Contact: Project Manager Peter Knight, ext. 7144

1 Summary

1.1 This report advises the Social Care Policy Review Committee of the outcomes of the Best Value review of Care Management.

1.2 Care management is the mechanism through which vulnerable people in Hampshire have their social care needs assessed, met and reviewed. In the financial year 2001/2, 423 care managers assessed the needs of 26,503 clients. The total number of people currently receiving services accessed via the care management process stands at 22,724 older people and 8,713 adults receiving services during this period.

1.3 A review leader and two project managers have overseen progress with this review. Additionally there have also been significant contributions from core team members and other stakeholders.

1.4 Through the course of the review a wealth of qualitative and quantitative data about care management has been generated and analysed, from such sources as:

- statistical returns on key performance information to Central Government

- in depth interviews with users and carers, conducted by an independent body

- questionnaires to 700 users

- formal consultation with external stakeholders

1.4.1 Full details of this information were presented to Elected Members in the Options Report of the Best Value review of Care Management on 22^nd February 2002. The key findings arising from this activity are best encapsulated in the following quotes:

"They (users and carers) like it (care management) when they can get it - but they can't get enough of it": a service user

"Dissatisfaction that care manager experience within their role i.e. they are not finance clerks - or admin staff - or Barristers": a care manager

1.4.2 Therefore the Best Value review of Care Management has focussed considerable attention on:

- Making the care management process more efficient and effective, so that users, carers and external stakeholders have better access to care management services

- Rationalising the role and tasks of care managers and associated personnel, so that the right people are doing the task they perform best at the right time

- Addressing recruitment and retention issues in the workforce, that threaten to compromise the capacity of the service to work in an appropriate and timely fashion.

1.5 Proposals to deliver improvements in these key areas are contained in Appendix 1 below. These are rooted in the options supported by Elected Members and, in brief, are the following.

1.5.1 Development of a specialist financial assessment service

1.5.2 Creation of a care brokerage service

1.5.3 Implementation of a package of employee reward measures

1.5.4 Enhancements to the client care pathway, through improving links with partner agencies.

2 The Service under Review

2.1 Care management is the process through which people access and receive community care services from their Social Services department. Within Hampshire this is currently provided primarily through the Social Services Department. The key elements of this process are:

· Providing information about the services and how to access them

· Determining who is eligible for services and signposting to other agencies as appropriate

· Assessing the needs of vulnerable people and their carers

· Determining which services could meet the assessed needs

· Arranging for the services to be delivered

· Monitoring the delivery of care

· Reviewing at specified intervals whether the care is appropriate and still needed

2.2 There is a legal requirement for the local authority to undertake an assessment of need for anyone whom they consider might be eligible for their services. Reference to this and descriptions of entitlement and services offered are enshrined in the following Acts:

· National Assistance Act (1948)

· Chronically Sick and Disabled Person's Act (1970)

· Disabled Person's Act 1986

· The NHS and Community Care Act (1990)

· The Carer's Act (1996)

· The Human Right's Act (1999)

· The Carer's Act Amendment (2001)

2.3 The care management process is defined by "Care Management: a practitioner's guide" and "Care Management: a manager's guide" (HMSO, 1993) and eligibility for assessment and services are covered by case law (e.g. Barry v. Gloucestershire County Council, Penfold v. Avon County Council) and Department of Health notes of guidance (e.g. "Fair Access to Care").

2.4 Further detailed guidance is available in Hampshire's Care Management Practice Manual (revised and updated 1/3/99) and the Hampshire's Care Management Standards for Older People (January 2001)

2.5 Strategic objectives

The aim of the department is:

"to work with the people of Hampshire to ensure that their assessed social care needs are met with high quality, cost effective services, within available resources. In doing this we want to offer users and carers the greatest possible choice and to preserve their dignity, safety and independence".

