## Adult Social Care Efficiency Programme Interim Report 2013 Contents

| 1. Introduction	                                           |   4 |
|-------------------------------------------|-----|
| 2. Lessons learnt so far                  |   6 |
| 3. The value of challenge                 |  12 |
| 4. Summary of progress 2012/13 by council |  18 |
| 5. Two more detailed case studies         |  34 |
| Annex A: Summary of progress to date      |  43 |

## 1. Introduction Efficiency Savings

Councils in this programme had to make savings in a range from 0.4 per cent to 11.3 per cent of their adult social care budget for 2012/13. The average savings were 5.7 per cent of the budgets. The modal (most frequently reported) saving was 7 per cent, which is in line with the recent Association of Directors of Adult Social Services (ADASS) Survey of local authority efficiency savings. 

In November 2012, the Local Government Association (LGA) published its report 
'Adult Social Care Efficiency programme1; 
The initial position'. The report outlined the approaches of the 54 councils who had agreed to participate in this two year programme. It included pragmatic and aspirational approaches to achieving savings and improving productivity in adult social care budgets. This report looks to capture the lessons from the first year of the programme (April 2012 - March 2013), and seeks to assist all councils who are looking to reduce their spending in adult social care. At the end of the first year of the programme councils can be divided into three groups: 

•	 those who have made significant strides 
and met their efficiency targets 
The councils were projecting a further 5.7 per cent saving for 2013/14, 5.3 per cent for 2014/15 and 4.9 per cent for 2015/16 however the figures do not take into account the impact of the forthcoming spending review which is likely to increase the requirements. In addition, those councils which failed to meet their targets in 2012/13 are likely to face higher percentages for 2013/14.  

•	 those that have worked to better 
understand their position and while they have not yet met their targets they now have programmes in place to meet them 
•	 and finally those that have made less 
progress than they initially expected. 
Councils categorised 50 per cent of their savings as "reducing bureaucracy" - see Table 1 below. Examination of the data revealed that this included a wide range of interventions including reviewing packages of care, cutting services and reducing staff numbers. Councils identified a further 20 per cent of their savings from managing demand and 5 per cent from preventive measures. 

This report focuses on those councils who have made good progress and the lessons that may be learned from them. All the councils which have made returns as part of this update exercise are covered in this report. 

Projections for 2013/14 suggested that the balance would shift so that the proportion of savings achieved through reducing bureaucracy would decline to 43 per cent, managing demand would rise to 25 per cent and prevention would account for 10 per cent. 

A small number of councils were for a variety of reasons not able to submit a return for the end of year review. The return presented particular problems for groups of councils working together to deliver a project while others cited "capacity problems", often arising from redundancies or key people leaving the local authority. This means that the picture is at this stage incomplete. All councils will be visited in 2014 as part of the final evaluation and as much information as possible will be gleaned from them to maximise learning from the programme. 

While progress has been made in delivering savings in a number of areas, and early learning can be seen in subsequent sections, a significant number of councils within the programme are struggling to deliver their intended objectives. Some were late to begin their implementation phase so report that it is early days. Others cannot yet quantify whether and how much saving will be delivered through their identified approach. In some cases councils are openly and honestly saying that they are now behind where they would hope to be in delivering savings. This is likely to be impacting on the council's overall position and the savings they now need to deliver in 2013/14. 

## 2.	Lessons Learnt So Far

Councils in the LGA's ASCE programme have found that they can deliver efficiency savings through:
Some councils are using strategic partners to assist with driving transformation to deliver the scale of savings required. This approach is further explored later in this report. 

## Systematic Approaches To A Transformed System

One clear finding from this programme is the better a council understands its demands and the impact that its current approaches make on its expenditure the more likely the council will find further efficiencies. 

## Specific Actions Related To Practice And Commissioning

Models of care and interventions that focus on promoting independence can deliver better outcomes at lower cost. Officers need to develop a strong business case for transforming services in this way. There is a range of ways in which councils are now focusing more on interventions that promote independence, many of which are being implemented as a payments-byresults approach. The case study produced with Wiltshire is highlighted in this report but other approaches in Hackney, Suffolk, Calderdale, Darlington, Kingston and Kent all adopt this as a fundamental base to their transformation programmes. Many councils have established a review programme often focusing on higher cost packages of care. Some councils are working closely with customers to assist them through support which will help the person become more independent and thus need less care in the future. Other councils are reducing the care that is available. 

Reducing the number of older people entering residential care through a specific focus on what happens to older people leaving hospital. Many councils have adopted a policy that no one should be assessed in a hospital bed for a longer term service. Any assessment should be undertaken in an Intermediate Care Setting (domiciliary care reablement based service or a reablementfocused residential care bed) in order to avoid long term packages of care based on the individuals at a point of crisis. The summaries of council's approaches in section 4 show that the work in Suffolk, Northumberland, Cheshire West and Chester and Hackney can all evidence savings from this approach. Other councils make indirect reference to managing admissions to residential care.

Using a strategic partner to provide external challenge and to undertake a robust analysis of what is happening in a council can be useful. 

Establishing a thorough reviewing process is in place to ensure that the services that a person is receiving (including in some cases residential care settings) are delivering the outcomes that will help the person become more independent. Hackney have a strong project management programme which is monitoring savings as they are delivered. Many other councils are also adopting  
this approach.

All reablement services should know and understand the outcomes they produce. Developing a joint service model with health which has reablement at its heart may offer the most effective way of meeting older people's needs including those who have been recently discharged from hospital. Many councils report making progress through a renewed focus on reablement. Richmond are notable for their joint work with health services in this area, whilst Torbay continue their focus on reablement for older people who already receive care. 

Supporting carers and recognising signs when they are under stress and there is a risk of breakdown. Failure to do this will cost money in the longer-term. This is an issue which came up in the Kingston diagnostic - see section 5. This work is more related to cost avoidance than cashable savings. It acknowledges the estimated £119 billion worth of care provided free each year by informal carers.

A focus on getting it right for self-funders before they make a decision to enter residential care can save money in the longer term for councils. Ensuring that older people do not make a decision to enter residential care when there are better community based solutions open to them. Poole are amongst the councils to have focused on this challenge and report some early progress. 

A focus on diverting customers who do not need formal social care support away from council services towards the community and voluntary sector. This has been hard to measure in terms of the direct impact of savings though general evidence of fewer people in the formal care system can show the success (or otherwise) of this approach. Calderdale report savings from this in their programme.

Thoughtful use of telecare. It does not deliver savings in isolation but as part of a focused intervention which is aimed at promoting independence. Local authorities are keen to get a better understanding about which type of equipment can best be used in which setting and deliver it in a personal way. One council is developing the "telecare matrix" which links the appropriate equipment to the condition and needs of the service user. Both Kingston and Luton report early savings from the better use of this equipment. 

Improving the reablement service with a focus on the care pathway to ensure that everyone who may need longer term care and support receives a domiciliary care (or residentially) based care service before they are assessed for a longer term service. 

## On-Going Challenges Reducing Bureaucracy And On-Costs

There are a number of recurring issues that were identified in "The Initial Report" and are emerging as on-going challenges to local authorities. These include:

•	 leadership
Reducing the number of buildings from which councils deliver services, including reducing office bases, day centres and in-house residential care. This is a particular feature of the background to the savings in Wiltshire and is in process in many places. 

•	 efficiency savings in learning disability 
services 
•	 transition from children's to adult's services 
and also to services for older people
•	 evidencing savings, particularly in relation 
to integration with health, personal budgets and transforming transport 
Improving procurement. The open book accounting approach which is being developed in Yorkshire and Humberside links to the Department of Health Policy on Market Position Statements and working with the market, rather than against it through just holding prices. This work has been led from Wakefield.

•	 prevention and managing demand.
Making more efficient and effective use of social work time. This is a key part of the Central Bedfordshire approach and is also addressed by Kent and Kingston. Collaborating with partners can deliver some savings in relation to management costs. The tri-Borough in the North East (Darlington, Hartlepool, Redcar and Cleveland) and some of the authorities working to integrate more with Health demonstrate this. They are, however, limited to sharing the cost of posts, particularly senior posts. Early feedback from some places questions whether the level of savings is worth the challenge involved in putting in place the processes and new governance structures necessary.

Leadership It is noted that leadership is one of the most critical features for the delivery of efficiency savings. This will always be a combination of political leadership, which has to develop a clear vision and strategy for what social care will look like going forward (with less resources) and officer leadership. There are already risks emerging in this programme in councils where the leadership of the programme within the council or the sponsoring senior management has changed. Councils need sustained and persistent leadership in delivering the transformation that is associated with delivering efficiency savings; single changes are inevitable but wholesale management team turnover is a significant risk to sustainable delivery.

Annex A reports the efficiency savings by type and gives a number of authorities reported to be achieving savings in this way. It is recommended that readers contact individual participating authorities to find out further details and share learning. 

In addition to focusing on the transition from children's to adults' services Croydon are also looking at the transition from adult services to services for older people and a further transition group has been identified - mid-life people who have traditionally been cared for by their families but for whom that is no longer possible due to old age and infirmity. Croydon see carer support and forward planning as key to avoiding costly interventions and providing the best solutions for these groups.  
Learning disability services As highlighted in our previous report it is in learning disability services that councils continue to face the greatest challenges arising from increases in numbers, life expectancy and costs. The new models that are emerging for other service user groups (reablement for older people; recovery in mental health services; rehabilitation for disabled people and those recovering from substance misuse; etc) have not developed fully in the learning disability field. The work being done in Croydon within this programme is therefore of much interest to the sector. The sense at present within the programme is that councils have made some progress with reducing costs, particularly in reducing costs and numbers of people in residential care, reducing the amount of community support some people get, tightening of the application of eligibility criteria and getting out of buildings for day opportunities. 

