Strategic commissioning - adult carers
Commissioning is about having the most effective approaches and support in place in order to improve outcomes.
Stakeholders may be interested in different outcomes, so it is important to be clear about the respective benefits of breaks. Local authorities and health services have legal duties to develop integrated approaches for the benefit of individuals. Effective commissioning cannot be achieved in isolation. It needs to be co-produced with local people and by close collaboration with adults and children services, public health, housing, NHS partners and the wider community.
Anna McEwen, Executive Director of Support and Development, Shared Lives Plus
Knowing what’s on partners’ agendas and understanding their priorities will help identify opportunities to embed the breaks agenda across a wider platform.
How can you ensure carers’ breaks are everybody’s business and cross strategic agendas?
- Identify relevant reporting mechanisms and outcomes measures. How do your plans for breaks contribute to the local Adult Social Care Outcomes Framework (ASCOF) and the Public Health Outcomes Framework (PHOF)? What reporting on breaks is of interest to the local ICS and mental health trust?
- Social prescribing – how is this working locally for carers? Can breaks become a clearer part of this?
- The NHS Plan identifies that carers’ health is generally poor. How can you evidence the health benefits of breaks? How are these reflected in plans for integrated care services or sustainability and transformation partnerships (STPs)?
- Health and wellbeing board – has the board understood the needs and agreed priorities for breaks?
- How can you thread carers’ needs through local community plans, housing plans or equalities plans? This might be in relation to employment, ageing well, access to leisure, community engagement, or tackling isolation and loneliness.
- Don’t forget the role of local businesses as employers, as part of the community, their corporate social responsibility (CSR) commitment and as part of the breaks offer. My Time, Liverpool demonstrates fantastic community gains that are positive for business too.
- The local chamber of commerce may have plans and some businesses may be part of Employers for Carers.
Funding carers’ breaks
Each area needs to develop its own costed plans to address how carers’ breaks are to be funded. This will include funding from existing social care and health budgets for support packages or via personal budgets. It will also include, where appropriate, individuals funding their own arrangements.
Tim Anfilogoff, Community Resilience, Herts CCG
To identify funding for the development or provision of breaks, commissioners will want to consider local approaches for preventive budgets, invest to save and innovation plans. Wider strategic agendas, such as tackling loneliness, improving mental health services, may have funding attached that could support carers’ outcomes.
Better Care Fund
Funding for carers breaks is included in the NHS allocation to the Better Care Fund (BCF). The BCF is a pooled fund that exists in each local authority area. NHS and local authority commissioners agree a plan for the use of their pool that supports person-centred, integrated care for local people. These plans must include a joint approach to supporting unpaid carers and identify resource from the BCF pooled fund to support carers services.
Commissioners of carers services should be involved in this process, as well as local VCS groups. The Better Care Exchange, a collaboration site that is part of the NHS Futures platform, has some examples of good practice in Swindon and Portsmouth in carer support from BCF plans.
Swindon Borough Council Local Authority Open
The case study of carers services commissioned by Swindon Borough Council Local Authority aims to address the issue of a carer not having been sensitively consulted about how the person she supported was on an end-of-life pathway. The Adult Carer Support Practitioner (ACSP) undertook an annual carers relief review to address this experience and to consider ways to consider better outcomes for this and other carers. Having BCF in place enabled the ASCP to support carers to liaise with a wide range of professionals in order to achieve good outcomes.
- The ACSP introduced joined up working with Swindon carers centre and the GP. This helped clarify the carer’s questions and provided guidance.
- Options for breaks were reviewed and liaison with the council and existing care agency meant a new plan was created.
- Challenges were noted such as understanding who was responsible for the person the carer supported when end-of-life was mentioned.
The review’s key learning points were:
- The importance of annual reviews and hearing the voice of carers in the services for their dependants.
- Building good relationships across Voluntary Sector providers and Health/ASC can improve communication between services and support for carers.
Portsmouth Carers Service Open
The majority of carers assessments are carried out via this service, with continuing work to promote shared responsibility. Carers are given support with, accessing breaks, information and advice, emotional support, problem- solving and planning for an emergency. The service takes place at a community hub where different activities and events happen.
The service also has a ‘breaks offer’ including non-chargeable one-off payment for breaks expenses, replacement care equivalent to six hours per week sitting service and chargeable access to two respite beds depending on eligibility.
