Annex A: case studies of innovation, delivery and performance

Prioritising care and support: Between 2010 and 2017, adult social care has had to make savings and reductions worth £6 billion as part of wider council efforts to balance the books. But the service continues to be protected relative to other services. The latest Adass budget survey shows that adult social care accounts for a growing total of councils’ overall budgets, up from 36.9 per cent in 2017/18 to 37.8 per cent in 2018/19.[1] As a result, by 2019/20, 38p of every £1 of council tax will go towards funding adult social care.

Innovating: Councils are committed to innovation to help reduce costs while maintaining or improving services to the public. This has included changing the way that demand is managed, more effectively using the capacity in communities to help find new care solutions, and working more closely with partners in the NHS to reduce pressures in the care and health system. Innovative approaches can be found in all parts of the country.

    • Kent County Council is driven, like many councils, by the daily challenge of ensuring people have what they need to enable them to leave hospital safely. Daily multi-disciplinary meetings help to identify and reduce delayed transfers of care and weekly improvement cycle meetings address the reasons for the delays.  Staff training and good performance management have helped to embed the ethos, resulting in a 59 per cent reduction of people being discharged into residential care and a 54 per cent reduction in people being discharged into short-term beds. This equates to 350 additional people going to live back at home each year. In 2017 Kent saw 911 less residential and nursing care placements compared to 2013.
    • Kirklees Metropolitan District Council’s ‘Gateway to care’, co-located with community health, is a multidisciplinary ‘front door’ which provides simple care packages for a rapid response, care navigation, assistive technology provision and safeguarding support. Care navigators, located in four community hubs, help to embed a strengths-based approach by building community capacity and supporting people to find solutions in those communities. The front door deals with the majority of contacts first time, with just 6 per cent going on to a full assessment. In 2017/18 almost half of those with eligible care needs achieved good outcomes through community support, saving the council over £1.9 million.
    • Bristol City Council is changing the conversation it has with residents when they first make contact with adult social care, focusing on finding help and support from communities rather than from formal care services. This has resulted in 75 per cent of first contacts being referred to community support, with two thirds of those making contact saying that they felt positive about how they had been treated. In the first year, this approach has saved £6 million.[2]
    • In Swindon Borough Council, a review of patient cases showed that when someone was discharged to a residential care setting, 45 per cent of the time they would have achieved a better outcome had they been supported to return home (either with domiciliary reablement, or via intermediate residential reablement). However, neither of these services had the capacity or capability to take the additional volume of patients. Swindon’s health and social care teams designed and led a change programme which has achieved a 163 per cent increase in patients receiving reablement services, daily internal coordination meetings and a reduction in social care delayed transfers of care from 450 days in May 2017 to 30 days in March 2018.  It has also resulted in an annual saving of over £1.9 million to the health and social care economy.
    • Somerset County Council has worked with the social enterprise Community Catalysts to stimulate micro-providers to develop care and support services in rural areas. This enables people to get support from community enterprises in ways, times and places that suit them and their families, rather than from formal support services. This initiative has led to the development of a flourishing social enterprise sector with 178 providers offering low cost, flexible care and support to older and disabled people and their families. In the first year, care has been offered to over 700 people, collectively delivering 3,600 hours of care a week. The council estimates that this approach has saved over £800,000 a year while offering people a far more flexible and accessible service[3].
