3. Systems leadership, governance and management arrangements

Councils have a key role in the leadership and governance of the “Whole System” of care, support, health, and housing for adults with learning disability.


3.1 Introduction

Councils have a key role in the leadership and governance of the “Whole System” of care, support, health, and housing for adults with learning disability. This includes initiating actions that help to reduce the inequalities that adults with learning disability all too often experience. They also need to have management arrangements in place that quality assure their own contributions to the “Whole System” of care and support and ensure support is strengths based, personalised and maximises individual choice and control.

3.2 What good looks like

The best councils provide “Whole System” leadership to the care, support, health and housing system for adults with learning disability  to help develop and agree a shared vision of how they can be best supported to live the lives they want. Councils will agree a joint strategy with partners to deliver that vision. In many respects the director of adult social services’ role is akin to being a cultural change agent, hence it is crucially important for the director of adult social services to engage with politicians along on this journey, as political ownership of the vision will help build support across departmental boundaries and commitment to implementation.

The best councils collaborate with adults with learning disability, their carers, and with partners from across the care, support, health, and housing system to co-produce new approaches to improve the lives of adults with learning disability . They encourage and enable all parts of the system to make reasonable adjustments so support can be made accessible to adults with learning disability.

They establish, support and operate governance arrangements co-ordinated by the Health and Wellbeing Board to ensure the care, support, health and housing system consistently supports adults with learning disability to live the lives they want to, provides value for money and is transparent and accountable.

They establish, support, and operate management arrangements that monitor performance on an ongoing basis to ensure. Individuals are supported appropriately, individual outcomes are being achieved, value for money is being achieved, organisational learning takes place and improvement is continuous. (Go to Quick self evaluation, part 6, on efficient structures, systems, and processes for more information)

They encourage and support personalisation of support and facilitate innovation and promote the use of direct payments, individual service funds, managed accounts and individual health budgets and the systems that support these.

They expect, empower and support managers, in the council, and in commissioned provider services to:

  • Lead by example and communicate expectations to their staff, key partners etc.
  • Do whatever is necessary to support adults with learning disability in line with the vision within broad boundaries, for example the directive, “don’t break the law and don’t break the budget” encourages/permits innovation.
  • Manage and monitor performance to ensure transparency and accountability for the delivery of the desired costs and outcomes from the “Whole System”.
  • Be outward looking and open to constructive external challenge to continuously improve and learn from the experiences of others.
  • Share their own learning with others.

Who is good at this?

Case study: Hammersmith and Fulham

In the London Borough of Hammersmith and Fulham, the Health, Adult Social Care & Social Inclusion Policy and Accountability Committee formed a member-led task group to consider how the council could improve the experience for young people transitioning from Children’s Services to Adult Services.

This transition improvement process was co-produced with stakeholders. The task group comprised councilors and parents. Throughout the inquiry, the task group met with parental advocacy groups, council officers in Children’s Services, Adult Services, Health, and Housing, Education and with medical professionals, and third sector representatives.

The task group set itself the following three objectives:

  • Understand the current model and its shortcomings and challenges
  • Consider what a ‘good’ transition experience would be
  • Make improvement recommendations.

Whole system leadership was essential to the project as it involved education, children’s and adult social services, health, and housing services.

3.3 Expected outcomes

In terms of outcomes, councils that are implementing good practice should find that the:

  • Elected Members, care and support providers, people who are supported and their carers all feel actively involved in quality assurance, quality improvement and governance processes.
  • Decisions (within the council or with partners) are based on a clear vision and a shared set of values.
  • Strategic and operational planning processes are informed by learning from other councils and from participation in national, regional, or sub-regional research/development or pilot projects.
  • Inequalities (health and other) experienced by adults with learning disability reduce over time.
  • Autism self-evaluation, every two years, shows progress in implementing the Adult Autism Strategy. 
  • Quality of life, as reported by adults with learning disability, improves over time.
  • Quality of care and support services, as rated by the Care Quality Commission, for adults with learning disability improves over time.
  • Percentage of adults with learning disability and/or their carers who feel their support from adult social care meets or exceeds their expectations. Increases over time.
  • Value for money from expenditure on support for adults with learning disability improves over time.
  • Expenditure on support for adults with learning disability is being contained within the annual budget
  • Share of resources allocated to support for adults with learning disability is considered equitable.
  • Positive media coverage of the council’s support for adults with learning disability increases over time.

