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Contact: Rhiannon Hodson, ext. 7290; Barbara Sorkin ext. 5985

1 EXECUTIVE SUMMARY

1.1 This report describes the Performance Assessment Framework (PAF) used by the Department of Health to measure national and local performance. It reports on Hampshire's results for 2000-1, recently published, and highlights key achievements as well as areas for improvement. Finally it identifies major themes from the Autumn Position Statement, recently reported to the Department of Health, which sets County targets for the next few years for use in local and national monitoring.

1.2 Overall Hampshire's performance has improved, particularly in the child care sector. The county was awarded the maximum classification for 11 of the 44 indicators published; 5 for child care and 6 for adults and older people.

1.3 The minimum classification was awarded for 4 indicators (helping older people at home, helping people with a physical disability at home, providing a statement of needs and health care for looked after children). Although acknowledging relatively poor performance in 3 of these areas, data collection difficulties have contributed significantly to the classifications. The action underway to address the issues concerned is outlined.

1.4 The Executive Member for Social Care has requested the Policy Review Committee review the department's performance against the PAF indicators, to note the work underway to address the issues arising and recommend any future work needed.

2 INTRODUCTION

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

2.2 Performance data. When fully implemented, there will be 50 performance indicators associated with the Performance Assessment Framework (PAF). These are listed in Appendix 1. For 2000-1, information on 48 of the 50 indicators has been published. PAF indicators are designed to allow direct comparison between councils and, over time, allow targets to be set and monitored. The Department of Health sets bands which denote the level of performance against each indicator :

· (one blob) investigate urgently

·· (two blobs) ask questions

··· (three blobs) acceptable, but possibly room for improvement

···· (four blobs) good

····· (five blobs) very good

PAF indicators are very broad measures of performance and have a number of drawbacks : they are based on statistical returns and surveys which relate to performance up to 18 months earlier by the time they are published, they are predominantly measures of activity, they are not outcome focused and there are few measures relating to the quality of care received.

2.3 Evaluation. The Social Services Inspectorate (SSI) inspects social services and the SSI/Audit Commission together conduct Joint Reviews looking at how well the council discharges its social services responsibilities. The SSI carry out at least three inspections on every council over a five year period. Additionally, a Joint Review occurs every five years.

2.4 Monitoring. The SSI Social Care Regions (SCR) are in frequent contact with councils and regularly monitor progress in achieving national targets. They also follow up concerns arising from performance indicators, inspections, Joint Reviews and liaise with District Auditors in auditing Best Value Reviews and Performance Plans.

2.5 The Best Value Performance Plan. This is published annually at the end of March by the council and contains a specific subset of the 50 PAF indicators (those which are also `Best Value Performance Indicators') which are used to assess the 'corporate health' of the county council. For these indicators, forecasts for the current year and targets for the following year are prepared, which need to be robust and in line with national targets.

2.6 Overall rating. It is proposed that for 2001-2 onwards each council with Social Services responsibilities will be given a performance `rating' for Adults and Children's Services. These will be based on current levels of performance and the SSI's understanding of each council's prospects for improvement. The initial ratings will be published during May/June 2002. These ratings will :

"provide a simple summary of performance that service users and members of the public will understand. A service user will know that a council with zero stars is among the worst performing councils, and one with three stars is among the best."

LASSL(2001)9 from the Department of Health

A briefing paper on this new initiative is included as Appendix 2.

3 KEY NATIONAL MESSAGES FROM PAF RESULTS FOR 2000-1

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 any variations between councils narrowing.

3.2 On cost indicators, and some others, there is a noticeable difference between London and the South East and the rest of the country. The definition for unit costs has changed for 2000-1, with more management costs and capital charges being included in the calculation for the first time.

3.3 Several councils could not provide information for new indicators, and five could not supply financial information by the deadline for the report. However, there was an overall improvement in data quality.

3.4 When the data was published in October 2001, the Secretary of State also announced a list of the 15 best performing and the 14 worst performing authorities. The method used to determine this ranking is given in Appendix 2. Hampshire is identified as a middle ranking authority, but data has not been made available to determine our position relative to other authorities.

