The National Federation of Voluntary Bodies welcomed publication by government of the Value for money and policy review of disability services in July 2012. The National Federation engaged with the review in a spirit of constructive cooperation since its start date and is now looking forward to further engagement with the Department of Health and the HSE in the development of a comprehensive implementation framework. The Policy Review offers exciting opportunities and very real challenges to organisations to achieve a new vision for people with intellectual disability in Ireland and, in spite of the huge financial difficulties facing the sector, we are up for meeting the challenges required to achieve this vision.
What follows is a brief summary of what the author considers to be the key points arising in the Review Report. The National Federation of Voluntary Bodies carried out a comprehensive survey to ascertain where their membership stood in respect of the recommendations, the results of which were very positive.
The Value for money and disability policy review of disability services is an evaluation of the efficiency and effectiveness of disability services in Ireland wholly or partly funded by HSE, encompassing both the statutory and non-statutory sectors. It is an extensive report running to 285 pages and containing a total of 117 recommendations.
The review, which was overseen by a steering group chaired by Mr Laurence Crowley, was conducted under the government’s Programme of Value for Money Reviews 2009-2011. Its primary purpose was to assess how well current services for people with disabilities meet their objectives and support the future planning and development of services and to make recommendations that will ensure that the very substantial funding provided to the sector is used to maximum benefit for persons with disability, having regard to overall resource constraints.
As part of the overall value-for-money review, a separate Expert Reference Group on Disability Policy was established to look specifically at existing disability policy and assess whether it needs to be changed to better meet the expectations and objectives of people with disabilities. The Reference Group oversaw a public consultation process on existing disability services, which concluded that people with disabilities and their families want more choice in the services they receive and more control over how they access them.
The over-riding focus of the recommendations is on a programme of governance, delivery-model change and a detailed upgrading of information in respect of precision, scope and format. It proposes a fundamental shift in approach, moving from provision which is predominantly centred on group-based service delivery, towards a model of person-centred and individually chosen supports. The achievement of measurable outcomes and quality for service users at the most economically viable cost underpins the recommendations. Re-articulated vision and goals are proposed with a recommendation that a set of realistic, meaningful and quantifiable objectives be developed to support their realisation. With regard to implementation, the Review asserts that implementation of the recommendations should be driven at national level by a strong, standard and consistent approach.
Administration and governance:
The national disability function within the HSE must be strengthened and given a central directional role in funding, shaping and driving the Disabilities Service Programme. A Director of Disability Services would have responsibility for implementation of the Review recommendations.
Person-centred services and supports:
The HSE should drive migration towards a person-centred model of services and supports through the Service Level Agreement process. Agencies will be required to initiate demonstration projects to run in parallel with current services and evaluate their suitability for subsequent wider application. (Note work already being done in this regard: Genio Projects; Next Steps Project.)
Commissioning and procurement:
A new Commissioning and Procurement framework is needed to drive a directional re-shaping of certain services and models.
A national resource allocation model should be developed based on a standardised and appropriate assessment of need process, a methodology for associating standard costs with assessed needs, and transparent protocols for determining the basis for allocating finite resources.
The strategic information requirements needed for the effective management of the Disability Services Programme should be established, having regard to existing information sources and datasets, and an implementation plan put in place.
1. The Service Level Agreement process needs to be adjusted to make immediate improvements to information gathering and performance monitoring.
2. Standardise Financial Reporting – Development of a common coding system to enable expenditure to be tracked, analysed, and compared at national, regional and local levels.
3. A unique identifier should be put in place to facilitate:
—Individual needs assessment;
4. Examination of Value for Money Findings – Each agency should undertake an immediate examination of the findings and key recommendations of the Value for Money Review, and draw up an implementation plan to give effect to the recommendations with a particular focus on the following:
Audit of rosters: Rosters should be critically examined with a view to making the necessary adjustments to rationalise staff deployment across service units in accordance with client need and cost effectiveness.
