Developing 16 Commissioning Intentions in LancashireCounty Council

By Lucie Stevens, New Economics Foundation

In September 2009 the Adult Social Care Team in Lancashire set out tocombine local intelligence with a number of national strategies to develop a coherent and consistent approach to commissioning that would support them to deliver the radical solutions required to make the fundamental shift in services towards prevention and early intervention. The elements in place at the start of this activity, acting as direct and indirect drivers, included a change in political control within the council, an internal restructure with a specific focus on community, a financial imperative and a number of historic block contracts that needed to be addressed.

Time was invested for staff within Adult Social Care to come together as a team to consider and begin to respond to the Putting People First agenda and challenges in the future of social care. Alongside time for thinking and reflecting they began the process of action planning. A critical aspect at this stage was ‘a tolerance for confusion’[1]. Their work generated 16 commissioning intentions which are positioned as the focus of service improvement and redesign over the next four years. The illustration in the attached appendix provides a graphic representation of the process of development, implementation and evolution of this work.

The commissioning intentions are consistent with the vision and priorities described in Putting People First (2007) and Transforming Social Care (2008) and reflect the four quadrants of Putting People First. They are underpinned by an understanding of need in Lancashire and their own vision, the ‘Lancashire Offer 2013’[2]. In their commissioning intentions document they note the importance of a greater coherence across and between services;

‘Social care has a significant contribution to make to the wider ‘place shaping’ and sustainable communities agenda and reform will only be achieved by focusing on the importance of universal services in the lives of citizens and the need for all partners to work together to shape communities that promote wellbeing for all.’[3]

The 16 commissioning intentions strongly incorporate community capacity building approaches whilst also addressing a broad range of national strategies including,Valuing People Now (2009), Our Health, Our Care, Our Say (2006), New Horizons (2009), The National Carers Strategy (2008), The National Dementia Strategy (2009), The National Stroke Strategy (2007). In developing a coherence across this work they are better placed to address the significant challenges in the reform of social care whilst also making best use of existing resources within services and within communities. The commissioning intentions are shared openly with local stakeholders including current and potential providers.

The 16 commissioning intentions ‘hold the work together’ in Lancashire and are an active, working document supported by a delivery team. Lancashire’s commissioning intentions all have a clear rationale, defined outcomes and a set of actions to ensure delivery. They systematically see people as ‘citizens’ rather than narrowing people down to ‘service users’ defined by a certain condition or experience. The strategy states that they are seeking to develop ‘a system which is characterised by:

  • accessible information and advice to all citizens with care needs
  • a range of services that promote independence and prevent people needing ongoing care or support where this can be avoided
  • the importance of universal services in the lives of all citizens especially those with care and support needs
  • the extension of choice and control for all citizens with care or support needs
  • all stakeholders working together to shape communities, with the needs of citizens at the centre, creating an environment where all citizens feel safe through a pro-active approach to safeguarding
  • ensuring that the delivery of services is cost effective’[4]

The key intentions that particularly relate to community capacity building activity are:

Intention 1: Work with partners to ensure that people have access to a wide range of practical support and useful information. This will enable them to improve their sense of wellbeing and independence and help them make choices about their lifestyle so that they can combat loneliness and isolation and make a contribution to their community. Under a prevention and well-being framework for Lancashire this will include;

  • Universal access to advice and information
  • Development of practical support services and social activities through Help Direct
  • Improved employment and volunteering opportunities including the promotion of Time Banks
  • Improved networking of resources and activities in the local districts so that people can easily find the support which meets their needs
  • A more focused role for VCFS commissioned services
  • Building the capacity of local communities and communities of interest
  • Improved co-ordination of housing related support with other services

Intention 3: Re-model/ re-commission mental health community residential rehabilitation services, utilising principles of a ‘socially inclusive recovery model’ as part of a clear pathway and stepped care approach.

Intention 6: Commission assertive outreach supports for people with alcohol related issues as part of a stepped care pathway, linking to community based tier 1, 2 and 3 supports.

Intention 8: Commission community pathway models to support key areas of self-directed support including citizen brokerage, advice and support and training utilising a consortia of user-led organisations.

