Hampshire County Council

Executive Member, Social Care Item 1

20 December 2002

Performance Assessment Framework

Report of the Director of Social Services

Contact: John Clifton, ext. 7283; Barbara Sorkin ext. 5985

1 Executive Summary

1.1 This report describes the Performance Assessment Framework (PAF) processes used by the Department of Health to measure national and local performance. It reports on Hampshire's results for 2001-2 and highlights key achievements and areas for improvement. The report explains the two star rating awarded to Hampshire Social Services and how this fits in to both the PAF and the Corporate Comprehensive Performance Assessment. Finally it identifies major themes from the Autumn Position Statement, recently reported to the Department of Health, which includes County targets for use in local and national monitoring.

1.2 Overall Hampshire's performance has improved, albeit with variations across sectors. The county was awarded the maximum classification for 10 of the 48 indicators published; 4 for child care and 6 for adults and older people. The minimum classification was awarded for 3 indicators (Employment, education and training of care leavers, Health care for looked after children and Provision of a statement of needs to adult service users); although acknowledging scope for improvement in these areas, difficulties in collecting information have contributed to the classification.

2 Introduction

2.1 The White Paper "Modernising Social Services" sets out the arrangements for assessing the performance of each Council with Social Services Responsibilities (CSSR). This assessment process pulls together information from a number of sources to provide a comprehensive overview of the social care performance of each council. This process includes the following elements:

2.2 Performance data. There are 50 high level performance indicators associated with the Performance Assessment Framework. Four of these indicators relate to health authorities and their interface with social care; of these, two are collected by Health Authority area and have been ignored in this analysis. The range of PAF indicators available facilitates direct comparison between councils, helps in the identification of regional and/or service trends whilst also allowing realistic targets to be set and monitored. They are underpinned by many indicators specific to the national agenda for social care; being derived from Quality Protects, National Service Frameworks, White Papers etc.

2.3 Evaluation. There are in-depth Social Services Inspectorate (SSI) reviews for specific services. These are increasingly being linked to work within councils on Best Value, where the SSI agree the scoping of the BV Review and play a more proactive role., replacing their historic role of auditing after the BV review is finalised. Historically SSI/Audit Commission Joint Reviews have looked at how well the council discharges its social services responsibilities every five years. This function is being replaced by the Comprehensive Performance Assessment process which looks at corporate health and the inter-relationships between departments in implementing corporate strategies.

2.4 Monitoring. The SSI Social Care Regions (SCR) are in frequent contact with councils and regularly monitor progress in achieving national targets. The main vehicles for this are the Spring and Autumn Position Statements which contain performance data, action plans and risk analysis. They also follow up concerns arising from statistical information, inspections, Reviews or health colleagues and liaise with District Auditors in approving Best Value Reviews and Performance Plans.

2.5 The Best Value Performance Plan, published annually by the council, contains a specified subset of the 50 PAF indicators which are used to assess the 'corporate health' of the county council. Forecasts for current year performance and targets for the following year are published here, highlighting the need for targets to be robust and in line with national and Public Service Agreement targets.

3 KEY NATIONAL MESSAGES 2002-2

3.1 The national picture emerging from last year's PAF indicators is that there has been an overall improvement in performance within personal social services, with variations between councils narrowing.

3.2 Performance at the interface, for which Health and Social Care are jointly accountable, is mixed.

3.3 Most cost indicators increased at a rate above inflation, with those relating to children's services rising most.

3.4 The balance between care at home and in a residential setting is improving, but there is scope for further improvement.

3.5 Virtually all children's and adult residential homes were inspected during 2001-2. From 1 April 2002 this responsibility transferred to the National Care Standards Commission, effectively removing 2 indicators from the PAF set.

3.6 Improvements continue to be made in children's services, although many councils still fall short of national objectives. For example, only 37% of councils reviewed all their cases.

3.7 34% of new users did not get their first service until more than 6 weeks after their initial contact with social services.

4 HAMPSHIRE'S PERFORMANCE

4.1 Hampshire's performance is reported on by client group. Detailed PSS PAF results are given in Appendix 1, with full details available from the Department of Health website at http://www.doh.gov.uk/paf/index.htm .

4.2 Adult & Older Person's Services

4.2.1 These indicators cover all people over 18; thus they include people with a physical disability, learning disability, mental health problems and all older people.

