ITEM CA11
CABINET 16 SEPTEMBER 2008
FUNDAMENTAL SERVICE REVIEW - DAY SERVICES FOR OLDER PEOPLE
Report by Director for Social & Community Services
Purpose of the Report
1. A report was presented to the Social & Community Services Scrutiny Committee on 2 July 2008 updating it on progress with the above Review. The Review is now concluding its work and this report is presented to Cabinet to summarise the key findings. Background
2. Oxfordshire County Council (OCC) has recognised the growth in the population of older people through to 2029 and beyond. The Director of Public Health estimates that the number of over 65s and over 85s will increase by 62% and 126% respectively between 2004 and 2029.
3. This will present the Council with a number of challenges including:
· a projected increase in demand for services; · a need for a wide range of service options to be available; · a need to ensure the availability of local services as travel and accessibility may be problematic; · financial pressure as the demand for services increases.
4. To respond to the above, and as part of a wider strategy to allow vulnerable adults to remain in their own homes for as long as possible, the County Council has commissioned a Fundamental Service Review of its Day Services for Older People.
5. A Fundamental Service Review (FSR) is a process to review the County Council’s core services typically over a 5 year cycle. The aim is to improve service delivery and improve efficiency and effectiveness. Reviews use the themes of challenging, comparing, consultation, and competing to help come up with ways to respond to current and future demands.
6. The Review initially looked at day centre services for older people provided by the County Council and those day centre services delivered by external providers that operate under contract to the County Council. However the focus of this exercise changed during the Review as it became evident that there needed to also be a wider consideration of services available in the social care market including those delivered in the health sector and locally based community groups that do not have links to the County Council. Main Findings
7. The following summarises the main themes of what has been found.
(a) Type of Services
The Review identified three categories of service provided in Oxfordshire to:
· services that are provided directly by the County Council · services provided by external organisations operating under contract to and receiving funding (either in part or in whole) from the County Council; and · independent services that exist without funding or contractual links to the County Council.
(b) Service Delivery
The Review collected activity information from a core sample of 59 service providers. These included:
· 7 Centres operated by the County Council including the one Resource Centre that is based in Bicester. These sites provide 1,290 places per week;
· 18 day centre services operated by Age Concern Oxfordshire providing 423 places per week;
· 34 services of varying size delivered by smaller voluntary sector organisations operating under contract to the County Council that provide 1,355 places per week. These are mainly day centres but also include 3 or 4 Luncheon Club services that may be managed and run by volunteers within a local community setting.
14 of the above operate for 4 or more days per week (7 of these are run by OCC) with 27 operating for just one day a week.
The total number of places available in the sample is 3,068 per week. However, the average actual attendance for a sample week in 2007 was identified as being 77%. This suggests that approximately 730 places per week across the county are not being utilised.
By taking a wider view of day services the Review Team has become increasingly aware of the number of independent non-contracted services that exist throughout the county. Work by the Community Development Team identified approximately 300 smaller day services that are being delivered independently across Oxfordshire by local community groups and organisations. This figure will almost certainly understate the true number in existence as it is based on a time-limited piece of work carried out during the Review. Further work will be needed in this area as the existence and location of these services may well make a significant contribution in the future to social care, health and wellbeing support structures within Oxfordshire.
(c) Demand for Service
Service users at day centres are reported to be older and much frailer with the over 80’s requiring the most care and support. Furthermore the likelihood of dementia increases with age. We should assume that more people who attend our day services would present with physical and mental health issues.
From discussions during consultation with providers and from information collected from the core sample it is evident that future service delivery will require a changed service and a different staff skill mix from that which may be currently available.
(d) Referrals
The major source of referrals to the sample day services comes from Social & Community Services (S&CS) and Community Psychiatric Nurses who jointly account for 52% of all referrals. GPs are reported to refer c.7% followed closely by District Nurses at 6% of service users, with self/family or other referrals accounting for 35%.
There appears to be little relationship between funding levels from OCC and referral levels at some Day Centres, while it would appear that knowledge of eligibility criteria for such services among staff from Adult Services is inconsistent.
(e) Transport
Survey information suggests that the County Council transports 57% of those service users who attend the sample day centres. Volunteers supported 16% whilst self/family/carer or other account for 27%. What is clear is that as service users become older and frailer, their mobility and the availability of transport is a major influence on attendance. It will continue to be so in the future and will impact on the service supply strategy.