Intention 10: The development of accessible e-market systems that allow easy access to information on a wide range of services and facilitate transactions both of services provided by organisations and person-to-person services.

Intention 15: contribute to the development of an effective transport infrastructure across Lancashire.

The strategy recognises that ‘these ambitious changes’ are required at a time of ‘significant financial restraint’ but highlights that ‘whilst the focus of reform has mainly been on the impact of personal budgets, the fundamental shift has to be towards prevention and early intervention’. This explicit focus on prevention and early intervention supports the commissioning intentions to focus beyond simply the rethinking of existing services, but more broadly at universal services, mainstream access and a socially inclusive approach that will include community pathways.

Commissioning intention 8 is included below to illustrate how intentions are set out, backed by national and local rationale including links to relevant national strategies. The intentions are also clearly linked to outcomes for individuals, services and communities. The way in which the rationale and outcomes are set out enables team members to ensure that they are each delivering on their own particular policy directives whilst also aligning with and contributing to the overarching shift towards a community capacity building approach.

Commissioning Intention / Rationale / Outcomes
This needs to be clearly defined and specific / Why are we doing this? What is the evidence base? Is it a population need? Research evidence? National Policy requirement? / What is the outcome we are trying to achieve for local people? What will local people/ individuals gain from it? How will they notice the difference?
Commission community pathway model to support key areas of self-directed support including citizen brokerage, advice and support and training utilising a consortia of user led and community organisations. / PPF: Person centred planning and self directed support to become mainstream and define individually tailored support packages AND personal budgets for everyone eligible for publicly funded social care AND support for at least one local user led organisation and mainstream mechanisms to develop networks which ensure people using services and their families have a collective voice, influencing policy and provision.
VPN: Ensure people with learning disabilities and their families are supported to make effective use of supports to embed the wider implementation of personalisation.
Demand on services is predicted to increase over the next 5 years at the same time as financial constraints are expected to tighten.
There is a need to create capacity within personal social care to enable staff to focus on validating personal budgets and support plans and delivering a robust and person centred review process.
Individuals tell us that they want to be able to choose how they are helped to manage their support. / People will have greater choice and control over how they are supported to manage their own support.
People will have greater choice and control over how, where and when their support needs are met.
People will have support plans with clear outcomes.
People will be actively involved in reviewing their outcomes.
People will feel they are part of their community.
People will experience improved quality of life, physical and mental health and wellbeing.
People will be supported to take risks.
People will feel safe.
Resources will be utilised more efficiently and effectively.

Once developed, the 16 commissioning intentions became an umbrella that acts to provide coherence across activities, holding the golden thread within and across services. Each intention is linked directly to geographical and service area plans but also includes common themes, such as rehabilitation, which appears in a range of intentions. The commissioning intentions are shared publicly, in particular with current and future providers. Strategically in embedding the shift towards a community capacity building approach it has been very important to maintain a consistent approach by, for example, ensuring that the ‘person centred approach’ described in strategic papers is followed through in dialogue and contracts with providers.

Whilst it is possible that the development of a framework such as the 16 commissioning intentions may not seem to be unique within local authorities, it is clear that the process by which these intentions were identified and agreed has had a significant impact on the extent to which they now guide day to day activity. They remain a live working document and continue to drive activity across Adult Services in Lancashire.

One key aspect of ‘how’ Lancashire Adult Services works seems to have enabled them to progress innovation locally. This is the way in which time was invested in developing local and national learning for example, some teams strategies included identifying national best practice by reviewing strategies and practice from outside the area then bringing this learning back to share across the department. For example, during the development of Help Direct (see more information on following page) finance was found from the social reform grant to enable the wellbeing team to explore best practice elsewhere. They were also able to consult locally with citizens and professionals on the reality of local applicability of good practice from elsewhere. The information generated from this learning has been shared with the Local Strategic Partnerships, regional partners, commissioners and providers, using local networks wherever possible. Time has also been invested to enable team members to contribute time to national pilots to generate future best practice. Through taking part in national pilot initiatives and linking into learning at this level additional resources have been generated to support further innovation in Lancashire and to ensure that locally they are able to avoid reinventing the wheel.

