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The Care Act Expert Webinar
The document summarizes key points from a presentation on implementing the Care Act. It examines challenges to implementation, discusses orienting practice around outcomes to improve wellbeing, and addresses partnership working. Some of the main topics covered include the final regulations and guidance, wellbeing and eligibility criteria, working in partnership through greater integration and co-production, and shifting to an outcomes-based approach. Representatives were asked about issues they are facing in their planning and how to strengthen cooperation across services. The presentation aimed to help organizations prepare for the changes required under the Care Act.
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The Care Act Expert Webinar
- 1. Chris Davies Associate Director,RiPfA Patrick Hall Practice Development Manager, SCIE Implementing the Care Act 1
- 2. Aims for today Wewill • Examine organisational and process-based challenges to implementation • Ask how you can orient practice around the outcomes that will improve people’s wellbeing • Address barriers and enablers to partnership working 2
- 3. We will askhow the Care Act will affect • Your relationships with people who use services and carers • Your working practices • Your relationships with providers and other agencies 3
- 4. The format fortoday 1. Final regulations and guidance: headline news 2. Wellbeing, eligibility and outcomes 3. Working in partnership 4. Concluding remarks 4
- 5. Where are weat? • Last month, the final Care Act guidance and regulations were published • Consultation on the regulations and guidance received 4000+ responses • Local Authorities are now able to go ahead with their plans for implementation 5
- 6. Your initial views •How have the final guidance and regulations affected your planning? • Are there particular process-based challenges you are facing to do with implementation? 6
- 7. 1. Final regulationsand guidance: headline news 7
- 8. The funding question Respondentsto the consultation said: • ‘Adequate funding for the reforms … is essential’ (LGA/ADASS) DH said: • £470m to support reforms (announced 2013). • National cost modelling exercise has led to adjustments to impact assessment. • £100m per year to be reallocated from areas where the impact is ‘not likely to be as great as previously assessed’ Better Care Fund • 30th Oct: DH announces BCF now totals £5.3bn • 151 plans received and 97% of these have been approved 8
- 9. Prevention The guidance hasbeen strengthened to make clear that prevention is not a one-off activity. In preparation by SCIE, for launch in January 2015: Prevention Library of • Good practice examples • Evidence • Evaluated practice examples Submit your examples at scie.org.uk 9
- 10. Information and advice Noadditional funds to support this new duty; however, DH promises generic text, tools and web-based resources. Support material is currently available from RiPfA, TLAP and Skills for Care Download from: • ripfa.org.uk • skillsforcare.org.uk • tlap.org.uk 10
- 11. Advocacy • Local authoritieshave a new duty to ensure that people have access to independent advocacy • SCIE publish guide to Commissioning Independent Advocacy Access at scie.org.uk 11
- 12. Provider failure andservice interruption You asked: • How are local authorities to gauge the financial ‘health’ of providers? • What is best practice in developing contingency plans for interruptions? DH said: • We might commission support materials. • CQC plans to publish guidance in the new year on how it will oversee the most ‘difficult to replace’ providers From now until Dec 2014: CQC is developing its approach and methodology. 12
- 13. Carers All the relevantchanges for carers will be put into a single ‘at a glance’ document. The final guidance strengthens the economic case for avoiding the excessive charging of carers. New safeguarding expectation that carers will be listened to in relation to abuse or neglect. 13
- 14. Young Carers As withany young person who has care needs and is approaching adulthood, young carers are entitled to a ‘transition assessment’ provided by Adult services. The key is to prevent a ‘cliff edge’ between Children’s and Adult Services Over to you: • How prepared are you for this duty? • How are you working with children’s services to prepare for this? • What would support you in this duty? 14
- 15. Safeguarding The Care Actenshrines in law what is already good practice: • Duty to carry out a safeguarding enquiry – ‘wherever there is reasonable cause to think that the person is experience, or is at risk of, abuse or neglect’ • Duty to cooperate with other organisations (i.e. share information) • Safeguarding Adults Boards need to report annually • Self-neglect is now included under abuse and neglect 15
- 16. Making Safeguarding Personal Making SafeguardingPersonal means safeguarding: • Is person-led • Is outcome-focused • Enhances involvement, choice and control • Improves quality of life, wellbeing and safety (Care Act Guidance) 16 Download from lga.org.uk
- 17.
