Written evidence from the Association
of Directors of Children's Services and the Association of Directors
of Adult Social Services (CFI 49)
The Association of Directors of Adult Social Services
(ADASS) represents Directors of Adult Social Services in Local
Authorities in England. As well as having statutory responsibilities
for the commissioning and provision of social care, ADASS members
often also share a number of responsibilities for the commissioning
and provision of housing, leisure, library, culture, arts and
community services within their Councils.
The Association of Directors of Children's Services,
ADCS, is the professional leadership association for Directors
of Children's Services and their senior management teams.
This written evidence is focused upon the following
specific point "The commissioning of services that either
work across (health and social care) boundaries, or are intimately
linked is therefore an issue to which the committee attaches great
importance, and we intend to review the effectiveness of the structures
proposed in the Bill which are designed to safeguard co-operative
arrangements which already exist and promote the development of
new ones".
This response is drawn from our previous written
and oral evidence presented to the Committee, as well as reflecting
upon the Committee's Report, the subsequent Government's response,
the Health and Social Care Bill 2011 and submissions to related
Department of Health consultations on the Adults Social Care Outcomes
Framework, the DH Business Plan (and early interpretation of the
current consultations on the Public Health White Paper, Public
Health Outcomes Framework and Public Health Funding and Commissioning).
We welcome the opportunity to comment further on
the integration of commissioning and we are committed to work
closely with stakeholders to realise the opportunities and benefits
that these reforms could bring.
1. We are pleased to note the statutory status
of the proposed Health and Wellbeing Boards (HWB) as an important
structure to work with and direct local commissioners in their
commissioning activity.
2. Although GP Consortia are required to prepare
a Joint Health and Wellbeing Strategy with the Local Authority,
informed by the Joint Strategic Needs Assessment (JSNA), the GP
Consortia Commissioning Plan itself is not specifically committed
to the Joint Health and Wellbeing Strategy, but only has to make
due regard. This restricts the opportunity to integrate priorities
across health and social care. We would urge that this arrangement
becomes more stringent and that the GP Consortia Commissioning
Plans are signed-off by the Health and Wellbeing Boards.
3. We also consider it important to strengthen
the role of the Health and Wellbeing Boards to hold the local
integrated system to account for delivery of agreed outcomes rather
than just the development of a Health and Wellbeing Strategy and
the JSNA.
4. We welcome the Integrated Outcomes Framework
across the NHS, Public Health and Adult Social Care (documented
in the DH Business Plan 2011—15 consultation ) as a means
to direct and coordinate shared "commissioning priorities"
but are concerned that this arrangement does not take into account
the development of outcomes specifically for children and young
people across the spectrum of need, nor the proposed NHS Commissioning
Board "Commissioning Outcomes". Additionally we note
the DH Business Plan 2011—15 consultation, is heavily weighted
to the medical model of outcomes. This bias can create an artificial
barrier to integrated commissioning across health and social care
and therefore in meeting the needs of our local populations.
5. Alongside the Integrated Outcomes Framework,
we welcome the development of Quality Standards for Social Care
as means of determining quality of commissioned services and influencing
the extent of integration. However we will seek opportunities
to work alongside NICE to maximise the opportunities for integration
and to make sure they take account of the needs of our populations
across the life course.
6. Although the Integrated Outcomes Framework
attempted to address the inter-relationships/dependencies between
different organisations in terms of preventative/early intervention
activities and up-stream benefits, the measures within the framework
do not fully address this, limiting the opportunity for joint
objectives and integrated working. In response, we acknowledge
the offer by Government to work together on developing a refreshed
set of meaningful, integrated outcome measures for 2012—13.
7. The development of meaningful integrated outcomes
measures must also ensure there is a focus on the needs of the
more marginalised and vulnerable members of our populations. Of
particular concern are the specific needs of more vulnerable children,
young people and adults, for instance looked after children, adults
and children experiencing poor mental health, adults with HIV/AIDs,
children with special educational needs and disabled children
to name a few specific cohorts. In these cases an integrated coordinated
response is essential to address the complex interplay of needs
experienced by these more vulnerable/marginalised groups. These
cohorts of have tended historically to be overlooked and we would
welcome any outcomes framework that places the needs of these
more vulnerable groups at the centre of activity.
