brighton & hove city council - think local, act personal

Brighton&HoveCityCouncilWithfundingfromImprovement&EfficiencySouthEast

APersonalisedModelofCareandSupportAtVernonGardens,Brighton

MaximisingPotentialforSelfDirectedSupport

30July2010

NicholasDayAssociates

15FeltrimAvenue

St.Leonards

EXETEREX24RP

Tel:01392877544

NicholasDayAssociatesforBrighton&HoveCityCouncil/InterimReportonVernonGardens/28July2010 2

Title Contents PageNo.

ExecutiveSummary 3

1 Introduction 4

2 ProjectScope 4

3 Developingthemodel–thebasicapproach 5

4 DevelopingtheModel–theconsultationprocesswefollowed 5

5 DevelopingtheModel–themethodologyweused 6

6 TheModelofService 10

7 TheProviderRecruitmentProcess 12

8 Facilitatorreflectiononwhathasworked 13

9 Reflectiononlessonsforthefuture 14

Apdx1 TenantFeedbackFormforevaluatingthedevelopmentprocess 16

Apdx2 Aframeworkformappingholisticneeds 18


ExecutiveSummary

E1. Brighton&HoveCity Council (BHCC) is totally committed to awhole City approach topersonalisationintheirtransformationofAdultSocialCareservices.Thisreportsetsouttheexperienceofdevelopingonesmallstrandofthisapproachtomaximisethepotentialofself‐directedsupportforvulnerableindividuals.TheworkhasbeenfundedbytheIESE(Improvement&EfficiencySouthEast).

E2. Forthelast7monthsthepotentialtenantsofanew10‐flatextracarehousingschemeforsingle,physicallydisabledpeoplebeingbuiltbytheGuinnessTrustandduetoopenthisOctoberhavebeenworkingwithafacilitatortodevelopamoreapersonalisedmodelofcareandsupport.Thisreportcovers thevarioussteps taken in thedevelopmentof thismodel, the work required to turn this into a service specification for the tenderingprocess,recruitingtheprovider,andrecordstheexperienceoftheprospectivetenants.

E3. Thefacilitatorsmadeadecisionattheoutsettoconsultwithpotentialtenantsprimarilythroughagroupprocessthatalsoinvolvedcarersandrelatives,togetherwithotherkeyBHCCstaffinvolvedinpersonalisationandprocurement.Thiswasdesignedtomaximiseinteraction, promote creativity and generate learning. All the tenants reported theyvaluedthisapproach,creatingself‐confidenceandself‐knowledge.

E4. Weemployeda‘whole‐of‐life’serviceapproachtoneedsmappingthatallowedtenantstocompareandcontrasteachofthemodelsdiscussed. Italsocreatedacommonlanguagebetween tenants and professionals for the development work required. The needsframework had eight elements: housing management; housing related support; socialcare;personalcare;healthcare;meaningfuloccupation;andsocialsupportnetworks.

E5. Theoutcomeof theconsultationwasan interestinghybrid:all thepotential tenants felttheirneedswouldbemetbyacombinationof:

AservicecommissionedbytheLocalAuthorityfortwospecificelements:a‘rise‐and‐retire’servicebasedonsitetocovergoingtobedandgettingup;anda ‘emergencyandon‐callnightservice’thatwillsupporttherise‐and‐retirestaff.

Services commissioned by individual tenants (with the help of personal assistants)frompersonalbudgetsacrossthecompleterangeof‘wholeoflife’services

Commissionedservicestransferredacrosswiththetenantfromacurrentprovider.

E6. Weseetheproposedmodelasevolutionaryanddynamici.e. ithastheabilitytochangeover timeas tenants learn to take controlof commissioning servicesandbecomemoreconfidentaboutmanagingtheprocess.Forexample,therewasnoenthusiasmforpooledbudgetsatthisstage.However,allthetenantscouldseethisasanoptioninfutureyearsastheygainedgreaterself‐confidenceincommissioning.

E7. The overall model also breaks something of the ‘established’ mould in that the localauthority commissioned elementwill formonly 42%of the total current estimatednetcareandsupportbudgetspentfromBHCCfundsonthepotentialtenants:atthesefigures58%wouldbeavailableforpersonalbudgets.

E8. Potentialtenantsarebothexcitedandnervousaboutthefuture.Nervous,inthatittakessome of them into unchartered territory i.e. services they commission for themselves.Excited, in that theywillhavemuchmorepotential controlover thesmall things in lifethatmanyof us take for granted e.g. choosingwhenwe get up and go to bed.And thebenefit is not just to the disabled people but to families and carers too. As one familymemberofatenantsaid:“Thisprojectisaboutafutureforusall”.


1. Introduction

1.1 Nicholas Day Associates have been commissioned by Brighton & Hove City Council(BHCC) to develop a newmodel of care and support for a 10‐flat extra care housingschemeforsingle,physicallydisabledpeoplethat isbeingbuiltbytheGuinnessTrust,and will open in October. We have been required to do this in consultation withpotential tenants, and taking account of the principles set out in the Government’sStrategy Putting People First to maximise the potential of self‐directed support. TheworkhasbeenfundedbytheIESE(Improvement&EfficiencySouthEast).

1.2 BHCC is totally committed to a whole City approach to personalisation in theirtransformationofAdultSocialCareservices.Aspartofthecommissionwearerequiredtoreportonthecostandbenefitsofthepotentialmodelsofcareandsupportthathavebeen considered, and the process by which the chosen model was developed andevaluated.WearealsorequiredtocontrastthechosenmodelwiththoseattheexistingextracareschemesforolderpeopleinBrightonatPatchingLodgeandNewLarchwood.

1.3 Thisisaninterimreportthatcoverstheperiodfromcommission(13January)untilaninterimevaluationeventwithpotential tenantson14June,andtherecruitmentof thenewprovider(CareUK)fortheelementofthecommissionedservice.(Thefinalreportwill cover scheme opening, some initial data on the moving‐in experiences of newtenants,andsomecost/benefitevaluationsandcomparisonwithexistingschemes.)