A major service redesign in 2017 was introduced to reduce a long and complex assessment process to four more simple steps.
An evaluation on how carers assessments are completed enabled some positive changes such as ensuring person centred approach for carers assessments and reducing when carers have to fill out a form. Carers are now able to access breaks funds on the same day as their assessments through pre-paid cards being offered through the Carers Service and can draw on wider community support for their breaks.
Social prescribing and universal personalised care, both key commitments in the NHS Long Term Plan, may be additionally be relevant in addressing carers’ needs for breaks. GPs and primary care professionals can use social prescribing to refer to a range of local, non-clinical services or activities to address people’s needs in a holistic and personalised way.
Local authorities, as part of their information and advice service, should seek to make available potential sources of funding for breaks for individual (self-funding) carers. The national organisations such as Carers UK and Carers Trust provide information about grants and funding for breaks and holidays.
Hazel Brown, Liverpool Carers Centre
See also: NHS Commissioning for Carers
Adult Respite Support – Review and codesign of services
Cheshire East Council Open
In 2017/18, council commissioners embarked on a 12-month review of their current service, talking to service users and carers, with the aim of creating a modern respite service to meet the varying needs of Cheshire East residents. It was apparent that for some people, the bed-based support was a lifeline; however, it was clear that it was not appropriate for others.
Co-production was at the heart of the re-designed service including one-to-one meetings, group meetings, an online survey (with support available via telephone to complete), and a direct survey being shared with local carer groups and forums. Recommendations based on the evidence collated were presented to service users, carers and professionals. This was then used to inform the specification for a new service.
One outcome of this was the Carers Hub offering information, advice and guidance and a 24-hour chat line manned by other carers with access to community, health and wellbeing services. The Hub offers a dedicated carers support worker specialised in fields such as young carers support and dementia.
The Community-based Respite Support service was launched in January 2019, offering a range of different services including a sitting service, support to access employment or volunteering support and employment-related skills, daytime opportunities and residential respite support. Residential bed-based support has been maintained and the range of different bed types available to support individuals’ different needs has been extended.
It is too early to assess the overall impact of the newly co-designed range of respite support services. However, the Carers Hub was launched on 1 April 2018 and the following feedback has been provided:
You and your service make my life more bearable. You are always there for me to talk to. It helps me to cope as a carer, in what are sometimes difficult situations.Female Carer, aged 75–84
I think the service is amazing. It lets the children be children and not have to worry or be carers. It also lets them make friends. The kids love it and there is always someone there they can talk to.Parent of two young carers
This service has allowed my pupil to no longer feel isolated and that no one else understands. He is now engaging in fantastic opportunities and thriving on the care and understanding given.Head teacher, primary education
Funding: £1.1 million per year (Carers Hub, Community and Bed-based support)
Family Carers’ Prescription – Access via GP to Carers Trust worker
Provider: Caring together Open
A Family Carers’ Prescription (FCP) gives carers of all ages, including young carers, access a specialist worker at Caring Together who will discuss the support options available, support the carer to access them and give them an information pack. The worker supports the carer to design a short break that works for the carer and they also provide support for this break to happen. The carer decides what gives them a break – it may be assistance going out with the person they care for, someone being with the person they care for whilst they do something or it could be something else. Carers access the ‘prescription’ through their local health professional, including GPs, or directly via Caring Together who will then liaise with the GP on their behalf.
This service was commissioned to prevent carer breakdown based on evidence that this was the biggest cause of avoidable hospital admissions. The aim is to prevent unnecessary admissions to hospital and/or permanent care and to raise awareness. Originally commissioned to provide care/emergency breaks and to support carers to attend their own health appointments, they recognised that other breaks and support for carers are equally important. They adapted the service to enable more tailored solutions (comparable to a personal budget approach), with support available to meet the needs of the whole family. They introduced help with planning ahead in case of an emergency and, adapted the service to enable a broader range of health professionals to prescribe, not just GPs (e.g. community-based practitioners). As a result the service is now more preventative, with earlier identification, not just crisis response.
Examples of family prescriptions include Kieran, who is 6 and helps care for his sister who has cerebral palsy. Due to his sister’s deteriorating condition, his mum had to give up work. The financial impact of this meant that they also had to give up the weekly swimming sessions which impacted on Kieran’s mental health. The FCP funded Kieran and his mum to go swimming together as their break.
