Embedding Early Intervention within the Commissioning

Pathway

Ian Curryer, Corporate Director, Children and FamiliesCandida Brudenell, Director, Quality and Commissioning

Chris Wallbanks, Programme Manager, Early Intervention and Partnerships

Purpose

‘To provide an opportunity for leaders from across the region to engage with leaders from Nottingham, explore their approach and share learning from their experience.’

Programme• Nottingham as an Early Intervention City –

Ian • Developing the Commissioning Pathway –

Candida • Early Intervention within the Commissioning

Pathway – Chris• Considering the challenges and sharing

practice – All• Embedding Early Intervention – Candida• Examples of shifting resources – All• Next Steps - All

• High levels of deprivation; high spending LA• Strong Nottingham Plan and CYPP • Ofsted Inspection of Safeguarding and Looked After

Children Services December 2010 Nottingham has…’an extensive and outstandingrange of early intervention services, making amarked shift with vulnerable children andfamilies’

Nottingham City

Nottingham, Early Intervention City

‘Our aim is to break the intergenerational nature of underachievement and deprivation in Nottingham by identifying at the earliest possible opportunity those children, young people, adults and families who are likely to experience difficulty and to intervene and empower people to transform their lives and their future children’s lives’

Programme approach:

Governance

Pilot projects

Learning and Evaluation

Knowledge

Finance

Learning from the EI Programme

• Think like a Partnership – Joined-up decisions and an integrated workforce

• Use the ‘F’ word = Fidelity– Roll-out evidence-based programmes properly– Engage the right families

• Evaluate and build your evidence-base– Standards of evidence and evaluation

• Seek first to understand– Insight – what’s really happening?

• Costs – know them!

Using EI principles to change our systems and structures

• Family Community Teams• Family Support Strategy• Workforce Core Standard - consistency• CAF target groups• Thinking more holistically around

complex families• Corporate parenting is everybody’s

business

10 year profile of one complex family

Family

MumDadChld 1Chld 2Chld 3Chld 4Chld 5Chld 6Chld 7Chld 8Chld 9Chld 10

FIP

10 Year FIP Family Timeline

PoliceHealth

Social CareHousing

APAS = Alcohol Prevention Advice ServiceISVA = Independent Sexual Violence AdvisorVPP = Vulnerable Person Panel

FTA = Failed To ArrivePRU = Pupil Referral UnitYIP = Youth Inclusion ProjectCP = Child ProtectionDV = Domestic Violence

IEP = Individual Education PlanMALT = Multi Agency Locality TeamCAF = Common Assessment Framework

July 2001October 2002

May 1999

April 2004

Action Owner Key:

January 1970July 1965

January 1990August 1991

February 1993January 1994

December 1996May 1998

S47 = Section 47 Child Protection assessmentS17 = Section 17 Child in Needs assessmentIA = Initial AssessmentCA = Core Assessment

D.O.B

Perm Exc = Permanent ExclusionBST = Behaviour Support TeamTWOC = Taken Without Owners ConsentNSP = Notice Seeking Posession

SchoolCourt

VoluntaryComm Protecion

MALT

2006 2007 2008

2009 2010 Glossary of terms & abbreviations:

FIP involvement

in family begins

2000 2001 2002

2003 2004 2005

Alcohol Assessment showing improvement

for Mum

Chld 4 attendance improving, Chld 3 still not attending and

staying out overnight

Mum's MARAC meeting takes place - Mum still

engaging with ISVAChld 2 sporadic attendance college. Chld 3

passed final exam - starts college Sep. Mum attends meeting at school - Chld 4 65%

attendance. Chld 6 got reward for improved attendance. Chld 7 concerns re behaviour

Family have their first day out together and go the park

Whole family go on a Narrow Boat so FIP can

do an assessment of interaction

School contact Mum - benefits stopped for school meals.