- 18. 2. Wellbeing, eligibilityand outcomes 18
- 19. Wellbeing The wellbeing principle: ‘Localauthorities must promote wellbeing when carrying out any of their care and support functions in respect of a person.’ What issues have emerged in your area relating to the wellbeing principle? 19
- 20. Wellbeing • Wellbeing underliesthe central ideas of dignity and control • Wellbeing underlies Care Act approaches to: • Integration • Prevention • Personalisation • Safeguarding • Wellbeing is also central to the new National Eligibility Criteria 20
- 21. National Eligibility Criteria •To be eligible, it is the case that an adult needs to: • be unable to achieve two or more outcomes from a finite list that this is related to a ‘physical or mental impairment or illness’ and that this has a ‘significant impact on the adult’s wellbeing’ • The language of ‘basic care activities’ has been replaced by the language of ‘outcomes’ 21
- 22. Centrality of assessment RiPfA’sAssessment Change Project found: 1. Assessments need to be proportionate 2. Assessors need the right capabilities 3. Assessors need the right support. Professional judgment is still key to making the best use of resources. 22
- 23. Resources It is unclearhow the new system will differ from the present one, in which: • Eligibility is determined by available resources rather than any objective criteria of need • Different thresholds under FACS make no significant difference to spending levels • Under FACS, variations in spending levels are not determined by different eligibility threshold but by other factors (e.g. overall spending; age group) (Slasberg/Beresford 2014) 23
- 24. A focus on‘outcomes’ Two different senses of ‘outcome’: 1. The list of 10 ‘specified outcomes’ given in the eligibility criteria 2. The outcomes a person wishes to achieve in their day-to-day life, as identified in their assessment. 24
- 25. A change ofculture From To Doing things for people Doing things with people Risk assessment as Prevention Risk assessment as an enabler Focus on what’s important for people Focus on what’s important for people and what’s important to them People have disabilities People have abilities See the problem See the person 25 What issues are you facing in shifting to an outcomes approach? Stirk and Sanderson, 2012
- 26. Supporting an outcomes approach RiPfAWorking with outcomes tool • Helps staff address barriers and enablers to outcome conversations • Supports conversations to identify a person’s outcomes • Provides means to enable, review and measure outcomes 26
- 27. Approaches that work 1.Introduce new service responses 2. Commission providers to deliver outcomes 3. Engage and empower people 4. Enhance social work practice 5. Make changes to documentation and key processes 6. Practice a person-centred approach to risk 7. Lead culture change 27
- 28. Commissioning for betteroutcomes Good commissioning is • Person-centred and outcome focussed • Inclusive • Well led • Sustainable and diverse market 28 Download from adass.org.uk
- 29. Over to you •What issues are you facing in shifting to an outcomes approach? • What issues have emerged relating to the wellbeing principle? • Are you changing how people in your area learn about, engage with and shape social care? • What is the role of Health and Wellbeing Boards in these changes? 29
- 30. 3. Working inPartnership 30
- 31.
- 32. Integration Integration under theCare Act 2014: • Local authorities must aim to promote greater integration with NHS and other health-related services; • Local authorities and their partners must cooperate generally and specifically in relation to care, support and carers wherever they can. Integration is a means to promote wellbeing, prevention and improving the quality of care and support. 32
- 33. Integration 33 Where roles arechanging: • Negotiate roles with the relevant parties across the whole system (not just within one organisation) • Review responsibilities periodically to ensure boundaries are clear and duplication is avoided King’s Fund 2014 Download from kingsfund.org.uk
- 34. Integration Promoting multidisciplinary working by •Considering the person’s whole care pathway • The practitioner’s role changes from ‘cowboy’ to ‘pit crew’ (Gawande 2011, cited in King’s Fund 2014) 34 Download from kingsfund.org.uk
- 35. Learning from Pioneersites • Large scale service changes take time • Define intervention clearly • Be explicit about outcomes at the outset • Intervention + context = outcome • ‘Chicken and egg problem’ – tackle by involving all stakeholders • Track implementation as well as outcome • Carefully consider evaluation models • Work with what you have 35 Download from nuffieldtrust.org.uk
- 36. Co-production ‘Transformative co-production’ • involvesgenuine power- sharing between people and professionals • recognises and uses people’s assets • develops and delivers services accordingly 36 Download from tlap.org.uk
- 37. Over to you •How will you increase cooperation with partners in health, housing and elsewhere? • To what extent is there strategic link-up between these services? • What approaches to getting ready for the Care Act have worked well in your area? 37
- 38. Summary We have • Examinedthe organisational and process-based challenges to implementation • Asked how you can orient practice around the outcomes that will improve people’s wellbeing • Addressed barriers and enablers to partnership working 38
- 39.