New Directions - Departmental Plan 1999-2004

2.6 In May to July 2001 a total of 424 care managers (373 full time equivalent) were identified across the Department plus 15 unfilled vacancies (12 full time equivalent posts), a 3.2% vacancy rate. This equates to 14,245 hours per week of care management time available to the Department when fully staffed. In July 2001 13,801 hours per week of care management time was actually available. However concerns have been raised about the validity of this information owing to the methodology used (manual head count), which may have under reported vacancy rates. Therefore a more sophisticated electronic staffing profile system is being developed to generate more accurate information on a regular basis.

2.7 Between 1/4/00 and 31/3/01:

· 14,700 people had their needs dealt with at the initial point of contact -62% of whom (9,185) had referred themselves

· 26,503 screened contacts from clients led to assessment or commissioning of ongoing services. Of these 30% were referred from secondary health (8,068), 18% from primary health (4,857), 17% from family/friend/neighbour (4,491), 12% referred themselves (3,298), 12% from Local Authority departments (3,289) and 9% from other sources (2,500).

· 8,482 scheduled client reviews occurred

· 17,920 scheduled client reviews were not carried out

· 588 separate carer assessments were carried out and 8,881 assessments were completed jointly with the carer

· 8,713 adults received services during this period, of which 8,085 (93%) were community based services

· 22,724 older people received services during this period, of which 18,534 (82%) were community based services

3 The Review Process

3.1 The core review team met on a fortnightly basis throughout the process of this review, to allocate tasks, coordinate activity and understand the results of this activity.

3.2 Given the size and complexity of the service under review, 2 project manager were assigned to it, both of whom had previous experience of working in this capacity in Year 1 Best Value reviews (Day Care for Older People and Supported Employment).

3.3 Dedicated issue groups were convened, to develop the proposals around care brokerage and employee retention and reward. These met on a monthly basis, following the approval of the scoping report, throughout the course of the review. The composition of this group included interested parties from provider services, operational social work team managers and representatives from social work administration support services.

3.4 The nature of the finance specialist initiative was such that a Corporate steering group was developed to plan and monitor it's implementation. A project manager from the Best Value review of Care Management was a core member of this steering group, which met on a fortnightly basis.

3.5 Consultation

3.5.1 Consultation for this review involved three approaches

3.5.2 Analysing and understanding the results of previous consultation with stakeholders. This included

(i) The Performance Assessment Framework (PAF) questionnaire to 700 users and carers who had recently had an assessment of their needs (2001).

(ii) Results from MORI poll of staff working for Hampshire County Council (2000)

(iii) Care Management Conferences (2001). This structured consultation involved over 70 operational care managers

3.5.3 At the early stage of the review original formal consultation exercises were held with both internal and external stakeholders, to prioritise the areas that the review should focus on. The principal activities in support of this were:

(i) Commissioning Consumer Audit to conduct 40 in depth interviews with users and carers to elicit their experiences of care management and recommendations for it's improvement

(ii) Convening internal stakeholder focus group: composed of 14 team and care managers

(iii) External stakeholder focus group: 18 representatives from external partner agencies, including hospital consultants, General Practitioners, Community Nurses, District Nurses, Hampshire Care Association and 2 representatives from a local user group.

(iv) Undertaking an electronic questionnaire to all team and care managers across the County, encompassing all client groups

3.5.4 At a later stage, the options emerging from the review to date were formally presenting to internal and external stakeholders to establish the degree to which the proposals would address their stated concerns. These necessitated:

(i) 2 consultation events at which 50 team, service and care managers participated

(ii) 1 consultation event for 14 external stakeholders, including representatives for Primary and Tertiary Health care, user and carer representatives and representatives from the voluntary sector.

3.6 Compare

3.6.1 Principally the Review team have compared the performance of Hampshire County Council's Social Services Department in key result areas with other Local Authorities who have been matched with Hampshire by District Audit. The detailed results of this comparison were presented in the Options Report to Members on 22^nd February 2002, and were highly influential in determining the review's focus of attention.

