Brighton and Hove City Council

 

Health and Adult Social Care

Commissioning Strategy

 

 

2020-24


 

Contents

 

 

1)  Executive Summary.

 

2)  Purpose, Policy and Principles.

 

3)  Context and Strategic Objectives.

 

4)  Commissioning Priorities and Plans.

 

     

 


 

1)    Executive Summary

 

This section to be drafted following July 2020 HWB

 

 

 

 


 

2)    Purpose Policy and Principles

 

Purpose

This strategy outlines our approach to the commissioning of adult social care, public health and supported accommodation and rough sleeping services in Brighton and Hove to improve outcomes; sustain quality; and improve resilience and sustainability of the wider health and social care system. Commissioning is more than just a process to be followed. Good commissioning in the Health and Adult Social Care directorate will promote good health and wellbeing for all our residents, promote independence, provide high quality sustainable services and fundamentally improve the lives of people with eligible needs, their families, carers and the wider community. The commissioning strategy also makes clear the role that adult social care plays in the economy both locally and nationally and the need to reframe its economic significance in its own right. This element will be developed further in the city’s Market Position Statement which will be available from the summer 2020.

 

Public health both sits in the directorate as a distinct function with statutory authority and equally as a principle that is and will continue to be woven into our future commissioning activity focusing as it does on improving health outcomes, reducing inequalities and setting the strategic direction for health improvement and wellbeing in Brighton & Hove.

Strategic Commissioning is the process of ensuring that population level needs can best be met within available resources through the process of assessing local needs, understanding and shaping the market to best meet those needs, and developing and implementing a plan to meet them.

 

As illustrated in the table below our approach to commissioning forms a continuous cycle of action and improvement, from identification of needs through to review of delivery and achievement of outcomes and includes commissioning, procurement and contract management activity.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Through our commissioning approach we will ensure that the right care is available, in the right place and at the right time. We will also ensure that this is financially sustainable and of good quality.

 

Policy

Prior to the Care Act 2014, people had different entitlements for different types of care and support. These were spread across various Acts of Parliament, some over 60 years old. The law was confusing and complex and the statutory policy framework within which local authorities were required to operate equally so. The Care Act updated and brought together all this previous legislation into one place, and with the adoption of a new duty on promoting Wellbeing charged local authorities to ensure adults and communities:

 

·         receive services that prevent their care needs from becoming more serious, or delay the impact of their needs

·         can get the information and advice they need to make good decisions about care and support

·         have a range of provision of high quality, appropriate services to choose from.

 

Additionally, the Care Act placed carers on the same statutory footing as the people they care for and increased the local authority’s responsibility to provide diverse services for carers. The overarching principle of well-being means that the services commissioned by local authorities must focus on maintaining physical and mental health as well as independence.

 

The Public Health budget is currently received as ring fenced grant and spend is monitored by Public Health England against mandated and non-mandated functions aligned to the national public health outcomes framework.

 

In 2019 Brighton and Hove City Council, together with local NHS partners and in consultation with the Voluntary and Community sector adopted the Joint Health and Wellbeing Strategy (HWBS) for the City. The ambition of this 10-year strategy running up to 2030 is such that it requires action and engagement from partners and stakeholders across the city. With a vision for the city stating:

 

EVERYONE IN BRIGHTON AND HOVE WILL HAVE THE BEST OPPORTUNITY TO LIVE A HEALTH, HAPPY AND FULFILLING LIFE

 

the HWBS provides an important policy framework for the Health and Adult Social Care directorate. Prepared under four wells; Starting Well, Living Well, Ageing Well and Dying Well, each area has implications for the directorates commissioning of services for public health and adult social care. The link to this strategy and the accompanying action plans is on the Council website and is recommended reading in providing additional policy context.