Editor's Notes
- #3 this is a first ‘conversation’ about what our challenges as a sector are in delivering on the Care Act. We can’t possibly solve all of the issues in a one hour webinar. We will from today take forward actions that inform the resources and activity that RiPfA commits to in the coming months- as well as ideas for future webinars themed around specific elements of the Care Act. We will be producing a report after today that outlines the challenges -- and will include any good practice points that are shared by colleagues in the chat box today. With so many participants today from across the country, we have a great wealth of expertise present in the chatbox and this is a great opportunity to share your successes as well as raise your challenges. [Note about Patrick Hall TBC]
- #7 A reminder that we will collate your responses to the questions we ask today and share these in a report. While you enter your comments, we have some examples: A reminder that we will collate your responses to the questions we ask today and share these in a report. While you enter your comments, we have some examples… We know partners are running learning and development sessions for staff; we are delivering Care Act implementation workshops for various partners; Skills for Care’s learning materials and events programme are on their website. We have been asked by a few organisations to deliver sessions to first-line managers on implementing successful change. From our change project on assessment, we know that several Partners are redesigning their forms to include wellbeing and outcomes – there will need to be process changes to fit with the new eligibility regulations and law on carers assessments for example. Followed by (if poss) brief acknowledgement of issues raised in chatbox (saying which will be addressed further on).
- #9 £470m: ‘In the 2013 Spending Review settlement, the Government announced a total of £470m for 2015/16 to support implementation of the care and support reforms in this first year. This includes £135m of revenue and £50m capital funding which was incorporated within the Better Care Fund, in order to release additional benefits through integrating plans with the NHS, and £285m in additional local government grants.’ DH Response to the consultation, p5 ‘not likely to be as great as previously assessed’ – p6 – the guidance doesn’t give examples of which areas these are.
- #10 http://www.scie.org.uk/care-act-2014/prevention-library/
- #11 Forthcoming DH resources -- To be provided at no charge to local authorities and other providers
- #13 On CQC regulation of social care New inspection regime from April 2015, featuring Ratings reintroduced (inadequate, requires improvement, good, outstanding) Aim to inspect all providers by Mar2016 End to annual inspections (highest rated providers may go up to two years between inspections) Specialist inspectors introduced Check for understanding of Mental Capacity Act among all care staff. http://www.communitycare.co.uk/2014/11/04/care-quality-commission-changing-way-regulates-social-care/?cmpid=NLC|SCSC|SCDDB-2014-1105
- #14 The Care Act is fundamental shift in the relationship between carers and services. On the one hand, carers are on an equal footing legally to the people they care for, in terms of entitlement to an assessment, access to information, advice, education, advocacy. On the other hand, carers’ special requirements and the essential nature of the role they play is recognised. By protecting carers’ wellbeing you enable them to continue caring. Providing simple services to carers to allow them to continue providing specialist care is going to be far more cost effective than providing the specialist care. According to Carers UK, carers save the economy £119 a year.
- #15 A young carer’s assessment must have regard to the extent to which the young carer is participating in or wishes to participate in education, training or recreation, and the extent to which the young carer works or wishes to work. The Children and Families Act and Care Act share a focus on outcomes, personalisation, integration. Suggestion is to train Children and Adults staff together Align assessment processes between Children and Adults Adult social care should be involved in the Year 9 review of any young people whose care needs are likely to continue beyond 18 – meaning Adult social care forging links with schools Work towards a common commissioning process across the 0-25 agegroup Promote market of quality services aimed at the teen-to-25 age group: LA to work with education and training providers Health Employment and housing agencies Look at integrating personal health and social care budgets for post-16 Ensure Care Act Information and Advice provision is linked to Local Offer/Parent Partnership Service Consider a joint 0-25 info service.
