Appendix 1 - The National Context

There is clear consensus on the need for radical and ambitious social care reform, and a growing realization that boundaries between health and social care can be problematic for people who require community based support. Adult Social care has thus attracted a considerable amount of legislation, and policy and procedural guidelines- some generic, and some specific to adult social care. Specific Legislation, policy and procedures are outlined below.

1.1 Key (recent) Legislation

Health and Social Care Act 2012http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted

The Health and Social Care Act 2012 restructures the NHS, abolishing NHS primary care trusts (PCTs) and Strategic Health Authorities (SHAs) and transferring purchasing powers to "clinical commissioning groups lead by general practitioners (GPs) in England, and local Councils take on the public health facility.

Health and Social Care Act 2008

http://www.legislation.gov.uk/ukpga/2008/14/contentsThe Health and Social Care Act 2008 established the Care Quality Commission as the regulator of all health and adult social care services, with tough new powers to ensure safe and high quality services. It also introduced a new form of professional regulation and strengthened clinical governance..

The Public Services (Social Value) Act 2012

Received royal assent on the 8th March 2012. The Act’s purpose is to require public authorities to have regard to ‘economic, social and environmental well-being in connection with public services contracts and for connected purposes. All public authorities are now required to consider, prior to undertaking the procurement process, how any services procured (whether covered by the Public Contracts Regulations 2006 or otherwise) might improve the economic, social and environmental well-being in areas which that public authority exercise sits functions. Furthermore it must consider how it can secure such improvements as part of the process.

This legislation is complementary to the public sector duties under the Equality Act (2000). The kinds of implications has could be far reaching. It could mean that a mental health service is delivered by an organisation that actively employs people with a history of mental health problems to help deliver the service – the social value of commissioning these services being partly related to the person with mental health problems having a job. Housing services could choose to provide greater social value by promoting careers through construction and trades contracts. Whilst it was possible for public authorities to include such elements within public contracts (and conduct procurement activities with such elements in mind).

1.2 Forthcoming Legislation

Care and Support White Paper July 2012http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_134740.pdf

The draft Care and Support Bill creates a single law for adult care and support, replacing more than a dozen different pieces of legislation and provides the legal framework for putting into action some of the main principles of the White Paper, ‘Caring for our future: reforming care and support’, and also includes some health measures.

1.3 Best Practice/ Procedural Guidelines

Government policy of 21st century has emphasised the need to help people to live independent lives giving them better choice and control. “Putting People First “(2007) was its first paper, setting out the following themes:• Facilitating access to universal services• Building on social capital within local communities• Making a strategic shift to prevention early intervention• Ensuring people have greater choice and control over meeting their needs

More recently this guidance has been further detailed and developed, and absorbed in an increasing number of performance measures for local authorities. It was followed in November 2010 by

A Vision for Adult Social Care: Capable Communities and Active Citizens

http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_121508

"A vision for adult social care: Capable communities and active citizens “set out how the Government wishes to see services delivered for people; a new direction for adult social care, putting personalised services and outcomes centre stage. The Vision for a modern system of social care is built on seven principles:

Prevention – Empowered people and strong communities will work together to maintain independence.Personalisation – allowing people to take control of their care.Plurality and Partnership – ensure there is arch and divergent mix of provision of high quality.Protection – There are robust safeguards against the risk of abuse or neglect.Productivity – there is a focus on the local authority identifying value for money comparing the cost effective’s ness of care services, and comparative interventions enabling higher productivity and high quality care and support services.People – the social care workforce are supported and trained to deliver outcome focussed personalised care packages, and personalised services

Partly as a response to the above, in January 2011 the following was produced:

Think Local Act Personal

http://www.thinklocalactpersonal.org.uk/Think Local, Act Personal is a sector-wide statement of intent that makes the link between the government’s new vision for social care and Putting People First and gives a way forward for personalisation and community-based support.It asserts that councils, health bodies and providers need to work more collaboratively to personalise and integrate service delivery across health and adult social care; and make vital public funding go further. It also recognises the contribution that individuals, families, carers and communities make in providing care and support – both to those who are publicly funded and those who either pay for themselves or rely on family carers.