3.5 A more detailed assessment of the national picture, linked to Hampshire's performance, is given in Appendix 3.

4 HAMPSHIRE'S PERFORMANCE AGAINST PAF INDICATORS FOR 2000-1

4.1 In considering Hampshire's performance against the PAF indicators, it is important to take note of our funding position. Many councils in SE England receive a low Standard Spending Assessment (SSA) due to their perceived affluence and consequential reduction in need for local authority provision of social care. Despite this, 'affluent' councils are measured against the same targets (for example, the number of people helped per thousand in the community) as those deemed by the Government to have a higher need for social care. This distorts the banding, and may account in some way for why many of the councils 'named and shamed' by the Department of Health in October were in SE England. A briefing on this issue is included as Appendix 4.

4.2 Hampshire's performance is reported on by client group. Detailed PAF results are given in Appendix 5, with full details available from the Department of Health website at http://www.doh.gov.uk/paf/index.htm .

4.3 Children's Services

4.3.1 In general Hampshire's performance is 'good' or 'very good' for 8 of the 18 indicators and 'acceptable' for a further 4. This is an improvement on last year's performance. However, lower scores than expected were awarded for several indicators, but this was linked to government definitions preventing the counting of some children in Family and Friends placements (on which Hampshire is currently developing national policy with the DoH).

4.3.2 A summary of results for 2000-1 by indicator shows:

A1	Stability of placements of looked after children	Very good
A2	Educational qualifications of children looked after	Good
A3	Re-registrations on the Child Protection Register	Very good
B7	% of children looked after in family placements	Acceptable

B8

Costs of services for children looked after

Ask questions

B9	Unit costs of children's residential care	Acceptable
B10	Unit costs of foster care	Ask questions
C18	Warnings and convictions of looked after children	Acceptable
C19	Health of looked after children	Investigate urgently
C20	Reviews of child protection cases	Acceptable
C21	Duration on the Child Protection Register	Good
C22	Under 10s looked after in a family setting	Ask questions
C23	Adoptions of children who had been looked after	Good
C24	Children looked after absent from school	Good
C25	Inspections of children's homes	Very good
D35	Long term stability of children looked after	Ask questions
E44	Relative expenditure on supporting families in the community	Good
E45	Ethnicity of children in need (1999/2000 data)	Ask questions

4.3.3 Taken overall the performance of Hampshire's children's services is good, although there is room for improvement. The government has provided extra money for children's services through Quality Protects and other initiatives, helping progress improve against many indicators.

4.3.3 Several indicators are affected by the age profile of the looked after children population. 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 and independently, are expanded using Quality Protects monies; these services will also improve Hampshire's relative expenditure on family support (E44).

4.3.4 Over the last year there is evidence that the Adolescent Support Service has already had some effect on helping young people to remain with their families. This has helped stabilise the number of children looked after.

4.3.5 Many of the County's difficulties in the children's sector involve recruitment and retention issues, for both staff and carers (to provide sufficient foster carers and adoptive parents for Hampshire's looked after children). The centralisation of the family placement team has resulted in a net gain of foster carers, at a time of severe recruitment difficulties. This will allow a better targeted "matching" of foster carers and children, which is expected to increase placement stability. Improved data collection and more detailed costings - which remain priorities - are promoting greater understanding and better decision making.

4.3.6 Fourteen professional foster carers were appointed earlier this financial year, together with additional support workers, who will offer peer support to foster carers and provide a response out of hours. This should help to improve performance under D35 for the current, and future, years.

4.3.7 The increases in unit costs for residential and foster care are mainly caused by a change in government definitions, although a shortage of available placements has led to some price increases. Benchmarking for unit costs has been established and this has been the subject of further examination within the Best Value review of looked after children's services that is underway.

4.3.8 Residential costs will appear high in comparison with other authorities for several reasons:

Hampshire's in-house homes frequently offer outreach services to children in the community. These services are effectively treated as residential expenditure.

Several homes were undergoing a change of use during the year, attracting residential cost expenditure whilst having no residents.

4.3.9 A residential strategy for children has been formulated, which will help improve the use of available resources. This is designed to support more children in their own homes, make better use of in-house facilities and reduce the numbers of out-of-county placements required.

4.3.10 All PAF indicators measuring care in a family setting are affected by the rule preventing the counting of children placed with their own parents. This type of care is considered good practice, but is omitted from the statistics. It is believed that if these indicators were amended to include these children, Hampshire's performance would be rated 'good' or 'very good' rather than acceptable.

