TLAP’s ISF event York 12th January 2016 –
issues resulting from the event
Practically how are ISFs reviewed? Is it a social work review of outcomes /
financial or both?
Let’s clearly distinguish between the personal budget – an agreed an amount of
money the council provides to a person to help them address their assessed eligible
need; and the ISF – an agreement between a provider and that person on how their
needs will be met by services.
The personal budget has to be reviewed by a social worker or a designated person
at identified times to check if the eligible needs and agreed outcome are being met,
or whether circumstances have changed. The timing of these reviews will depend
on risk to the individual and the public purse and if there is significant change in
circumstances. The review is part of the councils system for managing personal
budgets.
The ISF is about how that personal budget is used to address the assessed needs
and agreed outcomes i.e. the purchasing and delivery element.
The social work review of the personal budget and how it is deployed i.e. by an ISF,
and whether or not assessed need and outcomes are being met by that deployment.
The ISF arrangement should allow each individual a way of ending the agreement
with a provider with no fuss or problems.
What would be really useful and positive is if the council could have a system for
checking individual satisfaction levels, and support people to exit the ISF
arrangement if they are unhappy, and of course support them to re-engage another
ISF provider, without entering the formal social work personal budget review
mechanisms. How, and the ease with which this transaction can be managed is a
key issue for all parties.
So in answer to the question, the personal budget is reviewed, as usual in regard to
the social care / social work system, but the ISF is different, it is actioned rather than
reviewed.
If ISFs save money by providing less care / change in care worker T&Cs, how
will this ensure good quality care and staff?
ISFs may save money in some individual cases, because the money will be spent
more effectively in ways that support and do not replace informal networks of
support. (This saving should be held by the individual as part of their ISF to address
fluctuating need and flexibilities). In other cases the money will simply be spent
differently, but without an efficiency gain. Some the costs may go up as meeting
individual needs in non-standard ways may take more time and require greater skills.
Calderdale’s experience was that when using ISF arrangements overall cost
increase, and cost more than the block purchased council managed service.
However, the efficiencies are achieved because these increased costs enabled
people to stay at home when they may have otherwise have gone into residential
care, at much greater costs. I.e. the efficiency they experienced came from both
budget areas, domiciliary care and residential care taken together as a whole.
In either way of making efficiencies (better individual support, or delayed or avoided
entry to residential care) it is not necessarily the case that terms and conditions of
staff have to be varied. Except to say that, in both cases more person centred
responsive staff behaviours and skills are needed, elements which I suspect may
already be required in most job descriptions. Although, if terms and conditions
specify a rota or schedule for supporting people that is inflexible, these may well
have to be changed.
Good quality care will be enabled with an ISF arrangement because it will be what
the individual needs in the way that they want it, rather than a ‘get what you are
given service’.
Good quality staff will be retained because meeting individual needs better is more
rewarding than delivering badly timed, too quickly delivered services.
It is acknowledged that this response leads to the identification of two critical issues:
1. More money needs to be invested in domiciliary care
2. More person centred service may take more time both to work out and to
deliver,
3. More person centred service is likely to require different skills / competencies
on behalf of the worker involved
How is supply of care workers going to be addressed?
This is a major issue for councils, providers and the sector. The solution stretches
beyond a discussion about ISFs. It has to involve a national settlement around
funding for the Living wage, so the care sector can complete with its competing
sectors: retail, hospitality and restaurant. The solution will also involve developing a
structured career pathway for young people entering the sector including
qualifications and accreditation systems. See the Skills for Care web site.
How will you stop fear amongst care providers that ISFs may destabilise care
markets?
Places like Calderdale, where ISFs have been introduced into the domiciliary care
market, and Southwark, where they were introduced to the learnings disability
market, have not found that they destabilised the care market. Rather they did the
opposite and generated stability. This is because, in Calderdale’s case, the ISF
approach enabled providers who, for one reason or another, were not able to win a
place on the Councils three provider – geographically based block contract; were
never the less able to maintain a customer base by developing a more personcentred offer to their customers.
In the Southwark example, Choice Support were able to re-model their block
contract and sub-contract for the right service for some people which they were
previously unable to do.
There are plans in place to develop work with providers on ISFs that will help
develop this market area, enabling greater flexibility in providers without destabilising
the market. ISFs since the Care Act are a new innovation, practice is emerging.