Evidence of savings Those places that hoped to achieve that efficiency savings through health and social care integration have so far been disappointed that they are not able to evidence the savings. Where health and social care have worked together to achieve specific outcomes i.e. in improving reablement or other out of hospital care services there is some evidence of efficiencies and better outcomes being achieved. 

Some councils have looked to use employment schemes to help offer people useful activity during the day with some income available to both fund the activity and to pay an allowance to the worker. These do not appear to offer sufficient momentum for workers to assist them into permanent jobs which is the long term goal.  
In the Northumberland Care Trust there has been a 7 per cent reduction in the numbers of older people in residential and nursing care. This is in line with reductions made elsewhere within this programme but it will be interesting to explore in the final report what proportion of the reduction could be attributed to the integrated service model. While no one in the programme has yet demonstrated that personal budgets deliver efficiencies, there are some anecdotal stories of savings. However most of these focus on a change of care setting which could be achieved without a personal budget. 

Transitions It is interesting to note that only Croydon Council has wanted to explore the challenging area of transition from children's to adults' services within this programme. This is often an area where councils identify challenges in both the levels of funding for new packages of care and meeting the expectations of carers and sometimes customers. 

Recent work from the Institute of Public Care (Oxford Brookes University) has identified the approaches that councils may take to "prevention" and these are mostly contained in the programme:
There are some risks that the arrangements for framework contracts associated with customers arranging their own packages of care can allow prices to increase in an uncontrolled way. There are many reports of councils reducing the care packages that people receive and this is reflected in a reduction in the amount of money available through a personal budget. 

•	 Universal provision - the preventative 
aspects of universally available services. A focus on the wellbeing of the population, keeping fit and well with a healthy diet and positive wellbeing. This will include a focus on improved health outcomes that may reduce demands for social care. It should feature strongly in Health and Wellbeing strategies that are currently being drafted. 
Transforming transport services appears to be a challenge for most councils. Most approaches focus on how a personal budget with a citizen contribution (reducing the previous levels of subsidies) can deliver this. 

•	 Preventative provision for populations 
that contain some elements of vulnerability - specialist services that may tackle some aspects of need but not ones which would have led to an assessed social care intervention. Many of the former supporting people funded services would fit the bill. The Department of Communities and Local Government's programme for payment by results reinforces how this approach could be truly preventive. 
Prevention and managing demand Many argue that in order to deliver the level of savings required now and into the foreseeable future there needs to be a radically different approach to social care. The most common model that is emerging from within councils is one which focusses on prevention and managing (and rationing) demand. This approach is clearly evident in the programme - the work in Hackney, Suffolk, Kent, Kingston, Wiltshire, Bradford, Torbay, Calderdale, Waltham Forest and South Tyneside all demonstrate strong elements of this approach.

•	 Targeted restorative interventions - 
interventions targeted on very particular populations in the evidence based belief that if successful they will lessen potential future demand for high intensity care. This includes the future for reablement and recovery based services.
•	 Deferred interventions - interventions 
that are preventative in that they defer people for a time from a poorer outcome. This might include early diagnosis of dementia and putting in place support arrangements which will enable the person and their carer to remain together for a longer period. 
If a focus on prevention as outlined above is linked to a focus on outcomes that promote independence as outlined in the Hackney Council Mayor's Compact for Social Care the basis for a transformed and efficient model for social care emerges. The model balances a focus on rights but with responsibilities. It offers a compact for the person who needs care where the state will offer a set of solutions developed with the customer where promoting their independence is the basic assumption. The model will focus on interventions that assist people to resolve the crisis that they face based on recovery and restoration. The aim of social care will for the first time be preventive - an emphasis on helping people where appropriate to stay out of formal care and to build on capacity in communities and in the voluntary sector. This report captures the end of the first year of a two year programme. The final evaluation and report will be produced in the summer of 2014. Building a stronger evidence base for prevention will be critical to the overall success of this project.

## 3. The Value Of Challenge

A number of councils in the programme have adopted a strategic partnering approach - Hampshire, Coventry and Peterborough have established partnership arrangements with Ernst & Young, Price Waterhouse Coopers and SERCO respectively as part of a corporate savings programme. Cheshire West and Chester also report that they have engaged with a strategic partner. 

response to the original brief set out by the LGA in the programme. That was to invite a consultancy to undertake a diagnostic and then to use the information to assist with transforming services. These councils have taken this further. Interestingly they adopted the same process and at the end they have both chosen the same partner, Newton (Europe) a company that did not have a long track record in social care but a much wider reputation in both industry and the health sector. At the beginning of the programme (with the £20,000 grant from the LGA) both councils chose an organisation to assist them to undertake a diagnostic of their current activity and data to identify areas where savings could be made. A detailed analysis of the activity and performance of the council was presented with an estimated savings figure shown for each part of the analysis. 

Other councils have longer term relationships with consultancies such as OLM (Portsmouth, Stockport, Swindon); IMPOWER (Bradford and Calderdale); Charteris (Liverpool, Warrington and Wirral and Central Bedfordshire). A further group of councils have appointed consultancies on a short term basis to assist with specific pieces of work such as the former Berkshire Authorities; Cheshire East, Hackney, Lambeth et al. The following consultancies have also contributed directly to the programme - People Too; Institute of Public Care; West Midland RIEP; iESE; Alder; Red Quadrant; Atlantic; Helen Sanderson Associates; KLG Consultants; Outcomes UK and PA Consulting. There may also be other arrangements which have not yet been reported to this programme. 

The councils then went out to tender to select a "transformation and efficiency partner". The work of the initial diagnostic was offered to all those organisations who were interested in bidding for this phase of the work. Bidders for this phase had to demonstrate their ability to deliver the savings, not to do further diagnostic work. The decision to bring in a partner to assist with delivering savings is seen as controversial in some local authorities and may be described as a sign of failure by some - "why can't our officers deliver the One approach that has been adopted by two very different types of council in the LGA programme was to select an "efficiency partner" to work with them to assist in meeting their savings targets. The approach adopted by Kent and The Royal Borough of Kingston has developed as a direct The Kent report describes how they saw the process rolling out and why they decided at the final stage to select Newton as their efficiency partner:
required savings, it's what we pay them to do?" is what some councillors may say. Those who work in the private sector may be more familiar with this efficiency model than the public sector where those appointed to a senior post are expected to be able to deal with everything that is thrown at them including day to day management! There was much political debate before the final decisions were taken to adopt this approach.

"In October 2012 an independent efficiency review was undertaken. Based on the considerable amount of detailed analysis, this evidenced that significant opportunities exist for adult social care to transform as well as to help support achieving savings of the order of £18m in the first year. KCC does not have readily available capacity of appropriate capability to manage a programme as large and as complex as Kent's Social Care Transformation Programme.

In fact within the LGA ASCE programme another council, Hounslow, decided that having received a full diagnostic from Newton (Europe) they determined that the transformation needed to be driven by the managers working within the council (alongside a neighbouring Borough, Richmond, who are also part of the LGA programme) and local health services. Later in this section the pros and cons of this approach are considered. The report to the Cabinet in Kent on 23 March 2013 sums up this debate for the County Council:
The expertise of the consultancy used during the review, and the way they worked with KCC staff, was a positive and successful experience. This gave KCC confidence that it was possible to work in partnership with a consultancy. It also gave KCC clarity regarding the added value a transformation and efficiency partner could bring to the implementation stage of the programme and ways of sharing risk. Transforming social care will be a complex and time consuming task - taking at least 4 years. This change programme will be resource intensive and require KCC to transform the business, whilst simultaneously ensuring we continue to meet our statutory duties. The complexity of improving outcomes for vulnerable people in Kent, building a sustainable social care market which is fit for the future, whilst simultaneously working within reduced budgets is a huge challenge. KCC intends to reduce the risks associated 
"KCC's financial deficit over the next two years (2014-16) is estimated at around £200m and it is clear that public spending will remain under pressure for a number of years. As adult social care is a third of KCC's non-school budget, Families and Social Care is preparing to make significant savings over the coming years. The basis of the Adult Social Care Transformation Programme is that savings of the magnitude that will be needed can only be achieved through transformation (re-designing how social care is delivered). This approach was set out in the Adult Social Care Transformation Programme Blueprint and Preparation Plan which was endorsed by the County Council on 17th May 2012."
with managing a programme of this size and complexity by: a) using a consultancy with enough capacity to support our programme; b) using a consultancy with a high level of expertise and with experience in implementing similar programmes elsewhere.

in itself, moreover the external challenge has been seen as key to delivering efficiencies. The process of tendering for a partner was based on the view that Kingston needed extra capacity, with a level of skill and knowledge not available in-house and that the challenge such an approach offered was positive.

Without a transformation and efficiency partner KCC's ability to transform adult social care will be severely hindered.

Newton Europe was the successful bidder. They began work on the programme at the end of November 2012, since then good progress has been made and benefits are beginning to be identified and agreed. A key decision was to co-locate the Newton Europe team with the adult social care management team in Kingston. Simon Pearce, Head of Adult Care highlighted the importance of this collaborative approach between the local management and Newton Europe which he considers to be key to effective working of the programme.

If a transformation and efficiency partner is not appointed - KCC will need to fully resource the programme alone. As KCC does not have enough staff with the composite skills and experience, a significant proportion of this resource will need to be recruited externally. As resources are likely to be recruited individually, it will take time to build a team and for them to get up to speed and work in consistent and co-ordinated way. This will mean a delay to implementation starting and therefore a delay to the realisation of the benefits."
The fee paid to Newton (Europe) is determined on the outcomes of the work, so payment is contingent on savings being delivered. From the council's point of view there is a risk and reward strategy here. The rewards paid to Newton (Europe) if the full savings are delivered are high and as such are likely to attract local media interest. However, the payment is a "one off" and is a relatively small proportion of the savings that have to be delivered. The savings are delivered in a certain time frame but once the transformation has been implemented the money should be taken from the system for the ensuing years and the savings to the council are thus quite significant. Every £1 million delivered in Year One becomes £3 million saved by Year Three. The county council were very clear that the delivery of savings would require a culture change from within the organisation. 