The FCP has been used to help support carers where they have their own health needs. For example, one young adult carer was struggling with her anxiety and was becoming very isolated at home. She loved reading and so an FCP paid for her to purchase books from a local charity book shop – this supported her to get out of the house more as well as purchase books to help her to try and relax at home.
Surveys indicate that over 95 per cent of those using the service would recommend it to a friend or relative. Eighty-nine per cent said they were less stressed or anxious. Eighty-eight per cent said they coped better with the caring role. Carers said they benefited from: replacement care being supported to access a flexible break by attending a carers hub; accessing emotional support or being supported to access an activity to promote health and wellbeing such as relaxation therapies.
The estimated saving through avoided hospital and residential admissions was £1.7 million in 2018/19. These figures do not take account of the additional potential savings associated with the prevented admission of the person they care for, nor those associated with maintaining either individual’s physical, mental, or financial health or wellbeing as a result.
Feedback forms are issued after each home visit and follow-up phone calls are scheduled to review, and to give a measure before and after the intervention. Feedback through other services highlighted the need for a lighter touch carers assessment, which has also been introduced and carers were involved in the development of this.
Budget £400,000 pa.
Mytime – Breaks in partnership with hotels, leisure services, restaurants etc in Liverpool
Liverpool Carers Centre, Local Solutions (not for profit) Open
Evidence from carers accessing the Liverpool Carers Centre showed that the most requested type of support was a respite break. With demand in the city outweighing supply, the Centre looked at how best to respond. Contact was made with a hotel and it offered complimentary bed and breakfast for a carer and a guest.
The service now has 30 hotels and 32 other organisations providing offers to carers. This includes overnight stays in hotels, and access to restaurants, theatres, universities, leisure and tourism, football clubs, watersports centres and Aintree Racecourse. There are 1,300 carers now registered with Mytime, which is run by 1.5 paid members of staff plus a manager and two volunteers who were themselves carers. Carers chose the name and design of Mytime. They are also involved in the development of offers. This project was recently recognised by Nesta and the Observer as one of their ‘New Radicals’.
Mytime supports the whole family. Examples include breaks that are family orientated, to allow parents who are carers to be able to take their children on the break. This could be family concerts at theatres where children are encouraged to come and try the instruments, or using tickets provided by Children’s BBC to see their roadshow. Many families that have young carers enjoy going to the pantomime together. There is support available for families who are caring for someone with dementia to take them to the event and help to make a memory.
An evaluation of the service shows an increase in carers’ health and wellbeing using the Warwick and Edinburgh Mental Wellbeing Scale. They also use the carers outcome star to assess the carer pre and post activity. Carers are reporting that the services have helped them to remain in their caring role.
One of the key lessons Mytime learned, was that some carers are unable to leave the person they care for overnight so they worked with organisations such as theatres and restaurants that could offer a few hours of activity to carers during the day, such as Barista training.
Mytime support a diverse range of carers. For meals, everyone is asked if there are any food requirements to be aware of. One of the volunteers who is also a carer is able to speak several languages and, for example supported a carer whose first language was Punjabi to access a break.
The aim is to make Mytime as inclusive as possible and work on an individual basis to reduce any potential barrier to a carer being able to access a break. Mytime is aiming to expand to other geographical areas and work with more commissioners.
Mytime has received four years funding from Liverpool City Council which gives stability to the project. Mytime Wigan has also been set up which was well-received by the commissioner in Wigan and was offered two years’ funding for the project.
Budget: Approx £80k per annum. At present the service is funded through the Big Lottery Fund and other charitable trusts.
Residential support for people with learning disabilities, autism and behaviour that challenges – Cheshire East
Commissioner: Cheshire East Council Open
Cheshire East Council recognised that adults and young people over 16 with learning disabilities and/or autism who may also display behaviour that challenges (including those with a mental health condition and/or a physical disability) were often unable to access appropriate respite care within the borough. Evidence showed that existing services were often unable to meet these more complex needs, resulting in many people having to use respite in out-of-borough placements, which often did not offer best value for money.
In April 2018, the council hosted a series of consultative group meetings, issued easy read surveys and attended meetings with people who use services and their carers. Results showed that carers valued accommodation-based respite away from the family home, in order to give them a break from their caring role, while knowing that the person they cared for was in a safe environment with appropriately skilled staff. Furthermore, people who draw on services wanted to undertake activities to develop their independent living skills and to be able to go out into the community.