Historically the County Council’s support to Older Persons Day Centres has been developed on an ‘as and when possible’ basis building upon its existing support to Learning Disability services. Consequently the Fleet Operation appears unable to significantly increase its current scale of transport due to these other service commitments. Whilst generally delivering a good service overall it can be seen on occasion and by some to be constrained and unable to respond to new demands for individual services.
However, in response to current requirements the County Council’s Fleet Operation and Social & Community Services are exploring opportunities to develop a two-session day at OCC day centres in order to maximise attendance and the use of existing transport capacity.
In the future and with an ageing and more frail population it is likely that the demand for special transport may increase. But with volunteer drivers also ageing and possibly reducing in number the solution appears to be to increase special and public transport opportunities whilst at the same time delivering more localised day services that allow for easier accessibility.
If we are to respond to increasing service demands for more special transport then it is likely that there will need to be an associated increase in resources to allow this to be either delivered in-house or procured externally.
(f) Staff & Volunteers
Volunteers play a key role in running services. Providers in all sectors are supported by volunteers; this includes services operated by the County Council. However volunteers are getting older and are themselves becoming frailer, they tend to volunteer in a buildings based service setting and providers report that numbers are reducing. A few organisations have reported difficulty in recruiting Trustees.
(g) Buildings
OCC has a capital budget programme to develop more Resource Centres across the county. Bicester has already been completed, with future developments planned for Witney, Abingdon, Banbury and Wantage by 2010/11.
Opportunities exist to jointly plan and deliver services and avoid duplication as part of (a) our Extra-Care Strategy and (b) alongside Health colleagues as part of their review of their Day Hospital provision. The co-location of services delivered by Carers Centres and other voluntary organisations can be built into service plans as well as educational opportunities provided by the Adult Learning service.
(h) Finance
Analysis has identified a wide range of unit costs that fluctuate depending on attendance levels at each centre. In some examples maximising attendance levels would help reduce actual unit costs by up to 50%.
There is a range of unit costs across County Council centres for a variety of reasons. Bicester is the most expensive by some way but it is also the only Resource Centre in the county. Despite this it appears to have a staff budget that is out of proportion to other centres with an associated imbalance of care co-ordinators to care staff. This will need to be reviewed and unit costs considered when arrangements for Self Directed Support develop.
Charging for attendance, meals and transport services is also inconsistent across the 59 sampled providers. In the case of meals provision the charges appear to bear little relation to the actual cost of meals production.
The County Council may wish to consider the introduction of a level of charges that more accurately reflect the cost of service delivery for non-S&CS referrals.
The funding allocations to external services appear historical and incremental and should be reviewed to provide consistency in their make-up. If the County Council were to finance a service to help voluntary sector organisations secure alternative funding streams to support their services, then any funds generated could be used to replace the existing County Council investment. The released County Council funding could then be used for reinvestment to develop new services. This is a strategy that should be explored further.
(i) OCC Day Centre Provision
Processes within OCC’s internal service are consistent in design and use but are based on manual systems. Introducing an IT system would improve effectiveness and provide efficiency across a range of activities.
The internal service also operates a system whereby day centre places are kept open for a period of 6 weeks when an individual is absent. The extent to which this contributes to lower than expected attendance is not known but it should be explored and the arrangement reviewed.
There is a difference between published hours of operation and a restricted core time period when most service users attend. In some cases this is partially due to transport constraints. Times of opening should be reviewed to see if improvements could be made.
(j) Contracting Arrangements
Whilst the contracting systems with external service providers appear effective, a number of contracts are of relatively low financial value; 15 above £25k per annum and 37 below £25k per annum. It is felt that improvements could be made to reduce bureaucracy and generate some efficiency in this area. This would be more appropriate for contracts identified as low financial value and low risk, although such a change would require changes /some flexibility within County Council Contract Procedure Rules.
(k) Feedback From Stakeholders
Service Users from the sample day centres consider that a meal and socialising are the important things about the day centre. Approximately half state that transport, trips, activities, entertainment and exercise are important to them. Care Management agree that such provision supports the prevention agenda.
The Community Development Team has identified the need for more activity opportunities to be provided. The development of local services should be encouraged to respond to the challenges of life in more rural settings.