In Kingston the process happened earlier in the year and progress was reported to the last LGA ASCE event in November 2012. Kingston is a relatively small council and had been working on becoming more efficient for several years through the "One council/ One Kingston" programme, enabling the council to live within its reduced resources. The challenge of making further significant efficiencies from adult social care is a major one. Councillors are very keen to maintain front line services, so knowledge, expertise and resources are necessary to look for ways to further improve processes and commissioning. The council did consider whether this could be sourced in-house, but this presented significant difficulties. Recruiting and maintaining a team of people to deliver the efficiencies is a significant task They specified that all learning was shared and transferred during the programme from the consultants to staff in order to help ensure that the transformation was sustainable. Councils who have looked to develop a partnership have usually chosen an organisation that can demonstrate an ability to both "get into the data" and analyse and interpret it in a way that can demonstrate 

## The Advantages The Disadvantages

The efficiency partner takes away some of the responsibility and burden of delivering the savings and allows the council to focus on meeting the needs of local citizens.

Transformation is dependent on the culture of an organisation as well as the delivered changes - local managers are often best placed to understand the culture and deliver the changes required. 

The efficiency partner brings new skills and knowledge which is unlikely to exist in the council (even a large council such as Kent). 

In the longer run those skills are required by the council to both sustain and continue with the new transformational models that are put in place The ability of the efficiency partner to understand the data and interpret how it leads to greater efficiencies may not be available within a council. The project management approach that skilled consultancies bring to local government is still an emerging skill for councils, particularly in adult social care.

Democratic accountability is an important part of the local political process - any changes that are proposed need democratic support from local members - that can only be delivered by their paid officials.

The need for external challenge is being seen as a critical part of the LGA programme - without that challenge many councils are finding it very hard to make the changes required to deliver the budgets that they have been set. There is a lot of talk within adult social care that further efficiencies cannot be made. The consultancies are proving otherwise. 

how efficiencies can be delivered. A key lesson within this programme is that councils are more likely to find savings if they understand their data, understand the impact that their current approaches have on managing demand and are open to looking to alternative approaches that might deliver better outcomes at lower costs. So what might be the pros and cons of adopting this approach?

Concern that the consultancy will only tell us what we already know? The LGA has already developed a model of Peer Challenge to assist with the need for external scrutiny. Will the efficiencies being delivered in the short-term be sustainable longer term particularly as the demographic pressures beginning to manifest themselves in Health are sure to hit social care very soon. 

The figures that are paid out at the end of these partnerships can be high (into millions of pounds) - can this be justified to the local population when we are making savings.

If councils carry on doing things in the way in which they have always done things it is unlikely that they will be able to make the efficiency savings required. It needs a total transformational approach to the whole system. This may require some people to look at the challenges with a fresh pair of eyes.

Payment can be set up in a way that makes it contingent on the level of savings required being delivered: No win, no fee. This is the best guarantee a council can get. This is a competitive market with several potential partners - chose the partner carefully and the process should work for both sides.

The TLAP model, highlighted below, offers an alternative approach through both peer challenge and self-assessment. This will provide external challenge without a significant cost. Consultancies vary - some diagnostic skills are basic and delivery skills are poor when tested on the ground. 

The approach has proven to identify significant savings in two ASCE authorities, however there has been no evaluation as to which approach offers the best outcomes (see an alternative below). 

## Self-Challenge And Peer Challenge

The Towards Excellence in Adult Social Care Programme, Think working with Local Act Personal Programme has recently launched a self-assessment tool to assist councils with their self-evaluation around "use of resources" in adult social care. This not only updates the original DH Publication, Use of Resources in 2010 but adds a tool which guides councils to challenge themselves about the progress they are making. The resources and tools can be found on the TLAP website: www.thinklocalactpersonal. org.uk. For those councils who want to develop an approach through selfassessment and peer challenge these are the most recent products available. The LGA and ADASS will be using these tools as part of the peer-challenge process. 

They support the on-going efficiency work that many are continuing to undertake and will be of interest in the programme going forward. •	 A Problem Shared: Progress in delivering budget savings in adult social care 2007/8 - 2011/12 http://tinyurl.com/mrulznj This report presents and analyses national data on how councils have spent their budgets in adult social care over the last four years - and especially during the period since the 2010 Spending Review. It compares changes in expenditure with changes in activity, costs and income over the same period. 

•	 Self-assessment tool http://tinyurl.com/lsk2fwa This self-assessment tool is broadly based on the framework provided by the Association of Directors of Adult Social Services (ADASS), "How to Make the Best Use of Reducing Resources: A whole system approach". It can be used on its own, or with the other optional tools in  
the toolkit.

•	 The toolkit comprises: - Optional Tool 
3: Useful resources and guidance http://tinyurl.com/n2z5rto This list of useful resources and guidance is designed to support the use of the self-assessment tool. It focuses on publications, guidance and tools that have been produced in the UK since 2009.   
Many councils in the programme have not yet delivered the scale of transformation required and are behind in their programmes to deliver the savings projected - this is threatening the stability of both social care and the overall finances in some councils. 

•	 Guide to the self-assessment toolkit  
http://tinyurl.com/kvb5ekr This guide explains how to use the selfassessment tool and the other optional tools, which include the descriptors of "What good looks like", examples of "Relevant nationally-available metrics", and other "Useful resources and guidance". We know that many councils are carrying out wide-ranging reviews of all departments including adult social care.

•	 **Use of resources information template** 
http://tinyurl.com/l3nlvo5 This information template will help councils assemble the important data and background information they need before getting started with the self-assessment process.
•	 Optional Tool 1: What Good Looks Like http://tinyurl.com/l3plk6w This optional tool describes "What Good Looks Like", based on recent research, guidance and case studies from across England. Councils can choose to refer to these descriptors when completing their self-assessment tool.

Evidence from participating authorities on the LGA programme suggests that external challenge is a really positive way in which councils can explore new ways of thinking and find new solutions to their problems. The approach taken by those working with an efficiency partner demands serious consideration. The list above identifies some of the risks but councils can ensure that they have looked to take actions that mitigate these risks (this is mostly done in the process to select the right partner). We would encourage Councils to consider one of these approaches. We will continue to share information on the progress made and any lessons that emerge over the coming year. 

•	 Optional Tool 2: Relevant nationallyavailable metrics http://tinyurl.com/lrltvfg This optional tool lists metrics that are currently collected nationally, and that councils may choose to use when completing their self-assessments. However, it is acknowledged that better indicators and a stronger evidence base are needed to assess the value for money of adult social care services.  

## 4. Summary Of Progress 2012/13 By Council

This section contains a summary of the progress that was self-reported by Councils to the LGA in March 2013 (the end of the first year of delivery of the programme). There are two more detailed case studies that are written up at the end of this section. These relate to the Royal Borough of Kingston and Wiltshire Councils whose work was highlighted at the first programme event in November 2012. They both show excellent examples of how councils are tackling their challenges in different ways. 

(A&AS) which is already showing progress and is ahead of schedule. The Access, Assessment and Support service was allocated £300,000 of growth money in the 2012/13 budget settlement which, as a result of accelerating changes within the service in line with the Improvement Programme, was not required. As well as this the A&AS service achieved its recurrent savings target of £600,000 and indeed achieved a further £168,000 compensatory savings which will be released to fund vacancies in line with the changes identified in the A&AS Improvement Programme.

## Bradford Metropolitan District Council

Overall across adult services the savings target for 2012/13 was £8.68 million and whilst not all the savings targets have been fully achieved, alternative savings were identified. The majority of these are one-off in year savings 2012/13 and the budget was balanced at 31 March 2013. 

## Calderdale Council

The first phase of the work in Bradford focussed on the 'Use of Resources' which considered how to reduce spend on higher cost residential care as well as achieving savings in procurement costs of individual care packages, changes in providers, management savings and through greater use of technology.

Calderdale have been working more closely with customers, the voluntary sector and other partners to promote independence and divert people away from the social care system. Savings of £2.1 million have been made in 2012/13, 3.6 per cent of the net budget, which brings the service in under budget. The majority of the savings have been achieved by taking a more rigorous approach It took until September 2012 to clearly develop Phase 2 of the programme which identifies further efficiency opportunities to help in planning for 2013/14 and beyond and incorporates a greater focus on the potential for behaviour change and demand management. In particular, the recommendations in the report are being used to assist with achieving the efficiencies required from our current Access, Assessment and Support programme Further work will develop examining the productivity of staff with a view to making more efficient use of social workers time. 

to pursuing re-ablement and the subsequent allocation of funding for individual care packages. Further savings were achieved by reviewing the skills mix and make up of teams, a review of in house services and better procurement and contract management. 

This has helped to meet the target of 7.4 per cent efficiency savings in 2012/13. Future savings targets are 7.39 per cent and 5.7 per cent for 13-15.

## Cheshire East Council

A further £3.1 million efficiency saving is projected for 2013/14 (5.6 per cent of the net budget). This will be achieved through further modernisation of the customer journey, including the introduction of a resource allocation system and putting into place more effective and efficient alternatives to out of area placements. The Council will continue their commitment to look for new ways of delivering in-house services including home care maintenance, day services and extra care services as well as decommissioning an intermediate care facility.

## Central Bedfordshire Council

A consultancy has continued to assist the council with residential and community fee negotiations, including implementing a quality framework for future contracts. The council has benefited from a positive relationship with them and have continued to utilise their support, for example in the completion of an accommodation needs review. Most recently the council has also engaged, on a pilot basis, with "Skylakes" to review and reassess a sample of 50 individual's cases, the aim being to assess whether external scrutiny might provide an insight into internal practice. Early indications suggest there are reductions in care plans and costs. During the remainder of 2012/13 a combination of remedial measures have helped to mitigate the extensive spending pressure, some of these actions have been continued into 13/14, whilst a larger programme of change is put in place. The savings target of £6.6 million (7.2 per cent of the £91.5 million net budget) has been met for 2012/13. Projected savings rise to 10.38 per cent for 2013/14 and then 4.3 per cent for 2014/15. 

