All 152 Local Authorities with Adult Social Care responsibilities are required to ensure they operate a sustainable, high-quality market for their local population, with efficient operation of all adult social care.
The Care Act 2014 sets out the law around market development in adult social care. It enshrines in legislation duties and responsibilities for market-related issues for the Department of Health, CQC and Local Authorities.
However, quality assurance and risk profiling processes differ locally, sub-regionally and regionally. For Local Authorities, this means disparate market oversight approaches are taken, with little to no collaboration with other Local Authorities – even those in close proximity.
In addition, Providers that work across boundaries are subjected to numerous quality assurance and contract management processes, increasing the burden on an already stretched market. The effect of this is huge, as Providers try to manage / meet different contract management approaches, some of which may be conflicting.
CQC produce a ‘State of Care’ report each year: while 2018’s report shows most people in England receive a ‘good’ quality of care, a comparison of 2017/ 2018 data shows the number of Providers rated as ‘inadequate’ or ‘requiring improvement’ is increasing. For a full breakdown of the CQC’s annual assessment of health and social care, visit https://www.cqc.org.uk/publications/major-report/state-care.
In addition to the evidence that care quality is reducing, and the increasing difficulties for the regulator, CQC, to inspect all regulated services in a timely manner, recent high-profile media coverage about the CQC invoking a ‘Stage 6 notification’ is alarming. Due to the fragility of Providers, huge amounts of Local Authority resources are being focused on contingency planning.
We will approach the problem in 4 key milestones:
- Benefits case (BC): ‘Should there be a nationally adopted quality assurance (QA) framework for regulated services assessed by health and social care organisations? Or should this be locally, sub-regionally, or regionally configured?’. ADASS East and its 11 Local Authorities (LA) and health partners have an agreed set of outcomes for their regulated services. We want to determine whether this can be scaled up, or whether regional and sub-regional differences would occur. The BC will describe the East region’s QA approach, and contract and workforce management. It would also discuss their initial results (i.e. quality improvements, cashable efficiencies, cost avoidance around Provider failure), and any learnings.
- User research report: We will test the QA methodology with participating authorities to determine whether a similar methodology could be adopted, or if there are any discrepancies that would make this difficult. We would write a report based on our findings. Our user research will present the hypothesis of a nationally adopted QA framework, then test this with end users. We’d understand the benefits, any difficulties in implementation, and how frontline staff react to changing working practices. We would also answer the question, What does a single Risk Profiler across all LAs look like?
- Accessible product: We would take the learnings from the user research report and try to find a way that an accessible product can be delivered to each of the participating authorities, addressing the individual differences that we believe will be highlighted within the user research report. Once all issues have been addressed, supplementary training documents, support portal, and online training videos will be created.
- By April 2019, we will produce a conclusion regarding whether a nationally adopted QA framework can be adopted, and any potential technologies that may underpin this approach to make it a reality.
As previously stated, the Local Authority (LA) care market is under pressure due to operating challenges, workforce recruitment and retention challenges, together with an increasing demand for service due to an ageing population.
As a result, LAs experience intermittent Provider failures, which generate operational response costs for the relevant Councils. By resolving the challenges in the current market, the benefits of this project to LAs are:
- Improved oversight of Provider care delivery
- Improved market oversight and early warning of Provider failure
- Ability to redeploy staff resources from supporting the market, to increasing care capacity and generating new initiatives / efficient ways of working
- Increased productivity in contract management activity
- Improved operational contract management, ensuring that services are delivered to the agreed standard and cost
- Freeing up of capacity to ensure continuous improvement and to ensure arrangements reflect best-in-class
- Improved contract reviews – with intelligence on KPIs and overall delivery of the outcomes required
- Reduced duplication of effort – only have to do a Provider review once, even if Providers work across boundaries
- Improved oversight across traditional boundaries, as well as sub-regional and regional views
- The potential to give national government/ADASS a greater understanding, as per their market oversight responsibilities with the CQC.
Providers also stand to benefit, as they’re only assessed once, and only need to work towards one action plan should improvement be required (rather than having to work on multiple action plans, which may be conflicting). This frees up their resource to focus on providing high-quality care delivery.
By seeking to improve Provider quality and reduce Provider failure, LAs’ service users will also benefit, as they will receive a consistent, higher quality of care, with a reduced risk of their care package being transferred to another Provider.
See North West Market Review January 2018 [link]
Nationally, there is an increase in the number of failing services and the trend indicates that care quality is worsening over time. ADASS East wanted to improve this, ensuring quality and better outcomes for individuals.
The aims of the project were to develop a solution that would:
- maximise resources and reduce costs
- integrate with 11 different council systems
- support a consistent framework for managing Provider quality, helping to ensure that contracted suppliers deliver safe, effective and high-quality services in line with Care Act requirements
- bring together market intelligence, quality, risk and financial data from various sources, with the ability to easily analyse this on a regional, sub-regional and/or local level to improve commissioning decisions
- allow intelligence to be securely accessed / shared
- reduce the administrative burden for Providers, especially those working with multiple councils.