8. We welcome the proposed introduction of the
Health Premium targets, as detailed in the current Public Health
consultations, to address health inequalities and maximise integration.
We are concerned though as to the complexities of this approach
and the subsequent the degree of discretion that can be applied
in the selection of local targets. These may limit opportunities
for integration, particularly within marginalised communities
where long term health inequalities are not prioritised.
9. The proposed development of a Commissioning
Outcomes Framework by the NHS Commissioning Board is welcomed
as a means of holding GP Consortia to account, but it will be
important this is aligned to the proposed Integrated Outcomes
Framework and reflects social care outcomes alongside health outcomes,
to encourage integrated commissioning. We note that the Public
Health consultations have yet to conclude and currently the roles
between Public Health England, NHS Commissioning Board, GP Consortia,
Health and Wellbeing Boards and Local Councils is still not clear
and further clarity is urgently required. ADASS supports devolving
as many functions and services as possible to the local level.
10. ADCS remains concerned about the insufficient
focus on the needs of children and young people in these new arrangements
and consider that a much greater emphasis on this group is needed.
The needs and care for children and young people is potentially
fragmented across too many new structures at a local and national
level. For local impact to be successful, responsibilities for
this range of needs must be held by local agencies.
We see HWB as the means to make a real difference
to the needs of our local populations, but there have to be clear
expectations from the beginning as to the specific responsibilities
for specific cohorts. Consequently we are concerned that the Director
of Children Services will be the sole voice for the child on HWBs.
Given the perceived fragmentation of arrangements for health services
for children as illustrated in the arrangements for health visitors,
CAMHs, Early Intervention and children's centres this is an observable
disadvantage for local planning arrangements to focus on children
and young people in the most integrated effective way.
Members of our respective organisations have extensive
experience and knowledge in responding to the needs of these marginalised
and vulnerable individuals and communities and we welcome the
opportunity to work with GP Consortia, NHS and Public Health to
ensure commissioning is integrated and holistic to meeting the
needs of individuals and local populations across the life course,
from birth through to end of life care.
In this context and as detailed in previous submissions,
we welcome the opportunity to commission specialist services to
meet the (social care) needs of these marginalised individuals
and population, as opposed to reliance upon GP Consortia. The
opportunities for these new arrangements are significant and we
offer these observations as a means to realise this potential
given our experiences and knowledge locally in meeting needs and
listening to our local populations.
11. The transfer to Local Councils of duties
to promote public health is welcomed. Local Councils are well
positioned and have extensive experience in working with internal
and external partners towards addressing inequalities.
12. As noted in the previous ADASS submission,
replacing PCTs with a yet unknown number of GP consortia will
put GPs in a pivotal position. It will potentially break the co-terminosity
of PCT and council boundaries and weaken the ability to commission
jointly. There needs to be strong professional input to counter
this and an understanding that commissioning will need to flex
up to the footprint of regions for some services and down to neighbourhoods
for others. We recognise that there is a risk of fragmentation
and the potential benefit and risk of consortia taking very different
approaches.
13. In terms of broader integrated working, we
note potential conflicts between the policy emphasis upon greater
localism within schools and challenges to coordinate an integrated
approach to health promotion for example through programmes to
promote sexual health and safeguarding responsibilities.
14. We do consider it important to note that
we welcome the continued focus on safeguarding responsibilities.
However we seek further clarification regarding the accountability
and governance arrangements between HWB Boards and Local Safeguarding
Children Boards (LSCBs). We are also concerned about GPs attending
to their safeguarding responsibilities as GP Consortia begin commissioning
services. We are keen to support GP Consortia by using LSCBs and
Adult Safeguarding arrangements to ensure GP Consortia meet their
safeguarding responsibilities.
March 2011
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