Despite attempts no contact from mum, no renewal

CA for Chld 3 & S47 Chld 3 Enquiry/Assessment - No case

conference - S17 services - Risk unlikely to recur

Review of home - overcrowding, no doors as

closed doors associated with violence, few beds

IA for Chld 2, 3, 4, 7, 9 & 10

Chld 7 = 3 recorded injuries during 1999

Social Worker Enquiry - Chld 7 in care of Chld 1, at

time of the injury

S47 on Chld 10 - end Services - No evidence of abuse/neglect

Chld 7 falls - head injuries

Chld 6 referred to Paediatrician 4 times

Chld 7 falls - head injuries

Chld 9 attends A&E 4 times

Chld 8 referred to Speech Therapy

Chld 9 hearing referral - Mum FTA numerous appointments Health Visitor suspects

Emotional Neglect

Duty Team contacted by Health. Mum refusing immunisations for children. She

said willing to kill herself and been violent to partner in front of children

IA conducted for Chld 6, 8, 9 & 10

2 x CAMHS appointments for Chld

6 - FTA

IA conducted for Chld 2, 5, 9 & 10

Chld 1 reporting DV between parents & chld - threatening to run away

- Chld 3reprimand criminal damage ,final

warning

Police arrest Dad .Call from Chld allegation of violence to Chld3 1

when drunk

Chld 8 attends A&E - Sunburn

IA for Chld 1, 2, 4, 5, 6, 8, 9 & 10

Social Services review services & provision

Social services monitor provision for Chld, 1, 2, 4, 5, 6, 7, 8, 9, 10

IA for Chld 8 & Chld 5

Police contact Duty Team -Dad spending all money on alcohol and

four kids going without food

Court orders preparation of S7 report concerning all children - parents now separated - issues over custody and previous DV

Dad sets fire to the house - family moved to the Meadows

Dad accused of raping Mum - found not guilty

Mum FTA several Health reviews for Chld 8 - eventually seen without mum

Police attend address -DV incident -Dad threatens to kill Mum/children .Police

,suspect child neglect house unhygienic and

overcrowded

S47 for All Children - No case conference -

Sect. 17 Services - Significant Evidence of

abuse/risk to Child

IA & CA for all children

Senior Practitioner reports Neglect

concern - High risk of DV - inadequate home

for family

Social services monitor provision

for all children

Mum FTA school meetings regarding Chld 5 exclusion as well as reintroduction meeting

Multi Agency meeting chaired by Social

Services and unplanned visit - Did not meet thresholds

School contact Social services - concerns neglect, FTA's violence and

Police involvement

CA for Chld 2, 3, 4, 7, 9, 10

Chld 5 violent & racist at school - excluded for 5 days

Mum complains to Police -teacher used unreasonable . force on Chld5 .Doctor concludes wasn't unreasonable Strategy discussion about bruising on Chld 5 &Health

Visitor contacts Child Protection

Mum cancels Social Services visit - they do not visit again.

Multi Agency meeting regarding non cooperation

Multi Agency completed - case closed to Social

Services - Mum not cooperating - no

outcome

Chld 5 Permanent Exclusion -

Education Action Plan meeting -

Mum FTA

Letter sent from Parenting about further

engagment - no reponse, case closed

Mum aggressive with Parenting worker -

case left open

- Chld 4reprimandshoplifting

2 boys referred to Paediatrician FTA, 2 PRU meetings FTA, 10 school meetings FTA, 4 BST worker meetings FTA

,Several reports of Mum being drunk Mum complains of youths hanging

around

Chld 4 shoplifting -Mum attends as appropriate

adult -Drunk

Chld 5 bruises noticed - fighting brotherFurther bruises noticed - fighting sisterFurther bruise on face - no explanation

Chld 3 TWOC - 3 month referral

to YOT

School Nurse request for info - concerns on house overcrowding

Housing contact Duty Team - Mum not

living at home - told refer to police as missing person

School contact Social Services - Mum

appears not to be living at home

Chld 5 cut head, no school uniform, bruises on body & arm -

IEP's not returned to school

Dad now moved down to live in London

IA and CA completed for

Chld 5 Chld 5 sets fire to house c60k of damage - YOT

final warning

School Nurse contact Duty Team Chld 2 covered in bruises,

suspects DV - suggest initiating a CAF- Mum not

cooperative

School Nurse refers Chld 9 to opticians &

Speech Language

Chld 7 CP referral -injured thumb

ASB Case against address

Chld 5 discloses mums boyfriend smokes crack -

Chld 7 unsure if true

Health Visitor contact Duty Team - Makes CP referral - concerned about

family - children dirty, home a disgrace. Explained involvement of

YIP & MALT - Mum struggling

Letter from Health to Social Services -

concerns not followed up - referral closed and weren't

informed

School refer to Social Services - children no lunch despite letters

YIP/MALT attend arranged meeting -

Mum not home

Bus passes for all children to go to school

Chld 3 in Court - Breach of YOT order

Notice Seeking Possession ASB - also rent arrears

Demotion Order (Housing Order)

Presented at VPP

YIP/MALT attend 2nd meeting for

CAF - Mum retracts consent Plan & Family

Contract set up

Chld 4 & 5 found walking from Aspley to Bulwell by Police -

Mum drunk at boyfriends

Chld 10 not attending Nursery

Chld 5 shoplifting - Police give Youth

Restoritive disposal

Stronger Families referral

Mum attends benefits/welfare advice - plan put in place for arrears, other finances put in place. Wasn't getting all her entitlement - all bills now paid

Police Incident, Mum drunk - further police reports of Mum drunk

IA for Chld 2, 3, 4, 5, 6, 7, 8, & 10

2nd school referral to Social Services

Chld 7 - SENCO & Speech Therapist

support

Mum attends first APAS session

Parenting contract in place

Chld 3 - ASB in Lenton

Leisure cards for family

Health visitor organised for

younger children

DV still evident in family

Mum on Triple P Parenting course

Vaccs & Imms organised for

children

Mum FTA parenting programme - hungover

Chld 5 referred to MALT- not taken on

ASB complaint against children & Mum drunk

Chld 10 now attends Nursery

Housing & FIP discuss manual offer for new

property

Chld 5 now attending secondary

school

Mum exhibiting MH issues

Mum engages with ISVA for DV

Mum attacked by partner - goes on

drinking binge

Beds provided by FIP

No ASB complaints

Chld 7 attends A&E with fractured femur -

referred to social services

FIP request for gardening equipment provided by Salvation

Army - addresses complaints about state of

house outside

Police contact Duty Team - Mum presents at police station -

criminal damage by boyfriend - Police reviewed: long history of

multi agency support

Housing Fire safety check-high risk; Environmental Health Inspection - Cat 1

Hazard - represents risk to inhabitants safety,

overcrowding serious issue, re-housing urgent

issue

Arrears of £3k discovered on previous property held

with partnerChld 2 discloses

Mums alcohol intake dropped, but Chld 3 smoking cannabis

Chld 6 referred to BST - poor school behaviour

Risk assessment for house in Bulwell -

deemed inappropriate - too close to Chld 5's

previous arson offence

Mum engaged with APAS - no alcohol issues

Home maintenance improved as family take responsibility -doors put back on by NCH -

significant improvement

Mum continues ISVA & APAS work - Chld 3

stopped smoking cannabis

Negotiations mean BST work can continue -

Mum re-engages

Mum tells BST to go away

ABC for Chld 5

Jack bailed for alleged robbery

Risk assessment of new property in Clifton -

inappropriate

Parenting programme

Chld 6 successful transition to Bulwell Academy

Chld 4 Social Care referral - thrown out the house living with

a friend

Chld 5 referred to CAMHS

FIP secure tenancy on new property -

behaviour contract attached to tenancy to

ensure compliance

Mum, Chld 1 & 2 attend Freedom Programme

Chld 2, 3 & 4 referred to Connexions

Chld 3 starts construction

course at college

Ex City Council laptop provided to Chld 5 to

help with his work

Family move to the new 4 bed

property

Multi Agency risk assessment conducted

prior to house move

Fire safety risk assessment on new property

CAMHs Initial Assessment for Chld

5 completed and work begins

Chld 1 & partner move into own property under Housing Aid bond scheme (supported

by FIP and NCH)

Chld 7 referred to Catch 22

Chld 5 narrowly avoids permanent exclusion - has to attend Fill The Gap

until Sep 2010 when he will be reintegrated into mainstream

Chld 5 referred to Family Care for therapeutic work

around DV

Chld 3 charged with Supply of Class B Drug - 6 month referral

order and has to pay costs

CAF completed for Chld 5 and allocated lead

professional as part of handover/exit strategy

Multi Agency team agrees that FIP Tenancy and Behaviour contract

worked and NCH agree to turn the tenancy into an introductory tenancy

Chld 1 has a baby girl

Chld 3 progresses onto Year 2 of his

construction course at college

Connexions worker confirms Chld 2 has progressed onto

Level 2 childcare apprenticeship at Happy

Days Day nursery

CAF completed for Chld 7 and allocated lead

professional as part of handover/exit strategy

Chld 4 accepted to study retail at college in

Sept 2010 after completing school

Fathers Criminal History - Common Assault, Criminal Damage, Actual Bodily Harm, Breach of Community Service Order, Obtaining Property by Deception, Theft, Theft from Dwelling, Failing to Surrender to Bail, Taking Conveyance without Authority, Domestic Violence, Suspected Arson (Family Home)

BST close case due to lack of engagment

Key points:

Escalation

Non-engagement

Inter-generational

Symptom not cause

Silo focus

Child focus not family focus

High cost but outcomes getting worse

Family Community TeamsLocal Team

Delivering

Universal & Additional Support

Single point of access for Extensive

Support

Children Centres

Play & Youth services

Child and Adolescent Mental Health Services

Family Support Teams

Education Welfare

Educational Psychologists

Disabled Children’s Service

Youth Offending Team

Link to Partner Community

Services

•Area Management•Police•Midwifery•Health Visitors •Job Centre Plus •Voluntary and Community Sector•Extended Schools •Leisure•Education Improvement Partnership

Early Interventionstarts earlyas soon aspotential

difficulties areidentified and... ...requires

good assessmentof need

that should form...

…acomprehensive,

purposefulresponse to

tackleproblemswww.mynottingham.gov.uk/familysupport

Orhttp://www.nottinghamcity.gov.uk/ics/index.aspx?articleid=14713

Discussion

• In pairs, discuss what the term ‘commissioning’ means to you.

• As a group, record your shared definition on the flip chart paper and stick to the wall or window.

Commissioning

“…means outsourcing”

“ ...is about meeting your sales target”

“…is getting someone to do some art for you”

“ ...is a structured needs based approach to identify your service”

Commissioning“…is more than just about children”“…is the whole process of designing and

resourcing service provision. Who we deliver to, how much it will cost”

“...is about the life cycle. People often confuse it with procurement”

“…is an urban myth”

About half of our senior managers had an understanding of commissioning, but thought it related to EXTERNAL services only.

Our Commissioning Journey….

Commissioning Framework agreed in 2010 by the Council and One Nottingham

Not just the diagram! Details, tools and explanation on the website

Commissioning

Analyse

Plan

Review

Commissioning Model

Legislation and statutory guidance

Gaps?

Set priorities and outcomes

Service is delivered

Gather feedback- users- Councillors- others

Do

APPLY GUIDING

PRINCIPLES AT EVERY

STAGE

Data and feedback on needs

Existing provision/ service

Assess individual needs

Analyse market

Understand the market

Develop service specification

Manage and build the market

Secure the service (tender, grant or in

house)

Manage relationships

Let outcome based contract/ SLA

Review:- delivery- outcomes

Review contract/SLA/service outcomes

Manage the contract/ SLA/

service

Manage contract / SLA/ service

Review user/ citizen outcomes

Purchasing/Contracting

Agree Commissioning Strategy

Agree best way to deliver (take

account of impact on market)

Learning – to feed into ‘Analyse’

Develop procurement plans

Strong collaboration between partners and in particular the Voluntary and Community Sector

Our Commissioning Journey….

Underpinned by principles including: Early Intervention Local Jobs for Local People Supporting a thriving 3rd Sector

During 2010 Children and Families was reconfigured to bring together Adults and Children’s Commissioning

Framework translated into a ‘pathway’ First set of commissioning intentions

identified

Strategic Commissioning Intentions

Strategic Commissioning Intentions – origins

Plan ReviewDoAnalysePre-Pathway

Strategic Direction§ Review CYPP* and VAP**§ External drivers analysed

§ Strategic commissioning priorities agreed by councillors and communicated

§ JSNA updated§ Investment Plan produced

§ Market Development Plan produced

§ Priority and governance agreed (scheduled or right to challenge)

§ Business case agreed with Portfolio Holder, including rationale, outcomes, timescale, resource, interdependencies, strategic risks and opportunities

§ Appoint project team and sponsor

§ Identify expert team, including service users and routes to customer and provider voice (voluntary, independent and community)

§ Develop and implement Communications Plan

§ Timescale set

§ Cost/impact analysis§ Outcomes summarised§ Evaluation/evidence-

base summarised (involve service users)

§ Cashable savings identified

§ Re-investment plan§ Learning and

recommendations discussed/shared

§ De-commissioning/re-commissioning recommendations outlined

§ Options appraisal, ensuring balance of;

- quick wins / long- term outcomes - evidence-based programmes/ innovation and co- production with service users/providers - early intervention - projected savings - Equality Impact Assessments§ Resource§ Budget plan/strategy§ Joint commissioning§ Workforce implications§ Evaluation/monitoring

plan

Identify:§ Current and future need

(JSNA, provider and service user feedback)

§ Current market position and future business plans

§ Current spend§ Outcomes required§ Gap analysis§ Research evidence-base

(national and local) and current costs

§ Market development needs

§ Risks/opportunities

Pathway initiation date:

4 - 8 weeks

Phase completion date:

5- 10 weeks

Phase completion date:

4 weeks

§ Procurement process in place, involving service users

§ Communication and consultation process in place as appropriate

§ Incentivisation where appropriate

§ Contracts agreed - Outcomes focused§ Implementation of

services§ Monitoring/evaluation

undertaken (including user voice)