Central Bedfordshire Council worked with a consultancy to look at how older people's care needs can change over time with a focus on those who recover. This has led to a fresh approach to reviewing services - the review can focus on whether the person has recovered and if the service on offer is now the best service for them or whether there are more effective ways of meeting needs? The review looks at the specific needs of the customer and where they are in their life. While it is early days in terms of measuring efficiencies the approach has helped to change the mind-set of those involved in reviews.

## Cheshire West And Chester Council

For 2013/14 'a bolder community services programme' has been implemented based on the principles of building resilience and encouraging independence as a preventative approach. The programme aims to save £3 million over the coming year. 

The council aimed to assess the service against the vision expressed in the document "Shaping the Future Together".

## Croydon Council

The project aims to address the significant costs in supporting Learning Disability clients. It is focussed on two main elements:

a)	addressing customer/family expectation 
and case management cultural change. 
The consultancy which was appointed to undertake the assessment has been retained to implement phase 2, which aims to 'set the platform for an engagement strategy which develops the existing network and enables it to be more self-sufficient, inclusive and influential'. Phase 2 only began in February 2013 so it is very early days in terms of delivery. £3.74 million of efficiency savings were achieved in 2012/13 (4.1 per cent of the net budget). £0.6 million is projected for 2013/14. The council aim to achieve a 15 per cent reduction in residential care of older people, however changes to hospital discharge will influence this.

## Coventry City Council

The focus of the work in Coventry was changed after the initial diagnostics stage, to embed the use of technology into the overall Adult Social Care Transformation programme. Also to look at where further efficiencies might be identified within particular service areas, eg Home Meals, Home Support, and reablement / promoting independence, etc. 

Alder, the external consultancy engaged to support the work were focused on three strands - data analysis, practice analysis and strategy analysis. Data analysis looked at both national data for benchmarking purposes and developing initial lines of enquiry, and local data to confirm current performance and potential areas for improvement. Practice analysis included examination of case files and interviews with practitioners and commissioners to better understand current practice and how to develop it to meet key strategic objectives and deliver improved outcomes for people. Strategy analysis also included health and housing colleagues to develop an integrated and coherent strategy in respect of these services. The approach aims to better support clients towards an ordinary life and better manage risks. The analysis has highlighted some strengths and a number of areas that need to be addressed, including communication skills and dealing with expectations being primary among those. 

£2.1 million of savings have been achieved over the last 12 months through the outsourcing of the home meals service, closure of day provision in two under-utilised resources, de-layering of management structures and improvements to the commissioning process. 

Transitions have also been highlighted as an area for development and not just transition from children to adult services or adults to older people, but a further "transition" group has been identified. The new group includes those mid-life individuals that have been cared for by families but for whom that is no longer possible due to infirmity and old age themselves. This group often trigger emergency solutions due to little or no warning of breakdown of the existing arrangements and often lead to costly support due to the lack of forward planning. 

This is called the Neighbourhood Care Independence programme and is based upon Asset Based Community Development approaches to building community capacity. The provider began the grantmaking process in October 2012 in order to grant fund prevention activities with £867,000 per year for three years from April 2013. Decisions on which third sector partnerships of organisations would receive grants were made in January 2013 and the Neighbourhood Care Independence programme began in April 2013. The hypothesis is that by investing in these activities, eg advice and information, help with low level equipment, volunteer befriending, handy person and home from hospital support schemes that the need for adult social care services can be reduced, avoided and delayed. A consultancy, Institute for Public Care, has been appointed to fully evaluate outcomes and effectiveness of the programme during 2013/14. 

## Durham County Council

During 2012/13 savings of £6.3 million were made across adult social care as a whole, 6.3 per cent of the net budget. Similar levels of savings are projected for 2013/14 with a further £4.6 million, 4.8 per cent of net budget for projected for 2014/15. In the current year savings have been achieved primarily by reducing staffing layers in the council, introduction of assistive technology in learning disability supported living services, re-shaping of older peoples day care model to provide reablement focused resources centres and greater alignment with OT services, reviewing care packages and a review of transport arrangements for people with learning disabilities. Delivery plans will continue be implemented in 2013/14 with the introduction of life coaching targeted at learning disability customers in transition. 

## Cumbria County Council

The diagnostic phase identified a number of suggested savings aimed at managing demand for services, which have been incorporated into the Council's Medium Term Financial Planning processes. These include increased use of intermediate care; expansion of telecare service; supported living remodelling; review of day care; effective targeted commissioning of high cost packages; policing current eligibility criteria; charging review; expansion of reablement service and reduce transport costs.

The council has commissioned a Managed Service Provider, Cumbria Community Foundation, to fund prevention activities in the county. 

£7.5 million of efficiency savings were made in 2012/13, 4.8 per cent of the net budget. Further savings of 3.3 per cent are projected for 2013/14.

## Gateshead Council

of confidence for achieving a further £4.5 million in 2013/14. 

## Hampshire County Council

A brief report was received from Gateshead showing that £75,000 of savings had been identified through their prevention programme.

## London Borough Of Hackney

The original aim of the work in Hampshire was to look at efficiency savings gained through a focus on telecare, day care and transport. 

The council formed its second Transforming Adult Social Care programme in late 2012 which is driven by an overarching commitment to better promote independence. This was agreed by members and published as a clear statement. The programme incorporates projects focusing on re-ablement, preventative services, universal services, day care, directly provided services and integration. The project delivery approach is combined with a continued focus on workforce development, personalisation and user and carer involvement.   
Following extensive partner consultations the decision was taken to develop a business case for the adoption of a strategic partner for the delivery of mainstreaming telecare in Hampshire. The partner will drive a cultural change programme to embed telecare across the county, acting as the primary point of contact for all telecare provision. They are currently at the implementation phase prior to starting on 1 August 2013. Work has been progressing on a long-term transport commissioning strategy which ensures that transport arrangements complement changing demand arising from service transformation in learning disability and older people's services. The forecast savings target is currently being estimated but will be linked to a range of different areas of activity, including: 

•	 insourcing transport provision and 
maximising the use of in-house vehicles, through additional driver recruitment and looking at more shared journeys
The agenda is supported corporately through a dedicated Adult Social Care Budget Board which is chaired by the council's chief executive. The board monitors in-depth budget and performance information on a monthly basis. It also supports delivery of the programme. this year care management capacity was enhanced to undertake care management reviews in priority areas and work was undertaken with Ernst & Young to develop long term financial and demand modelling.    

•	 direct payments for transport •	 working with care managers to ensure 
they implement better checks to manage demand
•	 travel training for those who could use 
public transport with some initial support and guidance.
The programme has delivered all its key milestones in its first year toward its overarching aim to deliver its medium term savings target through an agenda for promoting independence.  In particular it is on track to achieve its £5 million savings plan for 12/13 (4.8 per cent of its net budget) and starts the new financial year with a high level 

## Havering, Barking And Dagenham And Redbridge Councils

Overall, £15.2 million efficiency savings have been achieved in 2012/13 (4.5 per cent of net budget) with a further 1 per cent saving projected for 2013/14. 

The objectives of the joint project were to:
To support early intervention and preventative work local voluntary sector groups were helped to develop the support they can offer to older people, especially those who are at risk of losing their independence but do not currently meet the criteria for adult services input. The work included compiling a directory of local services and helping to create new groups where gaps in provision were identified. 

1.	 Jointly identify, develop and implement  
opportunities to achieve financial savings and wider benefits through cooperation and working together around the key points of the health and social care interface. This is particularly in relation to older people and pathways out of hospital, given our shared dependency on discharge arrangements with the local acute health services including Queen's Hospital, Romford.
The council is providing reablement services to older people in crisis to maximise the clients' independence and minimise ongoing care costs. 

2.	 Explore and create opportunities and 
initiatives to develop community based and preventative care to support the reshaping of acute and secondary health provision through close joint working across our boroughs and with health.
Older persons' day opportunities are also being reviewed with a view to consulting widely with older people and their carers prior to retendering the service next year. In the meantime, some innovative day opportunity pilots are underway, including a joint project with Rushmoor Borough Council to provide day opportunities for older people from the Nepalese community in North Hampshire; a carers' service at Malmesbury Lawn day centre; and funding for the Gosport Live at Home Scheme (which provides befriending, a coffee morning, lunch club, advocacy, and outings).

The work aims to improve arrangements for Integrated Care across Barking, Havering and Redbridge (BHR), to deliver both policy objectives, in the achievement of integrated delivery and improved outcomes, and to improve management of demand within their system. A key priority has been to seek ways through which current reliance upon higher cost bed based services including those within an acute setting might be addressed. This is a particular issue not least as their JSNA readily evidences increasing numbers of people who are older frailer and with one or more long term conditions. 

