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Value for Money and Value for Money and Policy Review of Policy Review of

Disability Services in Disability Services in IrelandIreland

Presentation to the Irish Presentation to the Irish Association of Supported Association of Supported

Employment. Employment. 1414thth November 2012 November 2012

Colm Desmond, POColm Desmond, PO

Disability Services Unit, Disability Services Unit, Department of HealthDepartment of Health

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Background Background Review commenced in July 2009Review commenced in July 2009 Scope of the review:Scope of the review:

Define and describe the objectives of the Define and describe the objectives of the disability services;disability services;

Consider the extent to which existing Consider the extent to which existing policies are consistent with delivery of those policies are consistent with delivery of those objectives;objectives;

Assess whether current policies and Assess whether current policies and investments arising from those policies are investments arising from those policies are sustainable in the context of the changing sustainable in the context of the changing economic climate; andeconomic climate; and

Propose the policy changes, if any, needed to Propose the policy changes, if any, needed to ensure that overall objectives are delivered.ensure that overall objectives are delivered.

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Background (Cont’d)Background (Cont’d)

The review comprised two strands:The review comprised two strands: A examination of the effectiveness A examination of the effectiveness

and efficiency of the current and efficiency of the current disability services programme; and disability services programme; and

A review of current policy in A review of current policy in relation to disability services relation to disability services funded from Health Votefunded from Health Vote

LimitationsLimitations A number of factors limited the ability of A number of factors limited the ability of

the project team to look at the sector in the project team to look at the sector in totality:totality: The size & diversity of the sector & time factor;The size & diversity of the sector & time factor; Lack of agreed units of outputs for some Lack of agreed units of outputs for some

services;services; Lack of outcome measurement / reporting;Lack of outcome measurement / reporting; Lack of comparable financial data, collected in Lack of comparable financial data, collected in

a consistent manner;a consistent manner; Capacity of some agencies to engage with the Capacity of some agencies to engage with the

review notwithstanding their willingness to do review notwithstanding their willingness to do so.so.

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Final report signed off by VFM Final report signed off by VFM Steering Group on 5Steering Group on 5thth June 2012 June 2012

Review approved by Government and Review approved by Government and published in July 2012published in July 2012

Agencies requested to examine Agencies requested to examine recommendations & draw up a plan of recommendations & draw up a plan of action action

Implementation planning has Implementation planning has commenced in DoH and HSEcommenced in DoH and HSE

Current Position Current Position

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Key MessageKey Message

The Review proposes a fundamental The Review proposes a fundamental change in approach to the change in approach to the governance, funding and focus of the governance, funding and focus of the Disability Services Programme, with Disability Services Programme, with the migration from an approach that the migration from an approach that is predominantly centred on group-is predominantly centred on group-based service delivery towards a based service delivery towards a model of person-centred and model of person-centred and individually chosen supportsindividually chosen supports

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Key FindingsKey Findings 85% of expenditure is on pay, 15% on non-85% of expenditure is on pay, 15% on non-

paypay 45% of direct pay is on residential services, 45% of direct pay is on residential services,

19% on day services, 11% on multi 19% on day services, 11% on multi disciplinary services, 9% management & disciplinary services, 9% management & admin, 4% respite, 12% other servicesadmin, 4% respite, 12% other services

No national guidelines on rostering No national guidelines on rostering practices, skill mix or staff/client ratios, practices, skill mix or staff/client ratios, although these are essential components of although these are essential components of the cost of providing services.the cost of providing services.

Services are heavily professionalisedServices are heavily professionalised

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Key Findings (Cont’d)Key Findings (Cont’d)

Past: Past: focus on inputs, outputs and global focus on inputs, outputs and global costs. costs.

Future: Future: focus on outcomes and unit costs, focus on outcomes and unit costs, but:but: no common definition of outcomes, and no no common definition of outcomes, and no

national measurement or monitoring;national measurement or monitoring; Insufficient information to determine unit Insufficient information to determine unit

costs at individual service user level, costs at individual service user level, consequently no analysis or monitoring.consequently no analysis or monitoring.

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Employment - Key Employment - Key FindingsFindings

The provision of Health supports plays a The provision of Health supports plays a vital part in vital part in enablingenabling a person with a person with disabilities to access disabilities to access educationeducation and and employment. employment.