2. ProjectScope2.1 Brighton&HoveCityCouncilhassetthefollowingobjectivesfortheProject:

TodevelopamodelofcommissioningforcareandsupportatVernonGardensinconsultationwithpotentialtenants;

TocontrastmodelsofcommissioningforcareandsupportatexistingextracarehousingschemesintheCityinconsultationwithexistingtenants;

Toproduceafinalreport(thepropertyofBrighton&HoveCityCouncil)toinformlocalandregionalpractice.

2.2 Aspartofthedevelopmentprocessthefollowingadditionalexpectationswereset: Themodelsmustbecomparedandcontrastedintermsofvalueformoney,withattentiongiventoexaminingthecosteffectivenessofpooledpersonalbudgets;

Eachmodelmustquantifythevariousbenefitsandpositiveoutcomesforstakeholders;

Eachmodelmustlookattheimpactontheworkforcee.g.trainingneeds; EachmodelmustevaluatetheITsystemrequirements; Themodelsofcareandsupportselectedmustreflectserviceuserchoice; ThemodelchosenshouldinformtheselectionoftheCareandSupportProvideratVernonGardens;

ThemodelselectedforVernonGardenswillbecomparedtoPatchingLodgeandNewLarchwoodExtraCareSchemesinBrighton&Hove.

2.3 Wehavereachedthestageoftheassignmentwherewehavenowdevelopedthemodelofcareandsupport,recruitedthecareandsupportprovider,buthavenotyetbeenabletoassessvalue‐for‐moneybetweenoptions,orbeenabletocontrasttheproposedmodelwith existing schemes, or looked atworkforce and IT implications in detail. Thiswillformthefinalstagesofourassignment.


3. Developingthemodel–thebasicapproach

3.1 TheGovernmentexpectsthatbyApril2011allCouncilstohavetakensignificantstepstohaveapersonalisedsystematthecentreofallAdultSocialCare.BHCC’sstatementofvisionclearlymakesanunequivocalcommitmenttothisagenda:“Ourcommitmentistoempowerpeopletomakeinformedchoicesaboutthesortofsupportthatsuitsthemandtoachieve theoutcomes theywant tomaximise their independenceandqualityof life.Thisincludessafeguardingthosepeoplewhoseindependenceandwellbeingareatriskofabuseandneglect.”1

3.2 InBrightonourprimarytaskinPhaseOnehasbeentoworkwiththepotentialtenantsoftheschemeatVernonGardenstodevelopa‘new’modelofcareandsupport.By‘new’the local authoritymeant one that broke themould of a service specified in terms ofbroad structure by professionals. The challenge given to us was therefore to find amodelthatwould‘fit’theself‐directedcareandsupportneedsofallthetenants.

3.3 Theapproachrepresentedarisktothelocalauthorityintwoquitedistinctways.Firstly,BHCCwasfullycommittedtoletresidentschoosethemodelofservicethatbestsuitedtheir needs and aspirations. The outcomemight have been a request by the potentialtenants for the local authority to purchase the whole service on their behalf in atraditional block contractmanner. Secondly, and quite an opposite risk in the aim ofhelpingthemachievetheoutcomestomaximisetheirindependenceandqualityoflife,afully self‐directed support service could turn out to be significantly more expensivewhen social workers reviewed the support plans of new tenants and based theirreassessmentofcareandsupportneedsonadifferentaddress.

3.4 Ontheotherhand,theexercisewasalsoarisktothepotentialtenants.Theywerebeingaskedtoinvestenergy,timeandhopeintohelpingtheCitydevelopanewmodelofcareand support for a housing schemewhere, at the outset, therewas no guarantee of afutureplace.Partofourprimarytaskwasthereforetohelpbuildandsupporttheir‘actoffaith’thattheeventualoutcomewouldbefavourabletoeachone.

3.5 This piece of work represents change for all, including independent facilitators! Thereport therefore attempts to capture the diversity of perspectives on this journey. AsBHCCacknowledge:“Thismeansnotonlymustourcurrentsystemsandserviceschangebutalsothoseofourpartnersandproviders.Statutoryagencieswillhaveadifferentnotlesserrole.Weneedtotakeaproactiveandenablingapproachandbepreparedtobelesscontrolling.ItwillputtheprinciplesofindependentlivingintopracticeandenablepeopletobeactivecitizensoftheCity.Itisaboutflexibility,choiceandhavingadecentqualityoflife.ItispartofcreatingahealthierCitywithstrongerandsafercommunities”.2

4. DevelopingtheModel–theconsultationprocesswefollowed

4.1 Wemadeadecisionattheoutsettoconsultwithpotentialtenantsprimarilythroughagroupprocessthatalsoinvolvedcarersandrelatives,togetherwithotherkeyBHCCstaffinvolved in personalisation, outcome based support planning, and procurement. Thiswasdesignedtomaximiseinteraction,promotecreativityandgeneratelearningwithinthe timeand resourcesavailable. Sections8,9 and10 reportonhow farweachievedtheseprocessobjectives.

1‐“PersonalisationStrategy201011:TheCityConversation.”BHCC2‐Ibid


4.2 When inFebruarywestartedourconsultation8potential tenantshadbeen identifiedthroughtherelevantAdultSocialCareTeamatBHCC,althoughnoneofthemhadbeenthroughGuinnessTrust’snominationandallocationprocessatthatstage.Thehousingschemehadbeen in theplanning stage for somewhile, so socialworkershadalreadystarted toconsiderwhomightbenefit fromamove.VernonGardenscomprises3self‐containedtwo‐bedroomflats(fortenantswhomightrequirealive‐incarer)and7self‐contained one‐bedroom flats. For all the potential tenants the move would meet thestrategicaimsoftheAdultSocialCareagendai.e.promotinggreaterindependenceandenhancingthequalityoftheirlives.Theagerangeofpotentialtenantswas20to49.

