Agenda Item 5
Commissioning Review:
Core Service Offer
1
Objectives
• To review core service offer across universal, targeted
and specialist tiers
• To improve outcomes
• To identify efficiencies and cost reductions
• To pursue total place thinking
• To seek opportunities available through partnership
working
2
Principles
• Pragmatic and time-limited
• Needs focused and whole system thinking
• Green-field approach
• Challenging – back to basics
• Searching for minimum offer – to be supplemented with
service add-ons where budgets allow or political
priorities require
3
Radical efficiencies
•
Different, better, cheaper
•
Radical efficiency turns the role of provider on its head – no longer
solution ‘deliverers’, but pioneers of a new type of public service,
asking difficult questions about who they are trying to serve and what
they are trying to achieve
•
Services will look different in different areas
•
Radically efficient systemic reform moves from being desirable to
being purposeful, pragmatic and urgent
•
Embedding radical efficiency at the heart of a new approach to public
services would require a fundamental reshaping of accountability
frameworks, funding sources and allocations; understanding of
risk and of shared values
•
Better together – for radical efficiency to be possible, integration has
to be a habit and an instinct, not a behaviour forced into being by
financial reward or legislation
The Innovation Unit 2009
Approach
Project
Scoping
Needs
Analysis
Service
Analysis
Policy
Review
JCG
Workshop
JSNA
Review
SUM Interviews
Develop
Approach
KPI
Analysis
Workforce requirements
Project
Initiation
Service
Specs
Questionnaires
Policy review to identify
statutory requirements
Service Mapping
VFM and Impact
Identification of core
functions
3 Projects
Needs
confirmed
As Is
Picture
Options +
Costings
Conclusions
Configuration
to core
functions
Universal Under 5,
Early Intervention
and Complex
Scope for
integration
DMT review
Resources:
Reshape,
Recycle or
Released
Proposed
Future
Model
Political
consideration
Decisions on
selected
transformation
Agreed scope
Service
Transformation
5
Needs analysis conclusions
• Research from JSNA, services specifications, KPIs
• Confirms current needs analysis still appropriate to
inform service planning
• Suggests further scope to strengthen the impact of
services – particularly at the targeted tier
• Needs analysis has been used to underpin the review of
the core offer
6
Proposed Strategic Direction
Push Down
Step 2: Over next 12-36
months meet some
complex needs earlier
Step 3: Reshape early
intervention services on
an invest to save basis,
reducing costs where
possible
Step 4: Achieve
Further Savings
Improve Outcomes
Locality Model
Multi-Agency Teams
Pull Up
Step 1: Over next 12
months redirect
efficiencies from
universal tier
i.e. A Whole System Approach
7
Conclusions: Universal Services
Universal Under 5 Proposal
Vision
• Within 12 months an integrated partnership service will provide a
core programme of advice, assessments, and development
interventions for all pregnant women, children under the age of 5
and their families in Lewisham, reducing costs and improving the
efficiency and effectiveness of local services.
Objectives of Project Scoping
• To define the core universal under 5 service offer and service model
for its delivery
• To reduce costs of service provision
• To improve outcomes
• To achieve significant savings across the CYP partnership
9
‘As is’ mapped against ‘To be’ Services by Tier:
‘As is’ Services by Tier: Universal
UNIVERSAL
LOCAL AUTHORITY (GEN FUND)
LA/PCT (GEN FUND & GRANT)
Standards & Achievement: Strategic Secondary
Access & Support: IYSS (Youth Service Areas,
Borough-Wide Project and Programme and Activity)
Access & Support: IYSS (Young People's
Participation Project)
Standards & Achievement: Strategic early years
Access & Support: IYSS (IAG)
Standards & Achievement: Governor services
Standards & Achievement: Business & Governor
Services
Access & Support: IYSS (Adventure Playgrounds)
Standards & Achievement: Strategic Primary
HEALTH
PCT CHS: Health Visiting
PCT CHS: School Age Nursing
PCT CHS: SRH services (Adults)
PCT: Newborn Hearing Screening Programme
(Southwark Provider)
Access & Support: IYSS (Summer Holiday Activities) PCT: Vision Screening (Kings College Hospital)
Access & Support: Educational Access (Admissions) Education & Development: Strategic ICT
UHL: Midwifery Service
Mayor's Office: Young Mayor & Advisors
Education & Development: 14-19
PCT: GPs
Mayor's Office: Young Citizens Panel
Education & Development: Pupil Places
Education & Development: BSF school engagement
Education & Development: PCP Programme
Education & Development: Healthy Schools
Programme?
