Value for Money and Quality Services

by Brian O’Donnell CEO Federation of Voluntary Bodies

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In Budget 2009, the government announced a review of disability services under the Value for Money & Policy Review Initiative. This review is an evaluation of the efficiency and effectiveness of disability services in Ireland, conducted in accordance with the guidance for Value for Money & Policy Review issued by the
Department of Finance.

In July of this year, An Bord Snip Nua (The McCarthy Report) noted the establishment of the value-for-money group and asserted that ‘unnecessary duplication of corporate and other services cannot be maintained in a budgetary environment where services are being curtailed and service developments are being deferred.’ The Group recommended that ‘there should be greater use of shared services, improved administrative efficiency and sharing of professional and clinical staffing resources by such voluntary bodies.’ It further stated that ‘there should also be robust and appropriate service level agreements in place with non-profit service providers which contain clear specifications of services to be provided for the resources being made available. There should be close monitoring of performance against the specified service levels and financial and staffing penalties for failure to achieve them.’

The National Federation of Voluntary Bodies has been, and continues to be, proactive in addressing the efficiency and effectiveness agenda. Indeed, during the course of 2007/2008, and prior to the government announcements mentioned above, the National Federation carried out a strategic review to identify an appropriate structure and configuration to best meet the needs of people with intellectual disability whom our member organisations support, and their families.

The task of looking at added value (which the members of the National Federation provide to its stakeholders including people with intellectual disabilities, families, funders, government and society generally) was an important priority when looking at how the National Federation works. This took account of the negative comments made about how there were too many agencies and the waste that came from that. While it was said that much of this criticism was based on perception and not on facts, the National Federation must make sure that our members are organised to provide the best service they can for people with an intellectual disability from the funding available.

Indeed, in terms of the performance of the voluntary intellectual disability sector in putting in place much needed services and supports, it is informative to read the Annual Report of the National Intellectual Disability Database Committee for 2008, which noted the following key developments over the period 1996–2008:

  • An increase of more than 60% in the number of people with intellectual disability living full time in community group homes;
  • A 68% reduction in the number of people with intellectual disability accommodated in psychiatric hospitals;
  • Continued expansion in the availability of residential support services, particularly planned or emergency centre-based respite services, which have grown by a substantial 428%;
  • Increased provision in almost all areas of adult day services and in the level of support services delivered as part of a package of day services, both for children and adults.
National Federation of Voluntary Bodies approach

The above significant achievements notwithstanding, at its meeting on 11 July 2008, the Board of the National Federation decided to establish a working group to assess how best in the future to enhance the particular value add which a vibrant voluntary disability sector brings to the lives of people with intellectual disability and their families in the most cost-efficient and effective way.

As a starting point, it was felt that any review of the sector should be guided by an overall government vision statement, underpinned by an agreed set of values and guiding principles for supports for people with disabilities in Ireland in the 21st century. It was felt that the existence of such a vision statement would inform an understanding of the work to be done and of the model of service delivery compatible with the strategic objectives which would give effect to the vision statement. This in turn would lead to a deeper understanding of the concept of benefit and value, together with an appreciation of certain unavoidable costs if the anticipated value is to be secured.

It was felt that this work should be overseen by the Department of Health and Children who have the statutory responsibility for policy development in this area. In this regard, the National Federation welcomed the establishment by the Department of Health and Children of a Policy Review Group in June 2009. The National Federation has already made a submission to the Review Group to assist in the development of a new vision statement. Our primary focus now is on developing initiatives to address the perceived administrative excess and cost-efficiency argument. Our Working Group developed a number of proposals which were the basis for a comprehensive consultation day with member organisations in May 2009.

A proposal which was the basis of a lot of discussion by member organisations on the day was that local disability-specific coalitions (e.g. intellectual disability service providers within a defined geographic area) should develop an efficiency-optimising arrangement. This proposal envisages the HSE’s Local Health Office working collaboratively with the various disability-specific service providers to plan the activity that needs to be supported within that area, for the known population. A top-line service statement of need should be developed for the population of people with intellectual disability identified as in need of services and supports. In response to this statement a top-level plan should be developed which will recognise the service input of all existing providers and explore areas of potential greater cohesion and collaboration between voluntary providers, and between the HSE and voluntary providers. Critically, this plan will essentially provide the content of a single Master Service Level Agreement to be negotiated with the coalition of service providers within the geographic boundary.