4.3.11 The County has a very good reputation for the educational attainment of children living in in-house residential homes; being considered amongst the best nationally. The PAF indicator (A2) reflects this, although having a wider base which includes foster children, children who have come into care recently and those with severe disabilities.

4.4 Older peoples services

4.4.1 Many indicators relating to services for older people come under the heading of adult services, and are not collected by specific client group.

4.4.2 A summary of results for 2000-1 by indicators specific to older person's services shows:

B13	Unit cost of residential or nursing care for older people	Acceptable
C26	Admissions of clients 65+ to residential or nursing care	Very good
C32	Older people helped to live at home	Investigate urgently
C34	Inspections of adult residential care (predominantly older person's homes)	Very good
E49	Assessments of older people per head of population	Good

4.4.3 Taken overall the performance of Hampshire's services to older people is good when arranging residential care. However, performance is not as good at supplying low level services to clients who remain in their own homes.

4.4.4 This is probably caused by two main factors.

Within cash limited budgets, a larger proportion of resources are targeted upon clients with the highest needs. However, the recent availability of partnership grants, and the introduction of intermediate care have enabled the provision of numerous innovative services to support more older people in their own homes.

In Hampshire, the voluntary sector has historically been aided (through both grants and purchasing) to supply a wide range of low level support services to a reasonable level. Many of these schemes are excluded from this indicator, as people are allowed to access these services without formally going through a care management process.

4.4.5 Achieving significant progress against some indicators in the short term is likely to prove extremely difficult. For instance, under C32 - the number of older people helped to live at home per 1,000 population aged 65 or over - Hampshire assisted 37 in 2000-1, compared with a shire county average of 71, and a "very good" target of between 100-140. Research with other counties has identified 21 existing services where the clients can potentially be counted, but we have not included these people historically. Work is underway to size these services and identify incremental clients for inclusion in this year's returns. This work is described in more detail in Appendix 6.

4.4.6 Hampshire is considered 'good' for the proportion of older people in the community receiving an assessment. For adults and older people the County was given an 'acceptable' ranking for people going on to access services. Given that these are average, the below average results for supporting older people at home seems to be an anomaly and will require close benchmarking against other authorities to discover why results vary so significantly.

4.5 Learning Disabilities

4.5.1 Many indicators relating to services for clients with Learning Disabilities come under the heading of adult services, and are not collected by client group.

4.5.2 A summary of results for 2000-1 by indicators specific to learning disability shows:

B14	Unit cost of residential or nursing care for LD clients	Ask questions
C30	People with learning difficulties helped to live at home	Ask questions

4.5.3 Both indicators reflect a worse situation than last year, so there is scope for improvement. The worsening of the unit cost indicator is probably more closely linked to Hampshire's comparison with Shire counties, many of whom are outside the London and South East area, where target costs have moved disproportionately. If Hampshire's costs are compared against the Outer London criteria, with whom many costs are comparable, performance would have been similar to previous years.

4.5.4 Hampshire is pursuing the objective of maximising independence for people with a learning disability through the use of supported tenancies in the community, rather than making automatic use of residential homes. This involves close 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. A consequence of this is that people remaining in residential/nursing homes are the users with higher needs.

4.5.5 Early stages in 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. Robust negotiations in relation to contracts should help to offset this, although some of the economies may be reflected in the reduction of purchased day care where residential homes will normally be expected to meet the client's care needs. Thus, this policy will have a perverse effect on both learning disability indicators.

4.6 Physical Disabilities

4.6.1 Many indicators relating to services for clients with Physical Disabilities come under the heading of adult services, and are not collected by client group.

4.6.2 A summary of results for 2000-1 by indicators specific to physical disabilities shows:

B16	Unit cost of residential or nursing care for PD clients	Acceptable
C29	People with physical disabilities helped to live at home	Investigate urgently

4.6.3 Overall, the performance of Hampshire's services to people with a physical disability is about average; with many services covered by the adults indicators rather than ones specific to physical disabilities. The County is good at providing residential care and direct payments and believes that the "poor" indicator (for helping users live at home) is somewhat misleading. As with services for older persons, problems around recording specialist referrals, direct access to services and centralised monitoring of equipment provision mean performance is under-reported. Plans are currently being prepared to address many of these recording issues before the next sets of data are provided to the Department of Health.

4.7 Mental Health

4.7.1 Many indicators relating to services for clients with Mental Health problems come under the heading of adult services, and are not collected by client group.