4.3 Wepersonally invitedeachpotential tenanttothe firstgroupmeetingon10Februaryby letter and ‐ where possible – a follow up telephone call, as a way of introducingourselves and beginning the relationship before we met face‐to‐face. We have keptcontact with the group between meetings as necessary, either for administrativepurposes or to gather additional personal data as required.We had furthermeetingswith the whole group on 24 February and again on 23 March. One potential tenantwithdrew after the firstmeeting, so the finalmodel devised is based on consultationwith7potentialtenants.

4.4 Inadditiontopersonalcontactandhistorytakingallthe7remainingtenantsagreedtoprovideuswiththeircareandsupportplans.Thisenabledustocheckandverifydatagatheredinthegroupmeetings.On23Marchwemettobrieftherelevantsocialworkteamontheemergingmodelsotheyhadthebasicknowledgetorevieweachpotentialtenant’s support plan based on a new address and care and support model. It alsoprovidedanopportunitytohelpthemidentifyclientsfortheremainingthreevacancies.

4.5 Thepurposeofthefirstmeeting,awholedayevent,wastointroducethework,outlinethepotentialmodelsthatcouldbeconsidered,andbegintogetanunderstandingofthepotential tenants’ care and supportneeds.The secondgroupmeetingon24February(subsequentmeetingswereahalfdayonly)wasusedtoshareandverifywhatwehadlearntabouttheircollectiveneedsforcareandsupport,andfillinthegapsabouttheirfutureaspirationsagainstthemodelthatwasforminginourminds.Bythetimeofthefinalmeetingon23March,BHCCandtheGuinnessTrusthadagreedthenominationandallocationprocess,concludingthatallofthe7potentialtenantsmettheschemecriteria.This was a very positive platform from which to present the proposed model toindividuallyandcollectivelyaddresstheircombinedcareandsupportneeds!

5. Developingthemodel–themethodologyweused

5.1 In order to find a framework that allowed ourselves and the tenants to compare andcontrast themodels, and create a common language for the development process,wehave taken a holistic approach to developing self‐directed support arrangements. Foreachmodelwelookedathoweachtenantwouldgainaccessto,andbeinvolvedin:

HousingManagement(Building&Services) HousingRelatedSupport(ManagingtheHome) SocialCare(DailyLifeTasks) PersonalCare(PersonalTasks) HealthCare(WellBeing) MeaningfulOccupation(Education,Training&Employment) SocialSupportNetworks(OtherResources)


5.2 Usingthis framework,wethenpresentedat the firstmeetingabroadrangeofservicemodels (set out in Table below) for the tenant to consider, pointing out the finaloutcomecouldbeahybridofanyoftheseoptions.

TypeofCommissionedService ServiceDescription

1.TheLocalAuthoritybuystheserviceonyourbehalf:

Traditionalwayserviceshavebeenpurchasedinthepast

LAdrawsupServiceSpecificationonyourbehalfandinvitesproviderstobidtodelivertheservice

2.TheLocalAuthoritybuyspartoftheserviceonyourbehalf:

LAdrawsupservicespecificationonyourbehalfforpartoftheserviceandinvitesproviderstobidtodelivertheservice

Theremainderoftheserviceispurchasedbyyou(throughPersonalBudgetsorDirectPayments)

3.YouhaveaPersonalBudgetandbuytheservicesyourself:

Thisisarecentnewermodelofpurchasingservicesforadultsocialcare

Youaregivenapersonalbudgetthatisheldeitherbyyouorsomeoneonyourbehalftopurchasetheservicesyouneed

4.YouhaveaPersonalBudgetbutthisispooledwiththeotherresidentsandyoupurchasetheservicesasagroup:

Asinthepreviousmodelyouaregivenapersonalbudget

Howeverinthismodelyourbudgetispooledeitherinfullorinpartwithotherresidentstopurchaseservices

5.YouortheLocalAuthorityusepartofthebudgettopurchasemeaningfuloccupation:

Thisisahybridmodelthatworkswithoneoftheothermodelsabove

Thisenablesyoutodevelopyourskillswhilemeetingsomeofyoursupportneedse.g.Learningtocooksoastoprovidemealsforotherresident’s,peopleusingresourcecentreand/orthewidercommunity

Table1ModelsofCare&Support(Aspresentedanddescribedtotheresidents)

5.3 Afterpresentingtheoptionsavailable,wethenindividuallyinterviewedduringtheday

all the potential tenants, together with their carers and relatives if present, takingdetailedhistories and statementofneeds about their care and support arrangements,and discussing each of themodels inmore depth against their current circumstancesandaspirations.(Wesubsequentlysupplementedthisthroughaccesstotheircareandsupportplanand,wheretheyhadone,theirsocialworker.3)

3‐3ofthe7potentialtenantsdidnothaveanallocatedsocialworker.For2ofthesepeoplethisrelatedtothestabilityoftheexistingarrangements;fortheother,hewasanewreferralandbeingdealtwithbythedutyteam.


5.4 At the end of the day we brought the whole group back together to ask their initialopinions.Therewasclearlyamixtureofexcitementandnervousness:excitementinthattheycouldhaveamajorsayintheirchoicesforthefuture,andnervousnessinsofarasitheralded change from current circumstances which, if not ideal, were familiar andsecure. At this stage we sensed that none of options presented in 5.2 had beendiscounted.However,reflectingonthisevent,werealisedthegroupneededmoretimetounderstandandreflectonthemodels,andweneededmoretimetosiftthestoriesandstatementsofneedtohelpthemwiththeprocessofreflection.

5.5 Atthesecondhalf‐daymeetingtwoweekslaterwecarriedoutanexerciseinwhichweaskedeachpersontomaptheirsupportneedswithintheframeworksetoutin5.1.(ThemappingdocumentisAppendix2).Weneededtobetterunderstandhowtheirpersonalcareandsocialcareneedsvariedwithdifferenttimesoftheday,andhowactivitiessuchasmeaningfuloccupationandaccess to theirsocialnetworkse.g.activityclubs,variedwiththedifferentdaysoftheweek.Bythispointthegroupwasbeginningtoworkasagroup:notonlydid theyseekadvice fromtheprofessionalspresent, theysharedtheirideasandunderstandingwitheachother.Asaresultofthiseventwehadastrongsetofmessages,whicharesummarisedinTable3overleaf.

