Commissioners’ conference: Successful Pathways towards Integration – Building Resilience within a Changing World

Commissioners conference:

Successful Pathways towards Integration – Building Resilience within a changing world

When wolves were reintroduced into Yellowstone National Park, this regenerated areas including forests now avoided by deer, changing rivers due to less erosion, and birds and beavers increased…. Alex Crawford, Senior Planning and Service Development Manager, Aneurin Bevan University Health Board, chairing the conference suggested that if the outcome had been specified as this, it is doubtful that anyone would have expected to bring in wolves!! He was underlining a key message of this conference on integration, that specifying outcomes in such a complex world can have such unintended consequences and is unlikely to lead to better commissioning.  Building on this, several conference speakers also emphasised the importance of building trust and relationships across services, between providers and commissioners, between and with communities and most importantly with people and families, listening to them and helping them to be in the driving seat.

Margaret Willcox OBE and current ADASS president opening saw the challenge as how to connect the different bits of health social care and housing & to be there when people most need it. The ADASS survey shows mounting cost pressures for working age adults with disabilities, with, for the first time, learning disabilities growth equalling that for the elderly, with the spend being at least as much on disabled people as on older people.  She stressed the importance in partnership of building trust and relationships and a common purpose, modelled from the top, with mutual respect, and valuing of each other’s contribution. People’s different roles still need a coordinating lead person for integration – ‘ a choirmaster so everyone sings the same tune’. She suggested if you get the relationships right and share the risks, agreeing responses when things go wrong, then the structure may emerge. But it needs proper resourcing with the Government understanding the need to look at both services who serve the same people. She urged that colleagues and Ministers to have a conversation about what the public want and how to pay for it BEFORE there’s a green paper looking at options.

Toby Lowe Senior Research Assistant from Newcastle University provided the research evidence to challenge the current outcomes -based contracting and performance management, showing how implementing outcomes-based performance management such as payment by results, outcome-based accountability or results-based management holding people accountable for particular outcomes, makes it harder to produce good outcomes. People look to produce good-looking data which then moves away from meeting client need. It becomes ‘gaming’, distorting efforts, leading to a lack of innovation (1998 study). The DWP’s work programme paid contractors by specified results but resulted in ‘creaming’ ie concentrating on those most likely to get a job, and ‘parking’ ie putting to one side those presenting the biggest challenges. The problem is the difficulty of measurement of the very variable impacts on people’s lives, so they count ‘proxies’. Most recently with VW cars, the measurement of emissions were “gamed” by measuring when the car wasn’t moving. In addition, there’s an attribution problem as we can’t assume an outcome from a particular input, given all the other factors out of our control.

Commissioning should be about making systems work better -systems being the people, the families, communities, the cafe, the postmen, landlords ….etc. Commissioning needs to recognise that most people want to do a good job so you don’t need to motivate this.  Learning drives improvement, so commissioners need to create an environment which encourages honesty about what happens and understands that decisions are made in uncertainty are complex so some will be wrong, but unless people talk about the reality, noone learns. Measurement will help reflection and understanding if used properly. Commissioners hence are eco-system engineers with networks key to developing healthy systems. They need to build positive relationships nurturing trust (between providers and with providers),  working with them and using the data to reflect and learn to improve.

Plymouth working on services for adults with complex needs won a public finance innovation award by working over 2 yrs with trusted relationships and co-production using a single alliance of 26 providers and a ‘wicked problem’ forum. By sharing the need to save and problem-solving together, they saved £500k. A Dutch nursing agency,  Buurtzorg, completely transformed their service by devolving the decision-making to self-organised teams of 12 who build bespoke solutions for and with each person. This decreased care costs by 50%.

Mark Saunders head of Greater Gwent’s Health Social Care and Wellbeing Transformation support programme shared how a residential homes’ abuse scandal Operation Jasmine led them to review their monitoring and to find more innovative ways to get feedback. Volunteers from an NHS retirement group have confidential discussions with people and relatives following My Home life Cymru standards. Tanya Strange from Primary Care inspired us with their community connecting activities, tackling loneliness having identified its workload on GPs and prescribing. Funded through the Health Technology Wales fund, their website was developed as a single point of contact for self-referral. It finds community connectors matching volunteers with lonely people according to their interests.. Further connecting activities and voluntary linkages have developed. The ‘Count Me In’ challenge got the Public Service Board signed up to allow staff 1 hr/week to volunteer and had 152 people in 1 week; the DWP refer disabled people into volunteering. One nurse in a nursing home with a lot of older people with families living abroad, bought a cardboard cruise ship, gave residents ‘passports’ and with staff dressed up as crew, they run a weekly cruise “calling” to someone’s relatives. ‘Skype a relative’ increased inter-generational activity with school children coming in. A cohort of welsh-speakers in Caerphilly/Abergavenny started a welsh scrabble club now hosting 2 bi-lingual clubs costing £24 for the scrabble sets and linking to children learning welsh. A sign language centre in Newport has deaf volunteers training police cadets in conversational deaf language so can go out.

