Learning disabilities services that draw hard on funding can be better commissioned for improved quality at a lower cost. Rob Greig, chief executive of National Development Team for Inclusion, explains the approach.
People with learning disabilities who are labelled as “challenging” are often placed in services costing up to £100,000 a year and all primary care trusts will have some people costing double that or more.
This cost is typically a service purchased in a private sector learning disability hospital, a challenging behaviour unit run by a trust or an out of district residential care unit run by the independent sector. A large proportion of these are purchased by PCTs directly and the remainder are jointly funded by PCTs and local authorities.
Despite this expenditure, outcomes are poor. Many people are placed in remote establishments, having little contact with friends and family, minimal meaningful activity and almost no prospect of the situation improving - so the cost to commissioners will continue.
This contradicts government policy in the Mansell report, which calls for local, individualised services rather than block “containment” solutions.
New Department of Health funded guidance, published by the National Development Team for Inclusion, aims to help. The report, written primarily for NHS and local authority commissioners, is designed to help them commission high quality, cost effective services for people with learning disabilities whose behaviour challenges services.
By studying places that have made progress the guide proposes specific, practical commissioning actions.
Where progress has been made, the starting point for improving quality and reducing costs has been a creative, open organisational culture. Commissioners worked alongside families to develop a medium term change strategy, involving shared financial risk with the local authority. Simplistic continuing care arguments about who was responsible for individuals were consigned to history.
Strategies were outcome focused and rights based. Organisations undertook to reject short term actions that compromised these principles, which helped to generate genuine confidence and trust between partners.
This was particularly important in the relationship between commissioners and providers, with agreement that when things went wrong (and they inevitably do), there were no attempts to apportion blame and revert to institutional provision. Rather people learned together about what had not worked and thus developed strategies to prevent a repetition elsewhere in the system.
Progress involved behaviour that is all too rare in some commissioning environments. For example, commissioners encouraged and supported innovative provider leaders to take risks. Clinicians and social care providers were expected to work as close partners, with clinical advice being followed, and NHS training to social care staff was part of NHS contracts. Most crucially, learning disabled people and families were genuinely at the centre of decision making about their services.
Commissioners had concluded that conventional tendering systems to select providers did not work. Instead, having initially attracted organisations to the locality based on their attitudes as much as traditional technical skills, providers were awarded new contracts on the basis of their past performance in working with partners and achieving outcomes with people. A small number of trusted, long term partnerships appears to be the key.
Systems to generate information on desired outcomes and costs are crucial. Effective commissioning includes a commitment to achieve cost savings over time - but only when the outcome evidence shows the person’s life is improving and their challenges reducing.
If applied before that, the service will collapse and expenditure increase.
The comprehensive spending review identified £1bn of NHS funding to be used to achieve linked benefit with social care. The approaches outlined in this good practice guidance are shown to improve outcomes and reduce costs and so could be a highly effective use of that all too scarce resource over the coming months and years.
Find out more
To read the good practice guidance visit www.ndti.org.uk/publications/insights
Case Study - Birmingham’s Slot team
Commissioning for people who challenge is too often reactive rather than planned. A crisis occurs, it is assumed that the service is failing, and an expensive remote placement is contracted. The skilled, individualised services that are shown by the evidence to produce better outcomes can initially be expensive - but if done properly can lead to significant savings.
In Birmingham, for example, the supported living and outreach team (SLOT) was started with Invest to Save funding - £500,000 over three years - and this resulted in the PCT then fully funding the team on the basis of dealing with a number of cases per year.
Recurrent savings of nearly £900,000 have been built up over eight years against a growing number of people being supported in moving into local rather than remote services.
The SLOT team is centrally involved in specifying and designing training programmes for support staff when new services open. It helps to deliver that training plus support to new and existing staff and families as part of the contractual arrangements.
Source: NDTI guide for commissioners
Seven areas for Commissioner Action
Vision and valuesL A commitment to the principles of “an ordinary life”. Know the evidence base. Accept there may not be quick results and support providers and families through difficult times
Leadership: Be actively involved in service development. Work with enlightened clinical leadership and social care partners. Champion and support leaders who take planned risks
Relationships: Work in partnership with the local authority. Develop a no-blame culture between organisations. Place people and families at the centre of decision making
The service model: Use person centred approaches. Separate out housing and support. Accept high costs in the early stages of a service
Skilled providers and staff: Choose providers that really want to work with people who challenge, have “in touch” senior managers, invest in staff and look outwards to local communities
An evidence base: Develop an outcomes framework and costing analysis with providers to evidence progress people were making and cost
Specific commissioning actions: Provide upfront investment; find flexible ways of choosing providers; use CH criteria creatively; openly aiming for reduced costs over time - based on evidenced improvements in people’s lives.