5.6 Wewerealsoabletomaptheestimatedshiftindemandfromservicescommissionedbythe local authority to those commissioneddirectly by the tenant (seeTable 2 below).This is basedon all the7potential tenantswhowent through thewhole consultationprocess.Allofthemcurrentlyreceiveamixtureofpersonalandsocialcare(elements1and2).Takingthegroupasawhole,atpresent86%oftheircurrentpersonalcareand77%oftheirsocialcareisdeliveredbyservicescommissionedonablockcontractbasisbyBHCC,and14%ofpersonalcareand23%ofsocialcare iscommissionedviadirectpaymentsfromtheserviceuserthemselves.ThedatasetoutinTable2showstheextenttowhichthepotentialtenantsatVernonGardenswishtohavegreatercontrolovertheircommissioningarrangements,particularlyintermsoftheirsocialcare(ashiftfrom14%to41%oftime/activity).

5.7 At present only 1 potential tenant receives a commissioned housing related supportservice (these functions areprimarilydone for theother6by familymemberswherenecessary);while2receivesomeformofcommissionedserviceforaccessingtheirsocialsupportnetworksandmeaningfuloccupation.Asthesearecriticalelementsforawholeof life service all 7 potential tenants were keen to access elements 3, 4 and 5 fromVernonGardensthroughamixtureofcommissionedandpersonalservice.

WorkingAssumption:HousingManagementretainedforallresidentsbyGuinnessTrustNotes:CFR=CommissionedforresidentbyBHCC;CBR=CommissionedbyresidentusingIB

0=Eithernotcurrentlyprovidedasaserviceorprovideddirectbyfamilymember(s)

CurrentHome CurrentHomeVernonGardens

VernonGardens

CommissionedElement CFR CBR CFR CBR1.PersonalCare 86 14 59 412.SocialCare 77 23 61 393.HousingRS 14 0 66 344.SocialNetworks 29 0 53 475.MeaningfulOccupation 29 0 53 47

Table2–Summaryoftheestimatechangeinthecommissioningprofileofthepotentialtenantsatthepointoftakingupresidence


LifeArea Themes

HousingManagement

ConsensusthatGuinnessprovidetheHousingManagementService…but: Tenantswantasayinwhatgoeson Somethoughtatenantsassociationwouldbeagoodidea ThereshouldbeaSchemeManager:residentswanttoknowwhatthe“normal”managementarrangementswillbeandwhataretheoutofhoursarrangements

AllwillrequireOTassessmentatoutsetandareviewonaregularbasis IT/Internet/FreeviewaccessTVinallflats!

HousingRelatedSupport

Mixofviewsaboutwhetherthisshouldbeacommissionedserviceorapersonalpurchase: Mostpeoplewantsomehelpandsupportwithbenefits Somewantsupportwithdaytodayissuessuchasrepairs,managinghouseholdbills Somethought‘drop‐in’typesupportwouldbeusefulwhenneeded Mostwillwanthelpwithmanagingthehealthandsafetyaspectoftheirtenancy CouldbeprovidedthroughtheirexistingPAortheirPAwhenappointed

SocialCare

MostwanttopurchaseownserviceeitherthroughPAorthroughexistingserviceproviders Somedemandforcommissionedservices(morereliableandlessriskyintheeventofillness) Somepeopleabletocookforthemselveswithsupport(andlinkedtoaccessiblekitchens),andtogoshopping

MostpeoplewillneedpromptingforappointmentsPersonalCare

MostwanttopurchaseownserviceeitherthroughPAorthroughexistingserviceproviders Demandforovernightoncallserviceforsomeserviceusers(especiallythosewhowouldnothavealive‐inovernightcarer)

Peoplewanttogotothetoilet,haveashowerwhentheywant,getup/gotobedatthetimetheychoose(andnotbedictatedbythecallingtimesofcarestaff)

MostpeoplewillneedhelpwithpromptingofmedicationHealthCare

Most(ifnotall)peopleaccesstheirownhealthcareandseethiscontinuing Norealneedordemandforpurchasedhealthcare(withexceptionofonepotentialresidentwhensheisill,butwhowillhavelive‐incarerwhenthishappens)

Demandforsupporttoattendhealthcareappointments/needs Somerecognitionthatsomeservicescouldbedeliveredonsitee.g.chiropody,districtnurse,asthiscouldbemorecosteffectiveforhealth(asallatonesite)andmorecost‐effectiveforresidents(noorreducedtravellingtoclinics)

MeaningfulOccupation

Useofindividualbudgets/selfdirectedsupporttoaccessmeaningfuloccupation Mosttenantsdoandwillorganisethisthemselves Someneedsupporttoaccesseducation,trainingandemploymentforgreaterindependence Particularsupportneededfortravel Wanttoparticipateinactivitiesincommonareasandbeinvolvedinwhathappensthere

Social/SupportNetworks

Useofindividualbudgets/selfdirectedsupporttobuildsocialandpersonalcapital Desiretoaccessbettersocialactivitiesandhealthyactivitiese.g.swimming/gym Forsomeitwillbeveryimportanttodevelopingnetworksoutsideoffamily,andreducerelianceonfamilyforsupportandcareandsocialactivities

Somedemandtohaveaccessto,andtobeabletomakeuseof,the‘communalspace’.OtherIssuesArising(notfallingintoabovecategories)

Supportneedstobeageandgenderrelevant/sensitive Communicationshouldbesensitivetolanguageandsigning ‘Frontload’theservicei.e.morecommissionedsupportshouldbeprovidedintheearlymonths,reducingovertimeasconfidenceandindependenceofSUgrows

Supportforholidays Somedemandtotakeexistingproviderswiththem...butalsoforlosingexistingprovidersandhavinganewone!