Services to the main black and minority ethnic (BME) groups in Oxfordshire work most effectively if specifically designed around individual cultural themes. Further work is needed in this area. Future strategies will need to support the increasing number of EU migrants that now reside in Oxfordshire.
(l) Self-Directed Support
All new service users from April 2009 should be able to have an individual budget and have a choice about how it is spent. It is not known what the uptake and potential rate of growth will be, but the impact on providers is likely to be limited in the first two or three years, maybe longer. Alternative services are perhaps more likely to develop in market towns than in rural areas, so the impact will be felt first where there are greater concentrations of service users per square mile and more choice options. It could be that there is reduced impact in rural areas because service users will be older and frailer and there may be restricted service and transport options available to them.
8. The Service Design Phase
During the Service Design Phase the Review challenged the existing basis of service delivery. There is nothing in legislation that requires the County Council to provide day centres, but it does have a statutory duty to make arrangements for vulnerable adults who are assessed as requiring support.
Buildings based services do play an important role in helping to discharge this duty. Services in a buildings setting will be required in the future to respond to those more dependent people whom OCC will always serve. Centres will need to be accessible by the whole community and not just those assessed as requiring support. Information and sign-posting services will be an important foundation upon which to deliver user empowerment, choice and to support the prevention, health and well-being agendas.
9. Oxfordshire County Council will need to respond to its statutory responsibilities in two ways:
· a menu of options where the service user exercises individual choice and commissions a service them self; and · a prescribed response where Social and Community Services commissions/provides a service for an individual.
10. To enable the above to take place the County Council’s future supply strategy should centre on a three-tier service structure.
· The first-tier is a Resource Centre-type service.
· The second tier should be delivered through locally based day centres/services provided by external providers.
· The third tier should include signposting/direction, information and adult learning services. This latter tier will support and empower the population to choose how they live their lives.
11. It is essential that our first-tier services are available to those persons assessed as most vulnerable. This will require more and more service users to be empowered to make choices about alternative community-based care and support arrangements where these are available. Feedback from Stakeholders
12. A Stakeholder meeting was held on 17 April 2008 to report back on the main themes found during the Review. At the end of the presentation those attending were asked whether the general direction being proposed was the right one. Participants were also asked to give their views on the main challenges and concerns for the future.
13. Initial responses indicate that the direction put forward is the right one with the main concerns being in the areas of increasing demographics/demand for services, service users becoming frailer, the unknown impact of Self Directed Support and provider income streams, transport arrangements and future levels of volunteering.
RECOMMENDATIONS
14. The Cabinet is recommended to:
(a) explore the provision of a Single Information Service across Oxfordshire with information provision supported by OCC, District/City Council, Health, key Voluntary Organisations, and others;
(b) revamp the image that Day Centres have and consider a separate work-stream to review how we market our services;
(c) redesign its referral processes to ensure local/community group options are explored as an alternative response to assessed needs before arranging services for service users;
(d) continue to increase its Resource Centre provision, ensuring that service developments undertaken by others are considered, and ensuring that a multi-agency Stakeholder Commissioning Group supports the location and service design of each service. The service design should include the provision of rehabilitative services, intermediate care services and support from mental health professionals. Resource Centres should be re-named Well Being Centres;
(e) support/facilitate an increase in the availability of independent (contracted and non-contracted) day centres and lunch clubs;
(f) concentrate service delivery to the core mid-week opening hours of some day centres and explore opportunities to open on a weekend;
(g) develop a strategy to improve the capacity of community support through increases in volunteering;
(h) encourage and influence the development of robust transport services that support access to day services for those service users most vulnerable and less mobile;
(i) implement localised networking/partnership groupings - involving one or two specialist centres supported by a range of other smaller day centres in specified geographical areas; (j) ensure that day centres/services are able to respond to diverse cultural needs where demand requires such a response;
(k) ensure the provision of IT links in external day centres where the number of days provision per week justify this to assist with signposting/information provision; and
(l) shift the focus of some care management tasks to some IT-enabled Day Centres and explore how Centres can enter and maintain data on SWIFT as part of its routine business to support Care Management processes.
JOHN JACKSON Director for Social & Community Services
Background Papers; Nil
Contact Officer: Andrew Colling, Project Lead – Fundamental Service Review Of Day Services (Social & Community Services) Tel: 01865-854493 andrew.colling@oxfordshire.gov.uk
September 2008
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