    • Bristol City Council, North Somerset Council and Bath and North East Somerset Council jointly commission sector-leading care and repair services across all three council areas from a single organisation, West of England Care & Repair (WEC&R). The councils have pooled their resources to secure economies of scale in the delivery of a range of services to support older and disabled people to live well in their existing homes, for example through providing home improvements, handyperson services, adaptions and support with hospital discharge. The scale of the contract has enabled WEC&R to ‘lever in’ additional funding from grants, and to secure additional private funding to complement the funding from councils. More older and disabled people are receiving a service in addition to what can be delivered from the core funding and for WEC&R it provides a viable and sustainable business.[4]
    • Patients in Mendip seeing a doctor can be referred to Health Connections Mendip, a team employed by the 11 Mendip general practices. Patients can discuss what is important to them and the team can help them access the support they might want. The End Loneliness Campaign in Mendip signposts people to clubs and activities, such as Talking Cafes, line dancing classes, community transport, men’s sheds and befriending services. Health Connections Mendip have a team of more than 600 Community Connectors – such as café owners, drivers, supermarket staff – who on average talk to about 20 people a year which means more than 12,000 signposting conversations a year. Health Connections Mendip works as part of a team which includes primary care, secondary care, adult social care, voluntary sector, town and district councils and the wider community. This partnership working has led to a 20 per cent reduction in local hospital admissions which is saving £2 million on the public purse. Every £1 spent on the scheme saves the NHS £6.[5]
    • Central Bedfordshire Council has addressed the housing needs of its older population by using a detailed qualitative and quantitative evidence base to produce an ‘investment prospectus’ that sets out its vision and development opportunities. It is a more attractive and engaging approach to stimulating the market than a traditional ‘market shaping’ document. The prospectus specifically identifies the range of opportunities that will, collectively, address the identified demographic, housing and care/ support needs, as well as the aspirations and requirements of older people. Delivery outcomes from this innovative way of engaging providers and promoting investment in housing solutions for older people include:
      • A council-developed extra care housing scheme of 83 units in Dunstable.
      • A private sector ‘rightsizer’ housing scheme of 32 units in Dunstable.
      • Two new care homes with 141 beds in Dunstable enabling the council to close some of its in-house outdated care home provision.
      • A housing association extra care housing scheme of 81 units in Leighton Buzzard.[6]
    • Councils are at the forefront of promoting choice and control through personal budgets. For example, in Harrow the council is working with the CCG to extend the My Community e-Purse system, which supports purchasing social care services and equipment via personal budgets to people with a personal health budget. This project will benefit people, their carers and their families by giving them more control and choice over their carer and support choices. It will also enable closer working between health and social care and find ways of releasing funding tied up in secondary care that could be more effectively used in social care. The council will manage 259 personal health budgets on behalf of the CCG and it is estimated that the savings – to be realised in 2018/19 – will be £147,000 based on the estimated 7 per cent savings that the council’s e-Purse system has already achieved.[7]
    • Shared Lives is a vital and highly praised approach which matches young people or adults who need support with an approved Shared Lives carer, who provides personal care and either a home or a place to visit regularly. Of the 14,000 people using Shared Lives, half live with their Shared Lives carer and half visit for day support or overnight breaks. My Shared Life[8] is an online platform that enables people to give their experience of the service.