5.	 Significantly increasing our use of 
Assistive Technology to provide 
alternatives to traditional support and where intervention is time sensitive.
The work to develop the approach to Integrated Care has been support by Ernst &Young and early modelling has been undertaken in relation to requirements for reinvestment into community services. In addition to the above, Havering, working with its partners, established a range of projects designed to improve efficiency and help to improve management of demand. These include:

6.	 We are currently developing a selffunders strategy - which will ensure that self-funders have timely access to information and advice about how their care and support needs might best be met and the choices available to them within the local market at equitable prices. The indicative business case identifies potential savings in excess of £300,000.
1.	 Detailed review of why residential 
placements are made with a view to 
enhancing the use of alternative solutions including those of community support. This area of work has a savings target in of £400,000 in 2013/14 and a further additional £600,000 in 2014/15. 
2.	 Increasing **re-ablement capacity** to 
ensure greater levels of inclusion, independence, self-care and management and reduce demand for higher cost long term services. 
3.	 Establishing a **Help not Hospital** 
scheme, designed to provide support to people presenting unnecessarily to hospital who need support to return home but fall under the council's eligibility for support. Forty people are currently supported through this service.
Redbridge have made efficiency savings of £3.03 million, 4.5 per cent of the net budget for 2012/13. Savings to date were achieved through contract re-negotiation, decommissioning, market shaping. The projected savings for 2013/14 is £2.96 million, ie 4.4 per cent of the net budget. They aim to achieve this through increased reablement service both through hospital and community referrals through external providers leading to reductions in long term placements and/or care hours for users; promoting more take-up of cost effective personal budgets offers through individual service funds and direct payments; more coordinated work with health (and thereby supporting service users through one coordinator, one shared support plan and review for both health and social care needs) through the integrated case management teams based across GP clusters based on a pioneering risk-stratification tool.

4.	 A pilot to use telehealth for patients 
with Chronic Obstructive Pulmonary Disease which has been shown to impact 
positively upon A&E related costs. For the sample group of approx. 20 people, A&E costs were £121,509 in the year before intervention and only £68,224 post deployment of the scheme.

## Kent County Council

This process is now complete. Newton Europe were awarded the contract and started working with the council in May 2013.

Since the adult social care transformation plan was agreed by the County Council in May 2012, work has been done to understand the many elements of Kent adult social care business and how transforming one element could impact others. During October 2012, Newton Europe carried out a diagnostic on Kent adult social care.  They worked closely with staff across the whole social care system to evaluate the way care and support is assessed, commissioned, procured and delivered. Findings included:
During 2012/13 the council made 2.8 per cent efficiency savings (£9.48 million). The majority of the savings were achieved through a review of residential and supported accommodation and domiciliary care. A further £1.6 million of savings were achieved through an increase in enablement reducing the need for on-going packages of care and reduced number of people entering the system.  Nearly £1 million was saved through streamlining back office functions, management structures and improving commissioning and procurement practices. Projected savings for 2013/14 rise to £18.8 million, 5.6 per cent of the net budget.

## Royal Borough Of Kingston

1.	 Care Pathway: A greater number of 
people could be supported to be more independent through short term, intensive services such as the Kent Enablement Service and a broader range of telecare equipment.
2.	 Optimisation: Whilst the adult social 
care workforce works very hard, some of the working time is not as productive as it could be. This is due to complex processes, excessive paperwork and burdensome systems.
3.	 Commissioning/Procurement: The 
very large number of providers we have contracts with in Kent makes it difficult for us to communicate with and work closely with all our providers. 
The Adult Social Care Team has taken a twin track approach to achieving efficiencies and service improvements. An internal improvement programme has been making significant savings since 2008 and by 2010 
had achieved savings of £1 million, largely through a review and reduction of staff numbers.  An integration project is on-going to deliver services jointly with healthcare colleagues through Your Healthcare, a community interest company, and other key workstreams include the recommissioning of day-care services and the establishment of a social enterprise to deliver supported-living services.  In total the programme is set to deliver sustainable savings of £3 million by 2014/15. 

These issues will be addressed as part of the transformation programme.  In December 2012 the council went out to tender for an efficiency partner to work in partnership on a risk/reward basis to provide support with the implementation of the Transformation Programme. 

•	 the successful outsourcing of the in-house 
community supported living service for learning disabilities
•	 diversion from long-term older peoples' 
residential care.
The council also engaged with Newton Europe Ltd in March 2012, using funds under the LGA efficiency programme, to undertake a diagnostic of further service improvement and savings opportunities. Subsequently Newton were also selected to deliver a programme of savings totalling £2.7 million (5 per cent of budget) that started in December 2012 and focusses on two key themes: making operational changes to increase the range and use of telecare, reduce reablement costs and increase numbers using the service; and provide more timely reviews of service for older people and younger people with physical disabilities.  Commissioning work is also ongoing to re-commission home-care services, review the costs associated with high-cost packages of care for people with learning disabilities, and reduce the prices paid for nursing and residential care.  The programme is currently on schedule and the council has recognised £459,000 of savings to date. The programme is due to complete in March 2014.

There has also been significantly improved performance in delivering direct payments and financial assessments leading to increased income. Independent benchmarking has confirmed that Lincolnshire Adult Social Care has the lowest management and non-front-line costs of similar authorities. Significant performance improvements delivered in 2012/13, including 100 per cent of eligible people receiving a personal budget, low admissions to residential care (6.9 per 1,000 aged 65+), improved outcomes from in-house reablement service (16 per cent increase in people successfully reabled and a 5 per cent decrease in people admitted to hospital from reablement service).

## Lincolnshire County Council

The renegotiation of funding contributions for services delivered in partnership with other organisations has enabled the council to reduce net costs and promote a more equitable approach to sharing risk between partners.

The service in Lincolnshire has delivered savings of £8.981 million in 2012/13 following savings of over £12 million in 2011/12. This means savings of over 15 per cent of the net budget have been achieved over the two year period. Savings in the second year of the plan have focused on:

•	 completing delivery of a fit for purpose 
adult social care (ASC) structure in which staffing has reduced by 25 per cent over the two years
•	 closure of all eight of the council's in-house 
older peoples residential homes
During 2012/13 a Transformation Unit was established partly funded by the ASCE programme. This unit has produced a blueprint for the Transformation of ASC in the next two to three years to coincide with the continued progression of the council to a 'Strategic Commissioner'. Two immediate elements of this Transformation involve further development of web based systems, in conjunction with Public Health colleagues, self-service and increased attention on prevention and early intervention.  

•	 a review of the Lincolnshire Assessment 
and Reablement Service

## Luton Borough Council

The service projects to make a further £7.3 million efficiency savings in 2013/14 (5.2 per cent of net budget). 

## London Borough Of Lambeth

Luton Council delivered just under £3 million of savings in 2012/13, 5.9 per cent of the budget. A further £3.7 million is required for 2013/14, 6.6 per cent of the budget. 

Lambeth aimed through this work to streamline the adult social care process, including looking at a more efficient use of staff resources and easier access to information and services. Considerable work has been undertaken to re-design the service and an outline operating model for adult social care has been agreed, with work now focusing on developing the detailed model. This includes demand mapping to determine the type and number of staff required, piloting of an Initial Contact service and a review of assessment processes.  
Savings have been achieved by more innovative use of assistive technology and particularly within learning disability services which has reaped significant savings. Savings have also been achieved through greater investment in respite facilities and services to support carers; review of inhouse provision and subsequent closure of all of the council's older person's homes; streamlining of staff structures within day services; review of all high cost care packages; contract negotiation with care providers and restructuring of some teams. The latter has included a rationalisation of operational management structures and a reorganisation of care management using best practice models. Implementing 'agile working' has significantly reduced the use of office space and staff travel time.

The savings target (£5.5 million, 7 per cent of the net budget) for 2012/13 was met primarily using savings obtained through posts vacated through a redundancy and early retirement process and vacant posts. Lambeth also made savings by managing demand through the use of assistive technology, re-ablement and extra care housing and by reviewing existing contracts. 

## Liverpool City Council

2013/14 will see an on-going review of all high cost care packages and out of borough packages to ensure ordinary residence legislation is applied. A review will be undertaken of telecare and telehealth arrangements to maximise the use of preventative technology. 

## Northumberland County Council

The council reports that £13 million of efficiency savings were achieved in 2012/13 (8 per cent of net budget). This comprises savings achieved by reviewing eligibility criteria, signposting users to alternative provision, improving procurement practices and reviewing existing care packages. 

This is a place where the management of social care services is located within a Hospital Trust as part of an integrated community service with local health services. 

The council projected that they would make savings of £1.4 million in 2012/13 and £1.9 million in 2013/14, 3 per cent of the net budget. Savings will be achieved in two key ways. 

The initial aim was to see if the impact of this integrated service could be shown within the efficiency programme. However, the impact of the individual elements of the areas we were interested in as part of the ASCE program are still being reviewed and it is proving difficult to attribute success in driving down costs and activity to any particular elements as they effect similar outcomes in terms of activity and spending. 

Firstly work is underway to reshape the Adult Social Care Helpdesk, in order to resolve more enquiries at this first point of contact and avoid further unnecessarily complex and expensive input. 

Northumberland have noted that there has been a 7 per cent fall in the numbers of older people in placements in residential care / nursing care placements between April 12 and February 13. This will continue to be monitored within the programme. 

## Peterborough City Council

A programme of activity is also in place to reduce residential placements made directly from hospital and create better opportunities for service users to remain independent at home for longer. This is supported by a new approach to more personalised care package reviews, which will reduce domiciliary care spend.

## Portsmouth City Council

Portsmouth, in part one of the work looked at efficiency savings achieved through improved processes and reducing bureaucracy. The focus in part two has included personalisation, learning disability services and reablement.  
The Adult Social Care Saving programme for 2012/13 targeted £4.1 million savings across a range of initiatives. These included £640,000 savings on improving reablement, over £700,000 on managing demand by reviewing care plans, transition planning and reducing residential and nursing placements. The latest projection is that savings of £2.9 million will be made against the original target, representing a shortfall in savings of £1.2 million, the majority of which was due to a significant delay in the closure of two remaining in-house residential care homes. 

## Poole Council

Savings of £200,000 were made in 2012/13, achieved through the review of assessments and care plans. The council have found that the methodology deployed in reviewing current practice as part of the transformation has increased staff buy in and improved the implementation of improvements. The hypothesis that customer service could improve through efficiencies, which historically have been considered 'cuts', have largely been proved.

Poole are focusing on the full savings programme with a special interest in the impact that you might have on reducing the demands of self-funders who run out of money. 

## Royal Borough Of Richmond Upon Thames

and community health intermediate care services. This should offer older people a clear care pathway for hospital discharge and the opportunity to receive the level and intensity of rehabilitation services at the time and for the duration they need it, from appropriate highly skilled workers. The multi-disciplinary team will perform the following functions:

1.	hospital discharge and early supported 
discharge
2.	crisis and rapid response 3.	community rehabilitation support.
Despite the fact that Richmond already had a good re-ablement service their aim was to improve it further. They have worked with Health to combine local authority services that support hospital discharges and offers re-ablement with the health community services which look to avoid hospital admissions and support speedy discharges. They are looking to improve services which already perform well with this process of integration. A consultant was appointed to challenge existing services and support the council to develop an integrated Community Rehabilitation service, which was then launched in spring 2012.  
Efficiency savings of £1.6 million (2.7 per cent of net budget) were achieved in 2012/13 and a further £1.7 million (2.9 per cent of net budget) is projected for 2013/14.

## Solihull Council

In July 2012, the council agreed to carry out a feasibility study with Hounslow and Richmond Councils, Hounslow and Richmond Clinical Commissioning Groups and Hounslow and Richmond Community Healthcare NHS Trust about the future development of an Integrated Care Organisation (ICO). The ICO would encompass the Community Rehabilitation Service, but would integrate health and social care services on a much wider scale. In February 2013, all partners agreed to commence work on the full business case for the ICO, following the completion of the feasibility study. 

Solihull aimed to reduce demand for services for older people, with a particular emphasis on telecare. This has been achieved predominantly through a review of 179 high cost care packages, a full case review, a review of block contracts, modernisation of day service provision and the application of lean principles to home care / reablement processes. The council have also increased the use of assistive technology adopted within care and support packages replacing traditional forms of provision. Efficiency savings of £1.5 million (2.9 per cent of the net budget) were achieved in 2012/13. A further £3.1 million is projected for 2013/14 (5.7 per cent of net budget) and £1.6 million (3 per cent of net budget) for 2014/15. 

It has been agreed that the implementation of the Community Rehabilitation Service would continue and form an early part of the ICO's range of services. The service specification for the new integrated service has been agreed by all partners. The new service will deliver a person-centred integrated community rehabilitation service, building on the best aspects of the borough's reablement arrangements. The council were unable to restrict care price increases as envisaged therefore predicted savings were not achieved in this area.  
The development of the Assistive Technology and Telecare Strategy and Business Case provides a clear road-map to developing the service and achieving savings in 2013/14 and beyond. Further savings will be achieved by the continued review of high cost care packages and retender of the current domiciliary care contract, leading to an overall reduction in the cost per unit. 

In order to meet budgets reductions for 2014/15 (£9.5 million) and 2015/16 (£12.5 million) the council are implementing a new operating model for adult care, "Supporting Lives, Connecting Communities", which aims to reduce or delay demand for services. The model focuses on helping people to help themselves by providing better information, prevention / early intervention and reablement.

Solihull reports that some savings identified in their Medium Term Financial Strategy for 2012/13 have proved problematic. These includes savings relating to transport, service management, domiciliary care re-tender and community recovery team

## Southend On Sea Borough Council

The model has been piloted and feedback indicates that it reduces waiting times, alleviates confusion and improves consistency for customers and provides more person-centred services. 

## South Tyneside Council

During 2012/13 £3.7 million of savings have been achieved, 8.2 per cent of the net budget. The council have increased reablement, reviewed in house provision of services and reviewed residential and domiciliary care prices. Further work on these areas is projected to realise additional savings of £3.3 million in 2013/14. It is felt that the lack of re-ablement capacity has been an obstacle to the progress of this work. The council are in the process of growing the market for this service.

## Suffolk County Council

South Tyneside Council aimed to reduce demand for older people's services and in particular, admissions to residential care. A consultant was appointed to review admissions and suggest potential efficiencies. Recommendations included the development of extra care facilities with specialist dementia carers, a Rapid Response team, a Joint Carers Support Team and the further development of stepdown facilities to provide additional time for older people to convalesce.

The council chose to undertake a full service review, with a particular focus on demand management and work with Health. Projected savings of £12 million for 2012/13 are on track to be achieved. Savings were achieved through improved contract management and procurement Through a clearer understanding of demand the council have tightened admissions to residential care and in 2012/13 achieved a 29 per cent reduction from 12.2 per 1,000 (2011/12) to 8.7 per 1,000. This equates to 96 fewer people aged 65+ being admitted to residential care.

There are six people currently holding a personal health budget in Staffordshire, with 11 people having had one since the Staffordshire pilot began. Unfortunately at this stage it is too early to indicate savings arising from this move to Personal Health Budgets In 2012/13 £3.5 million has been saved, 7.7 per cent of the net budget. Savings were achieved through the review of care packages to maximise independence, consistent application of eligibility criteria and implementation of a new model for day care and support in the community.

## Swindon Borough Council

Further savings are projected for 2013/14 (£2.5 million, 5.5 per cent of the net budget) arising from a review of complex cases, reconfiguration of home support services and a review of commissioning fees from the Clinical Commissioning Group.

Through their engagement on the programme Swindon reviewed their full savings programme with a particular focus on the "demand inquiry" and reducing costs in learning disability services.

Longer-term projects, such as the development of the new model for Dementia Services, are felt to be key to the sustainability of adult social care services in the area. The council believe that the model will provide essential services while helping to manage demand more effectively.

## Staffordshire County Council

Stage 2 of the programme is looking to take forward the initial analysis of the RAS and Support Planning forward and implement recommendations to modernise both in line with agreed proposals to Members. It is recognised that the RAS in isolation will not lead to more personalised outcomes and that cultural change will be required in operational practice to enable the change to take place. The aim is to work with partners to transform care provision to enable people to make personalised choices on how they want to be supported whilst also enabling the council to live within its financial envelope. This means giving people more choice and control, increasing the value and return on council investment and looking at different outcomes to meet care needs. There is also an expectation that costs will fall by 7.5 per cent.  An initial approach has been agreed and is being analysed. Learning Disabilities is a client group which is requiring more analysis to ensure the RAS will work fairly for that group of clients. 

Staffordshire are one of the Personal Health Budget (PHB) pilot sites. As part of this they have been financially supported to raise awareness of personal health budgets, both in Staffordshire and across the region through organising training and events to provide information. These three training courses and four events were subscribed to by approximately 250 people from within Staffordshire and surrounding authorities. All five Clinical Commissioning Groups in Staffordshire are supporting the local authority to lead on PHBs. Staffordshire is now considered an early-implementer as they have all the necessary powers to set up personal health budgets including direct payment powers.

## Torbay Council

Efficiency savings of 7.1 per cent of net budget were achieved in 2012/13 and further savings of 6.3 per cent of budget are projected for 2013/14. A significant proportion of the savings were achieved through reviewing contracts and further outsourcing of services. 

## Tameside Council

Torbay Council chose to focus their project on reablement for older people. Extensive staff development has been undertaken with the Virtual Review Team and Intensive Home Support Service. The former have focused on appropriately reducing packages of care for domiciliary and day care clients. Savings are estimated at £100,000 for this team. A six monthly evaluation is underway and is likely to result in a change to referral criteria. The Adult Social Care Commissioning Team is currently designing outcome based contracts and contracts for domiciliary and day care services will be developed in this way. At present, the level of domiciliary care savings achieved are not meeting the anticipated/required level. The council have, however, managed demand and seen no growth in 12/13. The process adopted by the Virtual Review Team needs roll-out to all frontline social care staff if the council are to achieve the size of savings required for 2013/14.

## London Borough Of Waltham Forest

The savings that were delivered were those identified as a result of the Financial Stress Test that Ernst &Young undertook on Tameside Adult Services. The funding received from the ASCE programme contributed to this piece of work. Ernst & Young were also selected to work with the council to undertake a future sustainability financial stress test on the adult social care system. This revealed that the council had adopted a proactive approach in making significant efficiency savings in adult social care over the past 10 years. They acknowledged that 90 per cent of adult social care interventions had been externalised and provided in the social care market place. They reviewed the savings programme that was in place for 2012/2013 and agreed that it was realistic, viable and achievable. Ernst & Young identified further efficiencies and savings potential of approximately £2.2 million.

Through the ASCE programme Waltham Forest aimed to undertake a full service review of adult social care. 

In 2012/13 the council made significant efficiency savings equating to £5.9 million, 11.3 per cent of the net budget. Savings were achieved by the rationalisation of day services for people with learning disabilities and review of all older people homecare packages. £1.8 million was achieved through staff reductions.

Efficiency savings of £2.3 million and £2.9 million are projected for 2012/13 and 2013/14, 2.3 per cent and 2.7 per cent of the net budget respectively. Savings in 2012/13 have been achieved by re-modelling of reablement and in house residential provision, re-structuring of staff and back office support and better commissioning and contract arrangements. 

Further savings will be achieved in 2013/14 through remodelling of day care services, better use of technology and a review of charges.

## Warrington Borough Council

Following the Phase 1 diagnostic the council awarded a contract to Charteris who are engaged from March to August 2013 to review savings made to date and determine the scope for further savings in adult social care. During 2012/13 the council saved £2.9 million from a net budget of £45 million (6.4 per cent). The range of savings include: establishing a social enterprise for in house services ; increased use of intermediate care; expansion of telecare service; supported living remodelling; review of day care; effective targeted commissioning of high cost packages; changing eligibility criteria; charging review; expansion of reablement service; reduce transport costs; review fairer charging policies. In the coming year (2013/14) the council project to save a further £2.7 million through the continuation of projects outline above. Warrington identify a number of political and operational considerations that impact upon timescales for delivering savings, including consultation timescales and the risk of legal challenge from both customers and providers. The range of savings suggestions also requires resource to be able to deliver changes in a timely manner. The table in Annex A looks to summarise these statements so councils working in similar areas can network with each other. 