4.2.2 A summary of results for 2001-2 by indicators across all adults show:

A5

Emergency admissions to hospital (Interface indicator)

●●●

B11

Intensive home care as a % of home and residential care

●●

B12

Gross costs of providing intensive home care

●●

B17

Unit costs of home care for adults

●●●●

C27

Admissions of supported residents 18-64 to residential care

●●●●

C28

Households provided with intensive home care

●●

D36

Users who said they got help quickly

●●●●

D37

Users allocated a single room on entering permanent residential/nursing care

●●

D38

Equipment under £1,000 delivered within 3 weeks

●●●

D39

Percentage of people receiving a written statement of needs

D40

Clients receiving a review

●●

D42

Carer assessments

●●

D43

Waiting times for care packages

●●●●

E46

Users who said matters relating to race, culture or religion were noted

●●

E50

Assessments of adults and older people leading to provision of services

●●●●

4.2.3 Hampshire's performance for adults was variable. It was quite good for most services, but Hampshire performs less well at activities linked to intensive care and process/information collection activities.

4.2.4 The Department has been in dialogue with the Department of Health about the definitions that should be applied to "intensive" care in B11 and C28. These indicators do not reflect day care, luncheon clubs, meals on wheels or Direct Payments. Full details of the impact such combined services would have on these indicators are given in Appendix 2. Were such services included our recorded performance would certainly improve.

4.2.5 The disappointing performance under D39, statement of needs, reflects the inclusion of "simple" services - such as meals on wheels and the provision of sensory and some OT equipment - where provision of statements had been considered by the department as an unnecessary bureaucratic activity. However, training has been given to care managers raising the profile of the written statement of needs and the importance of recording when statements are provided to users. Although not showing in the classification awarded, Hampshire's performance has improved significantly rising from 52% to 70% of users receiving a statement of needs.

4.2.6 Hampshire believes that performance under D38, items of equipment delivered within 3 weeks, can be improved over the coming year. Performance for 2001-2 fell to 88% following the realisation that items provided through the Technician's service had not been counted correctly. Measures are being put in place to support these services, and performance is expected to be closer to 90% for 2002-3.

4.2.7 Hampshire is investing, jointly with Health partners, in activities to improve the interface indicators for emergency admissions and delayed discharges. The current impact of these is hard to quantify as information has to be provided from Health systems, and difficulties are being experienced disaggregating data to local authority areas. The Department is working closely with Health colleagues to solve this problem.

4.3 Older peoples services

4.3.1 These indicators supplement those for all adults.

4.3.2 A summary of results for 2001-2 of indicators specific to older person's services shows:

B13

Unit cost of residential or nursing care for older people

●●●

C26

Admissions of clients 65+ to residential or nursing care

●●●●●

C32

Older people helped to live at home

●●●

C33

Avoidable harm for older people (falls and hypothermia - interface indicator)

●●●●

C34

Inspections of adult residential care (predominantly older person's homes)

●●●●●

E47

Ethnicity of older people receiving assessments

●●

E48

Ethnicity of older people receiving services following an assessment

●●●●

E49

Assessments of older people per head of population

●●●●●

4.3.3 Performance is good, although as many indicators for all adults are more modest, this impacts on performance as perceived by some service users.

4.3.4 Historically performance has not appeared acceptable when supplying low level services to clients who remained in their own homes (C32). The counting mechanisms have now been corrected and show that Hampshire's performance is similar to other authorities in the relevant peer group.

4.3.5 Hampshire is considered 'very good' for the proportion of older people in the community receiving an assessment. This makes the 'ask questions' for assessments of older people from minority ethnic groups a concern. It is believed that this result is linked to changing demographic factors since the 1991 census. If this belief is proved incorrect with the publication of the 2001 census results, work will be done comparing the Department's practices with those of other authorities and more detailed demographic factors will be investigated.

4.4 Learning Disabilities

4.4.1 These indicators supplement those for all adults.

4.4.2 A summary of results for 2001-2 by indicators specific to users with a learning disability shows:

B14

Unit cost of residential or nursing care for LD clients

●●

C30

People with learning difficulties helped to live at home

●●●

4.4.3 As with many other unit costs, the poor unit cost indicator is mainly due to Hampshire's comparison with Shire counties, rather than neighbouring authorities in the South East. In addition to this, Hampshire is pursuing the objectives of the High Needs Strategy and, working with partner organisations, developing support services and accommodation which will enable people to remain in their family homes or move-on to homes of their own. Early stages of the development of supported living options as "move-on" opportunities for people in registered accommodation, are initially concentrating on individuals with less complex needs. As this progresses, a rise in the average cost of residential and nursing home care (B14) can be predicted, as the majority of placements in such homes will relate to people with higher needs.