1.4 Integral Policy Papers

“Under Pressure, a report by The Audit Commission in February 2010 states councils must balance the need to provide social care and to support active aging, and warns if care service provision is increased alongside population growth, public spending on care services could nearly double between 2010 and 2026. Private spending on social care would increase from £5.3 billion to £23 billion over the same period, if trends in means testing and self-funding continue. It notes that 85% of older people do not use council care services, but may use other services such as housing, leisure and adult education, that play an important role in keeping them active and independent; and they use a full range of general council services.

Tighter finances create an opportunity to rethink and redesign services to improve lives, while spending less public money. The challenge of an aging population is a challenge for the whole council, not just adult social care services.

Financial implications for local authorities of an ageing population’ (October 2009) by the audit commission, looked at the costs of older peoples social care. It identified that there is no significant correlation between the Care Quality Commission (CQC) inspection ratings and the level of spend. Councils that spent more didn’t necessarily get better ratings. Spending more in home care did not mean that authorities spent less in residential.

Use of Resources (2009 Department of Health) notes that a local authority should:• Demonstrate how they have given priority for adult social care within other priorities• Define how resources have been allocated• Understand their patterns of spend and service costs, and manage its resources to deliver good quality outcomes and meet predicted demands by commissioning services at an affordable cost• Have a range of services to support people to live in their own homes • Achieve efficiencies through a system focused on early intervention, prevention

and re-ablement and personalisation of services

Making a strategic shift to prevention and early intervention (the Department of Health 2009) states that local authorities should be demonstrating improvements in performance to meet the demand for low level services, that are said to be the key to offer real, community alternatives to people having to go into residential care, due to impoverished or absent community facilities and care at home services.

Social care transformation has been a key concept for national government, and continues as the government still ponders the next steps for the future of Adult social care. The future funding of the increasing numbers of older people that will need care and support is a major government concern. Many of the recommendations of the report by Andrew Dilnot – Fairer Care Funding Report (July 2011) have been accepted by the Government as set out in Caring for our future: progress report on funding reform (July 2012).

"Living well with dementia - a National Dementia Strategy" was published in February 2009. It set out a vision for transforming dementia services with the aim of achieving better awareness of dementia, early diagnosis and high quality treatment at whatever stage of the illness and in whatever setting.

Appendix 2 - Current use of resources

2.1 Adult Social Care Outcomes

The performance of local authorities, with respect to adult social care outcomes, is assessed on a new framework. It provides information that can be used to compare performance between local authorities. This information shows areas where focus and improvement are needed, as well as areas of good performance. The following is information from February 2013 Adult Social Care Outcomes Framework

Measure DoncasterYorks & Humber average

England average

All EnglandHighest score

Lowest score

Social care-related quality of life 18.7 18.7 18.7 20.1 17.4

the proportion of people who use services who have control over their daily life

76.4% 76% 75.1% 82.7% 62.5%.

Proportion of people using social care who receive self-directed support and those receiving direct payments

47.4% 47.1% 43% 89% 3.9%

Proportion of people using social care who receive self-directed support and those receiving direct payments (direct payments only)

9% 12.7% 13.7% 43% 3.9%

Proportion of adults with learning disabilities in paid employment

7% 6.8% 7.2% 25.8% 0.9%

Proportion of adults in contact with secondary mental health services in paid employment

5.3% 8.1% 8% 25% 1.5%

Proportion of adults with learning disabilities who live in their own home or with their family

70.6% 76.4% 70.2% 95.9% 21.9%

Proportion of adults in contact with secondary mental health services living independently, with or without support

61.8% 57.9% 57.8% 92.6% 0.9%

Permanent admissions to residential and nursing care homes, per 100,000 populations (18-64 only)

