Report to Cabinet
Report of the Director of Adults' Services
The Care4you Service & Financial Review
1. Purpose of the Report
- To summarise the outcomes of the Care4you Service & Financial Review
- To recommend the full implementation of the Review's proposals
2. Background
2.1 At its 11 October meeting, Cabinet approved the Service & Financial Strategy for 2007/08 - 2009/10. As part of the strategic approach to managing costs and service delivery, fundamental Service & Financial Reviews are to be undertaken on each service over the next three years.
2.2 These service reviews will look at how services can be delivered offering better value for money whilst driving up quality and better meeting customers' need. . There will be a strong focus on looking at different and better ways of delivering services whilst saving on costs, increasing efficiency on procurement and support costs and increasing income. There will be independent input and challenge to these reviews. An Invest-to-Save fund was also agreed by Cabinet to be used on initiatives resulting from the reviews, covering areas such as ICT investment, costs of change and project management.
2.3 A review of the Care4you Service has now been completed and this report summarises its conclusions and recommendations.
2.4 The Care4you service covers the Council's own home care service, four resource centres and two residential care homes and the citywide community care alarm service. Altogether this represents 1,200 staff and a revenue budget of £21.9m.
3. The Review
3.1 The objective of the Care4you review was to identify how to sustain and improve the quality and effectiveness of the service whilst reducing costs in order to optimize the efficiency of the services and generate recurrent revenue savings
3.2 A Project Team, chaired by the Director of Adults' Services oversaw the review. The team, including external challenge from PA Consulting who are supporting the overall Transformational Programme, ensured the review was comprehensive and radical. The approach included: -
- Benchmarking with other councils
- Learning from best practice within the Council and our partners
- Listening to stakeholders, including Trade Unions
- Detailed business planning within Care4you
- Evaluating alternative options for delivering the services
- Soft market testing, led by the Transformational Programme consultancy support.
3.3 A range of options was evaluated, ranging from outsourcing or partnership arrangements, to internally managed options within the Council.
3.4 Each option was evaluated against five criteria. This was to establish how each option would, improve quality and innovation, create efficiencies and revenue savings and support the service strategies and council priorities. The Council's duties in respect of assessment and meeting need, deliverability and risks of each option were also considered.
3.5 The review concluded that the option that best meets the objectives of improving the experiences and outcomes for service users whilst producing recurrent revenue savings is to retain the service in-house and to accelerate implementation of the current service strategies as detailed in section 5 of this report.
3.6 The other options of outsourcing, or a strategic partnership were not judged to be as financially beneficial. The outsourcing option could also increase the risks to the council for service users experiencing a more inconsistent and unreliable service. Soft Market Testing also showed that nationally there is an immature social care market to progress a social enterprise or a strategic partnership.
4. Proposals of the Care4you Service
4.1 The proposals for Care4you either reflect existing Council strategies for the service, or are consistent with these and national policies. Nevertheless, they are still significant, as they require the service to accelerate its planned changes, deliver challenging revenue savings and adopt new ways of working across the whole of the service. It will also involve, over an 18-month period, a reduction in its workforce of between 250 and 300.
4.2 A summary of the changes for each service is now described.
5. The Home Support Service
5.1 The Council's agreed policy, ever since the Home Care Best Value Review, is for the Care4you Home Support Service to increasingly focus on providing specialist services to promote people's independence and help control the increasing costs of long-term care. These specialist services are the Short-Term Intervention Service (STIT) and a Mental Health Service. The Best Value Review also stated that the independent sector should increasingly take on providing on-going home support to service users and consequently the in-house service reducing its share of this type of service.
5.2 The Service & Financial Review now proposes this policy is taken to its logical conclusion and that the Care4you service, over the next 18 months, phases out provision of its non-specialist on-going home support and instead, this is purchased at the market price from the independent sector. As part of the planned new 2007 contracts for the Independent Sector the council will be increasing its investment in the market.
5.3 Overall, Care4you will provide a service to more people than present. This is because, as the on-going support element reduces, Care4you will increase the number of STIT service users at any one time by around 600. The service and financial benefits of this are explained in section 10 of the report. Briefly, STIT provides an intensive re-enablement service for around 6 weeks, and subsequently, many of the users do not require any on-going support after this period of support. This means the service will support many more people, resulting in both better outcomes for individuals and a reduction in on-going costs of provision.