4.5 Physical Disabilities

4.5.1 These indicators supplement those for all adults.

4.5.2 A summary of results for 2001-2 by indicators specific to physical disabilities shows:

B16

Unit cost of residential or nursing care for PD clients

●●●

C29

People with physical disabilities helped to live at home

●●●

4.5.3 Performance of services to people with a physical disability is about average.

4.5.4 Historically Hampshire's performance has not appeared acceptable when supplying low level services to clients who remained in their own homes (C29). The counting mechanisms have now been corrected and show that performance is similar to other authorities in the relevant peer group

4.6 Mental Health

4.6.1 These indicators supplement those for all adults.

4.6.2 A summary of results for 2001-2 by indicators specific to mental health show:

B15

Unit cost of residential or nursing care for MH clients

●●●

C31

People with mental health problems helped to live at home

●●●●●

4.6.3 The performance of services to people with a mental health problem is good. Historic problems around poor recording by social and health care workers in joint Community Mental Health Teams have been solved. The Department is working with health colleagues to develop a joint mental health information system (PHAMIS) needed for the implementation of the Mental Health National Service Framework.

4.7 Children's Services

4.7.1 In general performance is 'good' or 'very good' for 6 of the 19 indicators and 'acceptable' for a further 6. This represents a slight reduction in performance since 2000-1.

4.7.2 A summary of results for 2001-2 by indicator shows:

A1

Stability of placements of looked after children

●●●●●

A2

Educational qualifications of children looked after

●●●

A3

Re-registrations on the Child Protection Register

●●●

A4

Employment, education & training of care leavers

B7

% of children looked after in family placements

●●●

B8

Costs of services for children looked after

●●

B9

Unit costs of children's residential care

●●

B10

Unit costs of foster care

●●

C18

Warnings and convictions of looked after children

●●●

C19

Health of looked after children

C20

Reviews of child protection cases

●●●●

C21

Duration on the Child Protection Register

●●●●

C22

Under 10s looked after in a family setting

●●●

C23

Adoptions of children who had been looked after

●●●

C24

Children looked after absent from school

●●●●

C25

Inspections of children's homes

●●●●●

D35

Long term stability of children looked after

●●

E44

Relative expenditure on supporting families in the community

●●●●

E45

Ethnicity of children in need

●●

4.7.3 Overall the performance of children's services is acceptable. The government has provided extra money for children's services through Quality Protects and other initiatives, helping maintain performance against many indicators, but much of this money has been ring fenced to new activities which have placed pressure on the service. This pressure is two fold; limited resources have been stretched and management time has been diverted from core activities.

4.7.3 Several indicators are affected by the age profile of Hampshire's looked after children population, with around 60% being aged over 10 (with 17% being 16 or over). For adolescents who have been in care for a long period of time, who are looking to move into their own accommodation in the medium term, a change to a family based placement would be inappropriate (B7). Similarly, on initially moving into their own accommodation, they can affect D35 (stability of long term placements) adversely. It is expected that this demographic "blip" will be reduced as adolescent and care leaver services within the county, aimed at supporting these children in their family homes or independently, are expanded using Quality Protects and Supporting People monies.

4.7.4 During 2001-2 children's services were re-modelled. It is expected that the creation of the district reviewing teams will have improved review quality, consequently affecting services provided for children and the flow of information (C19) on the children concerned. As yet, the new arrangements have not been in place long enough for them to have settled down and impact on performance. In a similar way, the creation of the care leavers service should help educational attainment (A2) and increase contact with care leavers (A4) in the role of corporate parent; which remains until care leavers are in their early twenties.

4.7.5 A significant difficulty in the children's sector is recruitment and retention, of both staff and foster carers. The centralisation of the family placement team has resulted in improved "matching" of foster carers and children which has helped placement availability for younger children (C22).

4.7.6 The long term stability for looked after children (D35) remains poor. It is important to note the negative impact on this indicator of what are, in fact, positive policies including returning children placed outside county borders to Hampshire, so they can be closer to relatives, and older children preparing to leave care and moving into hostels. However, the shortage of suitable foster carers also affects this indicator.

4.7.7 The increases in unit costs for residential and foster care reflect the national trend, however Hampshire's residential care costs appear significantly higher than most other authorities. This is linked to changes in in-house residential provision where the early implementation of improved standards recommended by the National Care Standards Commission has resulted in a maximum size for children's residential homes of 6 children, so reducing placements in Hampshire by 16 and costing £1 million. Coupled with changes in use of some units, this is distorting the costs and occupancy rates for children's homes, particularly during the transition period.