Falls had reduced by 60% in one Essex Home as the manager decorated zimmers having identified that people with dementia don’t see grey very well. Tanya’s event called Pimp my Zimmer attracted 350 people with college student dementia friends doing a dance; exercises with zimmers; a zimmer and sticks cat walk and they’ve since developed a campaign to lobby manufacturers to pre-pimp zimmers.

They are linking with GPs and pharmacists on loneliness and the use of anti-depressants; getting assessments to consider the impact of living alone and on discharge, want to work with business in the community and get more public sector to release staff volunteering,  and to get nursing and residential homes to look harder at how to address having lonely isolated people surrounded by people? Thoughts include building recruitment in communities to train volunteers to look out for and protect people

Advonet with Leeds City’s Good Lives Leaders’ (GLL’s) project developed a contract management monitoring system using people with learning disabilities and family carers as quality checkers. Following a 4 days design workshop involving a range of stake-holders from CCG, Adult social care commissioning, advocacy, providers, people with learning disabilities and family carers, the GLL scheme, it aimed to give an independent, ‘expert by experience’ view of services for people with learning disabilities, to help improvements and provide extra value to other checks.

Experts by experience  go in to supported housing, residential and nursing homes and checks 3 key areas

  1. Is it a good place to live in?
  1. Do people feel valued in the community or at work
  1. Are people supported to have the full range relationships and a social life

Changes from their report-backs include: personal care support by same gender staff; change a lock that a wheelchair person couldn’t reach; someone wanting to move on/out referred to social worker and many more

The role is a valued one which ensures everyone is involved and listened to, gets thanked, has letters sent, is accorded the same access to the council offices as other employees and they have a  graduation ceremony at Leeds grand civic hall , are invited to events, get a Xmas party and gift cards. The mix of group working together has led to a better understanding/better collaboration on other things.

Their self-review has changed the report format to include more information, resulted in training on intensive interaction and now involves GLLs alongside Inclusion North in training new leaders.

Costs are relatively low as Advonet and CIN are already commissioned so they can use already existing rooms for example and there is a business support member. They’ve made 2 videos using 8 carers and 8 people with the success of the scheme shown by plans to extend this to other client groups. They decided not to patent it as they are willing to share their scheme widely.

Given the relative demise of day care ( see Mencap’s Stuck at home 2012 report) and the expectation that working age adults will be disproportionately hit by further cuts, Angela Catley from Community Catalysts made the case for the importance of doing things differently.Community Catalysts  aim to find ways to get more for less by unlocking assets and resources and developing and testing creative ways to deliver the support that people need. The  Enterprising Minds project run by charity Hansel and Community Catalysts in partnership with North Ayrshire Council supports people with learning disabilities or autism to develop their community involvement

Ashley loved to baking and her dog Murphy through local links developed ‘Bow wow biccies’ with help from a dog biscuit factory to sort out the complicated rules etc. She’s a wheelchair user with a severe learning disability and limited speech so wouldn’t have been thought able to have her own business. However, with links made to pet shops, dog grooming parlours etc she offers a fair trade which produces a little income. This impacts on how she sees herself and is seen.

In 2010 working with Oldham commissioners, 18 people were helped to start their own enterprises – one of whom was Jen Blackwell with Dancesyndrome(see Community Living 30.4  ‘It’s lift-off time for DanceSyndrome as Jen’s dream comes true’) .Kirklees’ ‘Do your own thing’ run by Community Catalysts looked at people not eligible felt to be at future risk and helped them to use their skills and talents. Jamie had a learning disability and loved working his allotment. Community Catalysts helped him set up and run his own gardening group called Learn and Grow where he made new friends and gained skills and confidence in his role as group leader. He’s been developing a second gardening group at a local café and working there as a volunteer. A busy local self-employed gardener got in touch offering the chance of future employment or self-employment for Jamie and others. Other groups have also been helped to grow like this where people help others to do for others and thus gain themselves.

 “…people…are not just passive recipients of social and health care, but have expertise, gifts, strengths that can help them achieve their vision for a good life, contribute to their local communities and maximise the impact of resources”

Bartnik 2008

To access the presentations on the day go to

Other keynote presentations included:

Peter Hayes on developing a practical toolkit for frontline commissioners as a key part of a partnership project with NHS Clinical Commissioners to develop a consensus on good practice for commissioning between NHS and Adult Social Care. (Also delivering a workshop on this)

Sue Evans CEO Social care Wales outlined their Social Services and Wellbeing (Wales) Act 2014 implemented in 2016 seeing this as giving permission to do things differently, ‘ going back to practice’, in considering what matters to the person and keeping specifications loose to give chance to change and adapt.

