identify suitable contracting and commissioning processes to support outcome-based domiciliary care.
• A desire to act on service user feedback about their wishes to use domiciliary care flexibly in a way that suits them.
• An opportunity presented through a strong proposal by Care UK to work in partnership with Lancashire to develop a service model to create a high quality, outcome-based service model.

What has the work involved?

• Care UK's initial proposal was considered by Lancashire's Commissioning and Contracting teams and staff were identified to work on the project. A project plan for the pilot scheme was then jointly agreed and implemented by Lancashire and Care UK.
• Service users were identified, in the Fleetwood area of Lancashire, to move onto the pilot. The pilot is restricted to people receiving services within the performance indicator C30 "helped to live at home" and doesn't include residential care.
• The Commissioning Team Review Officer, working closely with a Contracts Monitoring Officer, initiated a dialogue with service users to explain the project and gauge their interest. A pilot questionnaire was developed to benchmark peoples' perception of the services they were currently receiving.
• Care UK recruited and trained a care team, on guaranteed hours contracts, dedicated to an 'outcomes' approach.
• A framework was established to evaluate outcomes for service users on the pilot in line with the seven outcomes set out in the White Paper.
• Implementation of the pilot scheme involved the Directorate reviewing all service users and giving Care UK an outcome based care plan and a flexible weekly allocation of hours for each service user on the pilot. The hours are at a standard rate that Lancashire pays to all its preferred domiciliary care providers for older people.
• Regular ongoing liaison between Lancashire and Care UK to review progress and to develop and refine the service model. Regular review meetings are held with Care UK to review progress.
• Ongoing review of all service users on the pilot to evaluate outcomes and obtain feedback on their views of the new service model. Lancashire completes a service user questionnaire with individuals to evaluate outcomes.
• Service users are being given the option to use "banked" time from their care allocation that is left over after their "key" outcomes have been met, to meet further identified personal outcomes. Some examples for service user care plans are:
  • "Go to church"
  • "Getting washer fixed"
  • "Visit my husband's grave"
  • "Carer helping me to manage my money"
  • "Go to cafe for a drink"
  • "Walk in the garden"
  • "Have my hair and nails done"
  • "Help with my shopping list"
  • "Company when I go to hospital appointments"
• If the pilot is successful, Lancashire will shift all domiciliary care provision in the same direction and to apply the same principles of outcome-based care.

How have things changed for the better?

• The initial feedback about the pilot scheme is extremely positive. Improvements are evident in the self-confidence and self-esteem of service users on the pilot.
• Lancashire is now able to buy care in a more efficient way, which gives better value for money. As service delivery is no longer time/task based, people are getting more direct care time, as spare time after key outcomes have been met is now "banked". This spare time, rather than being lost, can now be used by service users to meet additional personal outcomes, or transferred to other service users, where a review indicates that the time allocation can be reduced.
• Services are now person-led rather than service-led and people are using their care resource in a far more flexible way.
• Improvements in the motivation of care staff on the pilot have been reported by Care UK, as they feel that they are doing something more worthwhile. There has also been a marked reduction in staff sickness. Staff retention reduces Care UK costs and gives greater consistency of care staff for service users.
• As the link between care workers pay and the amount of time spent with each service user has been broken, there is no longer an incentive to "call cram" i.e. to rush through care work or exaggerate the amount of time spent with service users.
• The pilot scheme has created a real sense of partnership between Lancashire and the care provider. This approach to commissioning, linked to geographical zoning of care, will offer opportunities to develop a more sustainable purchasing arrangement that give service users more flexible services and choice and control on how those services are delivered.
• The pilot is also helping Lancashire develop and refine a more outcome focused approach to its wider domiciliary care commissioning processes.

What have been some of the major challenges/drawbacks?

• A cultural change is required in the commissioning of services for services users - the service user needs to be given the power to use their service in the way that they choose. This means control over how the service is provided being transferred from the authority to the service user. This creates a different relationship between the service user and the care provider, requiring the care provider to be far more responsive to the service user's choices.
• Incorporating the approach into the Single Assessment Process.
• Developing an evaluation model to capture/measure the outcomes identified in the White Paper.
• Encouraging service users to identify outcomes - this has been difficult because service users are used to having care done 'to' them rather than them being involved in the decision making about what, when and how care time is going to be used.
• Developing care planning and recording systems - Care UK's paperwork has been overwhelming for the care staff. This is being amended on an ongoing basis during the pilot to achieve the minimum paperwork possible whilst still being able to measure and report appropriately.
• The Directorate's existing commissioning processes and support systems for reconciliation of invoices and service user charging are designed to support time /task input based services, rather than a flexible weekly care allocation. Lancashire is currently developing a contract to support this flexible type of commissioning. In the meantime, Care UK invoice for the weekly total hours, and keep a record of exactly what amount of care people are using and carrying forward for key outcomes/personal outcomes.
• Overcoming commissioners' perceptions of existing providers will be a future challenge as the authority shifts other services in the same direction. It will be important to identify providers that can be trusted in order to make sure that is the service users who have the choice and control over how services are delivered rather than the provider.

What lessons have been learnt?

• Outcome-based, person-centred domiciliary care seems to be the way forward. Small steps and being consulted make a huge difference to service users and their families.
• The importance of working with an enthusiastic and willing provider who is committed to, and capable of, providing outcome-based care and looking ahead to the future.
• The need to develop a good system of evaluating provider performance. Lancashire plan to achieve this through their preferred provider scheme which has been in place for 6 years, a model of evaluating provider performance which takes into account CSCI ratings, and regular service user monitoring/feedback on individual providers.
• The importance of briefing and training provider staff to ensure they are committed.
• The importance of staff retention in ensuring quality of care.
• The benefits of buying care in a way that gives providers some stability to enable them to guarantee hours to care workers - the Directorate committed to buying a certain number of hours each week in Fleetwood for the duration of the pilot.

How might this affect commissioning in the longer-term?

• The pilot is still ongoing and has not yet been fully evaluated, but it is already clear that commissioning on the basis of outcomes put the service user at the centre of the service.
• Whilst processes still need to be developed and refined, the Directorate will continue to move towards outcome based commissioning of domiciliary care.

Contact

For more information about this case study please contact:

Brian Monk, Contracts Manager, Lancashire County Council This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Julie Edwards, Team Manager, Lancashire County Council This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Phillipa Codd, Divisional Development Director, Care UK
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Care UK

May 2007