3.6.2 Useful qualitative comparison has also been achieved with smaller Unitary Authorities, especially in determining the relative efficiency and effectiveness of different models of client care pathways.

3.6.3 Additional comparison with external bodies has been achieved through:

(i) Engaging with other local public sector services, notably the transformation team at Southampton General Hospital (specialists in patient care pathways) and the Institute of Naval Medicine at the Defence Evaluation and Research Agency.

(ii) Reviewing the literature of existing local, national and international research evaluating differing care management arrangements.

3.6.4 This has been complemented by forms of internal comparison, whereby issues of parity have been evaluated between different areas of Hampshire in terms of an equitable response to service users and their carers, as well as the way the service responds to people from different client groups . This has involved:

(i) Comparison of the numbers of care managers employed who hold relevant professional qualifications and have completed their care management competencies, by client group and location.

(ii) Comparing the numbers of care managers available per head of population, by client group and geographical area

(iii) Interrogation of ACMS data to understand variations in service response from different geographical areas.

3.7 Challenge

3.7.1 Legislation (NHS and Community Care Act) requires that the Local Authority ensures that an assessment of needs in performed for all people for whom services might be appropriate. Other legislation (Chronically Sick and Disabled Person's Act, National Assistance Act, etc.) then require to Authority to make arrangement for the provision of appropriate services with due regard to the assessed needs and resource availability. Therefore the tasks associated with the care management role must be fulfilled to comply with our legal duties to the people of Hampshire.

3.8 Compete

3.8.1 Cognoscent of this statutory requirement, we have approached the question of competition by questioning whether particular elements of the care management role can be better performed by others, by effectively outsourcing these functions or by maximising the contribution that other stakeholders can make.

3.8.2 The results of such inquiry are crystallised in the proposals around the implementation of dedicated financial assessment specialists and care brokers. The outsourcing of this care brokerage function to an external agency (the Canadian model of care management) was also actively considered, but was ultimately rejected for the following reasons.

3.8.3 The viability of operating this model of service configuration has been challenged in respect of conformance with the requirements of the Data Protection Act and Caldicott principles, neither of which applied in Canada nor at the time that the British trials of Canadian care brokerage were conducted. Sharing of sensitive and personal client data would be required with and by such an external agency for the purposes of care brokerage. This would exceed the scope of Hampshire registration with the Information Commissioner and the external agency would also need to be registered under the Data Protection Act, subject to the development of sufficiently robust information sharing protocols. However, the view of the Hampshire County Council Social Services Data Controller is that maintaining the data within the Social Services would be a more secure and stable arrangement.

3.8.4 The location of care brokers in a separate building away from day to day contact with care managers is perceived to cause problems in itself. Concerns have been expressed in relation to this model compromising quick and easy communication between the care broker and the care manager, with attendant delays in providing the right services for users. These concerns are strengthened by research findings on interagency working that emphasise the positive benefits of co-location of employees.

3.8.5 The opportunity for the career development of social services administration workers into care brokers and care managers would be lost. This feature of the internal care brokerage system is held to be especially advantageous insofar as it:

_ Releases and capitalises upon the considerable experience and skills administration workers have in supporting vulnerable people

_ Qualitative research undertaken as part of this review indicates that personnel who are promoted internally to a care management position are less likely to suffer the pronounced drop in job satisfaction in the first 6 months of employment that affects care managers who are recruited from outside the organisation.

3.8.6 Costs associated with outsourcing the care brokerage function are seen to include:

_ Set up and infrastructure costs, principally connected with appropriate IT systems, establishment and maintenance of IT links to ACMS / SCIS, training of relevant personnel in the operation of the IT systems and in working with vulnerable people.