GRANT
Under 5's + provision
Children's Centres, Childcare & Play
(Sure Start Grant)
5 Steps Community Nursery
(CSU funded)
Ackroyd Children and Family
(CSU funded)
Acorn Children's Club
(CSU funded)
Bunbury Childminders Project
(CSU funded)
Lewisham Toy Library
(CSU funded)
Playhouse Community Nursery
(CSU funded)
St Andrews Community Nursery
(CSU funded)
Lewisham Opportunities Pre-School
(CSU funded)
Lewisham Playbus
(CSU funded)
Youth provision
2nd Deptford Scouts
(CSU funded)
Forest Hill Youth Project/ Platform 1
(CSU funded)
PSLA - Lewisham Branch
(CSU funded)
Wesley Hall Youth Committee
(CSU funded)
Young Lewisham Project
(CSU funded)
Youth Aid Lewisham
(CSU funded)
Lewisham Manor Scouts
(CSU funded)
Lewisham Young Women's Resource Project
(CSU funded)
Limelight Family Learning Centre
(CSU funded)
Marvels Lane Boys Club
(CSU funded)
Access & Support: IYSS (TP Prevention)
Play areas
Somerville Adventure Playground
(CSU funded)
Education
Supplementary Schools x 17
(Funded through LCF)
Other
Extended services
Conclusions: 1
• The majority of universal services for the Under 5s are
health related and determined by the key elements of the
CHPP, with the main exception being the early years
foundation stage (i.e. free entitlement to 3 and 4 yr olds).
• These requirements are likely to continue and are
consistent with indicative Coalition policy.
• This presents an opportunity to stop children’s centre
universal offer and re-invest into targeted services (e.g.
newly configured Early Intervention Service) / or continue
targeted provision within 30% most deprived areas.
11
Conclusions: 2
• Need to review the minimum role of LA i.e. in regulating PVI nursery
sector, academy schools and in the provision of information to children
and families
• Further opportunities exist to review the universal youth offer, and
reapply similar strategic principles. For example refocusing service to
targeted provision within 30% most deprived areas – potential to
income generate or leave to the 3rd sector
• Need to challenge some strategic programmes i.e. NCMP, Healthy
Schools Programme, TP Prevention, SRE commissioned through
Health, Public Health programmes – should we reallocate investment
to core health services and enable them to undertake activity in these
areas
• Impact of reduced universal provision could be significant for the third
sector
Universal Under 5 Proposal
•
The majority of universal services for the Under 5s are health related and
determined by the key elements of the Child Health Promotion Programme
(CHPP), with the main exception being the early years foundation stage.
•
The local authority is the main beneficiary of savings which could be achieved
through this proposal i.e. the reduction of non essential universal activity such
as children’s centre programmes, and the increased targeting of services and
interventions.
Key Conclusion: There is limited need to develop an integrated
Universal Service (whether for Under 5s or 0-19s). Activity is best left
to the health sector with discrete areas of educational input.
13
Universal Offer “To Be”
Antenatal
Newborn
1 to 6 weeks
6 Weeks to 6 mths
6 Months to 1 Yr
1-3 years
3-4 years
4-5 years
A full health
and social care
assessment by
12 weeks
Examination
and
Assessments
New baby
review by 14
days
Health Review 6-8
weeks
7-9 months
distribution of
Bookstart packs
13 months
immunisation
s
3 years
immunisations
Healthcare
review and
Foundation
Stage Profile
Routine
antenatal care
and screening
Newborn
healthcare
support:
feeding,
parenting, SIDS
Assessment
maternal
mental health
10-14 days
Assessment
maternal mental
health 6-8 weeks
Health Review 7
–11 months
Health
Review 2
years
15 hours Early
Education
Entitlement
National Child
Measurement
Programme
(reception
class)
28 week health
review for
prospective
mother/father
Newborn
hearing
screening
Neonatal
BCG
Assessment
maternal mental
health 3-4 months
12 month
immunisations
Dental check
Vitamin K
Distribution
Follow up
new birth visit
Immunisations at:
- 8 weeks
- 3 months
- 4 months
Breast
feeding
support
Breast feeding
support
Access to
community
health clinics
Access to
community health
clinics
Hearing &
Vision
Screening
15 hours Early
Education
Entitlement
Access to
community health
clinics
Access to
community
health clinics
Signposting to further resources
Access to advice and professional support
14
Conclusions: Targeted Services
15
Vision for an Early Intervention Service
• The partnership will provide targeted provision for children, young
people age 0-19, and their families, across Lewisham’s four
children’s services areas and all settings.