18.7 12.7 18.9 66.6 4.1

Permanent admissions to residential and nursing care homes, per 100,000 populations (65+ only)

933.6 683.6 707.1 1269.1 86.4

Proportion of older people (65 and over) who were still at home 91 days after discharge from hospital into reablement/rehabilitation services

56.9% 84.9% 82.6% 100% 56.9%

Delayed transfers of care from hospital per 100,000

12.2 7.8 9.8 31 0.5

Measure DoncasterYorks & Humber average

England average

All EnglandHighest score

Lowest score

populationsDelayed transfers of care from hospital, those which are attributable to adult social care

6.7 2.2 3.8 16 0.3

Overall satisfaction of people who use service with their care and support

60.5% 63.4% 62.8% 77.7% 47.3%

The proportion of people who use services and carers who find it easy to find information about services

77.6% 73.5% 73.9% 85.5% 62.2%

The proportion of people who use services who feel safe 62.3% 63.2% 63.8% 86.2% 49.2%

The proportion of people who use services who say that those services have made them feel safe and secure

78.4% 75.7% 75.3% 92.5% 54.4%

2.2 How the budget is spent

In the last financial year (2012/13) Doncaster Council spent approximately £109.5m on Adult Services, including care, support, assessment and care management and support services. The following table sets out the main areas of spend, together with the breakdown between in-house and external provision. There are some areas of overlap between classes of expenditure, for example between older people and people with learning disabilities. 

Sum of Revised Actuals 2012/13 Column Labels

Row Labels In house provision External provisions Income Grand Total

*Assessment & care management 9,270,956 514,443 -908,904 8,876,494

All Client Types 9,270,956 514,443 -908,904 8,876,494Care Home placements 11,661,098 35,097,081 -23,184,743 23,573,436

LD 2,166,774 8,608,080 -4,843,106 5,931,748MH U65 670,103 -123,724 546,379OP 8,432,580 24,984,906 -17,907,974 15,509,512PD 1,061,743 833,993 -309,939 1,585,797

Community equipment 429,755 2,813,269 -1,647,286 1,595,738All Client Types 429,755 2,813,269 -1,647,286 1,595,738

Day Care 5,235,911 1,989,394 -1,755,850 5,469,455LD 3,507,809 1,281,162 -1,513,075 3,275,896MH U65 90,747 90,747OP 1,728,103 617,485 -242,775 2,102,812

Domicilary care 3,415,772 1,749,792 -2,249,937 2,915,627All Client Types -1,717,697 -1,717,697LD 175,230 8,342 183,572MH U65 22,035 22,035OP 3,240,541 1,618,196 -532,240 4,326,497PD 101,220 101,220

**Other services 7,107,247 2,704,391 -3,250,490 6,561,148All Client Types 7,107,247 2,704,391 -3,250,490 6,561,148

Supported living 965,459 9,423,123 -5,780,181 4,608,401LD 965,459 9,423,123 -5,780,181 4,608,401

Individual Budgets 13,142,587 -4,888,954 8,253,632All Client Types 158,550 -1,127,770 -969,220LD 1,273,528 -199,271 1,074,258MH U65 30,351 -13,162 17,189OP 8,235,376 -3,181,699 5,053,677PD 3,444,781 -367,053 3,077,728

Supporting People 6,878,523 6,878,523All Client Types 6,878,523 6,878,523

Grand Total 38,086,198 74,312,602 -43,666,345 68,732,455*Includes all Social Work staff, Occupational Therapy staff and Administration staff**Includes Carer Services, Preventative technology, Commissioning Team, Contracts Team, Assessment Unit, Adult Protection

The major spend within last year’s budget for 2011/12 was on care homes. Doncaster has proportionately more people in care homes than its comparator authorities and compared to the England average. This is reflected in the Council’s spend on residential care.Appendix 3

Commissioning in Doncaster

The Commissioning cycle in Doncaster

It is the Commissioner’s aim to recognise, share and develop where resources are being well used and where, in the future, there needs to be greater focus and development. The local approach to commissioning has at its very heart the people of Doncaster and has been mapped to show how this process will be put into effect.

