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					 How to specify real outcomes
         in Social Care:
Benefiting users, carers, staff and
organisations through outcomes
       focussed contacting
                                              A condition of well-being for children,
                                              adults, families or communities.
                                             Children born healthy, Safe communities, Older
                                             People Independent
  OUTCOME                                     A measure which helps quantify the
  INDICATOR                                   achievement of an outcome.
  (BENCHMARK)                                 Rate of low-birthweight babies, Crime Rates, Rate
                                              of DToC
   PERFORMANCE A measure of how well a service,
   MEASURE     programme, or organisation is working.
                                              Three types:
                                              1. How much did we do?
                                              2. How well did we do it?
                                              3. Is anyone better off? = Customer Outcome
* ―Trying Hard Is Not Good Enough‖, Friedman M, 2005
              Customer Outcomes:
              Is anyone better off?

―Outcomes refer to the impacts or end
 results of services on a person’s life‖
 SCIE (2006) Adults Services Knowledge Review 13: Outcomes-focussed services
                                                             for older people
―Outcome Based Contracting‖

―Outcome based contracting is designed to
shift the focus from activities to results, from
how a programme operates to the good it

         M. Plantz, M. Greenway and M. Hendricks (1999) Outcome
         Measurement: Showing Results in the Non-profit Sector
          Pause for thought!

  Outcomes Focussed or Outcomes Based

             Is there a difference?

The 2020 Public Services Trust thinks there is!!
     Outcomes Focussed v Outcomes
   In general most performance management techniques take one or two
   approaches but rarely both: they specify outcomes or they pay on
   performance. For example, performance contracting involves paying on
   performance, but specified as inputs or outputs, not outcomes. On the
   other hand, Public Service Agreements in the UK are outcomes-focussed
   but do not involve payment on performance…These tools help the state
   to incentivise the delivery of inputs or outputs OR monitor the
   achievement of outcomes but with limited consequences. Outcomes
   commissioning seeks to integrate outcome specification snd payment on
   performance into a single approach – making payment on delivery of
   outcomes. It matters because despite repeated efforts to improve public
   services, in many cases public expectations are still not being fulfilled.‖

―Better Outcomes‖, Cumming LM et al, 2020 Public Services Trust at the RSA, December 2009
           Let’s sum that up…

• Outcomes based contract could suggest
  payment by results

• Outcomes focussed service specification sets
  framework for performance management
  according to ―Is anyone better off?‖ criteria
  The contract – key characteristics*
• Agreement between 2 or more parties
• An offer and acceptance
• Does not need to be in writing – custom and
  practice and oral agreements do count, but more
  often than not we form written agreements
• Can relate to one or more services
• Open ended or fixed
• Scope and meaning must be clear
• Specification needs to clearly identify the service to
  be provided and the outcomes desired

  *Leonie Cowen of Leonie Cowen and Associates speaking at INLOGOV Commissioning Course 2005
An example of a contract structure

                                         Generic Contract Terms

                                                                  Service Contract
    Care Home Specific    Dom Care Specific      SLS Specific                        LD Homes Specific
      Contract Terms       Contract Terms       Contract Terms                        Contract Terms
                                                                   Contract Terms

     Care Home            Dom Care              SLS Specific     Service Contract        LD Homes
       Service             Service                Service            Service              Service
     Specification       Specification          Specification      Specification        Specification
Developing a service specification
•   Meet with provider/s
•   Set up joint working group
•   Involve other stakeholders – consultation and engagement
     – Other providers
     – Service users/carers
     – Team meetings
     – Partner agencies
     – Corporate colleagues

•   Develop outcomes for the specification
•   Agree how will outcomes be delivered – inputs, processes and outputs
•   Develop performance measures and outcomes indicators
•   Assess resource implications
•   Consultation and engagement on findings
•   Write up contract terms with legal service
•   Write specification with stakeholders
•   Final drafts for consultation to relevant stakeholders
•   Final amendments following consultation
•   Sign off
   Performance Measurement

          Need to understand:
• How much effort we bought or have
  put in
• What the effect of commissioning &
  procuring the right services has been
  for people
             Performance Measurement
          Quantity                 Quality

Effort   How much               How well
         did we do?           did we do it?