• Services will interface seamlessly with universal services based on
robust and holistic assessments of need, ensuring no wrong door,
and providing interventions as a team around the child/family.
• This will improve outcomes and prevent needs escalating to a
specialist level. Improved needs assessment and targeting of
resources will both improve the efficiency and effectiveness of local
services and reduce costs.
Analysis to date suggests significant support amongst
professionals for a model of this kind, providing a core offer of skills
and interventions within each of the Children’s Services Areas
16
‘As is’ mapped against ‘To be’ Services
‘As is’ Services
by Tier: Targeted
by Tier: TARGETED
LOCAL AUTHORITY (GEN FUND)
Children's Services: LISA
Children's Services: Referral & Assessment
LA/PCT (GEN FUND & GRANT)
Access & Support: IYSS
(Youth Service)
Access & Support: IYSS
(Positive Activities Fund)
Children's Services: Children With Disabilities
Access & Support: IYSS
(Lewisham Autism Support - Commissioned Service) (Key work & mentoring)
Access & Support: Educational Access
Education & Development: Connexions
(Attendance & Welfare)
Access & Support: Educational Access
(LAC teachers)
Access & Support: Educational Access
(Exclusions )
Access & Support: Inclusion Service
(Educational Psychologists)
Access & Support: Inclusion Service
(Specialist teachers - CIT, VI, HI, MSI)
Access & Support: Inclusion Service
(Under 5's Early Intervention Team)
HEALTH
PCT CHS: Health Visiting
PCT CHS: School Age Nursing
PCT CHS: Family Nurse Partnership
PCT CHS: Community Paediatricians
PCT Public Health: Smoking Cessation Service
PCT Paediatric Audiology: Tier 2
(Southwark Provider)
UHL Midwifery service: Teenage midwives
GRANT
Youth provision
Young Lewisham Project
(CSU)
Platform 1 - Forest Hill Youth Project
(CSU)
Gems Youth Project
(CSU Funded)
Lewisham Way Youth & Community Centre
(CSU)
TP Prevention Commissioned Services
(ABG)
Sure Start Plus - TP support
(Sure Start Grant)
Youth Inclusion Support Panel
(LCF & YJB)
YOS Triage
(LCF & YJB)
Inclusion Service - BEST Team
(ABG)
NEET Programme
(WNF)
Restorative Neighbourhood project (WNF)
Broadening Horizons Leisure Card
(Big Lottery)
Family support
Social Work Company -Targeted Family Support
Service
(Grant & LBL)
YOS Senior Parenting Officer
(YJB)
SHS & Welcare - Parenting Coordinators
(PSSG & PEIP)
School focus
Young People’s Health Project – Mandiani
(LCF)
The Children’s Society: Genesis Project – Supporting
Transitions
Healthy Weight PT Advisor in SA nursing
(Grant?)
SLAM: Targeted Mental Health in Schools
(TaMHS)
Social Work Company: Targeted Mental Health in
Schools
SAGE Educational Trust - Parents & Schools
Learning Together
(WNF)
Education Business Partners - Learning Partners
(WNF)
Choice Advisors
Support for Disabled children & their families
Lewisham Opportunities Pre-School
(CSU funded)
Laban: Integrated Youth Dance
(Big Lottery)
Ravensbourne Project
(Aiming High/LCF)
SIGNAL
(Aiming High / LCF)
PSLA - Parent Partnership Service
(DCSF)
Substance misuse
CRI: Tier 2 Drug & Alcohol Service
(Drug Treatment Agency)
Conclusions: 1
• There are a number of areas where services overlap, with similar
activities or functions being delivered by different services
• Family support, outreach, mentoring and youth key work and welfare
services have the potential to be consolidated
• Support for children with additional needs can be improved through
developing expert multi-disciplinary teams, pathways and processes
with potential to improve
• Targeted support for children Under 5 has further potential for
consolidation, and to shift the focus to CYP and families in a range
of settings
• We should make better use of our core health services in delivering
targeted support
Initial analysis suggests there is real potential to both reduce costs,
extend the penetration of our targeted offer and improve outcomes
18
Conclusions: 2
• Many services remain too ‘settings’ focused – e.g. Clinics, CCs,
Schools or PVI nurseries, with CYP benefiting further down the
value chain
• Outcomes can be improved with a radical rethink of pathways
across the piece
• Many services are suffering from ‘scope creep’ – the partnership
needs to agree its function and remit and those areas which can be
left to the market
• Opportunity to review strategic programmes and services – where
evidence of impact can be identified
Clarity of role and evidence based pathways are needed
Family support & outreach: An Example
Attendance and
Welfare Officer
Family Support Worker
Key Worker
Health Professional
HV/School Nurse
?
