Mr Mark Lobban – Director of Strategic Commissioning was in attendance for this hearing.
1. Mr Lobban explained his role to the Committee, he was responsible for strategic commissioning across Families and Social Care (Adults and Children), he also lead on Adult Social Care Transformation and managed the day to day relationship with Newton Europe (efficiency partner). 4 teams – safeguarding, performance, accommodation solutions, and community support. Approx. 90 Commissioners in team.
2. In May 2012 the County Council approved a blue print for adult social care transformation. There was a need to manage demand and ensure that people were not inappropriately pulled into adult social care.
3. Relationships with providers are transactional. If receive £5m – 10k we treat them the same, no difference, limited strategic relationships – which does not make commercial sense.
4. Adults were 1/3 of non school budget so would have to significantly contribute to the Council’s budget deficit – recent analysis shows can do a lot around efficiencies and work smarter/differently. Need to manage demand and not keep people in adult social care when they do not need to be – so key role to look at how prevent need for someone coming in /staying in, so key to work with vol sector to ensure right services for this – (which do not have at the moment).
5. Clear need to look at what should happen and importantly what actually happens on the ground – big difference. Need to remove silo working – need flexibility to work, but also need to move at pace and deliver consistency and same standards (thanet/west kent)
6. 3 roles for Mr Lobban = Director of commissiong, role for transformation, integration (internally joined up and with partners (District, Boroughs and NHS).
7. Transformation important to commissioning - 3 key areas within Adult Social Care
· optimisation, making best use of staff and resources
· care pathways, to ensure people get the right service at the right time
· commissioning- services we buy (at the right cost)
There was a need to focus on all three and recognise the links.
e.g could commission the best enablement service, but if the hospital was under pressure, a person who could benefit from enablement could go straight to residential care which is not the right outcome for the individual and a greater cost to KCC.
8. One of the initial tasks for the ASC service was to carry out an audit of the projects underway, there were 150 projects running simultaneously and officers were struggling with prioritisation and sequencing (if all 150 are a priority then nothing is).
9. Integration meant joined up services around an individual - irrespective of who was providing the service. Invest to save – but need to focus on the 3 areas (optimisation, care pathway, commission), otherwise it was like pouring water into a leaking bucket – so get Optimisation then think about investment.
10. Adult social care programme being approached in 3 phases. Wave 1. The service has been working on making the best use of existing resources and matching staff to demand. e.g. utilization of enablement service was only 40% - so need to match staff/demand, either prevent going into hospital or on coming out. What didn’t show/measure previously was no of failed visits - where someone not come out of hospital yet and worker been deployed. Another example - the business process was being redesigned, and waiting times had been improved for contact with social services (in dover had been 28 days to see someone and now was only 5days. Approach has been largely transactional. 140 providers – spend 75% with 20 providers. The remaining 25% of the spend with 120 providers, gives issues re safeguarding as difficult to communicate with so many providers. If paying £5m want value for money – what else are we getting? Up till now no conversations along these lines as transactional - Wave 1 was about making best use of existing resources and determining where the service could work differently with providers. The market was consolidating without KCC’s intervention, (e.g. company taking over another with £1m contract – expect some benefits to this). Some of the residential care contracts were 12 years old and it was a priority to work with providers to re-let residential care contracts.
11. Wave 2 focussed on considering increasing the breadth of the services and Wave 3 focussed on integrating the service with the NHS. At end of each wave there were two things to ask 1. Had we made it better? 2. Had we made savings?
12. Wave 2 design was about increasing breadth of services. Domiciliary care had been time and task – (someone gets ½ hour in morning ½ hour at night/times not suitable/call cramming/no travel time ).. The Care Bill says cant do this anymore and so it was essential to move to an outcome focussed homecare system. How did we do this with 140 providers? Older people/clients are not choosing their provider it is social workers. An exercise was undertakento map workers, their visits and travel. This showed criss-crossing of workers enroute to their clients, large travel times/distances – showed clear need to look at volumes of work and services in area, rather than provider led, so can improve service and flexibility for clients and make timings and travel more efficient for workers. Extra Care Housing has dedicated team on site providing support as and when needed, so client sometimes may need more or less support- is a good model but don’t provide this in community. Need to think about dedicated community team for Domiciliary care area.