                     Is anyone
                     better off?

            #                        %
              Community Based Services for OP
              How much did we do?             How well did we do it?

                                          # visits per week
                                          Ave length of visit
             # of persons
Effort       served
                                          % service users who say
                                          the service is reliable,
             # visits                     flexible, respectful,
                                          friendly (SPRU))

                             Is anyone better off?

         # entry into hospital,          Rate entry into hospital,
         residential or nursing care     residential or nursing care
Effect   # carers report the service     % carers report the service
         helped the service user         helped the service user
         remain at home                  remain at home
Specifying the right services
          How should we specify the service?

            Quantity             Quality

         How much             How well
         we will do           we want

          (for providers to   services to
                              be provided

                      How we want

                      service users to
                      be better off
            HOW MUCH?                         IS ANYONE BETTER OFF?

                                HOW WELL?

               ACTIVITY                  INDIVIDUA       SERVICE       STRATEGIC
   INPUTS      / PROCESS    OUTPUTS          L            LEVEL        OUTCOMES
                                         OUTCOMES       OUTCOMES

*Many versions of this ―Logic Chain‖ exist, this is based on an example given by
Worcestershire Supporting People Manager (now Joint Commissioning Unit Manager) at
the NCCTC in 2008.
         How to Performance Manage?
           Quantity                       Quality

         How much                 How well
         did we do                did we do

                                  (Provider QA & Contract

                  Are service
                  users / carers be

                  better off?
                  (Provider QA, Care Management
                  Feedback & Contract monitoring)
Centre for the Study of Social Policy -
          Harvard Project on Effective Services
 • Using such an outcome focussed approach can replace (or at least
   diminish the need for) centralised bureaucratic micromanagement
   and rigid rules.
 • Outcome information can assure funders and the public that
   investments are producing results.
 • Agreement on desired outcomes can facilitate cross-systems
 • Agreement on a common set of outcomes and outcome measures
   not only makes collaboration easier, but also helps promote a
   community-wide "culture of responsibility" for children and
   families, and fuels the momentum for change.
 • Agreement on desired outcomes helps to minimize investment in
   activities that don't contribute to improved results.
 • Information about outcomes enhances community and agency
   capacity to judge the effectiveness of their efforts, and to modify
   activities in response to impact information.
 • A focus on outcomes clarifies whether allocated resources are
   adequate to achieve the outcomes expected by funders and the
Center for the Study of Social Policy -
           Harvard Project on Effective Services
• Funders, the public, and even programme people, may underestimate
  how long it takes to achieve significant improvement in outcomes.
• Funders could be led to confine their support to interventions whose
  effects are readily and quickly quantifiable.
• The shift to outcome-based accountability should not be seen as a
• When a community adopts a outcome-oriented system, fundamental
  changes in the allocation of resources will result and must be prepared

We believe that it is critical to start implementing systems of outcome-
       based accountability now, recognizing that the necessary
 procedures and technologies are still in the process of development.
                     Too much is at stake not to begin.
 Outcome focused
… some provocation
   What has research told us?
• ―Glossy‖ proposals often successful in getting
  funded – but don’t necessarily deliver
• Innovation can’t be purchased in conventional way
  – providers need freedom and flexibility
• Perfect compliance with process does not
  necessarily mean perfect outcomes (or any
• Developing real partnership with providers – getting
  round the table to discuss issues – gets results
                                      The Rensselaerville Institute
      Outcomes focussed contracting /
Designed to:
―…shift the focus from activities to outcomes, from
 how a programme operates to the good it
                          Outcome Measurement: Showing Results in the Non-profit Sector.

 Purchasing a contract relationship that maximises
  good service user outcomes rather than the outputs
  from a service
 The focus is on the lower right quadrant:
  Is anyone better off?
           Commissioning/contracting –
          Are we a Funder or an Investor?
A Funder                                An Investor
• Invites submissions and selects       • Seeks to uncover all possible
   from those applying.                   promising opportunities.
• Uses multiple criteria—including      • Answers three questions of each
   need, workplan, quality of             opportunity.
   proposal writing, evaluation            – What outcomes are we buying?
   design, etc., to select. May offer      – What are the chances of
   points for proposal sections.             success?
                                           – Is this the best possible use of
• Believes fairness means distance      • Believes fairness means intense
  from proposers.                         interaction with applicants.
• Considers grant decisions the         • Considers the initial investment
  high point of their work.               only the starting point
• Monitors for grant compliance.        • Asks: How can I help?
       Specifying and Managing
      Performance Successfully?