Responses from over 200 people in Shared Lives shows that:

      • 92 per cent of people felt that their Shared Lives carer’s support improved their social life.
      • 81 per cent of people felt that their Shared Lives carer’s support made it easier for them to have friends.
      • 73 per cent of people felt involved with their community but 93 per cent felt their Shared Lives carer’s support helped them feel more involved.
      • 85 per cent of people felt their Shared Lives carer’s support helped them have more choice in their daily life.
      • 84 per cent of people felt their Shared Lives carer’s support improved their physical health.
      • 88 per cent of people felt their Shared Lives carer’s support made their emotional health better.
  • Councils are supporting people with dementia. Sutton Council funds Admiral Nurses to give support to people living with dementia and their families. This has been supported by the local CCG, which recognises the value of providing extra support to these families. And Cumbria County Council is building three new council care homes to cater for residents with advanced frailty and dementia. This has been identified as an area where not enough private provision is available.
  • Digital and technology can play a key role in wider service redesign. It can help make the shift from treatment to prevention and there is a growth in consumer-based technology that can be purchased on the high street to support people remain independent at home. It can also help providers deliver more effective person-centred care and we are seeing examples of providers (across care settings) using technology to help improve communication with friends, family and those receiving care.
  • A number of councils including Hampshire, Barnet, Lancashire and Wolverhampton are using care technology to support people to remain independent at home for longer. In Hampshire, 8,600 people are being supported with 94 per cent of people saying that these approaches increase their feelings of safety and security. Ninety-eight per cent of people would recommend the service to others. It is a similar picture in Lancashire where 8,400 people are being helped to maintain independence and safety.
  • Areas such as Leeds, Stockport, Bristol, Dorset and Bracknell Forest are bringing information together from the council and health providers which is reducing the need for service users to have to tell their story multiple times. In Luton and Central Bedfordshire, care homes are being supported to improve sharing of information through access to NHS Mail and shared care records. The project with the ultimate goal of fully shared records is now being expanded to all care homes in the region.
  • There are a number of new social care technology-based start-ups emerging, which are using technology to improve the delivery of person-centred care. These providers are using technology to better match care workers to clients and digitising the care records so that carers can log on to information about their clients using their smartphone. Other care providers are using technology to store notes about clients, read up on those they are visiting and using it as a way to raise the alert if anything is wrong. Families and friends can receive notifications and log in to see how care for their family member is proceeding. These forms of technology are enabling care providers to improve the delivery of person-centred care whilst improving business efficiency of care providers. In Liverpool the council has worked to bring the home care provider sector together with technology suppliers which has resulted in the digitisation of care records and introduction of a network that allows for improved monitoring of people requiring care and support at home.

Intervening early and preventing needs: Investing in prevention has clear benefits for people and reduces costs to the wider care and health system.

  • Falls prevention programmes run by councils and their partners reduce the number of falls requiring hospital admission by 29 per cent. This represents a return on investment of more than £3 for every £1 spent.[9]
  • Research on Disabled Facilities Grant (a council grant to help disabled people make changes to their home) shows that every £1 spent on housing adaptations is worth more than £2 in care savings and quality of life gains.[10]
  • Evaluation of the Handyperson Programme has shown that handyperson services support large numbers of older and disabled people to live independently at home for longer and with greater comfort and security. Services include small repairs and minor adaptations that reduce the risk of falls, home security measures to help maintain independent living, and energy efficiency checks to help reduce excess winter deaths[11].
  • Partners in Leicester are improving hospital discharge and avoiding unnecessary admissions through, for instance, an ‘integrated lifestyle hub’ tackling the wider determinants of health, GP-led care planning for patients identified via a risk stratification system, wrap-around rapid access to services such as assistive technology, falls assessment and equipment, and proactive discharge follow-up for at-risk groups. As a result, attendances in A&E in quarter one of 2017/18 were down by 2.9 per cent from the same point in 2016/17.[12]
  • The Kent Pathway Service supports adults with a learning disability to achieve a more independent life. It supports people for between one and 12 weeks to learn or re-learn skills that help them become more independent and need less support. This has also led to an outcomes-focused practice project for people with a learning disability which aims to adopt a strength-based approach by setting goals and monitoring that providers are delivering and undertaking practice reflection sessions.[13]
  • Darlington Council adopted the progression model, making enablement a priority.  High cost packages of care and in-house services in supported tenancies, day opportunities and short break stays were prioritised as areas of greatest opportunity. Following a strengths-based assessment, James, an individual with a learning disability, moved from residential care to his own tenancy and transferred to tenancy support, making an annual saving of £88,600 to adult social care.[14]

Performing: The Adult Social Care Outcomes Framework (ASCOF) measures how well care and support services achieve the outcomes that matter most to people. Latest information from October 2017 (for 2016/17)[15] shows that, even in the deeply challenging financial environment social care has operated in over the last few years, performance has improved or been maintained in several key areas. The Personal Social Services Adult Social Care Survey (for 2016/17)[16] also provides encouraging findings:

  • 7 per cent of service users are extremely or very satisfied with the care and support services they received.
  • 6 per cent of service users in the community reported that they have enough choice over the care and support services they receive.
  • The proportion of people who use services who have control over their daily life is currently at its highest level (77.7 per cent) in the reporting period (2014/15 to 2016/17).
  • The proportion of adults with a learning disability who live in their own home or with their family is currently at its highest level (76.2 per cent) in the reporting period.
  • The proportion of people aged 65+ still at home 91 days after discharge from hospital into reablement/rehabilitation services is currently at its second highest level (82.5 per cent) in the reporting period.
  • The proportion of people who use services who say that those services have made them feel safe and secure is currently at its highest level (86.4 per cent) in the reporting period.
  • The City of Wolverhampton Council is improving outcomes whilst creating a financially sustainable service through the creation of a ‘Promoting Independence Team’ to undertake overdue reviews. To date, 700 cases have been reviewed, 22 per cent of which resulted in a decrease in the size of the care package, delivering a saving of £900,000 per annum. Use of the ASCOF tool to measure quality of life at start and end of intervention indicated that people felt more in control and were achieving better quality of life outcomes following the review.

[1] https://www.adass.org.uk/media/6434/adass-budget-survey-report-2018.pdf

[2] https://www.local.gov.uk/sites/default/files/documents/25.43%20Chip%20Efficiency%20Project_03_1.pdf

[3] Ibid.

[4] https://www.local.gov.uk/sites/default/files/documents/5.17%20-%20Housing%20our%20ageing%20population_07_0.pdf

[5] https://www.local.gov.uk/about/news/loneliness-initiatives-cutting-emergency-hospital-admissions-20-cent

[6] https://www.local.gov.uk/sites/default/files/documents/5.17%20-%20Housing%20our%20ageing%20population_07_0.pdf

[7] London Borough of Harrow Case Study, Care and Health Improvement Programme, April 2018, https://www.local.gov.uk/sites/default/files/documents/London%20Borough%20of%20Harrow%20LIP%20Case%20Study.pdf .

[8] https://sharedlivesplus.org.uk/short-breaks/item/484-my-shared-life

[9] https://www.local.gov.uk/about/news/hospital-admissions-due-falls-older-people-set-reach-nearly-1000-day

[10] https://www.local.gov.uk/sites/default/files/documents/building-our-homes-commun-740.pdf

[11] https://www.local.gov.uk/sites/default/files/documents/prevention-shared-commitm-4e7.pdf

[12] For further information, visit: https://www.local.gov.uk/leicester-journey-improving-discharge-and-avoiding-admissions

[13]https://www.local.gov.uk/sites/default/files/documents/lga-learning-disability-s-d9a.pdf

[14] https://www.local.gov.uk/sites/default/files/documents/lga-learning-disability-s-d9a.pdf

[15] https://digital.nhs.uk/data-and-information/publications/clinical-indicators/adult-social-care-outcomes-framework-ascof/current

[16] https://files.digital.nhs.uk/pdf/d/5/pss-ascs-eng-1617-report.pdf

What our partners have said

We’d like to thank our partners from across the sector for their thoughts, comments and input into the green paper. Here’s what they have to say…

Foreword

High quality social care and support helps people live the life they want to live. It helps bind our communities, it sustains our NHS and it provides essential economic value to our country.

Executive summary

While it is true that social care and the NHS are inextricably linked, it should be seen an essential service in its own right and the people who work hard to deliver the service should be seen as just as valuable as staff in the NHS.

Who is this green paper aimed at?

Questions about the future of adult social care and support, and the wider changes we need to make to our care and health system to improve wellbeing, should be everyone’s business.

4. The options for change

Why has it proved so hard for successive governments to deliver sustainable long term funding for this crucial service?

5. Adult social care and wider wellbeing

If we are to really tackle the full extent of future demand with quality services we need to refocus our efforts on intervening earlier and preventing needs developing in the first place.

6. Adult social care and the NHS

Joining up care and support and intervening and offering early support to keep people well is a more efficient use of resources but efficiency alone is not enough.

8. Have your say

Answer the questions relevant to you and your organisation and submit your views to be added to our research.