 

From a policy perspective it is important to reference the Council’s corporate priorities for the next four years published in January 2020. One of these corporate priorities, a Healthy and Caring City states we will:

 

·         increase healthy life expectancy and reduce health inequalities

·         support people to live independently

·         support people in ageing well

·         support carers

·         ensure that health and care services meet the needs of all

 

To help translate this policy framework into the operational working of the HASC directorate the Council has adopted the Better Lives Stronger Communities (BLSC) transformation programme which, explained later in this strategy, focuses mainly on adult social care but has relevance to all activity across the directorate and beyond.

 

In both meeting our national and local policy drivers the role and importance of strategic commissioning of health and adult social care is clear. This strategy provides the overarching framework underneath which the Market Position Statement and specific care group commissioning plans will be prepared to shape the range of services available to eligible adults and carers and affected communities of interest.

 

Principles

Commissioning of services for health and adult social care, irrespective of scale or value, statutory or discretionary will be guided by the following set of core principles:

 

Partnership and Collaboration- our approach to commissioning will encourage and support individuals, communities and organisations across the city to work together optimising our individual and combined strengths.

 

Prevention and Empowerment- we will actively commission services that empower people to take responsibility for their health and wellbeing where they can and enable communities to develop networks and local solutions.

Person Centred and Outcome Focused - Personalisation is enshrined in law which means that social care customers are entitled to choice and control over their support services. We will commission care based on the needs of the person rather than the needs of the service and move towards these being delivered against a set of agreed outcomes.

 

Co-Production - We recognise the transformational value of this approach built on the principle that those who use a service are best placed to help design it. We will develop relationships where we work more closely with service users, their families and carers to plan and deliver support together.

 

Value for Money- We will seek to optimise value for money through all the services we commission with respect to the most advantageous combination of cost, quality and sustainability to meet service user requirements including on a case by case basis giving consideration to bids to deliver services in-house.

 

Value the Care Workforce – our commissioning activity will value the workforce working in social care and health settings regardless of whether this workforce is in the public or private sector. We will ensure care workers are valued for their vital contribution in terms of their pay and conditions and identifying supportive career development opportunities.

 

SO WHAT!

Strategic Commissioning is the process of ensuring that population level needs can best be met within available resources through the process of assessing local needs, understanding and shaping the market to best meet those needs, and developing and implementing a plan to meet them. To support this we have an established policy framework, shared and supported by key partners especially Brighton and Hove Clinical Commissioning Group, which will support the decisions and approach we adopt and guiding principles against which we can be held to account for our commissioning activity over the next four years.

3)    Context and Strategic Objectives

To improve the health and social care outcomes for our local population we must respond to changes in the population, our population’s health and the health system. Several of the challenges we face are common across England, an ageing demographic with people living with increasingly complex health and care conditions thanks to advances in good public health and medical science. However, we have challenges also that are particular to Brighton and Hove, such as high levels of older people living alone at risk of social isolation and increasing levels of our working age population living with mental health conditions.

 

The Brighton and Hove Joint Strategic Needs Assessment illustrates that whilst life expectancy has plateaued in recent years, healthy life expectancy has fallen in the city meaning that on average a larger proportion of life is now spent in poor health. This has obvious consequences for our local health and social care systems and future commissioning will play a key role in trying to reverse this trend by helping to promote preventative approaches and deliver quality services closer to home, promoting wellbeing and independence.

 

There are currently around 290,000people living in the city and our population profile is comparatively younger than the rest of England. However, our population over the next 10 years is expected to increase at a faster rate than both the south east and England and by 2030 the age profile will be getting older also. In 10 years’ time there will be over 5000 more people than currently aged 75 or older including 400 more people aged 90 plus. Related to this, the number of people aged 65+ predicted to have a dementia diagnosis is expected to increase by over a third from approximately 3000 to just over 4000 in the same period.

 

The number of people with a mental health disorder in Brighton and Hove is expected to increase by 1,537 (4.03%) in the 18-64 cohort by 2035. This is a significantly higher proportion than the expected increase across England. The city has significantly higher levels of homelessness per 1000 households compared to the national average. According to published evidence, the impact of this further increases the pressure on all adult social care services, and particularly mental health, with recent surveys indicating up to 80% of homeless people in England reporting that they had mental health issues, with 45% having been diagnosed with a mental health condition.