Then can start to think about what else could we ask them to do …telecare etc. if move away from more traditional service to more outcome focussed.
13. There were barriers between service provision and there was a need to remove those barriers. 90% of social care services was currently outsourced, and there was a barrier between KCC’s social workers and the providers/care staff – with providers often saying that they couldn’t get hold of social services. Much of professional staff time was spent on paperwork,data entry attending meetings etc rather than on core business (face to face with service users). (80-20%). It was necessary to reduce bureaucracy to allow Social Workers to spend more time out in the community – how integrate provision of social services with providers – consider putting staff out there. Incentivise how they would work with the VCS/subcontractors. Very exciting link to wave 3.
14. Wave 3 – NHS has clear commissioner provider split. KCC had a mix. KCC fragmented service, NHS big providers. If KCC can create a firm foundation of consolidated service – becomes attractive to NHS as potential to integrate in community. The Chairman asked how the culture of the NHS was managed, Mr Lobban explained that this was improving, there was a need to focus on the sustainability of social care and the Council was committed to improving outcomes and saving money. The council had a statutory responsibility to provide care for older people. Can only cut non statutory services e.g. voluntary sector, enablement, which were the services we needed to be investing in if we were to be successful in managing demand and making the required savings.
15. Members raised concerns about receiving value for money, a mixed economy was considered to be most efficient with flexibility and leverage. With regard to the integration with the health service was support but Members considered there were uncertainties about the NHS’s readiness and commitment and as there were problems in the NHS adult mental health services, and this then provided a reputational risk to KCC. There was a brief discussion around CAMHS, this was being discussed at the HOSC meeting on 31 January 2014.
16. The proportion of investment was a factorI.e. joint health and social care responsibility but NHS invest 14m and KCC 1m Members suggested real danger not thought through before change.
17. Mr Lobban considered that if the Council was exploring the possibility a joint commissioning team for children’s commissioners with the NHS KCC should have a single team for health and social care hosted by KCC. With regard to mental health the NHS spend was significantly more than KCC’s spend on social care, which would normally result in the NHS leading however KCC would have to be assured of the risks and confident in the capability of the NHS to lead.
18. Members asked Mr Lobban to give thought to how the Select Committee could help the service to achieve what it needs to achieve.
19. In response to a question around the key challenges Mr Lobban explained that key was approach taken. Eg. contract to re-let the domiciliary care was critical as it was the platform for futher transformation, focus not about reducing providers from 140 to less but about moving towards an outcome focussed model of care, giving choice and control to older people, a consequence of which may be less providers. About outcomes not about number of providers.
20. If social care is to be sustainable then we need to integrate with the NHS, it would be necessary to have pooled a joint ‘better care fund’ of £101m by 2015 for integration of health and social care, and prevent people going into hospital and to allow them to come home as quickly as possible, reporting to the Health and Wellbeing Board. CCGs were also required to set out their 5 year vision and a 2 year detailed plan. Need NHS to plan their waves so are ready at the same time as Kent. E.g KCC needs to say when ready with enablement service to test market; NHS need to get ready with their intermediate service at same time. There were problems around the language used by KCC and the NHS, using ‘care pathways’ as an example NHS regarded care pathways as disease specific, KCC regards care pathways as ensuring right service at right time.
21. In response to a question around how it was possible to monitor and manage a commissioned service which was not up to scratch. Mr Lobban explained that this was linked to the cost and quality of the service, and whether serious concerns had been raised or any safeguarding alerts. A retendering process was underway for carehomes for older people, and there would be a constant evaluation between price and quality.
22. Barriers – Res care- none, people have a choice of accommodation and could move anywhere providing it was within the resources of the Local Authority, KCC could offer x bed, y bed or z bed. Dom care – had put in place a lotting strategyso big and small companies could bid for different lots/geographically. There was also a private market for care and direct payments– not all provided by KCC/directly funded – needed to ensure these people had right advice, to make an informed choice if own income.