4.7.2 A summary of results for 2000-1 by indicators specific to mental health show:

B15	Unit cost of residential or nursing care for MH clients	Acceptable
C31	People with mental health problems helped to live at home	Good

4.7.3 Taken overall, the performance of Hampshire's services to people with a mental health problem is above average. The historic problem around poor recording on the Department's ACMS system by social and health care workers in Community Mental Health Teams has been solved in most locations, and has contributed towards the improved performance. Additionally, the Department is working with health colleagues to develop joint mental health information systems as part of the implementation of the Mental Health National Service Framework.

4.7.4 The Department is increasing its investment in mental health services year on year, through additional grant funding. An additional £60,000 has been identified to improve data quality, from the Mental Health Grant. £300,000 Supplementary Credit Approval - already in place - will fund development of a mental health information strategy and related systems for the Department and others in the Hampshire Health community. An additional £264,000 has been secured to put additional services in place during the next financial year (20002-3), also from the Mental Health Grant.

4.8 Adult Services

4.8.1 Most of these indicators cover all people over 18; thus they include people with a physical disability, learning disability, mental health and older people.

4.8.2 A summary of results for 2000-1 by indicators across all adults show:

B11	Intensive home care as a % of home and residential care	Ask questions
B12	Gross costs of providing intensive home care	Ask questions
B17	Unit costs of home care for adults	Good
C27	Admissions of supported residents 18-64 to residential care	Very good
C28	Households provided with intensive home care	Ask questions
D36	Users who said they got help quickly	Good
D37	Users allocated a single room on entering permanent residential/nursing care	Ask questions
D38	Equipment under £1,000 delivered within 3 weeks	Good
D39	Percentage of people receiving a written statement of needs	Investigate urgently
D40	Clients receiving a review	Ask questions
D42	Carer assessments	Good
E46	Users who said matters relating to race, culture or religion were noted	Acceptable
E47	Ethnicity of adults and older people receiving assessments	Ask questions
E48	Ethnicity of adults and older people receiving services following an assessment	Good
E50	Assessments of adults and older people leading to provision of services	Acceptable

4.8.3 Hampshire's performance for adults was variable. The Department was reasonable at most activities, but appears to perform poorly at activities linked to intensive care and other support in the home.

4.8.4 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, mixed provision of services between in-house and external providers or direct payments. Were such services included, overall performance would probably have been assessed as good. Performance does, however, vary significantly between Areas for these indicators and this is being addressed in the re-modelled department.

4.8.5 The disappointing performance under D39 reflects the recent inclusion into the indicator of "simple" services - such as meals on wheels and the provision of sensory and OT equipment - where provision of statements had been considered 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. Work is underway to find a suitable recording tool for the provision of equipment which will both record the assessment, prepare the statement of needs and identify clients only in receipt of equipment (which assists in several indicators).

4.8.6 By the end of 2002 the Joint Equipment Stores believe that they can improve performance under D38, items of equipment costing less than £1,000 delivered within 3 weeks, to a level where around 96% of clients will receive equipment within the 3 week deadline.

4.8.7 The Department is investing, jointly with local Health Authorities, in activities to improve the interface indicators for emergency admissions and delayed discharges. The precise impact of this will be hard to quantify, as information is provided at Health Authority level instead of being disaggregated to local authority areas. Work is ongoing with colleagues in Health to monitor this locally, probably at a Primary Care Trust level, to assess the impact of these actions in a meaningful way for Hampshire.

4.9 Value for Money

4.9.1 Overall, Hampshire is providing services efficiently, at an acceptable cost. Unit costs for residential and nursing care across adult and older persons care groups compare well with national average performance, given Hampshire's location near London. The cost of foster care, although higher than the shire county average, is again consistent with other authorities near London. All residential care unit costs showed a significant increase last year due to a change in the defined calculation method, making comparisons between years meaningless.

4.9.2 It should be recognised - however - that as the trend to support more people at home continues, and the purchase of high dependency care consequentially increases as a proportion of the total, unit costs are likely to rise.

4.9.3 Departmental priorities are currently to target services at people assessed as being in greatest need, as well as to manage steadily increasing demands within cash limited budgets. The Department is reasonably successful at meeting these priorities, as evidenced by our performance against E49 (assessments of older people per head of population) and E50 (assessments of adults and older people leading to provision of services). However, this impacts upon the Department's ability to provide a high volume of services to meet lower level need.