6-12 months procurement12 months minimum

implementation

Phase completion date: Phase completion date:

Close Down Review (services continues)

§ Learning / strategic issues / opportunities§ Recommendations for other priority areas§ Outcomes / direction of travel summary

DRAFT CommissioningPathway

Analyse

ReviewDo

Plan

12 months – 2.5 years

* Children and Young People’s Plan** Vulnerable Adults Plan

Decision on resource with Portfolio Holder Preferred options and decision on spend with councillors

1A Preventative Strategy: Building a Capable Community & Supporting Choice

Version 3 – 20/05/2011

Improved outcomes for citizens

Reduced costs

Greater investment in prevention and EI

Improved pathways

Improved Efficiency

Commissioning Pathway

Plan ReviewDoAnalysePre-Pathway

Strategic DirectionReview CYPP* and VAP**External drivers analysed

Strategic commissioning priorities agreed by councillors and communicated

JSNA updatedInvestment Plan produced

Market Development Plan produced

Priority and governance agreed (scheduled or right to challenge)Business case agreed with Portfolio Holder, including rationale, outcomes, timescale, resource, interdependencies, strategic risks and opportunitiesAppoint project team and sponsorIdentify expert team, including service users and routes to customer and provider voice (voluntary, independent and community)Develop and implement Communications PlanTimescale set

Cost/impact analysisOutcomes summarisedEvaluation/evidence-base summarised (involve service users)Cashable savings identifiedRe-investment planLearning and recommendations discussed/sharedDe-commissioning/re-commissioning recommendations outlined

Options appraisal, ensuring balance of;

- quick wins / long- term outcomes

- evidence-based programmes/ innovation and co- production with service users/providers

- early intervention- projected savings- Equality Impact

AssessmentsResourceBudget plan/strategyJoint commissioningWorkforce implicationsEvaluation/monitoring plan

Identify:Current and future need (JSNA, provider and service user feedback)Current market position and future business plansCurrent spendOutcomes requiredGap analysisResearch evidence-base (national and local) and current costsMarket development needsRisks/opportunities

Pathway initiation date:

4 - 8 weeks

Phase completion date:

5- 10 weeks

Phase completion date:

4 weeks

Procurement process in place, involving service usersCommunication and consultation process in place as appropriateIncentivisation where appropriateContracts agreed

- Outcomes focusedImplementation of servicesMonitoring/evaluation undertaken (including user voice)

6-12 months procurement12 months minimum

implementation

Phase completion date: Phase completion date:

Close Down Review (services continues)

Learning / strategic issues / opportunitiesRecommendations for other priority areasOutcomes / direction of travel summary

CommissioningPathway

Analyse

ReviewDo

Plan

12 months – 2.5 years* Children and Young People’s Plan** Vulnerable Adults Plan

Agreed EBCS-C 13th July 2011

Commissioning Pathway

EI within the year 1 reviews

Analyse

• 85+ population to inc by 45% by 2030

• Budget £42.3m

• High use of residential

• High placement costs

• People lose skills in resi

• Citizens feel isolated but want to remain independent

• Consider EI models

• Involve partners and citizens

• Establish Business Cases

• Agree budgets

• Finalise details

Plan Do

• Procure/implement new models of delivery

• Monitor and evaluate progress quarterly

• Measure impact annually

• Adjust where appropriate

Review

• Client group feedback

• Measure longer term impact

• Evaluate the process

• Inform stakeholders and the market what works and what we want more of

EI Phase 1 Programmes

• Nottingham Circle

• Living Support

Networks

• Expansion of Telecare

Service

• Reablement Gateway

Low cost/no cost options

Needs Low level support in community

Friends and Family

Equipment and telecare

Reablement Alternatives to resi care (supported housing)

Crisis / rapid response service

Shopping

Cleaning

Food and drink

Social Contact

Personal Care

Medication

Parenting

Financial Planning

Year 2 Reviews

• Safe from Harm

• Complex Families

• Social Exclusion

Discussion

• What do you believe to be the key challenges in driving the EI agenda through the commissioning process for

• Providers?• Commissioners?

• How is your organisation meeting these challenges?

Embedding EI into Commissioning

• Base lining financial split• Engaging Councillors• Identifying a % shift• Pump-priming, but identifying the

mainstream budget• Focus on clear evidence-based

programmes• Scale up what works

Discussion

• What examples can you share of how you are shifting resources to Early Intervention?

Next Steps

• What can Nottingham do to support you further?

• What can JRIEP do to support you further?

Thank you

For further information contact chris.wallbanks@nottinghamcity.gov.uk

Website - www.nottinghamcity.gov.uk/commissioning