- #19 This section looks at the interrelated themes of wellbeing, eligibility and outcomes. In the words of the Care Act Guidance: ‘Promoting wellbeing does not mean simply looking at a need that corresponds to a particular service. At the heart of the reformed system will be an assessment and planning process that is a genuine conversation about people’s needs for care and support and how meeting these can help them achieve the outcomes most important to them.’ (page 5, Care Act Guidance)
- #20 Quote is from the Guidance The non-hierarchical list of areas wellbeing relates to ‘in particular’: • personal dignity (including treatment of the individual with respect); • physical and mental health and emotional wellbeing; • protection from abuse and neglect; • control by the individual over day-to-day life (including over care and support provided and the way it is provided); • participation in work, education, training or recreation; social and economic wellbeing; • domestic, family and personal; • suitability of living accommodation; • the individual’s contribution to society
- #22 List of outcomes from Care Act Guidance: (a) managing and maintaining nutrition Local authorities should consider whether the adult has access to food and drink to maintain nutrition, and that the adult is able to prepare and consume the food and drink. (b) maintaining personal hygiene Local authorities should, for example, consider the adult’s ability to wash themselves and launder their clothes. (c) managing toilet needs Local authorities should consider the adult’s ability to access and use a toilet and manage their toilet needs. (d) being appropriately clothed Local authorities should consider the adult’s ability to dress themselves and to be appropriately dressed, for instance in relation to the weather to maintain their health. (e) being able to make use of the home safely Local authorities should consider the adult’s ability to move around the home safely, which could for example include getting up steps, using kitchen facilities or accessing the bathroom. This should also include the immediate environment around the home such as access to the property, for example steps leading up to the home f) maintaining a habitable home environment Local authorities should consider whether the condition of the adult’s home is sufficiently clean and maintained to be safe. A habitable home is safe and has essential amenities. An adult may require support to sustain their occupancy of the home and to maintain amenities, such as water, electricity and gas. (g) developing and maintaining family or other personal relationships Local authorities should consider whether the adult is lonely or isolated, either because their needs prevent them from maintaining the personal relationships they have or because their needs prevent them from developing new relationships. (h) accessing and engaging in work, training, education or volunteering Local authorities should consider whether the adult has an opportunity to apply themselves and contribute to society through work, training, education or volunteering, subject to their own wishes in this regard. This includes the physical access to any facility and support with the participation in the relevant activity. (i) making use of necessary facilities or services in the local community including public transport and recreational facilities or services Local authorities should consider the adult’s ability to get around in the community safely and consider their ability to use such facilities as public transport, shops or recreational facilities when considering the impact on their wellbeing. Local authorities do not have responsibility for the provision of NHS services such as patient transport, however they should consider needs for support when the adult is attending healthcare appointments. (j) carrying out any caring responsibilities the adult has for a child Local authorities should consider any parenting or other caring responsibilities the person has. The adult may for example be a step-parent with caring responsibilities for their spouse’s children.
- #23 ‘The purpose of an assessment is to identify the person’s needs and how these impact on their wellbeing, and the outcomes that the person wishes to achieve in their day-to-day life. The assessment will support the determination of whether needs are eligible for care and support from the local authority, and understanding how the provision of care and support may assist the adult in achieving their desired outcomes.’ (Care Act Guidance, p77) (Note from Gerry: ) Assessment remains at the heart of this as a conversation about needs, their impact and what outcomes they affect – this then leads to a judgement on eligibility and on alternatives to care and support. Our assessment Change Project showed that the key issues here are: A proportionate assessment to make a judgement depending on the situation The right capabilities for assessors to make a judgement depending on complexity and how unusual the situation is The right support for assessors. Professional judgment is still key to making the best use of resources
- #24 The issue of resources to meet needs and achieve outcomes remains Slasberg and Beresford consider that resources will still be key in eligibility decisions. That is to say, despite the National Eligibility Criteria, the care that is available to you in a particular area will have more to do with local resources than with your level of need.
