Commissioning for outcomes and impact

Strategic approaches

Commissioning is about having the most effective support in place in order to improve outcomes. Stakeholders may be interested in different outcomes, so making the respective benefits clear. Local authorities and health services have legal duties to develop integrated approaches. However, effective commissioning cannot be achieved in isolation. It needs to be co-produced with local people and by close collaboration with adults and children’s services, public health, housing, NHS partners and the wider community. Knowing what’s on other people’s agendas and understanding their priorities will help identify opportunities to embed the agenda across a wider platform.

How can you ensure carers’ breaks are everybody’s business and cross strategic agendas?

  • 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 relevant for the local CCG 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 it understood the needs and agreed the 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 and as part of the offer. The local chamber of commerce may have plans and some businesses may be part of Employers for Carers. My Time, Liverpool demonstrates fantastic community gains that are positive for business too.

Commissioner, be brave and commission innovative solutions.

Carers’ Breaks Reference Group discussion, February 2019

Ensure choices reflect your community diversity. Don’t leave groups or communities isolated. Services should be accessible to all – adapt them if necessary. Otherwise it is lazy commissioning

Carers’ Breaks Reference Group discussion, February 2019

Look carefully at the care market for everyone – including self-funders.

Carers’ Breaks Reference Group discussion, February 2019

See also: NHS Commissioning for Carers

Practice examples

  • Cheshire East Council Adult Respite Support Open

    Cheshire East Council

    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)

    Website:  Cheshire East Council: Livewell - Looking after someone
    Contact: Jane Stanley-McCrave, Integrated Commissioning Manager

  • Family Carers’ Prescription Open

    Provider: Carers Trust Cambridgeshire, Peterborough, Norfolk (Carers Trust CPN)

    A Family Carers’ Prescription gives carers access to a specialist worker at Carers Trust CPN 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.

    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. So 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.

    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 £1.09 million in the first six months of 2019/20. 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 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.

    Website: Carers Trust Cambridgeshire: Family Carers’ Prescription
    Contact: Melanie Gray, Deputy CEO

  • mytime Open

    Liverpool Carers Centre, Local Solutions (not for profit)

    Evidence from carers accessing the Liverpool Carers Centre showed that the most requested type of support was a respite break. Demand in the city was outweighing supply so the Centre looked at how best to respond this request. Contact was made with a hotel and it offered complimentary bed and breakfast for a carer and a guest.

    It now has 26 hotels and 32 other organisations providing offers to carers. This includes restaurants, theatres, universities, leisure and tourism, football clubs, watersports centre and Aintree Racecourse. Some carers are unable to leave the cared-for overnight so mytime worked with organisations such as theatres/restaurants who could offer a few hours during the day. 1,300 carers are 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’.

    Evaluation gained from the project shows an increase in carers health and wellbeing. This is evidenced by 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 back that the services have helped them to remain in their caring role.

    One of the key lessons they 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.

    Budget: Approx £80k per annum. At present the service is funded through the Big Lottery Fund and other charitable trusts.

    Website: mytime
    Twitter: mytime_LS
    Contact: Hazel Brown, Head of Carers Services

  • Respite Support for Adults and Children 16+ with learning disabilities Open

    Commissioner: Cheshire East Council

    Cheshire East Council recognised that adults and children 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, safe in the knowledge that the person they cared for was in a safe environment with appropriately skilled staff. The survey also informed commissioners that service users 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 within Cheshire East, especially to support 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 a provider called 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). At this stage it is too early to evaluate the new service. However there have been early indications that the service provision is able to support complex individuals and that evidence of good outcomes have been achieved (with service users developing independent living skills and accessing social activities in the community as part of their respite 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 CQC registration process. Site visits by the council should also take place as part of the tender evaluation in future.

    Funding: £170,000 pa.

    Website: Cheshire East Council
    Contact: Mark Hughes, Senior Commissioning Manager

  • Review of Kingston Respite Services Open

    Royal Borough of Kingston upon Thames

    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.

    Contact: Michelle Murray, Senior Commissioning Officer for Adult Social Care

Shaping the market

The Care Act sets out market shaping duties to ensure a diverse, high quality market from which local people can choose. This needs to be based on locally identified needs, demographics, trends and aspirations. The statutory guidance sets out how local authorities should use ‘a wide range of approaches to meets the needs of all people in their area who need care and support, whether arranged or funded by the state, by the individual themselves, or in other ways’. Local authorities need to ensure a variety of different service providers, including a variety of types of provider, and should always encourage innovation.

The practice examples set out the richness and variety of approaches to breaks across England. A good approach for commissioners will include the following.