How do you promote ISFs as a good news story across the system?
Nationally TLAP will include details of ISFs in its Newsletter and capture the learning
from learning sates and share via its web site.
Locally Councils may want to think about a comms strategy which could include web
site, DVD, social media, but perhaps most importantly is to work with social work
team once an ISF provider has been identified and some initial work undertaken with
the to promote the ISF option directly with people who use services.
A piece of work on ‘pooling budgets’
Pooling budgets is not an activity we (TLAP and ADASS) have focussed on in much
detail to date. But it is true that, especially where personal budget amounts are low
or being lowered, people can get more value and service where they work together
and pool some or all resources.
Thinking this through would require some specific and detailed work which I will see
if we can add into TLAP’s work programme for next year, but in the meantime there
seems to be two ways of doing this:
1. An independent ‘time bank’ approach is used, where people can share the
things they would like to do that others might want to join them on, and see if
there is a small group of people who would share the costs. At the time of
writing I am not aware of any bespoke software that is designed to enable this
to happen.
2. The social care worker, or broker organisation, or an ISF provider, working
with different individuals gets the necessary permissions to share a pooling
activity, and create shared budget activity. Again, finance management would
be critical to enabling this to happen easily and intuitively.
Level playing field for ISFs and DPs
I am presuming this query is about the ‘cash envelope’ for each initiative, with the
notion that DPs, it is generally accepted, getting less cash than council managed
services. This is a massive disincentive to people who might be interested in taking
a DP. The concern from councils is of course that with the employment liabilities the
councils have to pay the individual employer such as a work based pension and tax,
redundancy etc. DPs become an expensive option. The permitted DP rate offsets
these additional costs. However, DP teams should perhaps re-think the processes
around DPs, which can lead to often onerous audit functions that are costly. For
example, DPs are a legal way of councils dispensing their statutory duty, the
individual becomes responsible for meeting their needs. DPs get linked to services
via the assessment, but if the output of the assessment is an outcomes and needs
statement, DPs could be given, not for services but for achievement of outcomes
and to meet identified needs. Financial audit of how these needs are met would not
then be necessary, only a social work review of whether needs and outcomes are
being met. Claw back would be sacrificed in some cases, but if people can use DPs
more flexibly, lower DP amounts may be used more creatively. In any case, large
clawbacks means ineffective processes earlier on provided by the RAS and social
work assessment. Part of the problem not good practice.
A learning set in the South West please?
There is a learning set established for the SWest that resulted from the Birmingham
event, please contact sam.sly@enoughisenough.org.uk who is organising the
second peer LS meeting
Agreeing budgets that are outcome-focussed – how do you shift from focus on
cost to outcome?
Some councils have developed a matrix which has number of needs on the X axis
(clustered into groups of 2 or 3 at a time), and risks, if these needs are not met, on
the y axis. This produces a box for each level or risk and each level of need – a
matrix. Each box contain a sum of money. The advantage such a RAS matrix has is
that it is pre-populated and can be used by social workers when doing an
assessment with a person. It is based on their professional judgement. With line
management and competency based workforce training essential for consistency
and accuracy of the judgements. More details can be provide don request.
In the first instance the RAS matrix is populated by the councils current ‘service
costed’ RAS, but over time the sum of money will become more firmly linked to
needs and risks alone. It seems that in principle it may be desirable to the replace a
needs and risk RAS matrix with one focussing on outcomes, but this would take a
significant amount of work, and may not actually be possible since individual
outcomes are defined by the individual and may not correlate to needs and risks at
all. TLAP would be interested to hear form any councils working on this area.
The issue of sufficiency in RAS allocations is addressed where a needs and risk
RAS matrix is used in two ways: 1.That using a strength-based approach to
assessment enables money to be used differently i.e. to achieve outcomes and 2.
There will need to be a (perhaps annual) a review of whether allocations are actually
enabling people to purchase sufficient provision of whatever kind in the local market
to meet their needs (once a strength-based approach has been taken at
assessment)
Client contributions net or gross?
The best way to deal with client contributions is…one way or another! By which I
mean, it doesn’t really matter as long as the system is consistent and clear and
works for everyone concerned. There seem to be 3 options:
1. Pay the provider the PB minus the assessed contribution i.e. Net
2. Pay the provider the Full PB and ask them to collect the client contribution i.e.
Gross
3. Pay the provider the full PB and ask council officers collect the client
contribution, also Gross
It seems to me from a minimum process point of view that paying net is most straight
forward?