3.8.7 The Canadian model of care brokerage was trailed in the United Kingdom, prior to the introduction of the Direct Payments Act, with the objective of enabling greater user empowerment. However these trials were roundly condemned by the British Coalition of Disabled People for actually introducing a further layer of disempowering bureaucracy (ref. "Means to control a review of the service brokerage model in Community Care" 1995). Furthermore, it has been argued convincingly that the use of Direct Payments operated by the user is a more effective means of achieving this objective of user empowerment.

3.9 Trials of the internal care brokerage system in the pilot area have already delivered qualitative and quantitative improvements for stakeholders. These include:

_ A reduction in the waiting time for care management assessments, leading to an improved service to users and other agencies

_ A reduction in the number of outstanding scheduled client reviews, which are now undertaken by reception and assessment care manager

_ A substantial improvement in the job satisfaction ratings expressed by care managers. With the MORI poll (2000) findings that job satisfaction ratings for this group of staff were a worryingly low 4%, this result has no small significance. Comments from care managers participating in this scheme include the following:

"The CPCs (Care package co-ordinators) have made a huge impact (both on duty and as a hospital care manager) in terms of time saving, efficiency and our sanity as social workers!

We don't waste our time

i.e. 10 different social workers constantly ringing 20-30 odd agencies each chasing the same care - which means more time to do the assessments & the job we spent all that time training to do. It's more efficient, coordinated, must be saving time for the care agencies also, and generally makes our job much smoother and more targeted... The wards love our new system, and it appears to be speeding up our discharges here."

"The use of the CPC's (Care Package Co-ordinators) definitely reduces the stress levels here and has helped to make the large workload more manageable."

"The CPC role has had a large impact on the work of Care Managers - particularly in R&A when a great deal of time could be spent in ringing around agencies to set up care. This is now a much better, more streamlined and efficient system as the CPCs have a good idea of the current market, good links with the agencies and are able to set up care packages quickly.

- From the Older Persons Team point of view, I have used the CPCs on many occasions - it feels a great relief to pass over the task of setting up care and allows more time for other care management work (such as reviewing and monitoring)."

3.10 Therefore, for the reasons stated above, the Review team recommends that the Canadian model of care brokerage is less beneficial to stakeholders than the internal care brokerage system employed in the pilot area.

3.11 An additional area of competition is the requirement of the National Service Framework for Older People (2001) to develop a single assessment process that encompasses both the health and social care needs of individuals. This is welcomed as an opportunity to maximise the contribution of other care professionals to the process of assessing need. This initiative is being implemented through parallel activity outside the scope of this review.

3.12 The review process has also sought to address the themes of

_ equalities

_ sustainable development

_ e-government and

_ crime and disorder

3.12.1 Issues of equalities have been considered in the following ways

3.12.2 Performance Assessment Framework indicators show that care managers in Hampshire undertake assessments of need with an appropriate proportion of people from black and ethnic minorities, in line with the base population in the County. Such assessments lead to an appropriate level of services being provided. Taken together, these indicators show that people from black an ethnic minorities are not discriminated against either in the provision of care management assessment or in the application of eligibility criteria which determine whether services will follow the assessment.

3.12.3 The numbers of staff from black and ethnic minorities employed within Social Services is in line with the composition of the background population in Hampshire. Further work is being undertaken through a more detailed workforce profile, to establish whether people from black and ethnic minorities are represented proportionately across all levels of the organisation.

3.12.4 Issues of sustainable development have been considered in the following ways

3.12.5 The review has concentrated it's attention on the following key themes of the Corporate Sustainable Development Strategy:

- Theme 1: Community Co-operation

The process of undertaking this review has necessitated extensive consultation with external stakeholders and the review recommendations address the issues that arose from this.

- Theme 6: Improving health and social wellbeing

The improvement of social wellbeing both for the people of Hampshire and personnel who deliver services to them has been the central aim of this review. The Review Team believes that the proposals detailed in the Implementation Plan will give rise to significant benefits in this area, by enhancing the access vulnerable people have to care management services and through enhanced working conditions.