5.4 Care4you will also increase its Mental Health Service by around 400 older people. This is part of a wider multi-agency strategic commitment to respond to the growing numbers of older people with mental health support needs. This provides a service to support Sheffield Care Trust and the Assessment and Care management Service for older people with dementia or mental illness.
5.5 Care4you would also provide, to around 150 people, on-going support to people with significant needs and/or have high level of risk.
5.6 The actual number of service users for Care4you and its performance targets would be determined on an annual basis through a Service Level Agreement within the Directorate. This will fit with a benefits realization model that will be developed for this project as a whole to ensure the review delivers its maximum potential.
5.7 The proposal to phase out the direct provision of on-going home support also brings the service in line with the existing policy decision that Care4you ceases to provide long-term residential care and instead, focuses on short-term interventions within the resource centres.
6. Citywide Alarm Service
6.1 The short-term priority for the service (CWA) is to gain accreditation with the Telecare Service Association. This award will allow the service to market itself more confidently and be in a position to expand its services and customer base.
6.2 Alongside its business development, the service has identified ways it can increase its efficiency and effectiveness within the workforce.
6.3 Over the coming months the service will develop a detailed business plan with favourable financial projections to be considered in budget planning from 2008/09 onwards.
6.4 This plan will fit with a wider housing investment strategy within Neighbourhoods and Community Care.
7. Residential Care Homes
7.1 Over the last four years the service has been implementing the Council's residential strategy and decommissioning programme of its residential care homes. Homes are decommissioned as alternative housing and support options are developed such as Extra Care Housing, additional home support, resource centres and, where appropriate, new care homes. There are now just two care homes within Care4you to be decommissioned. The Review noted Ravenscroft (Richmond) is already due to be decommissioned under the existing strategy in late 2007 as the Extra Care Village opens and has therefore included an estimate of the net revenue savings and capital receipt in the overall financial projections.
7.2 No decommissioning date has yet been identified for the remaining home, Newton Grange, in Stocksbridge, as this is linked to a wider strategy for developing housing and social care services for older people in the area.
7.3 In both care homes, regular meetings with relatives and residents take place to keep everyone informed of wider plans, timescales and to agree how best to implement the actual decommissioning in a professional and inclusive way. This takes account of the needs of individuals, the service's Best Practice Guide and learning from each decommissioning.
8. Resource Centres
8.1 The service has implemented the Council's policy to reconfigure eight of the residential care homes into specialist resource centers, four for older people with dementia and four for older people with physical disabilities or illness and in need of rehabilitation, recuperation or respite. Sheffield Care Trust now manages the four centres providing for older people with dementia.
8.2 In the last four years, two centres, which provide rehabilitation and recuperation - Sevenfields (Wisewood) and Hazelhurst (Jordanthorpe), along with the four centres providing for older people with dementia, have been refurbished through a capital programme of £3.2m. This was required to meet national minimum standards and to enable the units to operate over the medium term.
8.3 Longley Hill (Longley) and Tannery Lodge (Woodhouse) have not been refurbished as Cabinet approved their replacement with two new build resource centres with the allocation of PFI credits from the Department of Health. This is a joint project with the then four PCTs and is now being undertaken by the new PCT.
8.4 The rehabilitation and resource centres provide a range of services to help older people to remain at home. They also provide office accommodation for health and community care staff. The main focus of the centres is to work with NHS colleagues to help prevent people from being unnecessarily admitted to hospital or residential care homes and to facilitate timely discharge from hospital. Around 42 beds in each unit fulfill this role with a further 50 beds available for people who are seeking a short-term break or respite care. The centres also provide day care.
8.5 The Review has highlighted 25% spare capacity in its beds across all four centres. This is largely due to older people actively choosing to receive respite care in a more local home, or perhaps one in which they may eventually take up permanent residence. The review has concluded it would be possible to actually improve access and the existing service by operating only three units rather than the current four. This could be achieved by a small increase in the number of beds in the three remaining centres and through introducing an electronic bed management system. Some reinvestment from the fourth centre would also be made to increase staffing levels. This would allow more reablement work to be undertaken, so leading to speedier and better outcomes for individuals and a reduction in long-term care costs.