Helpandsupportwillbewantedtomanagepersonalbudgets(ArolefortheFederation?) SomeserviceuserswanttointerviewtheirownPAs,ratherthanbefoundbyLAorothers Someparents/relativeswillcontinuetoactasPAsfortheirchildren Joinedupandintegratedserviceswanted–noChinesewalls! Littledemandatpresentforpooledbudgets

Table3–Asummaryofthethemesfromtheconsultationwithpotentialtenants


6. TheModelofService

6.1 Theoutcomeoftheconsultationexercisecombiningthepiecesofworkmentionedin5.5and5.6producedwhatwasaninterestinghybrid:allthepotentialtenantsatthe3rdandfinalmeetingfelttheirneedswouldbemetbyacombinationof:

AServicecommissionedbytheLocalAuthority fortwospecificelements:a ‘rise‐and‐retire’ service based on site to cover going to bed and getting up; and a‘emergencyandon‐callnightservice’thatwillsupporttherise‐and‐retirestaff;

Servicescommissionedbyindividualtenants(withthehelpofpersonalassistants)usingpersonalbudgetsacrossthecompleterangeof‘wholeoflife’services;

Servicestransferredacrosswiththetenantfromacurrentprovider.

6.2 VernonGardenswillofferhousingwithcareandsupporttopeoplewithawiderangeofphysicaldisabilities.Alltenantswillberequiredtopurchasethecommissionedservice.Foronenewtenantwhopurchasesallhercurrentservicesthroughapersonalbudgetthenewsetupwill representa compromise.Forall theothers, themove toagreaterelement of self‐directed support represents a new dimension, but one the exercisesummarised in tables 2 and 3 shows theywish to embrace. Somewill bring existingproviders (who are both local authority and personally commissioned) to top upelementsofpersonalcareortodelivertheirsocialcareand/orsupport.

6.3 Weseetheproposedmodelasevolutionaryanddynamici.e.ithastheabilitytochangeovertimeastenantslearntotakecontrolofcommissioningservicesandbecomemoreconfidentaboutmanagingtheprocess.Forexample,therewasnoenthusiasmforpooledbudgets at this stage.However, all the tenants could see this as an option in years tocomeasawayofhavinggreatercontrolovertheirservices.

6.4 The overall model also breaks something of the ‘established’ mould in that the localauthoritycommissionedelement(whichwecurrentlyestimateas£137,592,seebelow,Table4)willformonly42%ofthetotalcurrentestimatednetcareandsupportbudgetspent from BHCC funds on the potential tenants4: at these figures 58% would beavailableforpersonalbudgets.Wecalculatedthisratiobasedonthemodelsetoutin6.1,andasetofworkingassumptions5.Insupportedhousingschemes,orextracarehousingschemesdeliveringcareandsupport, thatwearehaveresearched todate theratioofcommissionedtoself‐directedservicehasbeenintheorderof70:30.

ServiceElement Timecosts CashCost WorkingAssumptions

Rise&RetireService 6hrsx2staffx7days=84hoursperweek

@£18perhourx84hoursx52weeks=£78,624

2staffatalltimes,21.00to00.00,and07.00to10.00,7daysperweeki.e.6hoursperday

EmergencyOvernightService 9hrsx1staffx7days=63hoursperweek

@£18perhourx63hoursx52weeks=£58,968

1staffatalltimes,22.00to07.00wakingnightservice,7daysaweeki.e.9hoursperday

AllCommissionedElements 147hoursperweek;totalcostofservice£137,592

Table4–Calculatingthecostofthelocalauthoritycommissionedelementoftheservice

4‐TakingfiguressuppliedbyBHCCon17Februarywetooktheestimatednetforecastcostforthe7potentialresidents(£230,511)andgrossedthisupproportionallyfor10residents(£329,301)5‐Theseassumptionswerebasedondiscussionswithserviceusers,commissionersandsocialworkersabouttheexacttasksneededtodeliverthecommissionedelements,thetimingofthesetasks,andlikelychargingrates.


6.5 However this ratio and these costs will need to be recalculated once the final set oftenantshavebeenagreed.Theonlybudgetwehavebeenabletoworkwithatpresentisonebasedonthecurrentcostofdeliveringcareandsupporttoallthepotentialtenantsattheircurrentaddresses.AstheircareandsupportneedscouldbedifferentinVernonGardensnewassessmentsarerequired(seeparagraph4.4)andthiscouldalterthetotalcosttothelocalauthority.

6.6 Thenewbusinessmodel is highly customerdriven: CareUK, thenewprovider of thecommissionedservice,alongwithexternalproviders,havetheopportunitytobidfortheremaining58%ofthepersonalbudgetthattenantsdirectlycontrol.Italsorequirestheproviders to be very flexible: the consumers of their service will be able to switchproducts (within certain contract rules e.g. notice periods to change) according tochangingneedsandaspirations.Wehavebeenabletosumupthemodelina‘StatementofCommissioningIntent’(setoutinTable5),andwhichformedakeydocumentwithinthetenderingprocess.

VERNONGARDENSAstatementofcommissioningintent

Themodelisdesignedtoofferthebestpossiblecareandsupporttoaveryvulnerablesectionofthecommunity.Itmustbehome,notaninstitution.Theemphasisateveryturnwillbe‘doingwith’ratherthan‘doingfor’or‘doingto’.

Theconsultationprocesshaschallengedsomeofourassumptionsaboutwhatwemeanbyindependentliving.Asonepotentialtenantsaid:“MybiggestconcernisgettingupandgoingtobedwhenIwantto,andnotbetiedbythetimecarerscomeandgo.Thatisindependentlivingforme”.

Themodeloffersthemaximumflexibilityandchoicetotenants.Forexample,itisaboutbeingabletogetuporgotobedwhentheychoose,orevengotothetoilet!

Personalassistantshaveakeyroletoplay.Theyenablethetenanttobeincontrol,tofeeltheyarehavingasay,orchestratingwhatgoeson.