• Getting the right balance between FUNDER
  v. INVESTOR role
• Ask: How can we help?
• Change the way you discuss performance
• Maturity in managing poor performance
      Examples of Investor role
• Swine Flu – sharing resources
• Social enterprise radio station – giving
  support staff, space in Council building,
  funding etc.
• Offering specialist HR, business, finance
• Offering important free training through the
  Social Care Partnership (e.g. POVA)
• Offering office accommodation to block
    Maximising your investment
• Good dialogue
• Improved relations
• Mature approach to improvement
• Offering something that allows the provider to
  concentrate on their expertise and core
• Improve quality – reduce the ―lack of
  resources‖ issue
• Can require significant change in culture
• Outcomes focussed performance
  management becomes the
  responsibility of ALL
• Requires leadership at all levels
• Requires commitment from all - all
  partners and stakeholders involved
• Requires good communication
     Great, but how do we pay for
• Danger that performance management based
  on outcomes can become punitive (especially
• Payment by outcomes should reward good
• How do Sales Staff get paid?
• Example: Torfaen and Newport Quality
  Payment pilot
       Torfaen / Newport Pilot
• Research and consultation tells us that
  outcomes that relate to processes that effect
  service users (quality outcomes) are as
  important as those based around change or
  maintenance of condition
• E.g. People in care homes value their dignity
  and want to be listened to so that other
  outcomes fall naturally into place
• Quality Fee structure therefore based around
  Quality outcomes and Environment
        Examples of Outcomes
Maintenance            Quality         Change
•Feeling safe          •Listened to    •Improved
•Having things to do   •Having a say   confidence
•Seeing people         •Treated with   •Improved
•Staying well          respect         skills
•Life as want          •Responded to   •Improved
(including where you   •Reliability    mobility
live)                                  •Reduced
   Torfaen / Newport Pilot (cont.)
• Work with providers to develop a set of basic
  standards that would be expected as a minimum to
  maintain a pleasant and safe way of life
• Develop a set of enhanced standards that would
  ensure that the Quality Outcomes are being met
  and exceeded
• Pay those providers who meet the enhanced
• This gives you an ongoing benchmark for
  performance management and a basis for ―payment
  by results‖
            Other examples
• Payment by no. of Young People with
  Disabilities achieving recognised
• Payment by no. of Young People Leaving
  Care who maintain successful tenancy for 6
  months, 1 year etc.
• Payment by no. of people with mental ill
  health going into voluntary work

• Can require significant change in culture
• Outcomes focussed performance
  management becomes the
  responsibility of ALL
• Requires leadership at all levels
• Requires commitment from all - all
  partners and stakeholders involved
• Requires good communication
―If you do what you
     always did,

 you will get what
 you always got.‖
        Kenneth W. Jenkins
        President, Yonkers NY NAACP
             Discussion points
• Think about the relationships you have with
  providers. How do you develop the specification?
  Give some examples including how your approach
  might differ from the one I talked about.

• How can you monitor for compliance in a more
  investor approach – do you have to relinquish some
  degree of control? Is that healthy, is it SAFE and
  does it consider the risks enough? (think about what
  Cynthia Bower was talking about earlier)

                                         • Continued
      Discussion Points (cont.)
• How can you take an investor approach when
  procurement rules require you to be ―fair,
  open and transparent‖ to all?

• What is the best way to capture the ―Is
  Anyone Better Off‖ data?

• What other ―payment by results‖ examples do
  you have?
                Procurement Exercise
• Think of a service that could be procured – e.g. care home beds

• Decide what are the outcomes for all stakeholders
   –   Service users
   –   Carers/relatives
   –   Frontline staff
   –   Service Providers

• What process (in brief) would you go through to get to an outcome
  focussed service specification?

• What measures could be used?
   –   How much will we do?
   –   How well we want the services to be provided?
   –   How we want service users to be better off?

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