In our view, the Service Level Agreement should set out both the work to be undertaken collaboratively by the coalition and also specify the funding which HSE will make available to support delivery of the plan. It is envisaged that the Service Level Agreement will be designed so as to strongly incentivise efficiency-optimising behaviour within the coalition across all dimensions of efficiency to include:

  • All service-support areas
  • All ancillary-support areas
  • Transport
  • Information technology
  • Finance
  • Human resources (e.g. Core HR Project)
  • Training and development
  • Procurement
  • General administration
  • Maintenance
  • Research and development.
Non-Pay Efficiency

While recognising that all member organisations have worked hard to reduce costs in non-pay expenditure—including renegotiating with suppliers, exploring alternative arrangements, etc., our Working Group agreed to develop a strategy to maximise the bulk-buying opportunities for our member organisations by adopting a National Federation approach in the purchase of certain high-visibility non-pay expenditure items.

This work was divided into three distinct phases. Phase 1 of the exercise was recently completed and it has resulted in savings of in excess of €2m, which assisted member organisation to absorb the impact of recent funding cuts and maintain frontline services.

The National Federation is also anxious to ensure that the government’s Value for Money and Policy Review Group should identify and consider the ‘non-tangible’ elements which a vibrant voluntary sector contributes—for example, in mobilising and harnessing community supports, by promoting active citizenship and taking specific initiatives including the recruitment of volunteers to ensure that people with intellectual disabilities are included in the daily life of local communities. It is also important to recognise the huge amount of physical facilities which are made available to the state to provide residential, day and other supports to people with intellectual disabilities at little economic cost.

The National Federation takes the view that in assessing the overall efficiency of the voluntary disability sector it is important that some effort is made to measure the social and economic benefits of these elements. In addition, it is important that independent analysis of key efficiency measures within our sector be obtained. The Working Group feels that key data such as average unit service costs, percentages of overall pay budgets allocated towards management and administrative costs, absenteeism rates, etc. should be collated with a view to an independent comparative analysis with the statutory sector.

Research and development

The Working Group recognises that appropriate high-quality research is a necessary pre-requisite to ensuring that the National Federation remains a model of efficiency in terms of services development and delivery. There are many and varied understandings of what the terms person-centred best-value options mean, and it is important that national research is conducted to tease out these concepts to facilitate learning in the area. This research would also include evaluation of pilot projects, many of which are very innovative; but unfortunately they often cease due to lack of funding or because of ‘red tape’ or bureaucracy. Research in this area would demonstrate the uniqueness that person-entred responses contribute to added value and quality of life. Naturally, the reverse could also be a possibility—therefore research would also provide learning from what has gone wrong or what might need to be tweaked, which is also an important issue.

The Working Group recognises that there are many examples of excellent practice both in Ireland and abroad and it is important that the National Federation is proactive in ensuring that this evidence is disseminated to its membership on an ongoing basis. This approach would raise the bar and ensures that services reflect best practice, and indeed go beyond best practice which is often based on the immediate past. Therefore, we need to constantly strive to improve our services and supports.

While there is an expectation that substantial economies can be achieved in the ancillary areas, it is recognised that thesy represent a relatively small percentage of overall expenditure and greater economies and better results can be achieved in the direct service-support areas. Work practices and patterns need to be challenged to ensure that maximum direct support is provided and that services reflect the needs of the consumer. Education of the consumer and stakeholder group is also vital, as this will help to shape informed choice.

The Working Group therefore proposes the establishment of a Centre for Learning and Innovation in relation to supporting options and choices that best meet the needs of individuals. The primary purpose of the Centre would be:

  • An intelligence gathering resource which can source contemporary information / evidence in relation to international / national best practice.
  • An effective disseminator of this information to our membership.
  • An assistance to members to replicate and extend implementation of innovative service options in their own area.
  • To become by reason of its objectives and values an accepted and accredited forum for the promotion of innovative support options for people who use services.
  • It is believed that these objectives could be achieved through the development of fact sheets, the publication of case studies, the organisation of seminars, the development of a special section within the existing National Federation of Voluntary Bodies website, etc.
Conclusion

The National Federation of Voluntary Bodies fully accepts that its members should be fully accountable for the public funding which they receive and provide demonstrable evidence of the value which they bring in the most cost-efficient and effective way, not only to people with intellectual disability and their families, but also to their funders and to society in general. It is vitally important that any analysis of the sector is based on a factual assessment rather than perception and inaccurate presumptions which have characterised the discussion to date. The National Federation of Voluntary Bodies will not be found wanting in proactively addressing the general issue of efficiency and will engage constructively and openly in the government’s commissioned review.

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