In the Pan-Lancashire flexible agreement, 39 providers have been selected through competitive tendering to provide supported living to people with a learning disability and/or autism who display behaviour that challenges. This case study forms part of the Transforming Care useful information library.
In the Pan-Lancashire flexible agreement, 39 providers have been selected through competitive tendering to provide supported living to people with a learning disability and/or autism who display behaviour that challenges. The providers on the flexible agreement are able to bid, through a mini competition process, to provide supported living care and support packages for individuals leaving hospital or at risk of needing hospital. The allocation process is person-centred – every mini competition is based on different criteria according to individual needs. Since the agreement started in October 2016, 16 people have been matched to providers, three have been discharged and 13 are in the process of transition.
The Pan-Lancashire Transforming Care Partnership is a strategic alliance of four councils – Lancashire County Council, Blackburn with Darwen Unitary Council, Blackpool Unitary Council, and South Cumbria County Council – with eight CCGs and NHS England specialised commissioners.
Lancashire is a fast-track area, as described in ‘Building the Right Support’, and progressed its local plan before other transforming care partnerships (TCPs) in 2015. The area had a major provider of long-stay inpatient services, Calderstones, which Calderstones Partnership NHS Foundation Trust was acquired by Mersey Care NHS Foundation Trust in 2016, and care for people with a learning disability, autism or both is now provided through the Specialist Learning Disability Division. The commitment within Building the Right Support was that all provided forensic and secure services, and a range of services for people who had previously been in secure provision, as well as those with complex care needs.
One of the TCP’s key priorities was to increase the range of support in the community to facilitate safe and effective hospital discharge. Developing the market was an important element in this.
Building on existing TCP analysis and engagement, NHS England commissioned ACEVO Solutions to identify options for developing the market of providers who offered community-based support. Engaging with a wide range of stakeholders was an important part of the feasibility study.
One of the main issues identified by people with a learning disability and/or autism and their families was that services should be better joined up. People also wanted reliable and flexible support that helped them to be healthy, have their own home and a good social life, and to work towards employment.
Providers wanted better information and communication to help them with strategic planning. They also described the challenges of working with people with complex needs, such as the need for high levels of skill.
The study came to some broad conclusions about current provision across the PanLancashire region. While Lancashire was a proactive region, committed to transforming the lives of people with a learning disability and/or autism, a number of issues relating to the provider market needed to be addressed for the full shift from hospital to community settings to be achieved.
- The market was very clinically oriented due to the previous high levels of use of the specialist provider, and the wider market was fragmented. Commissioners needed to develop the full market and hold all providers equally to account. Greater strategic engagement with providers would lead to opportunities to develop solutions together.
- A lack of housing solutions was leading to delays in creating support packages in the community. A strategic approach to developing flexible housing options was needed.
- There was a reliance on spot purchasing rather than coordinated commissioning and contract management; this was labour-intensive and unlikely to deliver the best value for money.
The study also found a ‘very active local market’ with many providers, ranging from NHS trusts to national, regional and highly local private and voluntary organisations.
The report suggested that it was important to enhance the ability and scope of existing providers as well as attracting more providers into the regional market.
The study made a number of recommendations relating to strategic commissioning, market development, improving partnerships and clarity about costs. A key element in meeting the recommendations was to establish a supported living commissioning framework.
Lancashire County Council took the lead on developing the commissioning framework, working with the other TCP councils and CCGs. Aims of the framework, which is known locally as the Pan-Lancashire Flexible Agreement (FA), are to:
- Identify a set of providers who have demonstrated the ability to provide high quality, person-centred and cost-effective supported living in the community in line with the good practice identified in ‘Building the Right Support’.
- Create an environment of co-production between providers, commissioners and individuals, so that planning and problem-solving are done together.
- Support providers to be able to plan their business strategically through clearly established communication processes and regular data on future levels of need.