- #25 We’ve seen the eligibility criteria of ‘2 or more outcomes’ Focusing on what the person wants to achieve, rather than thinking in terms of services that can be provided, can help identify better, more efficient, more creative solutions. Second of these can be defined as ‘the things a person wants care and support to help them achieve’ ‘the impact support or services have on a person’s life’ In this next section we’ll think about individual outcomes both from the point of view of the conversations between person and practitioner, and from the point of view of commissioning for outcomes. Disco shower example: “ a man with learning disabilities was receiving personal care every day to enable him to shower, when everyone stopped to understand why, it was because he didn’t like being in the shower, not that he could not shower himself. So they installed a disco shower- with lights and music- he absolutely loved it- and stopped needing personal care”.
- #27 Asks the person what’s important to them, and what they do or don’t want to change, in each of the following areas: Having choice and control Food and drink Feeling personally clean and comfortable Feeling safe Having a clean and comfortable home Feeling respected Having enough things to do Spending time with others 2. For each outcome, the steps are identified and given a score from 1 (best) to 5 (worst). This process is repeated in review to gauge progress.
- #28 …align new or existing services with outcomes thinking. Eg Wiltshire ‘Help to Live at Home’; Hampshire Daybreak Ask providers to focus on outcomes. E.g. Wiltshire …Through provision of better information and through advocacy Shift from process to person -- through staff briefings, supervision, case discussions, reflections on practice, focus groups, champions, building practitioner confidence, addressing barriers to change needs based forms/processes replaced by outcomes-focused, enabling a far broader approach E.g. Wiltshire. Enable positive risk-taking. Crucially, involving the person in discussions about risk; focusing on allowing as normal a life as possible rather than on protection and risk avoidance. Leadership (that is, future-focus and promoting ownership of that future throughout the organisation). Ensure everyone has permission to challenge traditional ways of working.
- #29 The 12 standards set out ambitions for what good commissioning is. They are set out below, under the four domains to provide a framework for self-assessment and peer challenge. Good commissioning is: Person-centred and outcomes-focused Person-centred and focuses on outcomes Good commissioning is person-centred and focuses on the outcomes that people say matter most to them. It empowers people to have choice and control in their lives, and over their care and support. 2. Promotes health and wellbeing for all Good commissioning promotes health and wellbeing, including physical, mental, emotional, social and economic wellbeing. This covers promoting protective factors and maximising people’s capabilities and support within their communities, commissioning services to promote health wellbeing, preventing, delaying or reducing the need for services, and protecting people from abuse and neglect. 3. Delivers social value Good commissioning provides value for the whole community not just the individual, their carers, the commissioner or the provider. Inclusive 4. Coproduced with people, their carers and their communities Good commissioning starts from an understanding that people using services, and their carers and communities, are experts in their own lives and are therefore essential partners in the design and development of services. Good commissioning creates meaningful opportunities for the leadership and engagement of people, including carers and the wider community, in decisions that impact on the use of resources and the shape of local services. 5. Promotes positive engagement with providers Good commissioning promotes positive engagement with all providers of care and support. This means market shaping and commissioning should be shared endeavours, with commissioners working alongside providers and people with care and support needs, carers, family members and the public to find shared and agreed solutions. 6. Promotes equality Good commissioning promotes equality of opportunity and is focused on reducing inequalities in health and wellbeing between different people and communities. Well led 7. Well led by Local Authorities Good commissioning is well led by Local Authorities through the leadership, values and behaviour of elected members, senior leaders and commissioners of services and is underpinned by the principles of coproduction, personalisation, integration and the promotion of health and wellbeing. 8. Demonstrates a whole system approach Good commissioning convenes and leads a whole system approach to ensure the best use of all resources in a local area through joint approaches between the public, voluntary and private sectors. 9. Uses evidence about what works Good commissioning uses evidence about what works; it utilises a wide range of information to promote quality outcomes for people, their carers and communities, and to support innovation. Promotes a diverse and sustainable market 10. Ensures diversity, sustainability and quality of the market Good commissioning ensures a vibrant, diverse and sustainable market to deliver positive outcomes for citizens and communities. 11. Provides value for money Good commissioning provides value for money by identifying solutions that ensure a good balance of quality and cost to make the best use of resources and achieve the most positive outcomes for people and their communities. 12. Develops the commissioning and provider workforce Good commissioning is undertaken by competent and effective commissioners and facilitates the development of an effective, sufficient, trained and motivated social care workforce. It is concerned with sustainability, including the financial stability of providers, and the coordination of health and care workforce planning. http://www.adass.org.uk/uploadedFiles/adass_content/publications/policy_documents/key_documents/Commissioning%20for%20Better%20Outcomes%20A%20Route%20Map%2030.10.14.pdf