? ?
Mentor
?
?
Parent Involvement
Officer
Outreach Officer
Family
Child / Young Person
8 professionals, 1 family, 1 core objective: to
support the family to become self sufficient and
cope with challenging circumstances
Parenting Trainer
Conclusion: There is significant scope to be smarter in how we
pursue our shared goals and outcomes
20
Teenage Pregnancy : An Example
Family Nurse
Partnership
YOS Officer
Pharmacies
School Nurse
Connexions
SRH Service in
Schools
Sure Start Plus
GP
?
TP Officer
?
?
?
Social Worker
Youth Service
LAC Nurse
Young Girl
Family
VCS
Services
Girl’s Partner
Many different professionals providing advice
and support before, during and after pregnancy
School
Can we both simplify and strengthen our interventions?
21
What should be provided?
An Early Intervention Service should provide a core offer of:
A multi-agency locality panel allocating:
• Lead on co-ordination of TAC
• Targeted health visiting provision
• Targeted family support including parenting assessments, parental
support, family group conferencing and family mediation,
challenging non-school attendance
• Youth key work sessions and diversionary programmes
• Targeted mental health support to both CYP and their families
• Targeted school age nursing
• Targeted support for children with disabilities and their families
(including those with ASD) – in school, home & community settings
• Targeted substance misuse support
• Targeted support to those at risk of becoming pregnant and teenage
parents
22
Total Place Croydon: child, family, place
Croydon’s case for Early Intervention:
• very early experiences set the scene for later life
• we can identify early signs of difficulty
• the costs of getting the early years wrong are high
• it makes good economic sense to intervene early
• the cost-benefit evidence base in the UK is not yet sufficiently robust BUT there is a
growing understanding of what works, including:
– Support for both fathers and mothers in the earliest weeks and months is very
important - especially for mothers experiencing postnatal depression
– Parenting programmes can significantly improve parent-child relationships, build
parental skill and capacity, and significantly change child behaviour and
outcomes
– Families with high levels of need require intensive, tenacious interventions
addressing multiple issues
– The quality of the practitioner (in engaging parents, building relationships,
responding to the needs of the group) has an enormous impact on the outcomes
an intervention can secure
23
Total Place Croydon: child, family, place
Croydon Total Place Proposals
•
•
•
•
Total Place Proposal: Family Partnership teams in localities
The Family Partnership Team will have a devolved budget, including health visiting,
children’s centre revenue, parts of the social care and Special Educational Need
(SEN) budgets, speech and language etc.
Proposal to have some flexibility over use of Dedicated Schools Grant (DSG) in a
locality and also some use of Job Centre Plus funding
The team will own outcomes for all families in their geographical area.
Family Partnership teams will focus on:
• Attachment, including fathers
• Mothers and fathers responsive, authoritative parenting skills
• Family emotional wellbeing, especially maternal mental health and parental
relationships
• Supportive social connections
• Responding to specific needs e.g. learning difficulties
• Affordable, clean, warm housing
24
Current Work and Next Steps
• Developing configuration options and workforce profile
• Costings of service models
• Considering implications of changing grant context – and
any need to reinvest from savings released elsewhere
• Further consultation with key stakeholders
25
Conclusions: Specialist Services
26
Complex Needs and Resource Allocation
Vision
• Within 36 months the partnership will support those children and
young people with the most complex needs through integrated
planning, resource allocation and seamless delivery of care and
support, meeting needs in borough wherever possible.