4.7.8 Hampshire has a good reputation for the educational attainment of children in residential homes, being considered amongst the best nationally. The PAF indicator (A2) reflects this, although actual performance in 2001-2 was lower than last year acknowledging its wider base which includes foster children, children who have come into care recently and those with severe disabilities. As might be expected, the mix of such children varies between years and has a noticeable impact on academic performance. As part of re-modelling a team has been set up specialising in links with education; innovations include bursaries for children performing above expectations, personal education plans and improved contact with educational support workers.

4.8 Value for Money

4.8.1 Overall, Hampshire is providing services efficiently, at an acceptable cost. The SSI has announced proposals to include an 'area weighting factor' in future years which should facilitate comparison with other Shire counties; details of this are not yet finalised.

4.8.2 It should be recognised that as the policy to support more people at home gains momentum, the purchase of high dependency care will increase as a proportion of the total, causing Hampshire's unit costs to rise.

4.8.3 Departmental priorities were confirmed last year as remaining with services targeted at people assessed as being in greatest need; whilst managing steadily increasing demands within cash limited budgets. These imperatives impact upon both Hampshire's ability to provide a high volume of services to meet lower level needs and in the provision of increasing numbers of intensive care packages.

4.8.4 Historically it was not believed that people should be supported at home when it was cheaper to provide residential care, given the budget constraints upon the Department. Maintaining highly dependent individuals in the community is not a low cost option, although being a high profile government policy. The incremental expenditure on supporting people at home is particularly marked in rural areas due to the increased distances between clients and the lack of alternative facilities such as day care, luncheon clubs etc. Given the rural nature of much of Hampshire, this change in service provision will involve significant increases in expenditure.

4.8.5 Value for money - and quality - are, of course, the twin objectives of best value. The 2002-3 programme of reviews includes two major areas of activity: services for children in the community and for sensory services. It is anticipated that these fundamental reviews will lead to a range of improvements both in terms of quality, effectiveness and efficiency.

5 AUTUMN POSITION STATEMENT

5.1 The Autumn Position Statement is part of the six-monthly monitoring between the department and the DoH. Traditionally, the Autumn return concentrates on efficiency and effectiveness measures, children's services and progress towards targets set through National Service Frameworks and White Papers.

5.2 As part of this process mid-year estimates are provided for many PAF indicators, to help monitor improvement, along with past year (October-September) actual performance.

5.3 The Autumn return examines local authorities intentions regarding Care Trusts and its role in equalities issues. It is also used as a way of monitoring regional trends; such as the shortage of independent residential and nursing home places and the difficulties in attracting staff to social care.

5.4 A copy of the Autumn Position Statement has been made available in the members room.

6 CONCLUSIONS

6.1 The Performance Assessment Framework provides a very helpful comparative picture of overall performance, and highlights areas where further emphasis is required if Hampshire is to meet national priorities.

6.2 Whenever performance indicators are examined it is tempting to challenge whether the correct measures are being applied and whether all that should be counted, is indeed being counted. As the range of performance against PAF indicators is narrowing, it suggests that authorities are now counting similar activities against indicators.

6.3 Where it is felt that indicators do not provide an adequate picture of local performance, it is important to identify more relevant local measures. These are used for internal management processes and have been a feature of several Best Value reviews over the last few years.

6.4 It is not realistic to achieve top performance across the whole range of indicators in the framework, and it is important that Members identify priority areas for improvement in their consideration of the Department's core business and future budgetary position.

6.4 PAF largely provides a picture of inputs and outputs, rather than outcomes. Although this year's PAF contains some indicators concentrating more upon qualitative aspects of social care - such as user satisfaction and ethnicity - these are still in the minority. The user satisfaction questions have been found to contain flaws; for 2002-3 new questions are being asked of Older People concerning Home Care provision. It is very important that issues of quality and effectiveness are examined in a way that balances the more quantitative approach taken by the PAF range of indicators when making planning decisions.

6.5 An action plan, detailing proposed improvements on one and two blob indicators, will be taken to DMT in the new year. This will be made available to the executive member.

7 RECOMMENDATIONS

7.1 That this report be accepted.

7.2 That the executive member requests that the Social Care PRC advises her of matters of policy that require specific attention and of any actions required, subject to available resources.

Section 100 D - Local Government Act 1972 - Background Documents

The following documents disclose facts or matters on which this report, or an important part of it, is based and has been relied upon to a material extent in the preparation of this report.

None

NB the list excludes: