| Chapter 2 Better
and quicker decision-making |
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| Faster decision-making "Faster decisions are
central to achieving quicker responses and better care.
We must start putting service users first."
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| 2.1 One of
the key improvements we need in community care is quicker
and better decision-making, particularly by local
authorities. This plea comes most importantly from people
who use services, and is recognised by local authorities
themselves. This section deals mostly with local
authority decision-making, but the principles also apply
to other organisations. |
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2.2 Local authorities have several important
responsibilities in community care. Improving the way
they reach decisions about community care is central to
achieving quicker responses and better care. We believe
that they need to tackle five main areas. These are:
- building effective
partnerships with people who use services and
their carers;
- setting clear
strategic goals;
- reducing
bureaucracy;
- making decisions
more quickly; and
- delegating
financial responsibility.
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| Partnerships with
people who use services and their carers |
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| New
partnerships with people using services |
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| 2.3
Throughout community care, we expect people who use
services and their carers to be central to all decisions
made about themselves and the services planned. This
means building new partnerships between those responsible
for planning and delivering services and those receiving
or needing them. Effective partnerships with people who
receive services and their carers is a central part of
our new agenda. |
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| We can
achieve successful partnerships in several ways. For
example, users in Shetland contribute to their care plan
and have a copy in their home. And at a more collective
level, a well structured and integrated community care
forum is a good starting point (Highland, Borders). Focus
groups can consider care groups' interests and local
issues. |
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| Clear strategic
goals |
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| Developing
joint strategies |
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| 2.4 Local
authorities and their partner agencies need to introduce
arrangements which develop a joint strategic view of
goals and intended results. They then need to make sure
that joint spending and other decisions achieve these
goals. |
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2.5 Strategic plans already exist. But they
need to develop into:
- detailed care and
housing strategies for the area, not just to cope
with hospital closures;
- strategic visions
which look to the future and have measurable
targets and timescales; and
- joint strategies,
joint policies and joint investments which are
then included in community care plans, Health
Improvement Plans (HIPs), local authority housing
plans and Scottish Homes Regional Plans.
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| 2.6 The
recent proposals for Community Planning drawn up jointly
with representatives of the Convention of Scottish Local
Authorities and other statutory organisations focus on
joint strategic visions and policies, and effective and
co-ordinated programmes of action. We will help develop a
shared vision by making sure that HIPs consistently take
account of the views of partner agencies and other
interests. (This is already the case in some areas.) |
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| 2.7 Clearer
goals and priorities amongst agencies will lead to more
co-ordinated and joint investment. There is plenty of
scope to expand joint commissioning. And the revised
structure of the NHS can contribute not only through
delegated purchasing but through measures such as the
Joint Investment Fund (JIF). |
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| 2.8 The JIF
was introduced in 'Designed to Care'. It uses existing
health resources in several settings, together with new
resources if necessary, to develop or re-organise a
particular service or group of services. There is no
reason why the JIF approach should be limited only to NHS
resources. We need to identify opportunities for health,
social work and housing to secure a more detailed pattern
of accommodation and services. |
| 2.9 We can
also make better decisions by making sure that within and
between agencies financial and other incentives pull
towards shared goals. Too often incentives are unbalanced
or even damaging. Nationally, we will try to identify
areas where policy, finance or other influences might
lead to unsuitable incentives. But local statutory
organisations must also do this. For example, internal
decisions such as selecting care providers may be
influenced too much by the availability of in-house
services rather than by people's needs. |
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| Best use
of the community care £ |
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| 2.10 We need
to start putting the overall benefit to service users
first. Co-ordinating capital and revenue funding, and
getting the right mix of care and housing so that people
can avoid moving unnecessarily are good examples. More
particularly, 'efficiency savings' are not at all
efficient if they simply pass on the cost of care to
another agency. The 'community care £' represents the
total funding of community care by statutory
organisations. In future the most important factor
must be how best to use the community care £. Statutory
organisations need to create incentives which achieve
this. |
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| Reducing
bureaucracy |
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| Shifting
resources to services |
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| 2.11 This
means developing flatter management structures which
discourage centralised decision-making processes but
still hold people responsible for the results they
achieve. We expect to see less money spent on
administration and more on developing services. |
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| Some
authorities are already making good progress in removing
layers of management. South Lanarkshire has greatly
reduced the number of departments in the council. In the
Social Work Department it has also reduced the tiers of
central management, and is now looking at how individual
services and establishments are managed. The resources
saved have been re-allocated to providing services. |
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| 2.12 At a
more detailed level, assessment and care planning are
central to meeting people's needs. But specialist staff
resources are not always used effectively, and people are
being over-assessed (sometimes several times). We have
recently produced new guidance on assessment and care
management practice. We expect results quickly. |
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We can speed up decision-making in
assessment and care management by:
- self-assessment (for
example, for simple equipment for the person
themselves or to help carers);
- staff of one agency
accepting assessments from another, based on
agreed criteria;
- encouraging the staff
who provide services (for example, occupational
therapy assistants or home helps) to carry out
assessments themselves; and
- having joint
assessments and sharing records.
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2.13 These measures need:
- management support;
- clear budgets;
- training in resource
management; and
- good information
systems to support and monitor how resources are
used.
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| Several
authorities are already examining the scope for change.
South Ayrshire has revised its care management systems to
identify clearly tasks for qualified and unqualified
social care staff. They are using their specialist
resources more effectively, avoiding overlaps between
agencies and using common 'tools'. In Moray, carers assess their
own needs.