Tenantsseethisasanopportunitytocreateacommunityofcommoninterest.Twoofthepotentialtenantsaregoodfriendsbutseeeachotherverylittleatpresent.(Peopleusedwordslike‘joy’todescribethepotentialoftheirfuturehome.)

Itisaboutmanagingacommunityofverydifferentindividualsatverydifferentstagesonthepersonalisedjourneyto‘independence’.Thiswillbemanifest(1)inamenuofservicesasinallotherextracareschemes;and(2)sometenantschoosingtobringexistingproviderswiththem,choosinganewproviderwiththeirpersonalbudgets,and/orbuyingintotheLAcommissionedserviceatVernonGardens.

Themodeldistinguishesbetweenservicesthatare‘commissionedfor’thetenanti.e.theLAspecifiesthecontractwiththeprovider;andthosethatare‘commissionedby’thetenanti.e.theresidentspecifiesthecontractwiththeprovider.

Itisanevolvingmodel:bothforeachindividualtenantandforthetenantgroupasawhole.Itmustopenhorizons,notclosedoors.Thespecificbalanceof‘commissionedfor’and‘commissionedby’serviceswillbeinconstantfluxasanindividual’sconfidencerisesandfallsinresponsetothepatternoflife’sevents.

Asalways,thehiddenresourcewillbethesignificantamountoffamilyinputgoingintothecareandsupportofeachtenant.

BHCCareseekingaproviderwhohasaworkforcecapableofdeliveringanintegratedandflexibleservice,whocanacceptthechallenges,rewards,opportunitiesandrisksinherentinthismodel.

Table5–TheStatementofCommissioningIntentthatdescribestheunderlyingethosofVernonGardens


7. TheProcurementProcessfortheLocalAuthorityCommissionedService

7.1 OncethemodelhadbeenagreedinAprilwethenbeganworkingwiththerelevantBHCCcontractsandprocurementstaff,aswellasthePersonalisationManager,toturnthisintoaservicespecificationanddocumentsfortendering.Thishasinvolvedpayingparticularattention to issues suchas theaccuratedescriptionof the serviceaspartofabalancebetween commissioned and self‐directed elements, and appropriate questions in thePQQandITTdocumentstoenableBHCCeffectivelytestprospectivebidders.

7.2 Themainchallenge,inthecontextoftheobjectivesofthisprojectinparticularandthephilosophyofpersonalisationingeneral,hasbeentomakepotentialtenantsfeelcentralintheprocurementprocessforthecommissionedprovideroftherise‐and‐retireserviceand the overnight service. Tenants identified this service as the cornerstone of theirtotalindividualpackagesofcare,andtheyandtheirfamiliesandcarersmadeitclearintheearlyconsultationstheywantedassurancesthatthechosenproviderwascompletely‘intune’withthevaluesandconceptssetoutintheStatementofCommissioningIntent(seeTable5above).

7.3 Whilewedidnothavetimetoconsultontheexactwording,wedidgetguidancefromtheprospectivetenantsofwhatwasimportantfromtheirperspectivetotestintheITTproviderinterviews.Forexample,theywereveryclearthattheywantflexibilityonthetimes they are able to go to bed and get up; and, on the basis of past experience(particularlythosealreadyusingdirectpayments),theyexpectedallproviderstafftobetrainedtoNVQLevel2standards.

7.4 CareUKhavebeenchosentoprovidethecommissionedforservice.InitialexpressionsofinterestandsubsequentPQQapplicationfrom12organisationswerewhittleddownto6offeredanITT.TwoofthepotentialtenantsjoinedthePQQEvaluationTeam.Onewithdrew halfway through the day‐long event (as they found it both confusing as aprocess and difficult to engagewith due to language difficulties) and,while the othertenantmanaged it very comfortablywith the support of her father, reflected that herviewsattimeswerenotheardbythethreeother‘professionals’intheEvaluationTeam.

7.5 Involvingserviceusersinthecommissioningprocessforcareandasupportschemeisadeveloping art. Even where they are involved, as local experience shows, decision‐makingcanstilltendtobedominatedbytheprofessionals.However,thePuttingPeopleFirst agenda should challenge the very presumptions around formal commissioningarrangements, not just the processes of developingmodels of care and support. As aresultofthetenants’experienceinthePQQstagetheAssistantDirectorofAdultSocialCarestatedunequivocally:“Aslongaswe(theCouncil)aresatisfiedthatthefinaldecisionisprovidingvalueformoneyIamhappyfortenant'sdecisionstobethedrivingforce”.Wethereforedesignedthefinalstagesoftheprocurementtoreflectthisstandpoint.

7.6 The6organisations reaching the ITTstagewere scoredon theirquestionsbyapanelthatthistimecomprisedoneprospectivetenantandtwoparentsofprospectivetenants,andthreeCouncilOfficers.Wheretherewasdisagreementinscoring(whichhappenedoververyfewquestions)theCouncilOfficerswereveryattentivetotenant’sviews,withthe final score always reachedwith the tenants agreement. The 6 organisationsweretheninvitedtomakeapresentationtothePanel,augmentedbyafurther5tenantsandtheir families/carers. (On this occasion additional resources were procured to assistthosetenantswithlanguageorcommunicationdifficulties.)Theadditionaltenantsandfamilies/carersthengavetheirviewstothepanel,beforethetenderswererescoredinthetraditionalway.ThisenabledthePaneltobeunanimousintheirchoiceofprovider.


8. Facilitatorreflectiononwhathasworked

8.1 Inouropinionasfacilitators,potentialtenantengagementhasbeenverysuccessful!Wethinksomeofthereasonsforthisare:

Involvingthemfromaveryearlystageandhavingan“endgame”fromwhichtheywillbenefit(apropertyandaservice).Astherehasbeensomethingtangibleinitforthem they have taken a much more positive approach to engagement andparticipationinallstagesoftheprocess.