4.9.4 Historically, social services departments have been urged to provide care at home only where this was economic; it was not expected that people would be supported at home when it was cheaper to provide residential care. Despite this, Hampshire is working hard to increase the percentage of people with intensive care needs supported at home, rather than in residential accommodation and to prevent unnecessary admissions through short term crisis intervention; as shown by C26 (admissions of older people to residential or nursing care) where we were awarded 'very good'. It should be noted that maintaining highly dependent individuals in the community is not a low cost option. Incremental expenditure in supporting people at home is particularly marked in rural areas because of the increased distances between clients, the lack of day care facilities etc. Consequently, given the rural nature of much of the authority, it is more expensive for Hampshire than many other local authorities to support people at home.

4.9.5 Value for money - and quality - are, of course, twin objectives of best value. The 2001/2 programme of reviews includes two major areas of activity: services for looked after children; and residential/accommodation services for adults and older people. It is anticipated that these fundamental reviews will lead to a range of improvements both in terms of effectiveness and efficiency.

4.10 Areas of poor performance

4.10.1 Four aspects of Hampshire's performance were poor enough to get the rating 'investigate urgently'. The SSI is expected to ask searching questions about these indicators at the annual performance meeting in early February. Within Social Services, task groups have been set up to address performance issues around these indicators. The task groups are verifying the counting rules used internally with both the SSI and other authorities, looking at the impact on quantifiable performance of some local procedures and leading discussion on all aspects needed to facilitate improvement. More details on this work are given in Appendix 6.

4.10.2 The first two areas of poor performance are indicators of the support given to Older People and Disabled People to enable them to remain at home, measured against the number of people in the population. Research has identified significant undercounting, which is currently being quantified. However, the services being undercounted are heavily impacted by financial constraints. Councils which perform well appear to have higher funding and the performance issues highlighted in Appendix 4 appear to affect the ratings given.

4.10.3 The third area of poor performance is in the provision to users of a 'statement of needs and how they are to be met'. Historically, Hampshire has provided a statement of needs for all users receiving a care managed service for the first time and to those having a significant change in their requirements following a review. Users having unchanged services, and those receiving equipment or some sensory services were not provided with statements as it was considered an unnecessary bureaucracy. The task group is looking at simple ways in which statements can be issued to all users receiving services.

4.10.4 The fourth area of poor performance was in the centralised monitoring of the health records of looked after children. As health records have historically been kept near the children, a 'nil' return was made as there was no method of collecting the data required within the allowed time scale. Staff are currently working with both Health colleagues and care providers to enable a valid return for 2001-2.

5 AUTUMN POSITION STATEMENT

5.1 The Autumn Position Statement is a return which the Social Services Department must make to the DoH as part of the six-monthly monitoring process. Traditionally, the Autumn return concentrates on achievements against efficiency and effectiveness measures, on developments in children's services and on progress towards targets set in National Service Frameworks and White Papers.

5.2 The Autumn position statement is attached as Appendix 7. This return highlights the consideration being given to Care Trust status with New Forest PCT and the council's role in equalities issues. The return 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.

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. Where it is felt that indicators do not provide an adequate picture of local performance, it is important to identify more relevant local measures and this has been a feature of several Best Value reviews over the last twelve months.

5.3 Nevertheless, PAF largely provides a picture of inputs and outputs, rather than outcomes. Although this year's PAF indicators contain some that concentrate more on qualitative aspects of social care - such as user satisfaction - these are still in the minority. It is very important that issues of quality and effectiveness are examined in other, complementary ways which balance the limited coverage of the PAF indicators. Finally, it is clear from research with other authorities and the DoH that there are still many issues around their correct counting and interpretation.

7 RECOMMENDATIONS

7.1 That this report be accepted.

7.2 Given that it is not realistic to achieve top quartile performance across the whole range of indicators in the framework whilst remaining within current budget limits, it is important that Members identify priority areas for improvement in the Department's core business. The Policy Review Committee are accordingly asked to

· review the department's performance against PAF indicators

· note the work underway to address issues arising

· confirm the departmental priority to target services at people being assessed as being in greatest need

· recommend any future work needed.

Section 100D - 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.

NB The list excludes:

1. Published works

2. documents which disclose exempt or confidential information as defined in the act.

None