Through:
• Improved resource allocation
• Alternative models of specialist provision to placements
• Remodelling specialist provision in borough
• Redesign core pathways
• Transition to adult services
27
‘As is’ services – by Specialist Tier
LOCAL AUTHORITY
Children's Services: Family Support & Intervention
Children's Services: Family Support & Intervention
(spot purchased supervised contact)
Children's Services: Family Support & Intervention
(Galton - Family Group Conferencing)
Children's Services: Adoption, LAC & Leaving Care
Children's Services:Children in Need
(CWDS)
Children's Services:Children in Need
(Portage)
Children's Services: Children in Need
(MAPP & IAT)
Children's Services: Children in Need
(Meliot Road)
Children's Services: Business Support & Fostering
Access & Support: Educational Access (SEN)
Access & Support: Educational Access
(Strengthening Specialist Provision)
Community Services - YOS
(key work)
Community Services YOS (Reparation Orders)
LA/PCT (GEN FUND & GRANT)
Children's Services: Children in Need
(ExcelCare Commissioned Service)
Children's Services: Children in Need
(Crossroads Commissioned Service)
Freewood
(Aiming High)
House on the Hill
(Aiming High)
Ravensbourne Project
(Aiming High)
CSC: Hidden Harm service
(PEIP & CSC/DAAT tbc)
HEALTH
GRANT
PCT CHS: Community Paediatricians
Support for Disabled Children & their families
Contact A Family
(CSU funded)
Contact A Family: Parent Participation Worker
(Aiming High)
PCT CHS: Children's Community Nursing Team
PCT CHS: LAC Nurse Team
(Safeguarding team)
PCT CHS: Therapies Services
(SLT, Physio & OT)
PCT CHS: Special Needs Nursing Team
PCT CHS: Safeguarding Team
Paediatric Audiology - Tier 3
(Southwark provider)
CAMHS: Independent Sector Inpatient Provision
SLAM: Inpatient Provision
SLAM: Outpatient Provision
SLAM: SYMBOL Team
SLAM: ARTS Service
SLAM: Generic Teams x 2
SLAM: Inclusion Service
(schools)
SLAM: Lewisham Young People's Service
SLAM: Community Team
(GP Surgeries)
SLAM: Neuro-Development Team
Family support
FIP
(YCAP & Housing)
Building Bridges
(PCT)
Substance misuse
CRI: Tier 3 Drug & Alcohol Service
(Drug Treatment Agency)
Key Lines Of Enquiry
• Understanding use of services at the top of the triangle by different
cohorts of children and young people, and the movement between
services for some of our children
• The processes informing resource allocation
• Exploring reasons why our children are becoming looked after and
potential of specialist family support services to prevent this
• Evidence of impact of services supporting CYP to reduce risk of
placements or residential service interventions – i.e. Invest to save
• Case Studies to understand more about pathways and experiences
of children and young people within this tier, and use of resources
throughout their journey
• Exploration of business development opportunities with partners or
neighbouring areas e.g. Psychiatric Intensive Care Unit for CYP,
Rehabilitation Care
29
Conclusions:1
Resource Allocation
• Budget pressures within: CAMHS Tier 4, CAMHS independent
sector, SEN, Continuing Care, LAC
• Rising demand/need for specialist interventions
• Access to resources such as LAC placements or CAMHS Tier 4
inpatient provision is not currently through a panel system
• The most complex cases are often supported by more than one
service area and budgets – leading to inefficiencies and wasted
resources as different pathways cross over
30
Conclusions:2
Resource Allocation
• Scope to increase budget control through implementation of panel
process for decisions to accommodate, or provide Tier 4 CAMHS
treatment
• Holistic planning of care and intervention could lead to reduced
spend
• Further potential to commission services, introduce Preferred
Provider Frameworks across partnership (and wider i.e. with
neighbouring boroughs) to achieve better rates and cost volume
discounts
31
Conclusions: 3
Preventative services being explored
• Extension of the CAMHS Dialectical Behaviour Therapy (DBT)
outpatient service for emerging personality disorders
• Development of an Eating Disorder outpatient provision
• Assertive outreach service and day-care provision
• Specialist Family Support and Intervention
• Crisis intervention service to respond to cases at the point of family
breakdown and divert children from care
32
Next Steps
Next Steps
• To consult with DMT on proposed service
reconfiguration options
• Continued review of central government policy and
implications as this changes
• To model service costs and savings, and impact of
changing grant context
• To continue assessing strength of business case for any
invest to save proposals – particularly at the
targeted/specialist tier
• To consider impact of proposals on service users and
wider community
34