James Anderson NHS England on how they are designing an operating model of Integrated Personal Commissioning (IPC) across Gtr M/C in  health and social care in the 33 CCG areas and are using a model to roll out personalised care in Greater Nottinghamshire; Dorset; and Milton Keynes/Bedfordshire/Luton. He discusses pilots giving evidence for integration and personalisation, which approaches include health coaching, social prescribing, and personal health budgets with 156 pilots on wider personalised care including wheelchairs, learning disabilities and mainstream continuing health care and Warrington’s use of phbs for end of life care including health and social care working together with community assets.

A Conference Panel How to Improve Recruitment Strategies tackled the growing recruitment crisis Panel members included Steve Hale Recruitment & Resourcing Manager Exemplar Health Care; Geoff Roberts – Effective Purchasing Ltd; sharing ideas that have helped from social media use, promoting employee advocacy, reducing the time it takes to recruit, tailoring adverts to specific audiences… but also ideas of in-house academies to grow your own, and encouraging people into second careers from business. Aileen Murphy National Audit office who highlighted the huge losses from LAs’ budgets and the high turnover particularly in care and nursing, likely to worsen with Brexit. and Sue Evans pointing to the difficulties in filling leadership and management posts with nearly half having less than 2 years experience and more than 25% due to retire in the next 2 years.

Steven Pleasant MBE CE Tameside spoke on Learning the lessons – Reaping the benefits  Combining the LA/CCG commissioning functions within the Greater Manchester Combined Authority.

Workshops included:

William Roberts NHS England on looking at the vanguards on best practice in National Care Homes.

Michelle Atkinson and Rosemary Brookes Leeds City council on social value charter – How to derive greater and tangible social benefit from our commissioning activity.

Phil Messere Big Lottery Fund on what’s been learnt from outcomes based models since 2010, particularly those linked to adult services. Targeted at commissioners interested in payment by results, social impact bonds & improving fee for service models.

Lisa Thomas & Karen WilcoxCollins, Exemplar HC & Lesley Carver & Karen Massey NHS Vanguard:  on sharing best practice in residential care to reduce costly & avoidable acute admissions Case study showing how local level best practice & integrated working between health & social care delivers direct financial benefits to funders of acute care by reducing avoidable admissions.

Steve Vaughan National Commissioning Board & Fiona Richardson IPC on Market Analysis of Care Homes for Older People across England & Wales which will compare & contrast the care home markets for older people in England and Wales and identify key actions towards service transformation.

Margaret Willcox ADASS and Ellen Rule from CCG on Nottinghamshire ACS and Gloucestershire STP Challenges and Rewards Discover the learning so far. What has worked and what is needing to be improved

North Yorkshire County Council on Developing a preventative programme within Public Health focussing on Substance misuse contract – How tsave money whilst improving outcomes for service users

Aneurin Bevan University Health Board Reducing isolation through 3 strands – Chat, Community, Resilience- what impact has it had

The North East London Sexual Health Transformation Programme Collaborative commissioning approaches to transform integrated sexual health services

Vanguard Cheshire and Merseyside Ensuring that no child in Halton will attend secondary school overweight by 2020 Find out how they will achieve this

Bournemouth on Co-production in commissioning for carer services

Nottingham – Is there a role for LA Accountable Care Systems (ACS’s)?

Building a new home? Lessons to be learnt! Having tendered for the building of a new care home which should be awarded at the end of September- A LA shares the lessons learnt!

Stockport NHS Foundation Trust -Dignity in Care (Daisy Award Scheme)  How it improves outcomes

Leeds and Kent – Linked data-sets Can linked data-sets across health and local authority make a difference closing the health inequalities gap and improving health of the population?

LGA and NHS Clinical Commissioners guidance for integrated commissioning for better outcomes – LGA & DCLG

Welsh LGA- Options for Securing Services: How the boundaries and possibilities offered in commissioning Home Care services through the procurement regulations have been explored

Leonie Cowen  “What is a Grant & What is procurable. More than you think!

Data Sharing across STP’sDiscover the emerging thinking in data sharing models at STP level NHS England

Making Supported Employment work in an increasingly competitive jobs market London Borough of Newham

Market Analysis of Care Homes for Older People across Wales. Welsh LGA

Three Conversation Model that saved West Berkshire millions  Partners4Change/ OLM