 

While we are experiencing both increased demand and higher levels of complexity in adult social care, Brighton and Hove City Council has had to continue providing services whilst its central government funding has been reduced by over £40 million since 2016 (as indicated in the table below).


 

 

Cumulative budget gap from reductions in revenue support grant

and increased costs and demands

 

               

 

Responsible for approximately one third of the Council’s annual expenditure, whilst adult social care has had a degree of protection from the full impact of central government reductions to local authority funding, in real terms securing future financial sustainability remains the very real challenge. We continue to look forward to the much-needed long term funding arrangement for adult social care nationally that recognises the interface and co-dependency with supporting our NHS. In Brighton and Hove we are working ever closer with our NHS partners, be this through joint commissioning of services or operationally in the delivery of care to patients and services. Building upon strong foundations we look forward to further embedding our collaborative approaches with the local health economy and in the care specific commissioning plans we will provide further detail of what this will mean in practice.

 

The individual commission plans for the service groups will expand on the resource requirements in more detail for each specific area but the fundamental position this strategy acknowledges is that whilst demand and unit costs continue to increase, local government financing continues to require delivery of ongoing savings. In our ambition to further optimise the efficient allocation of our resources this strategy and the commissioning plans that sit beneath will need to be considered in the context of the Market Position Statement which will detail to the provider market what services the council will focus upon commissioning either on its own or in closer collaboration with health and other stakeholders.


 

 

The chart below shows the totals current spend on commissioned services in 2019/2020.

 

Spend (£) on Commissioned Services

Title: Spend by Area m

 

 

In 2019 the HASC directorate embarked upon a major service transformation programme, Better Lives, Stronger Communities (BLSC). This programme which is being implemented now and for the next three years and should be seen as our ‘business as usual’ across the directorate but predominantly for adult social care  adopts a strength and asset-based approach to delivery with a specific focus upon:

 

·         redesigning the front door service to improve access to advice and information and signpost to preventative community interventions that maximise independence and wellbeing,

·         improves the offer of short-term services such as community reablement to help positively turn peoples’ lives from dependency where this is beneficial to the persons best interest, and

·         reduce our current dependence upon long term placements into residential and nursing home centres except where this is the only safe and appropriate option for the person with eligible social care needs.

 

 

 

 

 

 

 

    Better Lives Stronger Communities Operating Model

                  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BLSC will underpin how we work differently now and looking forward and will require a significant cultural shift both in terms of our practice and that of our providers and partners. We will do this by focusing on what people can do, not what they can’t do, building on their individual strengths, networks and utilising community assets before we look to put in place more traditional services. 

 

We will focus upon commissioning the right services to support this new way of working.  To enable us to do this we will continue to work collaboratively and effectively with other Council Directorates, the NHS, the Police, care providers, community, voluntary and social enterprises, and other partners. The strategic principles that underpin BLSC transformation programme are:

 

·         Universal focus on supporting the wellbeing and independence of adults with care and support needs and their carers.

·         Enabling our local community to help itself and support vulnerable residents.

·         Developing ‘First Contact’ to resolve enquiries and meet need at the earliest possible point.

·         Streamlining care and support journeys to improve outcomes and efficiency.

·         Opportunities for automation, improved decision-making and new ways of working arising from the Council’s investment in Eclipse.

·         Efficient management of data to enable data driven decision making.

·         Maximise opportunities for more joint working with other directorates and citywide community partners.

 

This will mean working closely with the Voluntary and Community Sector to ensure that services are in place to support people within their communities, focussing on prevention and ensuring that people are able to support themselves wherever possible.