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| An
English social services department provides 93% of care
packages within five days of receiving a referral,
including referrals from 26 hospitals. This depends on
clear, delegated responsibility within the social
services department and good co-ordination with acute and
community health services. Service agencies in Scotland
should be able to achieve the same standard. |
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| Faster
decision-making |
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| 2.14
Decision-making in community care can be slow and
inflexible. Agencies need to review the systems on which
their decision-making processes depend to achieve faster
and better decisions. |
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| Delegated
decision-making |
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2.15 Our aim within community care is that statutory
organisations should delegate decision-making to the
lowest effective level, and set challenging but fair
targets for key decisions (for example response times
for assessments, and delivering individual services). One
of the main principles is that delegated decision-making
needs delegated budgets. We need to delegate authority
from:
- committees to
officials;
- senior management to
middle management and districts;
- managers to suitably
qualified professionals; and
- professionals to
users and carers.
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| 2.16 The
need for quicker decision-making must not be used as an
excuse for reducing the involvement of other
organisations or people who use services. Decisions will
be acted upon more efficiently, more quickly and with
greater co-ordination if everyone involved is fully
committed because they have had a part in the decisions.
Co-ordinated action need not take more time if delegation
is clear. |
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| Delegating
financial responsibility |
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2.17 We must give local staff the power to
make local decisions within their delegated budgets. This
calls for three major changes.
- Area management must
set broad central strategies, with local
management and professionals having more freedom
to meet local needs within those strategies.
- We must delegate
decision-making and resources to the lowest
effective level, to at least care management
teams and suitable local housing managers.
- We must encourage
front-line staff to use their initiative and
skills flexibly to deliver services based on
users' needs.
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| 2.18
Sensible delegation should become the norm. The emphasis
should be on encouraging and supporting decision-making
at the lowest possible level, supported by good
information and leadership. Many decisions are made
centrally for the wrong reasons. This may be due to fear
of overspending or of local teams over-committing the
agency. To commit financial resources, for example, an
authority may need new management information on costs
and results, and training. We will need to develop the
system for change at the same time as delegating
responsibility. |
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| Delegating
without bureaucracy |
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| 2.19
Delegated decision-making and resource management are
also important for health and housing. The new Primary
Care Trusts bring together primary and community health
services. They will be able to delegate to their network
of Local Health Care Co-operatives (LHCCs) the management
of resources for key services, including community-based
clinical services, prescribing costs and community
hospitals. The GP practice and primary health care team
will continue to provide front-line services, and the
LHCCs will bring together voluntary groups of GP
practices who will jointly manage the resources
identified for their area. LHCCs will operate within the
Trust accounting framework rather than as separate legal
organisations and will offer a useful model of delegation
without bureaucracy. |
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| 2.20 In
housing, local authorities should give greater
responsibility to local managers for budget control (for
example, for adaptations) and housing allocations. This
will allow local managers to co-operate effectively with
social work and health colleagues at a local level.
Housing and adaptations, and social work and other
support services need to be considered together,
recognising the 'trade-offs' between services. We will be
consulting interested organisations about further
guidance on co-operation between the statutory
organisations on housing and community care. This will
build on the 1994 circular 'Community Care: The Housing
Dimension'. |
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| Uniform
approach to buying and budgeting |
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| 2.21 Several
local authorities and other agencies have already
delegated budgets, but rarely for all services and to the
best possible level. For example, budgets for buying
external residential and nursing home care still tend to
be held centrally. Authorities' own services (especially
residential care) are also usually treated differently to
external services. To achieve the new aims authorities
need to develop a detailed and uniform approach to buying
and budgeting. |
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In Aberdeen, Aberdeenshire and
Clackmannanshire they already delegate budgets to care
managers. The advantages to people using the service are:
- a wider range of
opportunities for developing services;
- greater flexibility,
efficiency and fairness;
- clearer
responsibility; and
- creativity in meeting
people's needs.
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| 2.22 Some
authorities have computerised care management and client
information systems which, when developed and supported
properly, lend themselves to these wider uses. But
authorities cannot continue to develop systems
individually. If there are common needs, it makes sense
to create partnerships and groups which can use resources
effectively to develop common systems and processes. We
will lead a national review of what information
authorities should collect and how to collect it. |
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The client information system in Falkirk
already provides detailed information which:
- is easy to access;
- provides information
on care packages and their cost; and
- speeds up decisions
by care managers and team leaders.
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| With a small
amount of development, this system could provide full
information for managers. |
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| Making change
happen |
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| 2.23 We
expect the statutory organisations to have introduced new
approaches to and improve local decision-making by
December 1999. This chapter has identified the
results we are all aiming for and has offered some
examples of good practice. It is now up to each local
authority and partner agency to decide how to meet these
goals in its own particular circumstances and in
partnership. We will also work with them to achieve the
desired results (for example, to delegate budgets and
redefine care management). |
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2.24 We will ask each local authority to
show in its community care plans for 1999 and onwards how
it has improved decision-making by:
- allowing people who
use services to have their say in
decision-making;
- spending less on
administration and more on service delivery;
- improving response
times for assessments, service delivery and
accommodation;
- delegating
decision-making and budgets;
- co-operating with
other agencies, for example by pooling resources
and joint commissioning; and
- making the best use
of the community care £.
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| 2.25 We will
also monitor progress in these areas with health boards
and, where relevant, Scottish Homes. |