NHS Clinical Commissioning Groups are being established as part of the national changes to the NHS and there will be close working between strategic partners to ensure that pre-existing strong commissioning relationships with NHS Doncaster will continue as the new NHS takes shape. These relationships will be taken to a new level by negotiating and agreeing the most appropriate strategic lead for different commissioning priorities across social care and health.

These relationships and arrangements form the basis of the new Health and Wellbeing Board. It is anticipated that the Board will oversee a new commissioning culture with strengthened consultation and engagement networks to ensure that public involvement has a greater focus and impact on service development and commissioning. Adult Social Care commissioners will develop a dialogue between existing partnership boards and the Health and Wellbeing Board to ensure that local people and groups influence the emergent Health and Social Care agenda.

The local Health and Wellbeing strategy has been developed and sets out how Doncaster Council will work with partners, the public and communities to support independence and wellbeing. The key themes and outcomes of this Adult Social Care Commissioning Strategy are linked to the priorities identified in the Health and Wellbeing Strategy

What is already known about Doncaster

Available data and information highlights the need to work across the spectrum of the Adults and Communities Directorate to ensure that the people of Doncaster have the best possible outcomes in terms of independence and wellbeing:

In line with national demographic trends, Doncaster’s ageing population is rising which poses a significant challenge in terms of health and social care provision

There are currently 50,000 people over the age of 64 in Doncaster, by 2020 this will have increased to 60,800

Some parts of Doncaster have larger than average numbers of older people living on low incomes

Alongside an ageing population, Doncaster will have a greater number of people with dementia and other mental health issues associated with old age

The numbers of falls amongst older people is likely to increase, as a result of increasing numbers of older people living in the Borough

People and their carers generally think it is easy to find information about services which they use. Although this is not the case for all client groups, it appears to be less easy for those with a Learning Disability, Physical Disability or a Mental Health problem

Permanent admissions to residential and nursing homes are higher than the national average

The number of people, ages 65+ who are still at home 91 days after discharge from hospital is lower than the national average

Feelings of insecurity amongst those who use services are mostly felt by those who are older and have a physical disability

Appendix 4 - Demographic and Deprivation Factors

The Department of Health has developed some projections about the future needs of the local population in Doncaster1:

The number of people aged 65 and over will increase from 53,000 in 2012 to 61,200 in 2020.

The number of people aged 65 and over and classified as moderate which means they

1 POPPI (Protecting Older People Population Information System, PANSI (Projecting Adult Needs and Service Information

are unable to ‘manage at least one self-care activity on their own’ will increase from 17,639 in 2012 to 20,504 in 2020

Around 3,600 people aged 65 and over currently have dementia, this is approximately 7%. By 2020 this is projected to rise to 4,317

More older people aged 65 and over, and 85 and over are in care home accommodation than in neighboring Yorkshire and Humber authorities, and in England, per 10,000 population, and per 1,000 people age 65

The number of people aged 65 and over living alone will rise from 7,200 to 8,240 by 2020

The number of people with a sensory impairment will rise from 28,986 in 2012 to 33,656 by 2020

The number of people aged 18-64 affected by mental health issues will fall slightly over the next 10 years. However the numbers of older people with depression is likely to rise as the older population increases

There are around 14,600 people aged 18-64 with a moderate physical disability in Doncaster and another 4,300 with a serious physical disability

There is a relatively small (8.2%) minority ethnic population with the biggest change in the ethnic make up being a rise in Polish and other East European nationalities. The number of gypsy/travellers resident at any time in the borough is between 4,000 and 6,000

Overall the number of people with a learning disability is set to decrease slightly. However within that number, people with a severe learning disability who are likely to need more care is estimated to increase slightly. Support for people with autism is likely to increase as more people with autism are identified, assessed and supported

Carers receiving services in 2012 is around 1,250. For carers over 64 the number in 2012 is 916 and is projected to rise to 1,266 by 2030

Doncaster Index of Multiple Deprivation

Source: Department of Communities and Local Government, 2007

It is clear there is variation across Doncaster on varying levels of deprivation in the Borough. It is a priority of the Health and Wellbeing Board to improve opportunities and the quality of life for residents of Doncaster.