## 5. Two More Detailed Case Studies Introduction

At the end of the first phase of the programme the work that had been undertaken in Wiltshire and Kingston upon Thames was showcased at the launch of the first ASCE programme report, 'The Initial Position'. The LGA decided to write up as case studies the two presentations that were offered. This is a copy of these case studies. They were produced in January 2013 and so more progress and further learning will have been established since then. They try and offer a little bit more depth for the reader on how two councils have approached this task - quite differently!

## Case Study One: Royal Borough Of Kingston-Upon- Thames

This case study has been produced by the LGA in partnership with Kingston Borough Council based on a presentation given by Kingston at the LGA ASCE event in November 2012. The learning from Kingston is around the importance of having a robust analysis of the patterns of delivery of care when considering areas where a council could be more efficient and effective. The learning that Kingston were able to gain from a robust diagnostic undertaken by an independent consultancy enabled them to find areas for savings which may not have been obvious to them before. The improvements that are now being made in Kingston (as a result of the diagnostic) include changes in practice for front line staff as well as different approaches to procurement of services.

## Kingston Diagnostic

Kingston is a small London Borough with an adult social care budget of £53 million. They have an integrated care trust where the Director also is the accountable officer for the local Clinical Commissioning Group. The council had started to make significant savings in their budgets since 2008. In 2010 they reported £1 million saved through reductions in staffing. 

•	 There was a significant underuse of 
telecare by most care managers.
They continue to make savings through shared services and reducing administration and support functions. 

•	 The re-ablement and in-house domiciliary 
care service could be more productive and the care pathway through re-ablement needed to be more consistently applied.
•	 Reviews were often late. They missed 
opportunities to measure the progress people were making and therefore to reduce the size of care packages. 

## Savings From Commissioning And Procurement

•	 Domiciliary care providers had a lot of 
costs tied up with travel - this could be reduced making significant savings if a district model for allocating domiciliary care was adopted.
For the LGA programme they paid a consultancy (Newton (Europe) - after a competitive tendering process - the £20,000 grant they had received to undertake a full diagnostic of their activity and outcomes in adult social care. The diagnostic took three weeks to complete with "no stone unturned" as the assistant director responsible for the adult services Simon Pearce reported. The diagnostic identified £2.7 million additional (new) savings for the council, a further 5 per cent of the budget, through improved efficiency in the way they did things. Kingston went out to tender again to find a partner who would actually support the delivery of the savings. On the second tender Newton were also successful and have now embarked in supporting the council to deliver the targeted savings. 

•	 Domiciliary care provision was mostly 
managed through spot contracts which incurred unnecessary costs and did not incentivise providers to actively manage improved outcomes for service users.
•	 There were savings that could be obtained 
from better use of the transport fleet.
There are some interesting observations from the approach taken by Newton with Kingston. The diagnostic showed a number of facts about which the council had not fully been aware:

## Efficiencies From Assessment And Care Management

•	 The council's rules relating to the ceiling 
rates for older peoples residential and nursing care were sometimes not adhered to and there was an opportunity to renegotiate these.
•	 Care managers in Kingston could have 
avoided the deterioration of a number of client situations if they had offered appropriate support to carers.
•	 There were savings to be obtained through 
both better procurement of residential and supported living for adults with learning difficulties. 
•	 Care managers prescribed very 
different solutions for clients with similar assessments - one care manager would regularly find solutions to meet people's care needs at much lower cost than another. 
The final table Newton presented to Kingston.

| Work-stream                              | Source of the benefit            | Value    |
|------------------------------------------|----------------------------------|----------|
| Telecare                                 | Telecare - reduced care packages | £236,237 |
| Telecare - delay in care packages        | £ 81,775                         |          |
| Re-ablement                              | Volume through reablement        | £185,000 |
| Unit pricing in reablement               | £416,490                         |          |
| Targeted Reviews                         |                                  |          |
| (Dom Care)                               |                                  |          |
| Review of packages of care in a timely   |                                  |          |
| manner                                   |                                  |          |
| £236,000                                 |                                  |          |
| Commissioning                            |                                  |          |
| Domiciliary care                         |                                  |          |
| commissioning                            |                                  |          |
| Domiciliary care - Rate Equalisation     |                                  |          |
| saving                                   |                                  |          |
| £465,000                                 |                                  |          |
| Domiciliary care - Rate reduction saving | £124,000                         |          |
| Domiciliary care - outcome based         |                                  |          |
| commissioning                            |                                  |          |
| £ 75,000                                 |                                  |          |
| Transport and meals                      |                                  |          |
| on wheels                                |                                  |          |
| Transport rationalisation                | £ 95,000                         |          |
| Adults with learning                     |                                  |          |
| disabilities review                      |                                  |          |
| Reviews of residential care              | £243,000                         |          |
| Review of costs of supported living      | £195,000                         |          |
| Older peoples nursing                    |                                  |          |
| and residential prices                   |                                  |          |
| OP residential - ceiling rates           | £225,000                         |          |
| OP nursing - ceiling rates               | £ 98,000                         |          |
| Total                                    | 2,726,502                        |          |

Kingston has now commissioned Newton (Europe) to support the delivery of the savings that were identified. The contract states that Newton will only get paid after they have delivered cashable savings on a no savings no fee basis. 

Targeted prevention is a critical tool for all of adult social care - this includes getting the right care pathway for all customers, getting the maximum use from the investment in reablement and ensuring that investment is made in carers to avoid breakdown and much higher longer term costs.

## Lessons From Kingston

Commissioning domiciliary care on a district basis is a good way of approaching a more cost effective service. 

A thorough diagnostic of the activity and finances of adult social care can be a really helpful tool to focus the council on where efficiencies and savings may be found.

Having a dedicated, full-time project team to support the assessment and delivery of efficiencies allows for a more rigorous diagnostic and faster implementation.

Some of the savings rest with procurement but there is still much to save from improved practice on the ground. Identifying those care managers who can deliver better outcomes at lower cost is part of the challenge.

## Case Study Two: Wiltshire County Council

This case study has been produced by the LGA in partnership with Wiltshire County Council. The information has been taken from a presentation which was delivered by staff from Wiltshire at an LGA conference in November 2012. The approach taken by Wiltshire is usually described as "outcomes based commissioning". However, it offers more than that. It shows how through interventions that focus on recovery and promoting independence that many older people will need less care. The initial intervention is not limited to a six week recovery period but takes as long as is necessary to support the person. Providers are paid for the nature of the interventions that they offer in each individual case. The onus is on the provider to identify the best interventions that are most likely to help the older person regain more independence. The interventions may be based on reablement domiciliary care; but they might also include telecare and appropriate equipment; support to be integrated back into community life (tackling social isolation); housing repair or alternative accommodation; or other appropriate actions that will rebuild confidence and enable a person to live a fulfilled life in their community. The programme is in its first year and has enabled Wiltshire to deliver the savings that were required to balance the previous overspent adult care budgets and to improve the quality and experience of older people who needed some care and support in the county. The figures indicate a saving of around 10 per cent in the spend on domiciliary care since the inception of the programme with much higher user satisfaction rates also reported.

The new approach in Wiltshire Wiltshire Council has replaced traditional community care services for older people with an integrated system of care and support. Help to Live at Home (H2LAH) reconciles three competing aims of social care reform: personalisation, recovery and prevention. Assessments are now person-centred and focus on outcomes, especially outcomes that leave customers better able to live well with less care. The aim is first to help people recover their independence and second to reduce their reliance on care and stop it from increasing. In H2LAH reablement is not a special kind of service: it is the aim of all the council's services. H2LAH pays providers for the results they achieve. Results are outcomes that improve or preserve independence. The council applies financial penalties when customers' outcomes are not achieved and rewards care providers when customers recover faster than planned. Wiltshire Council believes that buying outcomes instead of hours is a commercial incentive to improve the pay and skills of the care workforce.

1 The problems of the past The system in Wiltshire was previously characterised by:

•	 poor recruitment, terms and conditions, 
training and pay cause poor care
Bureaucracy
Managing demand
Prevention
Other
•	 poor care caused bad outcomesbad 
outcomes increase needs, which increases demand and hence cost.
In 2009 Wiltshire Council held an event with various representatives from every part of the care and support system, including customers, social care providers, local NHS providers, politicians and commissioners. They asked stakeholders to tell them what they thought about the services and how it might be improved. A lot of feedback was collected but some very strong themes came up consistently and were confirmed repeatedly during the development of the service. Throughout the change process Wiltshire has retained a customer reference group who have commented and contributed to each stage of the change process (and are still active today when the project is now a mainstream service). 

This, however, leaves Wiltshire with two problems: 

1.	What front-line adult care service can 
review at this frequency? (And would customers really want so much intrusion?) 
2.	Care providers' business models generate 
profits from activity; a model that promotes independence and eliminates waste threatens their revenues.
The top left-hand graph represents a crisis2, when a customer needs most support. The blue line shows their needs reduce as they recover. In traditional systems, decisions about long-term care happen near the top of the "needs curve." At this point a decision is made about kind and intensity of care the person needs. Support then is provided at that level but, for people who then begin to recover, it is frequently left unchanged. The old system maintained this level of support, designed to meet a high level of need, for too long - in some cases 12 months or longer. 

Wiltshire decided that they needed a product that would solve these problems by changing the financial incentives for providers and not by drastically increasing reviews. Their view was that the objective of eliminating waste would be better achieved by tying providers' revenues to outcomes that maximise independence. Payment by results provided one solution. Providers are required to take financial risks on customers' independence. Wiltshire determined that Providers should assist older people to achieve the basic outcomes that enabled them to carry on managing for themselves the activities of daily life.

This is true of decisions that are taken in local authority assessment and care management. It is also true of people who buy care without asking their local authority for a statutory assessment. While not all customers improve in this way, we know our systems were not good at finding those that do. Councils are good at responding to increased needs, but our processes are not defined to identify improvement and reduce support when people get better. The pink areas represent the financial waste if a person who recovers from their crisis is not reviewed for six months. Wiltshire found that the longer a customer has things done for them that they can do for themselves the more, over time, they will come to depend on their care. This is a form of institutionalisation. 

