Removing the Barriers:

Joining up aids and

adaptation services in Dorset

October 2011

SOUTH WEST IMPROVEMENT &

EFFICIENCY PARTNERSHIP

  1. summary

A major review of the host of services available to remove the barriers to everyday living and increase the independence of disabled people was carried out in Dorset in 2011. The review identified a long list of policy and service improvements that would:

  • Ensure needs are better understood and planned for;
  • Make it easier for disabled people to find out about the options available;
  • Enable more people to receive help by recycling fundingand adaptation equipment and reusing accessible homes;
  • Simplify access to equipment and minor adaptations;
  • Provide more accessible homes in the ‘social’ rented sector and ensure these are let to people who need them;
  • Reduce the bureaucracy around provision of financial assistance;
  • Capture better information about performance of the service, including outcomes to enable improved financial planning in future.

Following the review partners were engaged in an option appraisal process to identify the optimum arrangement for service delivery in the future. The recommendation arising from the exercise was to move towards a fully integrated service, probably based around the new user led Centres for Independent Living being developed in the County. Although implementation has not yet commenced there are likely to be several stages in the progression towards the new model (co-location, alignment of policies/procedures and finally full integration of services and budgets).

This case study demonstrates the benefits that can be achieved by agencies working collaboratively across a county area with the aim of achieving better outcomes for disabled people. In addition to the service improvements listed above the expected benefits of the new service model include:

  • Amore attractive and accessibleroute into the service for potential customers;
  • Better value for money through more efficient processes and more effective use of resources;
  • Greater consistency and equity in service provision;
  • A quicker and more appropriate response to need - the right service at the right time.
  • Greater choice and control by customers.
  1. Project background

A strong commitment to partnership working between statutory and other agencies already existed in Dorset. The County can boast many examples of success in delivering services across the County or between districts including the Dorsertforyou website, a joint procurement service and waste collection and disposal contract.

The County has demonstrated an excellent approach to engagement of older people in developing the services they need. This is important in the face of the ageing population, increasing levels of disability, changing aspirations of older people and against a backdrop of reducing funding for major adaptations.

In common with most county areas the arrangements for delivery of aids and adaptations in Dorset is complex. The agencies involved with helping disabled people live more independently in their homes include occupational therapists, the equipment serviceoperated by the County Council and NHS Dorset, equipment retailers, home improvement agencies, local authority grants services, housing association aids and adaptations services and housing allocation services. On a broader front planners and housing staff are key to ensuring that new homes meet the needs of future generations and generic advice services are important in effectively signposting customers to appropriate services.

There is a long history of good communication about aids and adaptations services between Dorset County Council, the district councils and some housing associations but the approach was not strategic and inconsistent. That is not to say that individual agencies or managers were not committed to providing a good service. On the contrary high levels of commitment were manifest, for example, in commissioning the review with a clear view thatthere was a need to work more collaboratively in the delivery of services to achieve better outcomes and value for money.

A bid was made to the South West Improvement and Efficiency Partnership in 2010/11 for financial support to review the existing arrangements and identify a new model for service delivery. The Housing Consultancy Partnership was appointed in April 2011 to conduct the review and lead the project and they in turn appointed Access Dorset, a userled organisation focussed on the needs of disabled people, to review customers’ experience of the services and seek their views on potential improvements.

  1. Objectives

The project brief sought a review of the current service arrangements to identify:

  • The efficiencies that might be achievable;
  • Improvements to the delivery of aids and adaptations by all partners that could secure their long term, sustainable provision throughout the county and;
  • Options for improving the service and potential alternative business models for delivering housing adaptations in Dorset in the future.

The criteria for appraisal of options for the shape of the future service were developed in detail during the project and included:

  • Sustainability – potential for the delivery of long term, sustainable service across the County;
  • Value for money – potential for improvements in economy, efficiency and effectiveness (customer access, customer care, service quality issues);
  • Consistency/equity – potential for reducing postcode/tenure/financial capacity impacts;
  • Appropriateness – does the option contribute to the capacity to meet need at the right level and reflect a holistic model of service;
  • Timeliness – delivering what is needed when it’s needed;
  • Personalisation - synergy with the personalisation agenda, how each option might respond to improving the choice and control of customers;
  • Partnership – does the option enhance the integration of service, partnership working /development capacity, likelihood of different partners to engage and contribute resources;
  • Acceptable – likelihood of acceptability to partners, based on knowledge of resources and potential impact;
  • Equality – potential impact of the option for equality strands e.g. low income households, rural dwellers and other relevant groups;
  • Risk – assessment of risk to partners and ability to mitigate.
  1. Process