 

To know where we want to go in the future we need to understand the position now. The HASC directorate provides a range of different services from preventative services to those where we are required to fulfil a statutory duty. Whilst recognising that the majority of commissioning activity sits within adult social care under our duties outlined in the Care Act, this does not account for the total sum of commissioning activity in the directorate which importantly commissions services across public health and also supported accommodation services for single homeless and rough sleeping.  The groups of vulnerable adults for whom we commission services will generally fall into one or more of the following categories:

 

·         Older people

·         Adults with a Learning Disability and/or Autism

·         Adults with a Mental Health condition

·         Adults living with a Physical Disability or Sensory Impairment

·         Adult Carers

·         Single Homeless and Rough Sleeping

 

In providing services to these groups of vulnerable adults our main area of commissioned spend both in terms of volume and cost, is directed toward:

 

·         Care home placements; both nursing and residential

·         Homecare

·         Alcohol and Substance Misuse

·         Supported accommodation

 

The rising cost of services and the cost pressures experienced by many of our providers mean that ensuring we have the right services at a sustainable price is becoming increasingly challenging. As referenced earlier, the increasing demand and complexity of people’s needs requiring social care support is adding to these pressures.

 

Despite the financial pressures in relation to higher levels of health needs, increasing demand and reducing resources we must continue to deliver our statutory responsibilities. 

 

A snapshot of demand for adult social care in 2018/19 indicated the following activity:

 

·         Over 4,500 new requests for social care support resulting in 1300 people being provided with long-term funded care services and a significant proportion of others receiving short term support

·         Over 5,000 clients issued with equipment in their home to support their daily living and nearly 5,000 people registered to receive telecare primarily to support their safety and wellbeing;

·         Over 1,000 Clients received a short-term service to maximise independence;

·         Nearly 2,000 informal carers supported to maintain their caring role and lead a life outside of their caring responsibilities;

·         Nearly 1,000 Safeguarding enquiries were carried out; 

·         Nearly 2,000 Mental Health Act assessments referrals. 

 

During this period, we provided long term funded care services for 3,500 adults. This support was provided in the following ways:

 

·           1,700 Adults received domiciliary care in the community,

·           1,350 Adults received residential or nursing support (720 nursing care

       placements and 613 residential care placements);

·           Approximately 450 adults receiving their care funded via a Direct Payment.

 

The objectives of the directorate’s delivery of public health delivery are to:

 

The Directorate provides and commissions a range of services to meet these objectives. The functions mandated by the conditions of the public health grant provided by central Government include;

 

Local authorities must also have regard to the need to improve the take up of, and outcomes from, drug and alcohol services.

Our largest contracts include 0-19 children’s and young people’s services, sexual health services and substance misuse services. Other services commissioned from the public health budget include weight management, Ageing Well, suicide prevention and stop smoking services.  Our commissioned providers include NHS primary care, NHS Trusts and the community and voluntary sector.  The directorate is also a provider of services to improve the health of our residents, for example the Healthy Lifestyles service.

To ensure the successful delivery of the above services Public Health works in partnership with the NHS, other council directorates and a wide range of providers.

 

This section has outlined the societal challenges of demography and growing complexity of adult social care and public health set against the challenging background of increasing costs and rising demand. Additional to this landscape are further contextual factors which this commissioning strategy will factor for:

 

Workforce: The adult social care workforce is growing, although the sector continues to face considerable recruitment and retention challenges. If the workforce grows proportionally to the projected number of people aged 65 and over then the number of adult social care jobs in the South East region will increase by more than 40% over the next 10 years.

 

Staff turnover in Brighton and Hove is estimated at 26%, which although lower than the region average of 30% and lower than England at 31% is still significant. We estimate also that in Brighton and Hove at any one time approximately 8% of roles in adult social care were vacant, this equates to around 550 vacancies at any one time.

 

This challenge of recruiting and retaining a social care workforce is also impacted by the UK’s departure from the European Union as the proportion of EU workers in both the NHS and the social care sector has grown over time, suggesting that both sectors have become increasingly reliant on EU migrants. This Commissioning Strategy will need to respond to workforce challenges across the sector as the situation continues to unfold with respect to future migrant worker arrangements.

 

Service Quality: Overall provision of regulated services in the city is of a high standard. At present just over 90% of Care Quality Commission regulated services in the city are rated ‘good’ or ‘outstanding’ which is significantly higher than the national average of 83%.