8.6 An initial analysis of the respective unit costs, occupancy levels, and the wider services offered, and of the buildings themselves, indicate that consideration should be given to the decommissioning of Longley Hill rather than Tannery Lodge ahead of the new build centres. Its day service would be retained and relocated. Some reinvestment will also be required at Care4you's offices at the Manor to accommodate displaced Home support teams based at Longley Hill.
8.7 This proposal would be subject to consultation with service users and stakeholders with particular attention being given to the permanent resident who still lives at Longley Hill and their relatives.
8.8 It is also proposed to review whether there is a need in the medium term for three resource centres, or if the two larger new-build centres would be able to provide sufficient services across the city. Discussions and joint planning with the PCT will inform this.
9. A Revised Vision for Care4you
9.1 As highlighted earlier in the report, the review requires changes in working practices and new roles throughout the Care4you service. The changes will be subject to consultation with staff and the trade unions and include include: -
- Flexible working patterns for all home support staff to significantly increase productivity.
- The introduction of a Care4you generic support worker role with a consolidated pay and grading structure.
- All appropriate staff trained in reablement or mental health care and in the benefits and use of Assistive Technology for service users.
- More autonomy to the service to vary the input and level of care to individuals so that service users are able to reach their full potential and achieve the goals set by Assessment & Care Management as soon as possible.
- If the service is to maximise its efficiency and productivity, more home support staff will be required (and supported) to drive as part of their role. Implementation of this will be consistent with the Corporate Travel Plan and leasing of eco-friendly vehicles.
- The introduction of electronic systems and ways of working. For example, an electronic bed management system in the resource centres. The largest development will be Real Time Monitoring (RTM) in home care, which will eliminate missed calls, provide lone worker protection and produce performance information. RTM delivers financial savings in payroll costs, stationery, postage and manual timesheet processing. It will also provide accurate charging information and reduce opportunity for fraudulent claims or mistakes on timesheets
- The dis-establishment of around 25 management and business support posts and the establishment of new posts for improved skills mix, cost effectiveness and streamlined processes.
- A total reduction of between 250 and 300 posts, over an 18-month period.
10. Wider Benefits for the Revised Vision
10.1 In making these changes, there will be wider benefits for the Assessment & Care Management service and on the purchasing budget for older people services by helping to control demand pressures.
10.2 The Care4you teams will be undertaking some care management and reviewing tasks currently undertaken by the Assessment & Care Management (A&CM) staff. This will free up some of the Assessment & Care Management's working week to carrying out new assessments and other priority work such as adult protection investigations. The Care4you teams will be able to take on these tasks as a result of their time being freed up from reduced time on work programming and rostering.
10.3 The combination of Care4you providing the home support Short-Term Intervention Team (STIT), resource centre services and Assistive Technology, alongside some care management responsibilities, will enable efficiencies in purchasing, by establishing the right level of home support to be purchased from the independent sector. Evidence of this comes from other councils, formal evaluations and from our experience within the existing STIT service. This approach will also deliver an improved experience for service users with smoother care pathways and enhanced outcomes.
10.4 An initial analysis has been made on Care4you's home support STIT. This looked at older people who have received the STIT service in a 47-week period in 2005 and 2006. Overall, 37% of the users required no ongoing support and 40% were stabilized and transferred to an independent sector provider for an on-going home care service. Of these, 4% received a 52% reduction in their required service or 4.9 hours per week. This represents a full year effect saving on the purchasing of home care in the region of £113,000.
10.5 It is anticipated that increased capacity and focus on short-term intervention and reablement in STIT and the resource centres will either: reduce or delay the permanent admissions to a care home for individuals or prevent, delay or reduce the level of on-going home support for individuals. It is also anticipated that the use of Assistive Technology can also have a favourable impact on the demand for care home or home support services. This is based on evaluations being carried out on Assistive Technology in Scotland and England.
10.6 A separate piece of work to model the impact on service needs and demand and the consequential demands on the purchasing budget as a result of the implementation of the Care4you revised vision will be undertaken.