The project commenced with a thorough review of the existing arrangements. Web based research; a telephone survey and focus groups with customers; a comprehensive data collection exercise; face to face and telephone interviews were carried out to explore:

  • Variations in the policy and practice response to disability;
  • Best practice in Dorset;
  • Sufficiency of resources;
  • New resource sources and alternative pathways of support;
  • Inefficiencies in the current arrangements;
  • Procurement practice;
  • Inconsistency;
  • Performance monitoring arrangements;
  • Potential for costs savings and improved value for money through:
  1. efficiencies generated through health and social care expenditure;
  2. ‘Leaner’ systems flushing out efficiency savings from revenue budgets;
  3. ‘Smarter’ procurement, recycling of adaptations and maximising use of homes designed or already adapted for use by a disabled person.
  • Opportunities for increased customer choice or control;
  • The extent to which new housing developments were contributing to the pool of accessible homes.

Interviews were held with managerial, policy and fieldwork staff from the full range of agencies contributing to the service in its widest sense, including the commissioners of previous research into aspects of the service.Pro formas were developed by the consultancy team for the data collection exercise and the structure of the interviews to ensure that comparisons and contrasts could be effectively and consistently made at the analysis stage.

The consultants drew on their existing knowledge of best practice and carried out further research to identify potential options for Dorset. A range of options were generated along a continuum from the current situation to a fully integrated service, run by a single agency and with combined budgets.

The option appraisal process was conducted through a workshop involving most partner agencies. The engagement of all relevant agencies throughout the projecthas resulted in good support for the outcome of the option appraisal process. It was difficult initially to engage with all relevant people within the health service but the need to work more closely is supported by the service and it is expected that they will fully engage in the next stage of the project.

The project dovetailed with another Dorset initiative to develop new,user led Centres for Independent Living. The synergies between the projects were therefore explored throughout the process. The new centres, in line with those already operating in Dorset and elsewhere, will provide information, education and practical assistance to people who are experiencing barriers due to impairment. However, unlike many existing models the centres will put the person at the heart of the experience and focus on the individual, not the problem. The approach will follow a cycle of stages - engage, envisage, encourage, empower, enable and evaluate - to allow people to identify for themselves what might help them improve the quality of their lives by enabling them to live independently, with dignity and as part of the community.

The final recommendation from the project was to move towards a fully integrated service, probably based around the new Centres for Independent Living. However, in view of the distance between the status quo and the recommended model there are likely to be several stages in the evolution of the service model (co-location, alignment of policies/procedures and finally full integration of services and budgets).

  1. Benefits achieved

A long list of recommendations for improving the services within the current structural arrangements arose from the first stage of the project, the review of existing services. These were presented to partners prior to the formulation of the new service model. Although these are not yet implemented, they are expected to achieve significant improvement in outcomes for customers including:

  • Improved planning to meet identified needs and maximising the resources available through better engagement of all partners;
  • Increased numbers of customers that can be assisted in future through recycling grant funding; exploring alternative solutions to meeting needs; reuse of accessible or adapted homes by disabled people; recycling equipment and reducing unit costs through smarter procurement;
  • Resolving the complexities and overlapping activities of agencies and schemes providing minor adaptations and equipment;
  • Mainstreaming housing accessibility by adapting homes through housing association planned programmes and building new homes to an enhanced standard;
  • Ensuring that disabled people are able to access suitable social rented accommodation through improvements to the Dorset-wide choice based lettings service and provision of a consistent incentive scheme to encourage people to move instead of adapting existing homes;
  • Simplifying the arrangements for adapting homes using the freedom to innovate allowed for by the legislation;
  • Improving the performance monitoring arrangements including measurement of outcomes for customers and;
  • Development of service standards so that customers can monitor performance of the service and adopting uniform and user friendly formats for providing information and promoting the service

The implementation of the new model has not yet commencedand as no parallel example of such a service exists it is difficult to accurately forecast the benefits of the approach. Perhaps the closest example is St Helens.

Here, the Home Improvement Agency and the occupational therapists are based within the private sector housing section of the local authority. The manager also manages the equipment and Disabled Facilities Grant budgets and the team are responsible for a significant part of the local re-ablement funding. Health occupational therapists are seconded to the team on a regular basis which enables better links with the PCT. The arrangements have enabled them to reduce costs, cope with increased demand and at the same time improve the speed of service. Clear performance monitoring allows them to demonstrate the efficiency of the service.