 

Brighton and Hove City Council, the Clinical Commissioning Group (CCG), and Care Quality Commission (CQC) work in partnership to gather intelligence to prioritise intervention following any significant concerns about services provided to vulnerable adults living in the City.

 

We will continue to support this quality of service through our ongoing approach to quality and contract management (part of the commissioning cycle) to ensure the delivery of services commissioned is in accordance with the specifications for services and the quality expected. This will be explored further in the care group specific commissioning plans and the Market Position Statement.

 

The council currently provide several in-house services, including hostels, discharge to assess and respite care beds and a reablement service delivered in people’s homes. As stated in our principles earlier the Council will source the most effective way to provide future services of good, sustainable quality and will assess on a case by case basis the potential for these delivered through an in-house option as well as exploring external commissioning.


 

 

 

4)    Commissioning Priorities and Plans

This Commissioning Strategy for the next 4 years will be supported by commissioning plans detailing the specific priorities that need to be addressed within their individual area of focus.  Whilst these plans will contain greater detail of the demand and supply for specific services there are some key priorities of a scale that merit mention here. 

 

To deliver in practice the policy drivers referred to earlier in this strategy the following priorities will underpin our commissioning:

 

Promote Prevention and Empowerment

As stated in the health and Wellbeing Strategy we will continue to ensure that communities are supported to develop networks and local solutions that lessen social isolation and improve wellbeing which in turn will reduce the need for more specialist services.  We will do this in collaboration with our vibrant voluntary and community sector who are well placed to support in this area. 

 

Support Carers

An unpaid carer provides support to a partner, child, relative or friend who couldn’t manage to live independently or whose health or well-being would deteriorate without this help.  This could be due to frailty, disability or serious health conditions, mental ill health, or substance misuse. There are over 23,000 unpaid carers in Brighton and Hove and in 2016 their estimated economic value to the city was over £430 million per annum.

 

We will continue to invest and develop our support services for Carers to ensure that those providing informal care are supported in their roles. This includes the Carers Hub that was jointly commissioned by the Council and CCG and brings together local organisations with council staff to provide a single point of access for unpaid carers to get access to information and support in a timely way.

 

Reprofile the Residential and Nursing Care Home market

We currently place significantly more people into residential and nursing care than our comparators. Over 1,000 people in the city live in Council funded residential and nursing care, representing 67% of overall Community Care budget spend. Rates of admission to long-term care in Brighton & Hove are much higher than rates across England and these are increasing, whilst rates across England are decreasing, as shown in the table below

 

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A priority for the council will be to ensure a local market is in place that optimises support for people living at home to optimise their outcome potential and reduce our current level of placement particularly in residential care.

 

Whilst the need to reprofile the number of residential and nursing beds in the city is recognised we also appreciate the importance and often difficulty in developing alterative accommodation options. We will work collaboratively with existing care home providers in managing this priority and explore opportunities for providers to diversify where appropriate.  Population projections come with an associated rise in the number of people living with complex long-term conditions, including mental health conditions; whilst dementia rates are predicted to increase sharply in the next decade. So, whilst the overall number of beds will reduce, there is a need for increased specialist residential and nursing care provision that can meet this growing complexity of care needs.

 

Development of Supported Living/Accommodation Provision

We will work with providers to develop the market around supported living services to ensure that services are in place to meet the growing demand and reduce the reliance on residential and nursing provision. 

 

This will involve collaboration with a broad range of providers and partners, including other directorates within the Council to ensure that accommodation and development opportunities are maximised. This provision will need to be developed to support vulnerable adults across all the commissioning plans.

 

Increase access to Community Reablement

We believe that everyone has reablement potential and to support this we will develop a community reablement service to ensure that people are provided with the opportunity to improve their independence before moving to a package of care or residential placement.  This will ensure that peoples reablement opportunities are maximised and ongoing support reduced as much as possible.   