- #30 Examples from Gerry: We know from Partners that shifting to wellbeing and outcomes approaches in both assessment and safeguarding involve changes in the kind of conversations that practitioners have These require support for practitioners and changes in recording and processes. For example in Cumbria there is a new quality of life tool to identify outcomes at assessment and review, so that you can see how people’s quality of life/ wellbeing is changing. There has been extensive support for practitioners to use this and to share learning on how to ask the questions about quality of life For example in Wolverhampton there is new safeguarding paperwork to record outcomes and we have delivered training to use person-centred tools. We have been asked to do some workshops for partners around assessment based on the Change Project handbook – to embed the approach of assessing for needs, impact and outcomes; and then using analysis to make a judgement on eligibility and on what support will meet outcomes. Question – are people using the Health and Wellbeing Board to engage with people to shape social care
- #31 As we’ve covered, the person-centred ethos of the Care Act, as embodied in an outcomes approach, is about new ways of working in partnership with individuals. In this next section we will look at working in partnership in three senses 1. Greater involvement – ways to increase people’s control over their care 2. Partnership working within your own organisation – for example with Children’s services, Public Health, Housing – as well as externally, such as Health. 3. Co-production – working in partnership with communities.
- #32 http://www.kingsfund.org.uk/publications/people-control-their-own-health-and-care ‘The paper is aimed at those who are less familiar with the day-to-day concepts and practice of individual forms of involvement, and who would benefit from a strategic overview to inform practice, strategy and policy. It offers some ways of making sense of this complex agenda, appraises the different approaches, the impact that involvement can have when done well, and makes recommendations for how our health system can achieve the transformation required in the relationship between people and services.’
- #33 Exact wording in the guidance • local authorities must carry out their care and support responsibilities with the aim of promoting greater integration with NHS and other health-related services; • local authorities and their relevant partners must cooperate generally in performing their functions related to care and support; and, supplementary to this, • in specific individual cases, local authorities and their partners must cooperate in performing their respective functions relating to care and support and carers wherever they can. LS note: That’s about integrated working, stopping silos- but also the challenges around that how we pool budgets and enable shared agendas. I think it’s important to recognise the contribution of public health in all of this as well. It’d be worth people considering looking to the pioneers as well to see how well that’s worked.
- #34 For the first point, the example is given whereby nurses were asked to refer patients to the acute trust, but acute trust staff wouldn’t accept nurse-written referrals.
- #36 Expectations need to be managed as, despite pressure to demonstrate early impact, it will take time …be explicit about what is different compared to existing services …how they will arise – and also about interim measures Problem of generalisability Chicken and egg: the problem of having enough people to sample to properly measure impact, before impact has been demonstrated. Tracking implementation: Make sure that developing ownership of service change by all those affected is a key part. Interventions need time to bed in; won’t have a clear cut worked/not worked outcome; formative rather than just summative evaluation may be useful to modify things as you go. Integration can be lots of different things and has changed over time – integrated patient care need not mean integrated organisations. Focus on the changes on the ground.
- #37 At our Leaders’ Forum, Martin Reeve argued that what’s needed is a move from protectionism of organisational silos professional roles authority …to an open, systems-leadership approach which rethinks role of council in the community brings more people in shares power with communities TLAP’s new Framework for Health and Wellbeing Boards – co-developed with Public Health England: Developing the Power of Strong, Inclusive Communities – ‘the next stage of personalisation’
- #39 this is a first ‘conversation’ about what our challenges as a sector are in delivering on the Care Act. We can’t possibly solve all of the issues in a one hour webinar. We will from today take forward actions that inform the resources and activity that RiPfA commits to in the coming months- as well as ideas for future webinars themed around specific elements of the Care Act. We will be producing a report after today that outlines the challenges -- and will include any good practice points that are shared by colleagues in the chat box today. With so many participants today from across the country, we have a great wealth of expertise present. [Note about Patrick Hall TBC]