Wiltshire Council: Championing independence The challenge How we care for our rapidly ageing population is a huge challenge for local government. Councils are investigating new ways of delivering community care that balance cost-efficiency with a focus on promoting independence. Wiltshire Council has introduced an innovative outcomes-based commissioning approach. Its model, Help to Live at Home (H2LAH), is based on the principle that many older people can become more independent if their care is delivered in a way that supports their recovery and independence. Paying care providers by the results they deliver against agreed outcomes can decrease longer-term costs while improving people’s quality of life.
A plan of action In 2009-10, Wiltshire Council held a series of events with customers and representatives from every part of the health, social care and support system, asking them how services could be improved. Among the feedback was a consensus that the care system was characterised by poor recruitment and poor terms and conditions, training and pay for care workers, which resulted in poor outcomes and increased needs, demand and costs. The council decided that changing the financial incentives for providers would help to improve this situation and improve quality of care. Tying providers’ revenues to outcomes could maximise customer independence and improve cost-efficiency while also improving the pay and working conditions for care providers. Wiltshire introduced H2LAH which focuses on prevention, recovery and personalisation. Older people who need support receive a person-centred assessment that focuses on outcomes – particularly outcomes that will leave them able to live well with less
care. The aim is first to help people recover their independence, and second to prevent their need for care from increasing.
Payment by results H2LAH pays providers for the outcomes they achieve. The model applies financial penalties when outcomes are not achieved, and rewards providers when people recover faster than planned. James Cuthbert, Head of Information Management, says: “We believe that buying outcomes instead of hours is a commercial incentive that improves the pay and skills of the care workforce. A better workforce improves the quality of care; better care causes better outcomes. Better outcomes make for more independent customers and a more affordable care system.” The Wiltshire model focuses on what people want from their care. Knowing this helps to define the purpose of the care package (for example, being clean, learning to cook, or not falling in the bath). Following an initial assessment, the provider produces a support plan explaining how they will work to achieve the agreed outcomes, how long this is likely to take and what the plan will cost. The weekly price of the plan is the customer’s personal budget. Reviews are frequent and are used to decide whether providers are paid in full. The decision depends on the customer, provider and council agreeing that the outcomes have been achieved. Wiltshire’s “payable outcomes” are about simple activities of daily living: getting up, bathing, dressing, cooking and eating, shopping, seeing friends. If the outcomes are not delivered, the council decides whether the provider was responsible, in which case it can apply a financial penalty. The penalty for initial support plans (lasting about six weeks) is 80 per cent; for ongoing support plans (lasting up to six months) it is 15 per cent. The decision can be appealed. James Cuthbert says: “The model takes care not to penalise success. If providers achieve outcomes using fewer resources than agreed, we don’t recover the excess but we do ask how they did it. This combination of incentives for success and disincentives for failure encourages providers to innovate and find less costly ways of achieving the outcomes.”
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Delivering savings The service was launched in 2011 and has enabled Wiltshire to deliver savings that were required to balance the forecast overspend in adult social care budgets between 2011 and 2013. Savings in 2011/12 totalled £2.8 million, resulting from lower unit costs in all of the services replaced by H2LAH. Savings in 2012/13 resulted from fewer people needing long-term care, especially residential care. By the end of February 2013, the council’s forecasts showed that it was slightly ahead of its plan to save £4.8 million of its £57.4 million budget for services to older people. The system has simplified the council’s trading relationship with providers. Ninety separate domiciliary contracts worth £14 million have been reduced to eight payment-by-results contracts worth £11 million. Consolidating to a few providers creates economies of scale and was also intended to reduce the financial risk on businesses of recruiting and retaining a high-quality workforce.
Into the future A system that focuses on payment for outcomes of independence creates a financial incentive to help reduce customers’ need for care, rather than guarding the number of hours providers deliver. The focus is on what people can do rather than what they can’t. There is no means-testing until it is clear that a customer will need long-term care. The initial support is free for everyone whose level of need is eligible for public support. People who would otherwise be self-funders benefit from having the right care and can leave decisions about long-term care until the crisis ends, reducing the likelihood that people will use longterm care too early. An important factor in the success of Wiltshire’s model is a clear definition of the responsibilities of the council, customers and providers, with an emphasis on partnership between the three. Customers have access to quality care, support and advice and the council is able to manage an increase in demand at a time when its own resources are reducing. For further information please contact Nicola Gregson, Commissioner for Services to Older People, Wiltshire Council: nicola.gregson@wiltshire.gov.uk.
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Š Local Government Association June 2011
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