On such an ambitious project involving 11 LAs, effective engagement was critical. To achieve this:
- We set up a working group with representation from all regional LAs and relevant networks
- The working group supported local implementations for each respective authority
- Quarterly workshops were implemented to share experiences / lessons learned
- An online platform was introduced to allow users to contribute to the Product Roadmap.
This high level of engagement ensured positive end-user buy-in, as well as peer-to-peer support for sharing good practice. This entire process required significant behaviour change across 11 LAs, but with a clear understanding of the long-term benefits, this has been successfully achieved, as evidenced with a shortlisting for the 2019 LGC Awards [link].
Our work is relevant to all Local Authorities with social care responsibilities. It is also more critical than ever, with ADASS nationally stating that “more than 4/5 adult social services directors [have] reported Providers facing challenges to deliver high-quality care, which is already being reflected in CQC ratings, with nearly a quarter of services assessed as “requiring improvement”. More than three quarters of councils experienced some kind of social care provider failure last year.”
The Local Government Association also supports its members on Market Shaping, with the outcomes of this programme feeding into that strategy [link]. In addition, the Department of Health and Social Care helps health and social care organisations understand their roles and responsibilities, and how intelligent data can help make informed decisions and more timely decision-making, particularly around Provider failure [link]. As such, our work is perfectly in line with various agendas in this area.
Please see the Q2 response as to how we will approach the above project milestones. The conclusion will be shared online by the last week of the project, both on the solution website, and on the relevant regional ADASS websites. With regard to the impact of funding, the following benefits were realised in the discovery phase of the project. We therefore expect to see the same impacts, albeit on a much larger scale, across the participating regions:
- An improvement in care quality – the ADASS East region have already seen a 10% improvement in measurable Provider quality
- Financial savings for the participating authorities – for ADASS East, the project has delivered Y1 savings of £1 million+ by reducing duplication of effort from multiple Authorities
- Collating quality and financial data from many different parties – within the ADASS East region alone, the project brought together data from 11 Local Authorities, 2,000 contracted Providers, and 20,000 Service Users – delivering improved management information to all parties.
- Regional assessment criteria can be mapped directly to the CQC KLOEs – meaning a Provider meeting the regional standard should automatically meet the CQC standard, reducing duplication of effort for the regulator
- Faster, more efficient way of conducting Provider assessments – over 1000 Provider assessments already completed in the solution
- The project will ideally result in the successful adoption of a standard contract for care, together with agreed quality standards across multiple regions
- The funding will deliver a new level of performance transparency, allowing risks to be identified much earlier, reducing Provider failure across regions
- Value for Money data by linking spend to quality ratings, with the PAMMS analysis available by locality, region and/or sub-region.
Our users are:
- Quality Assurance Teams and Contract Management Teams at Local Authorities
To engage with them properly, we will:
- Have representatives of these in all of our participating Local Authorities (Kent, Gateshead, Wigan, North West ADASS, and ADASS East)
- Build on the work we did with ADASS East, taking the solution to each participating Local Authority, before conducting a gap analysis to try and understand how their local approach differs.
- Conduct site visits, sitting down with the Contract Management Teams, comparing different methodologies, and how these can be brought together (if and where they can). We will identify whether any peer learning can occur, and if there are nuances in the quality assurance process for one Local Authority that would complement that of another’s (i.e. something they’ve not thought of).
- Compile the user research report, documenting the validity of a single assessment methodology, and share with all participating authorities.
- Use established approaches to test the agreed assessment methodologies, which will further test the hypothesis of a single quality assurance process.
- Engage with other relevant partners, including Department of Health and Social Care’s ‘Market Overnight’ team, regional CQC leads, and the LGS’s Care and Health Improvement Programme (CHIP), to understand / test / refine assessment methodologies and risk profiling.
In addition to our user research objectives of delivering a user research report, and testing our hypothesis, we also plan to publish a thought piece, which documents the different quality assurance, contract management and risk profiling process from across the participants. One of our objectives as part of this work is to understand their strengths, weaknesses, commonalities and variances. The expectation is that peer learning will encourage the co-production of a single quality assurance approach and a single benchmarking platform to ‘risk profile’ services.
Between the participating authorities and HAS Technology Group, we have a strong skillset that we believe can fully service this project. In the discovery exercise, we found that we had sufficient skill sets for ADASS East, which included:
- Experienced Project Managers
- Expert Development Team Leads that deliver according to an Agile development methodology
- Expertise around the Quality Assurance approach, with users across a diverse range of backgrounds
- Training resource
- Technical support
- Actual system users, including Contract Managers
- Local IT Support at each of the participating Local Authorities.
As such, we do not see ourselves requiring additional support from the Local Digital Collaboration Unit at this time.
We can confirm that we have not applied for, nor been granted funding for this phase of the project in the past. ADASS East funded the discovery phase of this work, within its own region. No other funding has been applied for to date with regard to scaling up this solution and looking to deliver one Quality Assurance platform across multiple regions.