 

 

 

 

Recommission Home Care services

Alongside reviewing and developing our community reablement offer we will prioritise recommissioning our current Home Care services framework arrangements.  We recognise the increasing demand and changing nature of these services, for example in response to growing pressures on NHS services including the priority to discharge from hospital in a timely manner and understand the importance of homecare in enabling people to remain at home with the necessary support and reducing the need to enter residential care. To do this successfully we need to ensure that the homecare we commission can manage increasing complexity and has the appropriate workforce to deliver this.  By addressing this we will be able to support people to live well in the community and prevent people with significant health or care needs from having to use emergency services or being admitted to hospital inappropriately.  Home Care plays a significant role in supporting the overall health and care system in the city and ensuring that we have a sustainable homecare market and associated workforce in the city is a high priority. 

 

Promote Direct Payments

 

A direct payment is when a personal budget is paid directly to an individual to buy their own care and support in line with their assessed needs and they manage their care also, with support available if required. It allows those in receipt of a direct payment to have more choice and control over their lives by enabling them to make decisions about how their care is delivered.

 

We will look to grow our direct payment offer to support personalisation, choice and independence across both adult and children’s services.

 

We will look to develop our Personal Assistant (PA) market to ensure that those people wishing to employ a PA are able to access them and receive the relevant support in a timely way.  We also see this as an important way to support the growing demands and pressures on the homecare market

 

Expand Shared Lives

 

Shared Lives is a CQC regulated service where individuals and families provide care and support to people who live with them in their family home. People using the service have the opportunity to be part of the carer’s family and social network.

The provision of Shared Lives reflects the drive for more preventative, personalised, community-based care and support to reduce the reliance on more traditional services e.g. residential and nursing.  

 

The Council currently operates an in-house shared lives service and also commissions an independent provider both of which are predominantly focussed on people with a learning disability.  While we wish to continue to expand this area we will also conduct a review of the existing provision across both Children’s and Adults with a view to an enhanced shared lives offer to support a greater range of people who are able to live more independently and move away from more traditional residential settings.

 

Increase use of assistive/personalised technology

Whilst there is consideration in how assistive technology (primarily care link) can support people when they make contact with the council there is far more that can be explored in this area. The range of assistive technology available is increasing every year. We will look to develop a greater understanding of this technology and how this be used to support people to increase their independence.

 

Explore Outcome focused commissioning

 

We will look to implement more outcome-based commissioning / contracting to promote the achievement of outcomes rather than outputs with a view to driving and promoting a focus on independence and reablement.

 

Contracting methods already mentioned above such as Individual Service Funds can support this approach but will require providers and the Council to think more creatively about contracting and the associated risks etc. when moving to these more flexible approaches.

 

Explore the potential to use Individual Service Funds

We will look for opportunities to pilot different approaches to the traditional models of contracting and evaluate the possible benefits of Individual Service Funds. This contracting for flexible support can improve outcomes for individuals while enabling service providers to provide flexible support and can help build greater partnerships and trust between councils and providers while realising efficiencies.

We have already identified services within learning disabilities and an acquired brain Injury service both of which provide support living service and where we feel this approach may be of benefit.

 

Adopt a Council and City-Wide Approach

To support our transformational programme BLSC within Health and Adult Social Care, commissioners will need to work closely with other directorates within the Council and stakeholders across the City.

 

We will work in collaboration with the voluntary and community sector to support our focus on prevention and enabling and empowering people to take responsibility for their health wellbeing.  We will look to maximise community assets and support people to take early action to help people to live well for longer and to remain independent.

 

This will include ensuring we have clearly developed accommodation pathways focused on reducing admissions to residential care and supporting step down through a progressive and enabling approach. 

 

Commissioning Plans

 

Commissioning plans for the areas highlighted in this strategy are being developed and will be published through 2020 with a timetable presented to Health and Wellbeing Board for agreement in June 2020. This will be alongside a refreshed Market Position Statement that will also be presented to the Health and Wellbeing Board in June 2020 and will support providers in understanding service provision development opportunities and how the Council will support them to tackle the challenges that we face as a sector.