Communication was also a key element internally. The 16 commissioning intentions became an umbrella, discussed and developed collaboratively, between teams and with a focus on commonality, or the ‘golden thread’. This collaborative starting point, with opportunities to learn from one another internally has generated a whole system approach that is embedded across teams. For example, the Learning Disability team within the directorate had been working in a personalised way for over seven years and were recognised by colleagues as bringing valuable skills and experience. Structural practice such as regular ‘interface meetings’ between different teams continue to be needed in order to address the challenge of service silos. This planning and development time includes service commissioners plus procurement and contract management leads, ensuring that all aspects of service re-design are included.

Values are also very important to ensuring that this process actually leads to changes locally. In planning the 16 commissioning intentions some were driven by legality (the need of contracts or the CQC), some by morality (would we want our loved ones to experience this) and some by the need for innovation (increasing capacity and shifting things forward).The Adult Social Care team also discussed their values and identified the following elements as important;

-investing time in people talking/ planning/ learning together locally and nationally

-a ‘can do’ attitude, being solution focused and enabled in positive risk taking, supported by those in leadership roles

-trusting people as experts in their own experience, encompassing people who use services, but also people who provide them and professionals within the local authority with a unique perspective on how current systems could be improved

One practical example of how working in this way is leading to innovation is the development of a new service for all adults in Lancashire. ‘Help Direct’ will provide the practical support, guidance and information people need to get the most out of life. The service includes a ‘well-being directory’ which is a directory of services from across Lancashire to help improve quality of life including support provided by voluntary organisations, private companies and local councils. They also have a trusted trader scheme, managed by the local trading standards, to provide guidance and confidence for people employing contractors. Help Direct also provides pathways to employment through volunteering opportunities, bringing added value to the local third sector and signposting people to appropriate statutory services. The range of services available have been determined locally. As highlighted on the previous page, staff invested time in reviewing best practice examples for similar types of support services from across the UK then worked with people locally to identify how relevant these would be locally.

The purpose of Help Direct is to promote independence and improve well-being by providing people with information, advice and access to helpful, practical support and community services within their district. The target audience is adults who are becoming vulnerable but who are unlikely to quality for support from social services. A key intention is that through accessing these services people can get support at an early stage, preventing basic support needs from becoming a crisis. People can contact the service directly or be referred to Help Direct by local organisations or local agencies, such as GPs.

Help Direct is accessible online and in over 100 locations across Lancashire, in one-stop-shops, libraries, community centres, doctors surgeries, community groups and various other places. Help Direct can also arrange visits to people in their own homes.

Lancashirehas invested £4 million in the service over three years using four different locally based providers. Whilst aiming for a county wide service, Help Direct recognized the importance of tapping into local networks across the county. Flexible contracts are used order to ensure that services can evolve in response to particular local needs. Therefore each district across the county has Help Direct provided by a local provider in partnership with the county council and local district councils.

As part of the relationship between commissioners and providers, and the investment in change providers are brought together regularly to learn from outside expertise through regular forums. Commissioners are trying to develop a trusting relationship in which providers feel able to innovate and implement new ideas. Providers also have a relationship with the contracts team and have received support around being ready for contracting. Providers are encouraged to ‘take risks’, with commissioners trying to ensure that new approaches are not overwhelmed by ‘safeguarding’ but do recognise the need to keep a dialogue to understand when and if problems arise. This requires a greater investment in a relationship between commissioners and providers than might be generally expected.

Challenges to making this work in Lancashire

There is still a risk of silos, with mainstream policy and practice continuing to focus on individuals service needs, reducing the opportunity to view people as citizens. Ongoing time is needed to enable colleagues to recognise and learn from the good work already underway internally and maintain a dialogue around common outcomes. This would become easier with a shift from specialist teams into universal teams but protecting this time for collaboration in the face of forthcoming financial pressures will be very important.

Communication time must be invested in both vertically with the directorate and horizontally, between and across teams and between the strategic aspects of the local authority and the ‘frontline’. There is a particular tension with frontline professionals not always being seen as active stakeholders in strategic processes. It isn’t felt that a tipping point has been reached yet locally, but as the community capacity building approach is increasingly built into governance frameworks itis anticipated that this will help to institutionalise it. Future iterations of the commissioning intentions need to build in community intelligence and allow for broader conversations