- Theme 8: Social Inclusion

Improvements to the access people have to the care management service will enable vulnerable people to be better supported in the community.

3.12.6 Issues of e-government have been considered in the following ways

3.12.7 A range of information about Hampshire Social Services and other agencies involved in the delivery of care is currently available on the internet, via Hantsweb, including an updated list of available residential care vacancies. Further work is currently underway to develop the facility for people to electronically refer themselves or others. This is particularly relevant in Hampshire, where over 50% of households are "on line".

3.12.8 Consultation with local managers of reception and assessment teams has demonstrated their support for the development of electronic client self referral and consideration is being given to a secondment opportunity to allow an operational manager dedicated time to develop this service.

3.12.9 Initiatives to enable the sharing of electronic client records between Social Services and key partner agencies (notably Health) are described in the implementation plan

3.12.10 Issues of crime and disorder have been considered in the following ways

3.12.11 Care managers work with vulnerable people whose very vulnerability makes them more likely to be victims of crime and forms of abuse (e.g. financial abuse). They also work with a much smaller group of people whose behaviours are such that they may be perpetrators of crime, disorder and abuse.

3.12.12 The Review team believes that the adoption of the proposals detailed in the implementation plan will increase the amount of client contact time available to care managers, which will aid in the detection and rectification of such criminal activities. In addition, the deployment of appropriately trained financial specialists across the County will support the detection of financial abuse.

4 Member input

4.1 The review team has been grateful for the contributions of Elected Members (Councillors Mrs West, Dowden, Steele and Gale) allocated to this review, throughout the process. We have appreciated their support and useful suggestions both through individual meetings with them and within the Policy and Review Committee forum. Such contacts left us in no doubt of the value that is placed upon ensuring care management practices are as effective as possible for service users and carers. Additionally, Elected Members made it clear that they were very conscious of the pressures upon care management practitioners and the need for this to be addressed, lest the capacity of the service be compromised.

4.2 At the Social Care Policy and Review Committee of 22^nd February 2002, the Options report was welcomed by Members and endorsement given to further develop the preferred options for service improvement and report these as detailed proposals to a subsequent Committee. The request was also made for further evidence in support of the rationale for recommending an internal care brokerage model as opposed to an externalised brokerage model (the Canadian model of care brokerage), addressed above.

5 Lessons Learnt

The following learning points have emerged from the review

5.1 In part owing to the recent elections, we were unable to involve Elected Members as much as would have been desirable in the earlier stages of the review. This will be addressed in subsequent reviews, through seeking their active involvement from the scoping stage of the review process and subsequently throughout the process.

5.2 That there was much value to be had from thoroughly evaluating existing information sources before undertaking gap filling research. Examples of this would include understanding previous stakeholder consultation data.

5.3 That hard data and performance information on the operation of a given service can be time consuming to obtain and analyse; for this reason such information requirements should be identified at the scoping stage of the review and actions for its acquisition taken immediately thereafter. An example of this is the profile of the workforce that was undertaken as part of this review.

5.4 That the Best Value process generates essential data on the operation of a given service, on which service development and commissioning can be soundly based. Information produced by this review has already been used for a variety of functions and requests have been made to update some of the data on a regular basis. This will then afford valuable trend data.

5.5 That close involvement with operational staff throughout the course of the review is essential. An observation here is that such staff can identify and communicate innovative local practice which can then be generalised across the County, for the benefit of stakeholders in all parts of Hampshire.

5.6 That although this review has focussed on care management as it is practiced with adults and older people, valuable cross learning has been attained through close liaison with colleagues in Children and Families services, who are moving towards a care management approach for their client group

6 Conclusions

6.1 The Options Report presented to Members on 22^nd February 2002 discusses in detail the performance of the care management service against key performance indicators and the rationale for supporting the proposals presented below.