Appendix 5 - Strengths weaknesses and areas for future development

Strengths

Suitably resourced overall base budget Strong member interest and support for work

of adults and communities, including willingness to invest in service development

effective joint working with health partners Fully staffed and experienced commissioning

team, including a well-resourced, strong contract management service

High Opportunity Areas

Opportunity to define and develop a commissioning culture, within and beyond the organisation

Opportunity to move towards person centred planning and outcome based commissioning

Developing further opportunities for mainstreaming personalised care and personal budgets

Developing preventative services, by reinforcing use of neighbourhood services and community capacity

Develop a vibrant and diverse market of high quality providers

Workforce development well progressed ( NMDS)with high level of involvement from

providers Well established and high performing

learning disability partnership board Joined up working for older peoples dementia

services Well established community presence High spend in assessment and care

management

Potentially high profile for work of adults and communities in new health and wellbeing board

Drive down cost of residential care for working age adults with learning disabilities

Reduce further use of residential care for older people and people with a learning disability

Develop customer consultation and feedback for a Reduce transaction costs, by using new ICT and streamlining

invoicing and payment procedures, (esp. home care) Focus on developing extra care housing solutions Telecare –extend scope, partnership, prevalence, and

integrate assessments with early intervention; Telecare equipment - explore links with community teams, re

call monitoring ; and with ICES, to develop more seamless service provision

Embed and further extend reablement- preventing admissions to hospital and care, and following hospital discharge

Review and prioritise use of respite care, ensuring this is not used as a prelude to permanent admission to a care home,

Effective assessment and support for informal carers Implement learning from other local authorities, pilots, and

projects

Weaknesses

Above average spend on residential and nursing home care for all groups

Insufficient supply of beds for people with dementia in care homes with nursing

Above average admissions to residential care compared to comparator group authorities

Low numbers of completed carers assessments

Availability of suitable housing options is limited

Below average spend in residential and nursing care for people with mental health needs

Long waiting times for those with moderate needs for assessment by an occupational therapist

Limited opportunities

To improve on activity and financial management before the installation of a whole system integrated ICT database

To increase income from raising charges To review or further reduce revenue on housing support

services

Appendix 6 – Service Profiles

Older peopleThe situation now

Doncaster has a disproportionate population aged 45-60, and is projected to have greater than England’s average growth of older people over the next 20 years.

The population aged 65 and over is predicted to increase in absolute terms, and as a proportion of Doncaster’s total population:2012 = 53,100 (18%)2020 = 60,700 (24%)

Mental Health

In the Future Services will be organised around the needs of individuals and will be appropriately

balanced between hospital, the community and people’s own homes and more equally balanced between prevention and care

Recovery and inclusion based mental health services will be culturally appropriate, helping people realise their full potential and become active citizens within their local communities

All services will be non-age specific; services for people with dementia will have equal profile to all other services

Reduce the risk of people developing mental health problems and ensure more people have good mental health

Reduce the damaging effect of mental health on those who experience them, their carers and their families and ensure more people have positive experience of care and support

Ensure services are more personalised and that they fit into people’s lives and support people to manage their condition themselves with the right help from integrated health and social care services

Ensure all people have equity of access to, and quality and choice of, mental health services.