Can ISFs be held by an individual PA? Or independent trust? And
subcontracts (brokers) your package?
Some language difficulties here. If someone has a Personal Assistant then they are
employing that individual i.e. they will be an individual employer. They may be using
their own money or a direct payment to do this, but either way they are responsible
for the employment of that PA. In that case the arrangement would not be an ISF
arrangement.
However, a person paying for care themselves or a direct payment holder could
choose to pay a brokerage service, be that an individual or an organisation / trust to
use some or all of their DP or provided cash to purchase services on their behalf.
This could conceivably be called an ISF arrangement. Personally I think it confuses
the concept to call this arrangement an ISF. The individual, to my mind, is simply
contracting for a brokerage service that they want. An ISF, to me, is where a council
is contracting with a provider for a flexible arrangement between them and their
customer, i.e. it is part of the Council’s approach to direct service provision.
However, it should be noted, that over time even describing this as an ISF may
become a misnomer as what we are effectively talking about is actually contracting
in a way which creates flexibility so we get better outcomes
Could TLAP offer example, ‘straightforward’ i.e. two page’ contracts for local
authorities to emulate
Yes there is a simple example of a two-way agreement in the appendix of the Outline
Business case provided for the ISF event in both Birmingham and York
Newly qualified social workers understanding of ISFs
This is an issue, and TLAP with ADASS are working with Universities on ISFs and as
well as on initiatives connected to developing strength-based approaches more
generally. Councils own leadership and development courses need to support the
use and understanding of ISFs
How do we advertise ISF and benefits?
ISFs are beginning from a low baseline, they are in their early stages of
development, comms teams may be interested once success has been gained,
probably on a small scale initially? TLAP and seeking funding to continue the
promotion and development of ISFs nationally.
Easy read information needed
TLAP does not currently have easy read versions available of any of the work on
ISFs, subject to funding in 2016-17 we will look at delivering this.
How do ISFs fit with individual / integrated personal commissioning?
TLAP is already working with the IPC programme run by NHSE. The approach
lends itself to integrated working and pooling of resources for an individual at the
point of the provider.
Need to generate common understanding between key stakeholders
Agreed, TLAP will continue to work to do exactly this. Councils will need to address
this locally
How do ISFs work with models of PA employment i.e. providers providing a
PA?
Where providers employ staff to work as a PA for an individual, who in this case
would not be employing the PA, the provider would be coming to an understanding
of what is needed through discussion and agreement with the person using their
services. This effectively is an example of operating an ISF. The models of
employment for PAs used by the provider would need to be factored into the
negotiations with the customer. The customer might decide the model is not going to
work for them, and use a different provider, or they may decide it is acceptable and
work with the provider’s arrangement.
Set up Face book, Twitter, national group to share learning
TLAP’s comms team, may be able to address these points. There is a discussion
forum established for registered users of TLAPs web site.
ISFs or outcome based commissioning, or is this the same?
This is a great question, they are indeed aiming to do the same thing, and it is simply
a category issue about use of terms. i.e. ISFs are a way of commissioning for
outcomes. Commissioning for Outcomes formally is a set of practice standards see
the TLAP website for more information, ISFs are a mechanism for achieving
outcomes. Part of the commissioner’s outcomes based commissioning ‘toolbox’.
What are the basic checks that the LA completes when providers register?
This would be for procurement colleagues to agree, but they would need ensure
each organisation on the framework would be properly constituted and legitimate
legal entities. The general thrust would be PQQ sorts of questions. ITT type
questions would prescribe the service – precisely the action we are trying to avoid..
This service level activity needs to be led by the individual.
How do providers generate income / make money with an ISF?
A management charge would have to be agreed as part of the flexible contracting
arrangement with the council and the provider.
Can you tell us your experiences with joint funded packages?
This is an emerging are of work, TLAP will endeavour to gain case studies through
the peer learning set work
How have ISFs worked across shared hours?
I don’t have any knowledge about this, any comments from others would be
gratefully received via the discussion forum on TLAP’s web site
Workforce ‘mind sets’
These are critical for success, and using ISFs is firmly based on taking a more
strength-based approach to social acre and an outcomes based commissioning
approach. Culture change is paramount.