11. Human Resource Implications
11.1 It is recognized these changes will provide both opportunities and concerns for staff and it will be essential staff and the Trade Unions are fully involved in the planning and delivery of the change programme, through the Council's formal consultation process.
11.2 This consultation will include a strategy for managing staff reductions over an 18-month period, through a combination of natural turnover, planned retirements, redeployment and voluntary early retirement and severance schemes.
12. Equalities Impact Assessment
12.1 The Review included an Equalities Impact Assessment with baseline information regarding Care4you's customers and employees and the opportunity to make further improvements in services as part of the detailed implementation of Care4you's revised vision. The assessment concluded that the proposed changes and improvements were accessible to all users.
13. Legal Implications
13.1 The implementation of the Review's proposals will support the Council's legal duties and powers to provide community care services to meet the needs of the individuals. The ongoing and planned consultation process described in this report in respect of the rationalization of the resource centres will ensure the Council consults appropriately with those who will be affected by the proposals and responds to the issues raised by those who have been consulted. This will include the individual who resides in Longley Hill and others who may use the centre less frequently and other interested parties.
13.2 Appropriate consultation will also be needed with staff and trade unions in respect of any changes to conditions of service or reduction in staffing levels.
14. Financial Implications
14.1 The annual net savings arising from the full implementation of the review's proposals are estimated to be in the region of £1.8m to £2.3m, per annum.
14.2 A major change programme over 18 months is required prior to full implementation and therefore a net saving of £0.5m is being included in the 2007/08 budget planning.
14.3 In order to make the required changes and sustainable revenue savings in the service, an Invest-to-Save proposal will be submitted to the Organisational Transformation Board. This will contribute towards the ICT costs of Real Time Monitoring and the electronic bed management system, project management costs and a voluntary severance scheme.
14.4 The Capital Receipts in the region of £1.3m will also be speeded up and secured through the implementation of the Review, although as these receipts form part of the existing residential strategy, they have already been assumed as part of the overall capital programme.
15. Conclusions
15.1 The Care4you Review concluded that on the extensive information available, the most appropriate course of action is to progress the revised vision for Care4you, which will enable it to provide better outcomes for older people whilst also reducing its costs by between 8% and 10.5%. This would provide recurrent revenue savings of up to £2.3m.
15.2 This option does require the service to phase out and disinvest itself from on-going home support services and for this to be purchased at the market rate from the independent sector. It sees the completion of the existing Council policy to reconfigure home support into specialist services and to decommission the remaining two care homes. It proposes the service consults on divesting its spare capacity in the resource centres and the continuation of the Citywide Alarm service developments.
15.3 Delivery of the changes will also require robust project management, effective consultation and engagement of stakeholders, including Trade Unions, staff and service users and non-recurrent assistance from the Invest-to-Save fund.
15.4 If implemented, the Review's recommendations will result in better outcomes for service users, improved quality services delivered to more older people than currently. There will also be some re-investment into Care4you whilst also securing year on year revenue savings in the region of £1.8m.
16. Recommendations
It is recommended Cabinet: -
1. Approves the completion of the strategy for the Care4you home support service to focus on its specialist services and for the on-going home support to be purchased from the independent sector.
2. Approves the range of proposals for changes and improvements to working practices, including the training of staff to enable them to undertake a wider range of duties and the introduction of electronic systems for bed availability and Real Time Monitoring, as outlined in section 9 of the report.
3. Authorises the Director of Adults' Services in consultation with the Cabinet Member for Adult Services to consult service users and relevant interested parties in accordance with relevance guidance on a proposal to rationalise the number of resource centres and in particular whether Longley Hill resource centres should be decommissioned.
4. Authorises the Director of Adults' Services in consultation with the Cabinet Member for Adults' Services to review the responses to the consultation process and make any necessary further decisions in respect of the rationalisation of the resource centres and in particular whether and when the proposal to decommission Longley Hill should be implemented if satisfied this is appropriate following consideration of the responses of the consultation.
5. Reaffirms its commitment to the completion of the residential strategy through the planned decommissioning and ongoing consultation in respect of Ravenscroft, with final dates to be agreed by the Director of Adults' Services in consultation with the Cabinet Member for Adults' Services.