Learning Disability and AutismThe situation now

Estimates of population for adults with an autism spectrum condition are 1602 males and 176 females in 2013, a total of 1778 people. Within health and social care services we can identify 309 adults with ASC who have been in contact with services in Doncaster. This consists of 245 males and 64 females. The ratio of male to female prevalence reflects national statistics showing an increased incidence of Autism in males by approximately 3-1.

Together with the numbers of young people in education (Table 3), we have identified approximately 29% of the estimated population of Doncaster with Autism spectrum Condition (ASC) based on national statistics. However, not all of our population will have a diagnosis and the majority of adults will not have needed to access health and social care services.

Other LA’s place their clients in the Specialist Autism services and educational facilities provided by the independent sector in Doncaster. We therefore we have a population ‘moving into’ area who later may become ordinary residents. This includes from specialist education.

78% of people with an ASC known to us are between 18-40 years old. They will need advice and support services for many years to come. We can assume we have a hidden population of older people with ASC who may need services in the future relating to growing older.

Total population 18+ known to Local Authority 1831 (March 2012) of this number some 197 are on personal budgets.

A number of innovative services are run from Day Services in Doncaster however there is a scarcity of alternative day options for people with a learning disability. Doncaster has a reliance for day services on large day centres, there are 5 within the LA and 1 within Rotherham Doncaster and South Humber Healthcare Trust.

There is a significant investment in residential care within the independent sector. In addition many of these are high cost placements. Doncaster has 41 people in some form of residential care outside the borough (March 2012).

There has been significant effort in finding alternative employment for people with a learning disability, with a number of innovative social firms. However most people still rely on more traditional day services. There are 28 people in employment 40 in a mixture of unpaid work and employment and 40 in unpaid or voluntary work (March 2012).

People with a Sensory or Physical DisabilityThe situation now

There are currently 14,200 adults of working age (18-64 years) estimated to be living with a moderate physical disability in Doncaster and a further 4,200 are estimated to have a severe disability

Consideration needs to be given to how better to ascertain information on health status and outcomes of people with physical disability. For example, through better sharing of data between service providers and commissioners.

Increasingly people are living longer and are therefore more likely to develop long term conditions. As medical and assistive technologies improve people will live longer with more complex conditions

In the future

Trends indicate that more people are surviving stroke and therefore more people may potentially require additional social care services.

More preventative services need to be in place (primary and secondary) to support people to stay independent.

A high proportion of Doncaster expenditure goes towards residential care and there is a need to focus on supporting more people to live in community settings

There is requirement to gather evidence of deaf and sensory impaired service users that may have unmet need. This will be considered in terms of comprehensive needs analysis, access and service provision.

More preventative services need to be in place (primary and secondary) to support people to stay independently in their own home. This will include people with PDSI.

Housing Support Services (Supporting People)The situation now

Doncaster Council commissions a diverse range of housing support services for vulnerable people to enable them to live independently in the community. Client groups assisted include older people, people with mental health problems and

learning disabilities, as well as those with substance misuse issues, homeless people, offenders, young people at risk, people at risk of domestic abuse and teenage parents.

In 2011/12 3,279 people were supported to live independently. Access to appropriate move on accommodation continues to be an issue and requires close working with housing colleagues to ensure appropriate accommodation pathways are in place.

In the future

We will have a greater focus on engaging individuals and community groups in the design and delivery of services.

We will continue to improve outcomes for people accessing services through effective contract monitoring.

We will work with providers of services to improve quality of provision and strive for Level A in the Quality Assessment Framework across commissioned services.

We will implement a programme of strategic reviews across all client groups to determine future priorities and commission based on evidenced need.

CarersThe situation now

Within the population, the number of unpaid carers has increased - 31,944 in 2001 to 33,364 in 2011 (+4%). Those providing 50+hrs increased 8,165 to 9,419 (+15%)

It is predicted that there are 6,109 unpaid carers aged 65+. This is 12% of this age group. Numbers may increase to 6,899 by 2020.

DMBC currently has 1,250 carers in 2012 who are receiving services, of whom 916 are over the age of 65