Skill mix: National guidelines should be developed to advise on the appropriate mix of professional and non-professional staff needed to deliver supports through an in-depth examination of skills, functions and grades.
Unit costs: The HSE should work jointly with service providers to critically examine existing cost bases in the light of the findings and recommendations contained in Chapter 5 of the Value for Money Review, with a particular focus on establishing reasons for costs that remain higher than the average costs detailed in the review.
Average costs: Pending the development of a resource allocation model, the Service Level Agreement process should be used to reduce current direct pay costs.
Policy appraisal: The new policy direction enunciated in Chapter 7 of the Review should be appraised in accordance with government guidelines on policy appraisal.
Implementation plan: A robust Implementation Framework should be developed which takes account of the policy appraisal. It should be comprehensive in nature, paying particular attention to the following issues:
Disability Programme Objective—The review confirmed that people with disabilities want more choice in the supports they receive and more control over how they access them. They want flexible services that meet their individual needs and systems which vest more control with the service users, and, where appropriate, their families.
Economy and efficiency—The results of the data analysis conducted as part of this Review reflect the complexities of disability service provision, which is not a single, homogenous and easily-measured programme, but rather a multiplicity of service types and agency types servicing a very varied client population with widely differing needs.
The data showed that in general some agencies are more efficient at one particular type of service and less efficient at another. Some models are extremely cost efficient, but score poorly on quality of life. Other types of service are cost efficient and support the move to social inclusion and mainstreaming.
There is a requirement to develop a framework to assess need, identify outputs and outcomes and plan and monitor resource usage. The Review found that there is no national standard methodology for assessing client need or for linking those needs with target outcomes. Similarly, there is no nationally agreed means of predicting the amount of resources which an individual is likely to require, and no common method of calculating the amount of resources which an individual actually consumes and the cost of those resources.
Effectiveness—There is a requirement to develop national indicators to objectively measure the effectiveness of the Disability Services Programme in promoting personal progression, community inclusion and participation, and the application of choice, control and independence. The public consultation conducted during the course of the Review found that once people had accessed services, the supports received were considered by respondents to have a beneficial effect. However, almost all respondents indicated that the objectives of the Disability Services Programme had not been fully met and that services did not support choice, control and independence.
Governance and accountability—While the National Disability Unit of the HSE has lead responsibility for the management and delivery of the Disability Service Programme nationally, it has no authority over resource allocation on operational service delivery. This responsibility lies with the Regional Directors and Integrated Service Area Managers who discharge this responsibility by entering into Service Level Agreements with individual service providers. Partnership structures which are representative of the major stakeholders operate within a collaborative framework at a regional and local level.
Information framework—The Review found that the information systems operated by the HSE were wholly inadequate. Information on output delivery was not available in a comprehensive and easily comparable form. There is an immediate and urgent need to address this serious deficit.
Funding framework—The block grant approach to funding had a pragmatic historical basis, but is no longer sufficient to address the degree of accountability and transparency expected of the modern Disability Services Programme. The implementation of the Service Level Agreement process is a welcome development in this regard, but requires review, evaluation and refinement so that it will make a more positive contribution to monitoring performance, controlling expenditure and shaping service development.
Future policy direction—The Review found that current objectives are still valid, but the policy approach used to deliver these objectives has not been effective. The continued sustainability of the current policy approach is questioned, particularly given the demographic pressures and changing societal and family expectations which will place increasing demands on services. It was recognised that the delivery of services and supports has been evolving towards a more person-centred approach, but that the pace of change has been slow and uneven.
The Review concluded that instead of a slow and tentative drift towards individualised services, the policy approach should be re-calibrated to focus more closely on the proposed vision and goals, and that all future developments would be planned and evaluated in terms of their progress towards those vision and goals.
This progress should be advanced in parallel with the recommendations around reframing existing services, so that the development of new resource allocation models and units of cost can provide a basis upon which the transition from traditional programme type to more individual costing approaches can take place.