A service specification for the FA was developed with considerable input from the full range of stakeholders, including people with a learning disability and/or autism and families, co-production partner Pathways Associates, professionals such as social workers, nurses and psychiatrists, and providers. The specification is outcome-based and includes standards relating to matters such as positive behavioural support and safeguarding, staff and training, personalisation and advocacy.
Scope of the FA
The FA applies to people with a learning disability and/or autism with behaviour described as challenging, including mental health problems, who need a placement in the community following an inpatient stay, or to prevent admission to a specialist hospital. This includes people with a history of forensic care. The FA is also used for young people with a learning disability and/or autism making the transition to adult services and who are at risk of hospital admission.
The FA only includes services that provide community-based, person-centred supported living. There is a separate process for people assessed as requiring residential care. 4 The FA covers supported living, not accommodation. It is the responsibility of providers to source and secure suitable accommodation; providers are expected to work in partnership with housing providers to identify housing options.
Procuring the FA
A tender process was carried out to select providers who met the criteria to be accepted into the FA. A panel, made up of staff from the multi-disciplinary team (MDT) and commissioners, evaluated 44 applications and selected 39. The tender process started in July 2016 and the contract became operational in November that year. Being part of the FA means that providers can apply to provide supported living packages.
Allocating support packages
Support packages are allocated in two main ways:
- Mini-competition – in which providers on the FA are invited to apply to provide a service.
- Direct award – where it would be significantly detrimental to the health or wellbeing of a service user to have a change in service provider, or for placing a service user within a suitable vacancy within an existing supported living tenancy, or if other specific factors apply, such as service user’s choice, provider’s specialism or location.
It is also possible to award a contract to providers outside the FA via competitive tender or direct award for similar reasons to the direct award described above.
Allocating support packages involves close working between the multi-disciplinary team (MDT) who support the individual, commissioners and the procurement team.
Personalisation is central to the process. Mechanisms are in place to ensure the best match between the individual and the provider. These include:
- An individual service plan (ISP), compiled by the MDT together with the individual and, where relevant, their family.
- A pen picture template which allows the individual to describe his or her priorities and aspirations, including where they wish to live (the template is included as appendix B).
- A mini-competition questionnaire for providers, with questions based on the ISP and pen picture.
Questions are selected by members of the MDT and workers from commissioning and procurement. A list of questions has been developed by a range of stakeholders, including people with a learning disability and family members. The questionnaire is used to score the suitability of providers, and has the following sections:
- Service outcomes 20 per cent – example question: ‘How will you ensure co-production in the development and flexible delivery of support plans?’
- Transition 15 per cent – example question: ‘How will you support the individual through the transition, identifying their key needs and ensuring the least disruption?’
- Staffing 20 – example question: ‘What specific training would the staff delivering the services be provided with?’
- Supporting Independence 25% – example question: ‘How will you enable the individual to develop their interests and aspirations and build these into day to day life both within the home and in the wider community?’
While some questions are set, other questions can be added because each package is tailored to individual needs. An example of a question added by a family member is:
- What is your policy with regards to working with someone who has sexualized and challenging behaviour, and what specific training have the staff had to manage this?’
Support packages can be for individuals or for groups of people. A personalised approach is maintained for groups through providers having to demonstrate how they will meet the needs of each of the individuals involved.
Selecting a provider
The ISP, pen picture, and questionnaire are compiled into a pack and made available to providers on the FA through the e-procurement portal. Potential applicants can submit questions for the purpose for clarification through the portal. Providers who believe they can meet the needs of the individual or group submit an application.
An evaluation panel meets to select a provider. Panels must have a minimum of three scoring members, to include a social worker, a commissioner, and a learning disability nurse, supported by procurement as a non-scoring member – where the individuals are in-patients a member of ward or forensic specialist staff are also invited to join the panel. Applications are evaluated on a ratio of 80 per cent quality to 20 per cent price.
After a provider is appointed, the MDT and the provider work together with individuals to prepare them for a successful move.