6.2 Analysis of the service by the Department of Health has shown that the following areas of care management practice in Hampshire are considered a strength of the service:

6.2.1 Relatively low numbers of admissions of supported residents aged 65 or over to residential/nursing care. In Hampshire 86.41 older people per 10,000 are supported to enter residential and nursing care (Performance Assessment Framework indicator C26)

6.2.2 Relatively low numbers of admission of supported residents aged 18-64 to residential/nursing care. In Hampshire 2.67 people aged 18-65 are admitted to residential and nursing care per 10,000 of the population. (Performance Assessment Framework indicator C27)

6.2.3 Relatively high percentage of full assessments that lead to a service being provided. In Hampshire 81.18% of assessments lead to a service being provided, significantly higher than most other comparator Authorities (Performance Assessment Framework indicator E50)

6.2.4 Relatively high proportion of Carer's assessments. 47.23% of informal carers had their needs assessed either separately or jointly with the client (performance Assessment Framework indicator D42)

6.2.5 Accurate proportion of assessments of people from minority ethnic groups, that reflects the base population. In Hampshire 1.19% of people receiving an assessment of their needs are from a minority ethnic background. (Performance Assessment Framework indicator E49)

6.2.6 Appropriate proportion of adults and older people from black and ethnic minorities receiving a service. In Hampshire 1.09% of the people receiving a service following an assessment were from an ethnic minority. (Performance Assessment Framework indicator E48)

6.3 Areas of poorer performance

6.3.1 Relatively low proportion of older people helped to live at home. Hampshire has recorded supporting 36.62 people aged over 65 to live in the community per 1,000 people aged over 65 (Performance Assessment Framework indicator C32)

6.3.2 Relatively low numbers of adults with physical disabilities helped to live at home. In Hampshire 1.58 people with a physical disability were recorded as being helped to live at home per 1,000 population 18-64 (Performance Assessment Framework indicator C29).

6.4 Qualitative research with users, carers and stakeholders within Hampshire has revealed that, from their perspective, the most important area for improvement is about quicker and easier access to care management services. Essentially this is an issue of the capacity of the service to deal with the demands placed upon it.

6.5 Quantitative research within Hampshire supports this qualitative perception, in terms of the service not adequately meeting some of it's key objectives. Chief amongst these are the large numbers of reviews of client care that are not undertaken within Departmental timescales and the delays in completing assessments within Departmental timescales.

6.6 Therefore the aim of the review, as described in the Scoping and Options reports, has been to:

(i) Evaluate the efficiency and effectiveness of the care management service within Hampshire.

(ii) Provide costed options to improve these services from the perspective of users, carers and partner agencies.

(iii) Identify 5% efficiency savings in the way that these services operate

6.7 The Best Value Review team are convinced that adopting the improvement plans detailed below will assist the service to meet it's responsibilities and targets, by improving the efficiency of it's operation, which will be translated into tangible improvements in the service offered to users, carers and partner agencies.

7 Summary Recommendations

7.1 The attached implementation plan identifies outcomes, performance indicators, current performance, performance targets, barriers to achieving performance targets and identifies specific officers charged with delivering on specific actions in support of these.

7.2 The areas that the implementation plan addresses accord with the priorities identified within the scoping report for this review, which in turn are firmly based on consultation with stakeholders and the Department of Health's assessment of Hampshire's performance in respect of key areas of service delivery. Essentially they represent a development of the options for service improvement presented to the Social Care Policy and Resource Committee on 22^nd February 2002 .

7.3 The implementation plan seeks to effect service development within existing resources, and should be in the context of other policy initiatives, notably the workforce plan.

7.4 Therefore the Review team recommends the implementation plan detailed below to the Social Care Policy and Review Committee as a means of enacting the proposals for improving the care management service in Hampshire.

Section 100D - Local Government Act 1972 - background papers

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.

Records of the Best Value Library service review team meetings and working papers of the Best Value Review, held by the Review Team Leader.

None