The ‘balance’ of potential tenants selected appear to have been successful: thosecoming from currently fully commissioned services through to those who havesubstantialelementsofpersonalbudgets.Inthegroupand1‐2‐1mentoringsessionswehaveobservedpotential tenantsandtheircarerssupportingoneanotherintheprocessofbuildingtheirunderstandingandknowledgeofwhatisgoingon.

Thatthewholeprocesshasbeenkept‘open’andembracedtheprinciplesofserviceuser engagement from the outset, in which the consultants have sought to buildtrusting relationships so that the tenants gain confidence in the whole process,indeedbeginningtotakechargetosomeextent.Theredoesnotseemtohavebeenanysignificantbarrierstoinvolvingthemthroughouttheprocess.

8.2 AnothercriticalsuccessfactorinourviewhasbeenthecommitmentofstafffromBHCCtobeinvolvedinthisprocess.Therehasbeenawillingnesstotakerisksandallowtheproject to evolve according to development principles rather than diktat; they havecommittedasignificantamountofstaffresources;andtherehasbeenasinglepointofcontactfortheconsultantstogetthingsdoneandmitigateagainstriskwhennecessary,keepinglocalstakeholdersintheloopandgettingdecisionsfromkeyseniorstaffasandwhentheyareneeded.

8.3 We also feel that commissioningNicholas Day Associates as a non‐local, independentfacilitatorhasalsobeencritical.Wehavebeenabletoretainobjectivitywiththeprocessasithasunfoldedandtheorganisationsinvolved,challengingnegativeperceptionsandblockagesastheyhavearisen,andsupportingthetenantstoactivelyengage. WehavebeenabletoworkacrossthedifferentteamswithinBHCC,andtheGuinnessTrust,togetthings done in awaymeaningful for tenants; and also towork directlywith them toensuretheyunderstandwhatisgoingonandenabletheirviewstobefairlyrepresented.

8.4 Good,strongprojectmanagementhasalsobeenimportantinsupportingthisprocessoffacilitation and objectivity. Periodic meetings to review the original PID (ProjectInitiationDocument)andprojectbrieftoensurethatthingsareontime,tobudgetandcompliantwith thebriefhashelpedtoensurepositiveoutcomestodate.Forexample,thishasproducedtimelyengagementwiththesocialworkteam,explainingthemodeltothem so that they can support their clients; but also to appreciate the need for newsupportplanssowecancalculatethecostsofthenewmodel.

8.5 Afurtherpositivefactorhasbeentokeepthestakeholdergroupmembershipopenandaswideaspossible.Thishas,forexample,enabledpositiveengagementofthelandlordand occupational therapists at an early stage and ensured that actions critical to newtenantsyetoutsideoftheprocessofappointingthecareandsupportproviderhasalsohappened,suchasthesettingupofthenominationsgroupandgettingdecisionsaboutallocationsasearlyaspossibletomaintainactiveengagementofprospectivetenants.Ithas also enabled the landlord to better engageprospective tenants in planning futuredecisionsaboutthenewhomes,forexampletypesoffittings,coloursetc.


9. Reflectionsonlessonsforthefuture

9.1 Alotoftimewasspentintheearlymeetingssupportingthepotentialresidentsthroughtheangstofunderstandingtheprocessofdevelopingthemodelingeneralandpersonalbudgets inparticular.Weneed to remember that thiswas a timeof change for socialworkers too,moving to outcome‐based supportplanning andnew resource allocationsystems,aprocesswhichatthetimeoftheseearlymeetingshadnotbeenfinalised.Withhindsightthismighthavebeenmitigatedbytheinvolvementattheseinitialmeetingsofsomeof the key voluntary agencies that had both knowledge of these tenants and/orpersonalisation issues.We also think this has been amissed opportunity to influenceanddeveloprelationshipsthatwillbeessentialinthefuture,asthetenantgroupseekstofindwaystoretaincontrolofthecommissioningmodelithasdeveloped.

9.2 Findingsuitablevenuesforthemeetingswasachallenge:theBrightonCentrefeltabitimpersonal(althoughitseemedtowork!)andthelocationofHoveTownHallwasgoodbuttheroomsthemselveshavebeenvariable!VernonCourt‐thecommunalroomofanelderlyperson’shousingschemenextdoortotheproposeddevelopment‐wassuitable,butclearlyannexedanimportantresidentfacilitywhilewewereusingit;whilethestateof the kerb outside the front doorwas a significant health and safety hazard to somewheelchairusers.Thevenuesrepresentedacompromisewithinthetimeandresourcesavailable,butparticipantswhenaskedsaidthatallwereaccessibleandcomfortable.

9.3 Onthe14JuneNicholasDayAssociatesmetwiththeprospectivetenants,theirfamiliesandcarersandaskedthemtoreflectontheirexperiencetodate.(Thetemplateusedissetout inAppendix1).Themainpoints fromthediscussionabout theirexperiencesofararesetoutbelow:

Tenants felt theyhadbeen listened to, thatcommunicationsbetweenNicholasDayAssociates(NDA)andthemhadbeengood,whokepttheminthepicture,withgoodnotice to enable them to organise attendence at events. This reinforced our basicfeeling (see 8.1). However, one tenant with audio impairment and another withspecific language needs had difficulty understanding at times, and they said thatmore could have been done to assist them e.g. better practical arrangements atmeetings,suchasensuringatranslatorwasavailableandthepresenterswerebetterpositioned.ThislearningwasthenusedfortheITTpresentations.

Tenants felt itwasverypositive todo thedevlopmentworkasagroupandget toknow other people who will be living in the same building. This was a keydevelopmentprincipleweconsciouslyadoptedfromtheoutset(see4.1).Acoupleoftenants felt a littlemore timewas neededworkingwith them individually to helpthemclarifytheirneeds,sowewouldneedtoconsiderthebalanceofgroupversusindividualmorecriticallyinanyfuturedevelopmentprocess.