Implementation in Lancashire
The TCP agrees strategies and policies that apply on a Pan-Lancashire basis, but because each area has different circumstances, operational activity, such as procurement and contract management, is carried out separately by each local authority and its partner CCGs. The information in this section covers how the FA has been implemented by Lancashire County Council and the six CCGs in this area.
As at October 2017:
- 48 requests for supported living packages have been received, and of these 23 are inpatients and 9 people at risk of admission, and 16 young people at transition.
- Ten contracts for individuals have been awarded – 11 inpatients and five at risk of admission. Three of these people are now being supported in their own tenancies, the others are preparing to move to the community.
- A contract for a group procurement for three places with two vacancies in a fiveperson house/flat scheme with individual own front doors has just been awarded.
- A contract for a group procurement for three in-patients and two vacancies is about to be tendered
- A proposal to procure specialist support for 13 young people with a learning disability and/or autism who display behaviour that challenges who are due to leave residential college/school in 2018/19 is being developed and considered.
Providers are described as being enthusiastic about the Flexible Agreement, particularly access to data to assist their future planning. Lancashire provides information about discharge trajectories on a quarterly basis via Prior Notifications issued on the e-procurement portal.
Arrangements are in place to enable partnerships between providers, commissioners and health and care workers. The Learning Disability Provider Network includes an update on progress on transforming care and the FA. The Learning Disability Partnership Group is attended by provider representatives and self-advocates, and provides a forum for jointly developing ideas and influencing the design of future commissioning and procurement. Shared training for providers is taking place within the TCP, with an initial topic being positive behaviour support.
With the FA working effectively, there are no immediate plans to open this up to new providers. This may take place in the future, dependent on need.
Value for money
On the matter of value for money, early indications are that placements through the FA can result in significant savings. However, this is counter-balanced by some extremely large costs for bespoke individual placements. Overall, it is believed there will be some potential for savings. The financial situation will continue to be monitored.
How the new approach is being sustained
Monitoring and evaluation
An outcomes framework is part of the service specification and service providers must be able to demonstrate that they are meeting outcome measures and standards. The framework is built around twelve ‘I’ statements.
- I am safe.
- I am treated with compassion, dignity and respect.
- I am involved in decisions about my care. 4
- I am protected from avoidable harm, but also have my own freedom to take risks.
- I am helped to keep in touch with my family and friends.
- Those around me and looking after me are well supported.
- I am supported to make choices in my daily life.
- I get the right treatment and medication for my condition.
- I get good quality general healthcare.
- I am supported to live safe in the community.
- Where I have additional care needs, I get the support I need in the most appropriate setting.
- My care is regularly reviewed to see if I should be moving on.
Each of the statements has a number of outcome measures. For example, the standard on ‘involvement’ has the measure, ‘Number and percentage of staff that have been recruited with service user/family, carer involvement’.
A streamlined version of the outcomes framework based around key performance indicators is currently being developed in collaboration with contracts officers; performance will be monitored via self-evaluation and 6 monthly visits.
Both providers and commissioners are learning as the process develops. There remain challenges in securing the right sort of accommodation for people, such as investors more inclined to want to back housing projects for larger numbers of individuals. The TCP are commissioning a Housing Strategy to identify needs and assets, and to stimulate the development of housing options, which will support the FA.
It seems that some vacancies and voids in existing supported living schemes have proved suitable for some people’s needs, but, for others, more creative solutions to finding suitable accommodation will be required, including developing new builds, and taking better advantage of existing housing stock.
- It is essential to make sure that systems and culture are in place to help workers from multi-disciplinary teams, commissioners and procurement to work well together. This means understand each other’s roles, and developing an ethos of person-centred practice based on promoting independence.
- Barriers between multi-disciplinary teams, commissioners and providers need to be broken down, and relationships established based on transparency and respect, recognising that providers have built up considerable expertise in working with individuals.
- Finding suitable accommodation and preparing people to live there can take a very long time. Expectations on the time it takes to reach successful outcomes need to be realistic.
Sally Nightingale, Manager, Policy, Information and Commissioning Live Well.