Most people accessing specialist disability Most people accessing specialist disability services are not in employment in the services are not in employment in the open labour market. (Expert Reference open labour market. (Expert Reference Group reported that 2,389 of 25,302 Group reported that 2,389 of 25,302 people using day services could be people using day services could be considered to be in the workplace considered to be in the workplace (9%) ))

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Employment – Employment – Recommendations 1Recommendations 1

Indicators should be developed to measure the Indicators should be developed to measure the effectiveness of the disability services in effectiveness of the disability services in promoting personal progress through access promoting personal progress through access to day services and supportsto day services and supports.

The health sector should continue to be The health sector should continue to be responsible for providing health-relatedresponsible for providing health-related supports to facilitate access to mainstream supports to facilitate access to mainstream services in the following areas: education, services in the following areas: education, employment, housing, transport, healthcare employment, housing, transport, healthcare and community inclusion e.g. personal and community inclusion e.g. personal assistance supports for adults who live in the assistance supports for adults who live in the community or therapy supports for children community or therapy supports for children attending schools etc.attending schools etc.

Employment – Employment – Recommendations 2 Recommendations 2

In the absence of day service standards being set and monitored by HIQA, the HSE should establish a framework whereby they can satisfy themselves, within the context of the SLA process, of the outcomes and quality of day services through dissemination of quality assurance guidelines, self-evaluation and continuous quality improvement protocols.

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ChallengesChallenges

Capacity of the system to implement the Capacity of the system to implement the recommendationsrecommendations

Need to increase efficiency of current Need to increase efficiency of current system pending migration to new model system pending migration to new model and achievement of target cost per placeand achievement of target cost per place

Implementation of standardised assessment Implementation of standardised assessment method for services and needsmethod for services and needs

Change-over to provision of services based Change-over to provision of services based on identified need and personal choiceon identified need and personal choice

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OpportunitiesOpportunities Current financial climate will provide an impetus for Current financial climate will provide an impetus for

innovative solutionsinnovative solutions

Opportune time to make changes to staff mix and Opportune time to make changes to staff mix and embedded rostering practicesembedded rostering practices

Desire amongst many service users and their Desire amongst many service users and their families for greater choice, control, independence families for greater choice, control, independence and social inclusionand social inclusion

Realisation by service providers that the landscape Realisation by service providers that the landscape has changed and they must change with it has changed and they must change with it

Innovative practices already evident on the groundInnovative practices already evident on the ground

ImplementationImplementation

Framework for implementation will Framework for implementation will depend heavily on new structure of depend heavily on new structure of Health ServiceHealth Service

Options are currently being Options are currently being considered for a national considered for a national implementation plan for VFMimplementation plan for VFM

Would welcome feedback and input Would welcome feedback and input from sector to the report and to from sector to the report and to implementation implementation

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Implementation Implementation PrioritiesPriorities

Strengthen national disability functionStrengthen national disability function Initiate demonstration projects to drive Initiate demonstration projects to drive

migration towards person-centred modelmigration towards person-centred model Put in place commissioning and procurement Put in place commissioning and procurement

frameworkframework Develop national resource allocation model Develop national resource allocation model

which will provide a framework for which will provide a framework for individualised budgeting & ‘money follows the individualised budgeting & ‘money follows the patient’patient’

Establish strategic information requirementsEstablish strategic information requirements

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Immediate ActionsImmediate Actions Streamline SLA processStreamline SLA process Standardise financial reportingStandardise financial reporting Each agency to examine VFM findings and Each agency to examine VFM findings and

draw up plans for: audit of rosters, review draw up plans for: audit of rosters, review of skill mix, critical examination of cost of skill mix, critical examination of cost base, reduction in average cost per place base, reduction in average cost per place (for a range of service types and support (for a range of service types and support needs)needs)

Introduce unique identifier to support a Introduce unique identifier to support a move to individualised resource allocation move to individualised resource allocation and service provisionand service provision

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ConclusionConclusion Report sets out a clear direction for the Report sets out a clear direction for the

development of disability servicesdevelopment of disability services Policy direction is in line with the findings of Policy direction is in line with the findings of

various public consultations and recent HSE various public consultations and recent HSE reports (Adult Day Services, Congregated reports (Adult Day Services, Congregated Settings)Settings)

Broad welcome for the policy expected from Broad welcome for the policy expected from people with disabilities and families, and people with disabilities and families, and disability agencies, but concerns about continuity disability agencies, but concerns about continuity of service pending migration to new model, and of service pending migration to new model, and also the effects of the country’s current financial also the effects of the country’s current financial difficulties.difficulties.