The expected benefitsof the new model in Dorset were considered as part of the option appraisal process. Using the headings of the appraisal criteria these are:

  • Sustainability/ acceptability – simpler and easier to understand by customers and partner agencies alike. Improved value for money will increase the sustainability of the service.
  • Value for money – potential for greatly improved outcomes for customers (a more appropriate and timely service) through a more joined up service and the optimum opportunity for cost savings through avoidance of duplication and more streamlined processes and decision making.
  • Consistency/equity/equality – simpler and clearer access to the service will be enabled through a single point of contact and a single budget will enable the service to be targeted to needs therefore avoiding any postcode lottery.
  • Appropriateness – the combining of all aids and adaptations services provides greater potential for customers to access the right service at the right time.
  • Timeliness – potential for more streamlined processes, less duplication and quicker decisions will reduce timelines for individual customers. The development of a single point of contact which is well promoted will mean people will find out about the service and access it earlier.
  • Partnership – the model requires a commitment to working in partnership.
  • Personalisation – greater choice and control by customers is enabled by the full range of service options and self help solutions being available for consideration through a single route.

Transforming the service to achieve the recommended model will take time and no progress has yet been made to implementing it. However, partners have all signed up to taking the first step, that is to explore further what would be required to implement the first stage in the journey using the delivery chain assessment tool developed by the Audit Commission. A business case will be developed after this to be considered by partner agencies.

  1. lessons learnt

Partners recognised the importance of being able to see their services from the customer viewpoint. Commissioning an independent review of the broad range of services, including seeking customer feedback, helped partners to identify weaknesses in the current arrangements that were not apparent before. High customer satisfaction ratings based on simple end point satisfaction at the point of completion of adaptations are not an adequate reflection of the service as a whole, nor on the appropriateness of the response.

The fact that effective partnership working involves more than information sharing and ad hoc, joint projects was also a theme of the recommendations from the review. Although partners could identify examples of successful projects, including the joint procurement of stairlifts, they recognised that partnership working requires tenacity and resourcing– the stairlift procurement exercise, for example, was planned to be followed by a further project to provide savings in the installation of showers, ramps etc but no progress had been made.

Not all agencies will view the service under review with the same degree of priority. Early efforts to involve those with a less operationally central role are vital to ensure a full understanding of the broad picture and to contribute to an effective review. In this case, for example, it was seen as important to involve health at the outset of the project, including the commissioning of the review of services. Although theywere engaged in the consideration of the final recommendation and will be involved in the implementation stage, it would have been better to have had the service involved at an earlier stage. Unless there are well formed relationships at the outset it is easy to underestimate the work necessary to engage with other agencies.

Although the project title included both aids and adaptations, and the the focus of the brief was broadly inclusive, there was a strong focus on major adaptations. In this respect the brief could potentially have constrained the usefulness of the work. Meeting the needs of people with disabilities cannot only be considered in the context of major adaptations. The provision, for example of new housing, the operation of letting arrangements for `social` housing, wider housing options advice and preventative services all have a significant role to play. A wide focus considered these issues andalso enabled partners to think ‘outside of the major funder box’. Disabled Facilities Grant applicants and those receiving major adaptation funding from the County Council are just the tip of the iceberg. For most people an appropriate minor adaptation or equipment that they can try out in a non-institutional setting and can be provided quickly and cheaply often prevents a crisis situation and the need for more costly adaptations further down the line.

The project demonstrated the need to be inclusive. There is a danger of focussing only on those individuals who are entitled to financial support. In the context of means tested support, the provision of help and advice to those who are not eligible for financial support and are able to pay for aids and adaptations (or who had relatives who could provide financial support to them in the short term to avoid delays) is an important aspect of an overall service. In Dorset the approach is relatively well developed, but in more urban areas with higher levels of deprivation it would be relatively easy to overlook the support needs of more affluent people.

The environment within which a project of this kind sits can have a significant impact on its achievement. Often there is little choice about when the project will be undertaken but cognisance of risks and potential gains inherent in the environment is important. In this case there were positive drivers, for example, the need to reconsider the Supporting People funding for Home Improvement Agencies in the light of decreasing resources, the agreement to produce a housing chapter to the Joint Strategic Needs Assessment and a developing approach to the use of NHS derived re-ablement funding. More problematic was the alignment of community based health and social care staff, the associated reorganisation and the impact of the considerable changes being introduced for the delivery of NHS services. All of these provided considerable challenges to managers and made their effective involvement in the project more difficult to achieve.