A soft market-testing questionnaire was issued in August 2018 to gauge interest from the local and wider provider market. This helped commissioners in understanding the potential interest and ability of providers to deliver such a service, including supporting those individuals who may display behaviour that challenges.
In September 2018 the council invited tenders from potential service providers, who could evidence that they were able to provide community-based accommodation and could demonstrate that they would provide skilled support. The successful bidder was 1st Enable.
The service – provided by 1st Enable – was opened in January 2019. The service model consists of four beds (two beds in the south and two in the north of Cheshire East and included the flexibility for additional one-to-one/two-to-one support for those with complex needs). The service has now been in place for the initial three-year contract period (December 2022) and a two-year extension in line with the contract has been agreed with commissioners.
The respite service ensures that people’s diverse range of needs are understood and supported right from the start of their stay. This process begins before they arrive, by reading their initial assessments and meeting individuals and their families. Examples of this include helping a young person to their regular place of worship; helping them to remain an active member of their religious community during their stay. In another example a young person on a long-term placement required their hair and beard cutting. Staff supported them in visiting an ethnic hairdresser. Prior to the visit, staff went to the hairdressers and spoke to the barber to ensure they were able to cater to the person’s learning difficulties. At the visit, staff ensured that the individual was able to choose their desired hairstyle using photographs, alleviating the stress of them having to speak.
Diverse cultural backgrounds are also taken into account; individual menus are created for each person, ensuring they include their cultural foods, as well as taking into account religious, ethical and dietary needs. The service has several kitchens available for use, ensuring that we can accommodate food that must be stored and cooked in specific ways, for religious and dietary reasons. Themed nights provide an opportunity for people to have a taste of different cultural foods from around the world, giving them a more diverse experience during their stay.
In terms of lessons learned from the commissioning process, it was felt that more time should be given to the service provider for the development or modification of accommodation, the recruitment of skilled staff and to provide greater clarification around the CQC registration process. Site visits by the council should also take place as part of the tender evaluation in future.
The service has been able to support complex individuals, and there is evidence of good outcomes have been achieved with service users developing independent living skills and accessing social activities in the community during their stay.
The service remained active during the COVID-19 lockdowns but occupancy was severely affected with many people not wanting to utilise respite. As a result wellbeing calls and outreach provision was offered to provide carer respite.
A further success has been the increasing numbers of young people aged 16+ who have gradually began using the respite service. This has been a valuable support for the transition process into adult services, with people becoming more familiar with being in a supported living environment, developing new life skills and building relationships. The council commissioned an additional flat specifically for this age group.
The wonderful support your team have given my daughter, has enabled us to confidently leave her in your care. We have peace of mind, knowing that she is with people who are both capable and caring your service has given our family a much-needed break.Mr and Mrs P
This was an excellent piece of multi-agency work in my opinion leading to an extremely positive outcome for this young person. The experience of staff and management at 1st Enable was invaluable in assisting ourselves to support this young lady during a period of crisis and eventually leading to positive outcomes moving forwards.
Funding: £170,000 pa.
Inclusive commissioning – Review of Kingston upon Thames respite services
Royal Borough of Kingston upon Thames Open
The Royal Borough of Kingston is currently reviewing its respite services to ensure that carers have access to a variety of respite options. It is piloting an inclusive commissioning approach to ensure that the council and the market is well informed as to what is working and what needs to be improved. It contacted over 350 carers and a consultation report was sent to providers via London Portals to help inform future contracts for respite services. Carers were also invited to participate in the Providers Forum so that they and service providers were able to discuss respite services together. By emailing and telephoning carers directly, and by going to carers groups in the community; the council was able to get good qualitative feedback about what was working well and not so well. This informed respite service design and the council’s commissioning plan.
The case for improving respite services is clear. Data showed that providing overnight and day services respite for 27 families generated a cost avoidance of over £1 million per year. This was calculated by collated the level of care these individuals would need if they were not living at home (chiefly residential or supported living placements) minus the cost of the respite service itself.
The council’s approach involves approaching carers before a commissioning plan for services has been developed, and having the consultation report inform the commissioning plan, engagement with providers, and the business case for developing respite contracts for tender. Carers will be directly involved in writing some of the contract specifications. These carers will also help evaluate provider responses to those specifications in their bids. Carers will be invited throughout the commissioning cycle to help review contract performance and further service redesign.
Budget £500,000 pa.