Guidance

Good system leadership encourages and gives permission for innovation within broad boundaries: don't break the law and don't break the budget".
Stephen Chandler former Director of Adult Social Care at Shropshire County Council

3.4 Systems leadership, governance, and management arrangement outcome indicators

Outcome Indicators

Aim

National/Local

ASCOF (1A) Social care-related quality of life for - split out adults with learning disability.

Increasing rating

National data

Life expectancy for adults with learning disability compared to life expectancy for the whole population.

Lowering the gap

National data

Proportion of key partners organisations in the care, support, health, and housing system formally committed to the local vision, shared statement of values and joint strategy to support adults with learning disability.

Increasing percentage

Local data

Analyse Care Quality Commission ratings of local services in detail and monitor the percentage of providers rated “Outstanding” or “Good” for the key line of enquiry on “Are they well-led?”

Increasing percentage

National Data

Balance of positive to negative feedback about support for adults with learning disability from the most recent peer or similar external review.

Improving balance

Local data

Proportion of key partner organisations that publicly report the effectiveness of processes to ensure they make reasonable adjustments so people with learning disability (and other disabilities) can access their services.

Increasing percentage

Local data

Proportion of adults with learning disability accessing annual health checks and % leading to health action plans

Increasing percentage

Local data

 

Individual Experience Indicators

Aim

National/Local

Proportion of ALL local care and support services for adults with learning disability in the area rated “Outstanding” or “Good” by the Care Quality Commission in last year compared to previous years.

Increasing percentage

National Data

Monitoring of changes in care and support packages following reviews shows the percentage of individual: (1) Outcomes achieved in each reporting period, and (2) Care and support arrangements where support activities or costs change after a review in line with changing needs and/or preferences.

Increasing percentage

Local data

 

Financial/Value for Money Indicators

Aim

National/Local

The mix of learning disability  expenditure per head aged 18 to 64 by type of support e.g. show percentage on residential and other bed-based care including hospitals compared to percentage on community based and other types of support.

Lower percentage on bed-based care

National Data

Ranking of unit costs per week by type of learning disability support compared to benchmark councils.

Improved ranking

National Data

Ranking of learning disability  expenditure per head of population aged 18 to 64 compared to benchmark councils.

Improved ranking

National Data

Ranking of expenditure on learning disability support as a  percentage of total expenditure on ASC compared to benchmark councils

Improved ranking

National Data

 

3.5 Self evaluation questions

How to rate yourselves against the self evaluation questions:

For each chosen section the director of adult social services should consider each statement about good practice that follows and work with their senior management team, representatives of key partner organisations and local experts by experience to rate the council’s practice described using the following five-point scale.

The scale to be used is as follows:

1. Commitment

The importance of this best practice has been recognised. Conversations are taking place internally or with partners including experts by experience, but work has yet to begin.

2. Developing

Work on this best practice has commenced internally or with partners including experts by experience, but it has yet to be signed off, is only in the planning stages and with resource identification is still in progress.

3. Implementation

An agreed fully resourced and commissioned (where relevant) plan is in place. Implementation has started, but best practice is not yet fully operational.

4. Operational

Best practice is in place and is being used, albeit implementation is at an early stage, and further refinements in line with the learning from implementation may be needed before expected benefits are fully realised.

5. Sustainable Delivery

Best practice is in place and is working well. Long-term funding, resources and structures are in place i.e. best practice now represents “business as usual” and continuous improvement processes are in place.

Leadership, governance and management arrangements

Score 1 - 5

Basis of score

1. The council’s leadership provides “Whole System” leadership to gain a shared vision of how adults with learning disability can be best supported to live the lives they want and to reduce the inequalities they experience and to agree a joint approach to deliver the vision. This process includes political engagement to shape and commit to implementing the shared local vision.