Wethoughtourpresentationsandcommunicationsweregenerallyeffective,mainlydueto(whatwethink)isourabilitytothinkonourfeetandadapttotheimmediatesituation.Thiswas thegeneralconclusionof the tenants,but theyadvised that thepaperexercisewehadusedwith themto tryandworkout thedetailof themodel(Appendix 2), while arriving at the right outcome, was too complex: they said itwould have been enough to have asked the questions and recorded the answers.One tenant felt themodel eventually agreedwas obvious from the outset, thatwecould have arrrived at the same resultwith fewermeetings. Thiswas not a view,however,sharedbythemajority,whichmakesusfeelthatthepacewasaboutright.


SomeofthegroupsaidinJunetheywerenotentirelyclearaboutthebriefgiventoNDA,andacoupleoftenantswonderedwhetherNDAhadbeenduty‐boundtofollowaparticularprocesslaiddownbytheCouncil.However,othersthoughtthebriefwasclearandtheprocessfollowedwasappropriateandflexible.In8.4wereflectedthatstrongprojectmanagementwasessential,andthiswefeltwehadachieved:butitisbasedinthistypeofprojectonorganicprocesseswithnosetscript:thekeybuildingblocksareconstantclarityof intendedoutcome(in thiscaseaconsensusmodelofself‐directedcareandsupport),thekeydevelopmentprincipleiscontinualfeedbackon choices and reworking of ideas to get the ‘best’ result (commentatators havecalledthiscreatingthe‘receptivecontext’6),andthekeymethodisstrongandtimelycommunication with all stakeholders at each and every stage. Tenant feedbacksuggests,however,therewasprobablytheneedforbettercommunicationaboutthedifferentauthorities,principles,methods,rolesandresponsibilitiesetc.attheoutset,and which may have needed to have been repeated at subsequent events. Withhindsight,wethereforeneededastrongercommunicationsplanaspartofthePID.

ThetenantswentontosaytheywouldhavelikedtohaveseenbetterrepresentationfromGuinnessTrust in themeetings(becauseof the linksbetweenthecaremodelandthehousing),earlierrepresentationfromoccupationaltherapists(becauseoftheadaptionsrequiredtothebuilding),andtheongoingpresenceoftheTheFederationofDisabledPeople todealwith issuesof PersonalAssistants and social enterprise(The Federation are devloping a community centre, on licence from the GuinnessTrust,inthesamebuilding).Thisaddedtotheirfeelingsthat,inthewordsofoneofthem: “the process could have beena bitmore joinedup”.Therewas a strong viewamongtenantsthatthiscouldhavebeenmitigatediftheywererepresentatedonthestakeholdergroupattheearliestpossibleopportunity.

Thisclearlyshowsthecriticalimportanceofcommissioningstrategiesandinitiativesthatstartfromtheserviceuserperspective.Whilethegrouplikedtheideaofbeingconsultedonthecareandsupportmodel,asonetenantsaid:“it isonlyonepieceofthecake”.Theyspeculatedwhether thesameapproachcouldhavebeenapplied towhole process (buildings and service)? Could they have been invited to beparticipantsinthewholeprojectrightfromtheoutset?Thisviewwouldbeentirelyconsistentwithapersonalisationapproach,andhadnotstruckusuntilthetenant’svoiced this thought. It also reflected, in our mind, the self‐confidence the tenantsgainedthroughtheprocessofparticipationandbeinggivenrealchoice.

9.4 ThefinalstageofourworkwithtenantswillcomeinSeptemberwhenwewilldiscusswiththemandotherstakeholdershowtheycan,asagroup,retaincontrolandgoontodevelopfurthertheirchosenmodelofcommissioning.Forexample,theycouldchoosetopoolsomeoftheirpersonalbudgets.However,itisnotjustaboutchoicesovertheirownpackageofcareandsupport,asimportantasthisis:itisaboutanongoingchoiceoftheverymodel thatdelivers these individualpackagesofcare. In thissensetheyhavethebasisofauser‐ledorganisation,thebasisofabusinessthatcouldturnthetraditionallyprofessionallydominatedmodelsofcommissioingontheirhead.Itwillbeimportanttoidentify the resources that can be brought to bear to support this change, and tocontinuetorecordthestoryofthisjourney.

6‐KieranSweeney(2006),“ComplexityinPrimaryCare:understandingitsvalue”,RadcliffePress


APPENDIX1NEWTENANTFEEDBACKFORM

The purpose of these is to get feedback on the consultation process you have been offered tocreateanewmodelofcareandsupportforyouatVernonGardens.ItwillhelptheworkthattheCouncilandwedoinfuturewithnewtenantsinotherschemes.

1. WestartedworkingwithyouinJanuary.Howwelldoyouthinkwehaveconsultedwithyou?Havewegivenyouenoughinformationtomakedecisions?

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2. Asyouknow,wehavedonemostofourconsultationwithyouingroups.Didyouenjoyworkinginagroupwithotherresidents,familyandcarers?Whatweretheadvantagestoyou?Werethereanydisadvantagesworkinginagroupforyou?

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3. Didwespendenoughtimetalkingtoyouindividually?Wouldyouhavepreferredifwehaddonemoreindividualworkwithyoubeforedecidingonthemodelofcareandsupport?

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4. Didweexplainourideasclearlyenough?

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5. Werethepresentationswedidhelpful?

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6. Doyouthinkwelistenedtoyourideasandsuggestionsproperly?

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7. Didweinvolvethosepeoplewhocamewithyou(family,friends,carers,supportworkers,socialworkers)enough?Couldtheygettheirviewsacross?

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8. Atthesecondmeetingweusedatemplatetohelpyoudecidewhattypeofhelpyouneededandatwhattimesoftheday.Didweexplainthisclearlyenoughtoyou?Wasituseful?

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9. Doyouhaveanyothercommentsonhowwecouldhavedoneanyoftheabovebetter?

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10. Werethevenuesformeetingssuitableanddidtheyadequatelymeetyourneeds(intermsoflocation,facilitiesandaccess)

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11. DoyoufeelyoureceivedenoughinformationaboutthetypeofaccommodationavailableatVernonGardensinordertomakeadecisionaboutamove?

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