  • Ensuring a genuine choice of breaks – a wide range of provision and types of provision available at different times. This may include residential respite, sitting services, through to holidays and support around shared activities. This range needs to address equalities and specific needs that may require particular approaches.
  • Ensuring a sustainable market for breaks – moving beyond pilots and having contracts and meaningful monitoring (including by carers) that facilitate wellbeing outcomes. Addressing challenges in remote rural areas for low volume services.
  • An inclusive approach that checks that the market is responsive to the identified needs of different carer groups and communities.
  • Investing in quality and developing what works. This may include encouraging quality providers to diversify to offer breaks. Staff skills and experience are key to quality so linking providers with workforce development plans to collaborate on training – including by carers – can help.  
  • Articulating to providers the likely demand and the types of services that people say they want, and a shared local understanding ‘what good looks like’.
  • Ensuring carers (including self-funders and direct payment users) are aware of what is available and how much it costs.
  • Fostering a climate that facilitates the development of flexible services that are truly personalised and strengths-based. This includes whole family and integrated approaches building on community assets and local business opportunities such as ‘My Time’ in Liverpool.
  • Facilitating innovation, social enterprise and community-based models such as Shared Lives. Small charities and social enterprises may be put off by formal tendering processes but be able to offer tailored, innovative support. There are many ways that services can be engaged and funded. Tendering is just one way. Commissioners should not limit choice by inappropriately applying rigid procurement approaches.
  • Getting on with it! Not delaying progressing support for what clearly works.
  • Decommissioning services where there is not the need or demand or the service is unable to adapt to what is needed.

Practice examples

  • Carers Holiday Lodges Open

    Provider: Bournemouth Borough Council and Borough of Poole (Council-owned service)

    This is a local authority-led project. Carers in the two boroughs were asked if they would be interested in having a break in a lodge at a holiday park. Following positive feedback, the councils purchased lodges with money from what was then the primary care trust.  They involved a carer in the selection of the first lodge in the seaside town of Brixham in Devon. The second lodge was in Weymouth in Dorset as some carers could not travel to Devon. This lodge was specifically designed to be more accessible and dementia-friendly, as carers usually took the person they cared for. 

    Between 2016 and 2018, over 300 carers had breaks at the two lodges. The services receive regular, positive feedback from carers describing it as 'a breath of fresh air', 'a chance to renew my batteries'.  Holiday park staff are seen as especially helpful. Both parks have bus stops near to the entrances so that there is easy access to local leisure facilities.

    As part of the project design, carers agreed to a highly reduced 'booking fee' of £10 per night, as a way of contributing to the cost.

    Funding: c £25,000 p.a. to run both lodges. 

    Website: CRISP Carers Centre
    Contact: Debbie Hyde, Carers Commissioning Manager

  • mytime Open

    Liverpool Carers Centre, Local Solutions (not for profit)

    Evidence from carers accessing the Liverpool Carers Centre showed that the most requested type of support was a respite break. Demand in the city was outweighing supply so the Centre looked at how best to respond this request. Contact was made with a hotel and it offered complimentary bed and breakfast for a carer and a guest.

    It now has 26 hotels and 32 other organisations providing offers to carers. This includes restaurants, theatres, universities, leisure and tourism, football clubs, watersports centre and Aintree Racecourse. Some carers are unable to leave the cared-for overnight so mytime worked with organisations such as theatres/restaurants who could offer a few hours during the day. 1,300 carers are 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’.

    Evaluation gained from the project shows an increase in carers health and wellbeing. This is evidenced by 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 back that the services have helped them to remain in their caring role.

    One of the key lessons they 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.

    Budget: Approx £80k per annum. At present the service is funded through the Big Lottery Fund and other charitable trusts.

    Website: mytime
    Twitter: mytime_LS
    Contact: Hazel Brown, Head of Carers Services

  • Shared Lives Open

    Shared Lives offers adults the opportunity to use small-scale, family and community-based support to meet their care and support needs. Shared Lives is used by people of all ages from 16 onwards, with a wide range of difficulties. Support is offered through Shared Lives carers, who share their own homes and family life offering long-term live-in arrangements, short breaks or day care. Short breaks can be anything from a few hours a day on a regular basis to overnight stays for an agreed length of time. Time is spent making sure that the match between the service user and the Shared Lives carer is a positive one. At the heart of Shared Lives is the relationship between the person using the service and the Shared Lives carer and their family.

    Shared Lives is funded in the same way as other forms of short breaks. The local authority will undertake an assessment for the person being cared for and their carer. This will look at the needs of the person being cared for and consider what services they may be able to provide bearing in mind local priorities and availability of services. They will also do a financial assessment which means that the family carers or the person being cared for may be charged for the services according to means. Charges vary according to the area and the support needs of the person using Shared Lives.

    In 2015–16 Shared Lives participated in the Carers Social Action Support Fund project funded by the Cabinet Office which explored different way to support family carers. The evaluation of the project, undertaken by TSIP, showed that using Shared Lives for short breaks provided a reduction in caring stress and in the likelihood of breakdown and an improvement in wellbeing. (TSIP 2016)

    Website: Shared Lives Plus
    Contact: Anna McEwen

Use the wider voluntary and community sectors as they are trusted by local citizens.

Carers’ Breaks Reference Group discussion, February 2019

Use a wide range of local assets including the private sector.

Carers’ Breaks Reference Group discussion, February 2019

Providers can have great ideas as well. How do new providers in an area link in?

Carers’ Breaks Reference Group discussion, February 2019

Carers’ breaks: guidance for commissioners and providers
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