 

 

2. The council has strategic lead officer(s) of appropriate seniority in place for learning disabilities and for autism. Their role is to ensure learning disability care, support, and outcomes:

  • Receive appropriate strategic management attention.
  • Are considered across all areas of council activity - not just social care.

Note: Having an appropriate level of “positional” authority is important for these lead officers for them to be able to get things done/make change happen.

 

 

3. The council collaborates with adults with learning disability carers and with partners from across the care, support, health and housing system to co-produce strategies and action plans that aim to improve the quality of life and other outcomes of adults with learning disability in line with the agreed vision.

 

 

4. The council bases its plans on the best available evidence about current best practices by being outward looking, learning from the experiences of others, and sharing its own experiences. It actively:

  • Seeks constructive external challenge e.g. peer review processes.
  • Collaborates with partners to share learning and on pilot and other learning projects.
  • Promotes learning from the experiences of others by encouraging its own staff and its partners staff to attend external courses, conferences, and networking opportunities.

 

 

5. The council’s strategic approach to delivering the vision includes:

  • Tackling the causes of inequality for adults with learning disability.
  • Building on individual’s personal strengths and on the strengths of local communities and maximising individual’s choice/control and to facilitate individual “Progression”.
  • Encouraging and supporting maximum levels of individual independence.
  • Ensuring timely/personalised support is available when needed.
  • Minimising the use of residential care and hospitals and when these are used. ensuring that it is, wherever possible, a short-term arrangement.
  • Only placing people out of area as a last resort.

Separate approaches for adults with learning disability and for adults with autism where necessary.

   

6. The council has established and supports governance arrangements to ensure the care, support, health, and housing system consistently supports adults with learning disability to live the lives they want, provides value for money, is transparent and is accountable. This includes having:

  • A Health and Wellbeing Board (with health and other key partners) that ensures the joint strategic needs assessments (JSNAs) and the joint health and wellbeing strategy (JHWS) both have separate sections on adults with learning disability.
  • A standing agenda item at the Health and Wellbeing Board to review progress on separate (or joint): (1) Learning Disability Plans, and (2) Autism Plans.
  • The senior management team and (Joint boards with health and other partners) receive regular performance reports on integrated care and support for adults with learning disability.
  • Separate Learning Disability and Autism Partnership Boards.

Forums for providers, people supported and for carers.

   

7. The council, NHS Trust Boards, and other key public service organisations annually:

  • Assess their systems and processes ability to deliver “reasonably adjusted” services for adults with learning disability and to reduce health and other inequalities.
  • Publicly report on the findings and conclusions from this assessment.
   

8. The council operates management arrangements that monitor performance and assess value for money on an ongoing basis and ensure individuals are being supported appropriately and continuous learning is enabled. Key sources of evidence to be monitored by the senior management team include:

  • Impact of planned and unplanned reviews of individual care and support plans.
  • Records of the proportion of individual outcomes in people’s support plans achieved in each reporting period.
  • Findings from contract management/quality assurance checks.
  • Care Quality Commission ratings of local providers.
  • Analysis of complaints/compliments.
  • Analysis of staff feedback.
  • Analysis of feedback from adults with learning disability/carers incl. on their satisfaction with how they are supported and on their quality of life. 
  • Analysis of safeguarding alerts and enquiries.
  • Measures of inequality experienced by adults with learning disability.
   

9. Individual managers are empowered and supported to lead by example and to communicate expectations clearly to staff, partners, providers, carers, and the people they support in line with an agreed local vision. They re-enforce the vision through:

  • Empowering a “do what it takes culture” in the council to support people in line with the vison as long as people stay within broad boundaries.
  • Professional supervision.
  • Enabling group learning (for example, action learning approaches).

Personal performance and appraisal processes.

   
10. Individual managers model desired behaviour to encourage the social care workforce (including allied professionals) to work in line with their values, skills, and vocational calling.