So Wiltshire's "Payable Outcomes" are about simple activities of daily living - getting up; bathing; dressing; cooking and eating; shopping; seeing friends and family. If a customer struggles with these tasks because they are frightened —perhaps they fell in the bath and are afraid to fall again - or because they have never looked after themselves - perhaps they were bereaved - our providers' success is measured by what the person can do and not, directly, by what they feel.

The graph to the right shows a better alignment of activity and need through time. Reviews are more frequent and the package of support is adjusted more often. Regular reviews dramatically reduce the amount of money being spent on unnecessary care. There is still some waste.

## 2. The New Model

This diagram summarises the H2LAH process and highlights the council's and the providers' responsibilities and interaction.

Near the end of the support plan the provider reviews the customer to see if outcomes were achieved. The council checks the review with the customer, visiting them if there is any doubt. If they determine that outcomes haven't been met, and this is the provider's fault, they may apply penalty to their next payment.

H2LAH uses a familiar social care assessment and care management process. The model lays out the clear roles and responsibilities for the customer, the council and care providers. Assessments determine eligible needs but, unlike traditional community care assessments, they ask people what they want from their care. Support Plans are initially written by assessment staff with customers. These stipulate the outcomes that are to be delivered. The providers then use the support plan with the customer explaining how they will work to achieve the outcomes; how long they will need; and how much the plan will cost. The providers are paid according to these outcomes. The weekly price of the plan is the customer's Personal Budget, which they may take as a Direct Payment if they do not want services from their local "Help to Live at Home" provider.

53
       5
               2
                      5
                                     3
                                            7

So the Wiltshire model for "Helped to Live 
at Home" is based on paying providers to 
deliver the outcomes for which older people 
had been assessed by the local authority. 
It is based on the principle that many older 
people can become more independent if 
their care is delivered to them in a way that 
supports (not undermines) their recovery. It 
is a system that therefore pays by the results 
delivered - the results to be delivered as part 
of the assessment and always agreed with 
the potential recipient of the service - the 
older person. 

The outcome, and the reason for the outcome, must be easily observed and agreed; and it must result in the person being as independent as they can be. We when the assessment staff review outcomes, they check that what was agreed in the assessment - being clean; learning Older People said they want help quickly in a crisis. In Wiltshire the "Initial Assessments" are short and quick so that providers can start work with customers soon after they ask for help. The period from the beginning of an Initial Assessment to the agreement of an Initial Support Plan should be no more than six days.

Person-centred assessments make it easier for customers to tell us what they want from their support. They encourage people to think about ends (outcomes) before they think about means (services). 

how to cook a meal; not falling in the bath —occurred in reality. They are directly observable. Capability in these areas makes the difference between dependence and independence. 

H2LAH is more equitable than the service it replaces. There is no means-test when people approach Wiltshire needing shortterm support during a crisis. H2LAH "Initial Support" is free for all those whose level of need is eligible for public support. People who would otherwise be self-funders benefit from having the right care and leave decisions about long-term care until the crisis is past. A good decision at this point reduces the likelihood that people will use long-term care too early and so of needing council funding when their funds are exhausted Decisions on payment by results are part of the statutory review and reassessment process. When a plan ends the provider tells the authority what happened with the outcomes. The authority checks with the customer and decides whether they were or weren't achieved. If they weren't, the county decides if the provider caused the failure. If the provider was clearly responsible for the failure, operational managers may choose to apply a penalty that is deducted from the provider's next payment. Providers may appeal through formal contracts management. The penalty for initial support plans is 80 per cent; the penalty for on-going support plans is 15 per cent. The model penalises failure, but does not penalise success. If providers achieve outcomes using fewer resources than was agreed, the authority does recover the excess. This means that the agreement about the initial support plans is very important. It also encourages the providers to innovate and find less costly ways of achieving outcomes during delivery. 

The council has simplified its trading relationship with the provider market. We now provide reablement and care at home, housing support, equipment, Telecare and response services with six organisations. Ninety separate and very different dom. contracts worth £14 million have been reduced to eight very similar payment-byresults contracts worth £11 million with four of those six organisations. (The other two organisations provide equipment, small adaptations, Telecare emergency response that is used by the four care providers in holistic support plans.) Providers have access to the council's Carefirst case management system, which manages the whole assessment, supportplanning, purchasing, review and payment process. The data from this process are used in an online performance management system used by providers and council. This system gives daily and detailed updates on the performance of H2LAH.

The traditional distinction of "reablement" and domiciliary care services has been replaced with "Improvement" and "Maintenance" that are used in payment by results. They create a financial incentive to help reduce customers' need for care, rather than guarding the numbers of hours that they deliver. H2LAH replaces traditional care assessments, with their focus on what people can't do and services that will meet their needs, with person-centred assessments. 

## Council Decides On Payment The Results

Wiltshire have reported a reduction of £1 million in the spend on domiciliary care during the first six months of the full operation of their new service. This is equivalent to 3 per cent reduction of spend. (Wiltshire had previously reduced the costs of domiciliary care by 7.5 per cent through the tendering process for the contracts for the H2LAH service.) Since the services were put in place:

## Conclusions

•	 61 per cent did not need on-going care •	 19 per cent needed on-going support but it 
cost less per week than initial support
•	 20 per cent needed on-going support that 
cost more per week than initial support
•	 12 customers left the H2LAH service and 
moved to a care home
•	 the average price for initial support was 
£1,200. 
H2LAH is not one discrete area of the council's adult care activity - it integrates a number of different services. There is a clear definition of the responsibilities of the council, customers and providers. There is an emphasis on partnership between the three in order to deliver the most effective quality care. It is designed to give providers a clear financial incentive to focus on customers' outcomes, especially the outcomes of independence, by delivering quality care.

These figures would be impressive for any straight forward domiciliary care re-ablement service with the unit costs reported much lower than previously reported English Averages (between £1,500 - £2,000).

## Annex A: Summary Of Progress To Date

Areas where savings are being reported and some case examples The following areas are those reported by councils in which they have made savings:

| Category of savings                 | Efficiency savings   |
|-------------------------------------|----------------------|
| undertaking work in this area       |                      |
| Reducing bureaucracy                |                      |
| Reducing Staffing                   | :                    |
| Reducing staffing and costs of      |                      |
| bureaucracy                         |                      |
| In 2012/13 half of all              |                      |
| efficiency savings                  |                      |
| were said to arise from             |                      |
| reduced bureaucracy. In             |                      |
| 2013/14 this is projected           |                      |
| to fall to 43 per cent.             |                      |
| Making more efficient use of social |                      |
| workers time                        |                      |
| Better use of technology            |                      |
| Review of business support          |                      |
|                                     |                      |
| Delayering the management           |                      |
| structure                           |                      |
| Procurement                         | :                    |
| Negotiating fees for residential    |                      |
| care                                |                      |
| Improved contract management        |                      |
| and procurement                     |                      |
| Retender domiciliary care           |                      |
| contracts                           |                      |
Central Bedfordshire/Croydon/ Kingston/ Havering, Barking and Dagenham and Redbridge/Tameside Bradford/Croydon/Coventry/ Durham/Havering, Barking and Dagenham and Redbridge/ Luton/ Lambeth/ Solihull/Waltham Forest Bradford/ Calderdale/Coventry Bradford/Lambeth/Southend/ Yorkshire and Humberside / Suffolk/Calderdale/Kent/Liverpool/ Kingston
| Category of savings                |
|------------------------------------|
| undertaking work in this area      |
| Managing demand                    |
| Reducing the proportion of their   |
| spend on residential care          |
| Better use of Intermediate Care to |
| reduce admissions to residential   |
| care                               |
| 20 per cent of efficiency          |
| savings in 2012/13 were            |
| classified as arising from         |
| demand management. In              |
| 2013/14 the percentage             |
| is projected to rise to 25         |
| per cent.                          |
| Focus on specialist dementia care  |
| in the community                   |
|                                    |
|                                    |
| Rapid Response Team (focus on      |
| reducing admissions to residential |
| care)                              |
| Development of step-down           |
| services for older people          |
| Development of Extra Care          |
| Housing                            |
| Focus on prevention                |
| Diverting people away from formal  |
| social care through working with   |
| communities and voluntary sector   |
| Review the customer journey        |
| In 2012/13 5 per cent              |
| of efficiency savings              |
| were classified as                 |
| preventative. The                  |
| percentage is projected            |
| to rise to 10 per cent in          |
| 2013/14.                           |
|                                    |
|                                    |
|                                    |
| Focus on promoting independence    |
| Reablement - expansion,            |
| enhancement and / or integration   |
| with Health                        |
Bradford/Croydon/Kent Cheshire West and Chester/ Hackney/ Northumberland/ Poole/ Peterborough/South Tyneside Calderdale/Durham/Richmond/ Warrington/Kent/ Hackney/ Durham/ Calderdale/Hackney/ Cheshire East/Kingston/Wiltshire/Central Barking and Dagenham and Redbridge Bedfordshire/Croydon/Luton/ Peterborough/Portsmouth/ Solihull/South Tyneside/ Tameside/Kingston/Wiltshire 
Calderdale/Cheshire East/ Kent/ Lambeth
Calderdale/Lambeth/Cumbria/ Liverpool/Stockport/Poole/ Bradford Hackney/Calderdale/Coventry/ South Tyneside/Wiltshire/ Havering/Barking and Dagenham and Redbridge Calderdale/ Coventry/Durham Hackney/Peterborough/ Portsmouth/Solihull/ Southend/ Suffolk/WalthamForest/ Warrington/Kingston/ Wiltshire (new model), Torbay/Croydon(for LD services)/ Richmond/Havering, Barking and Dagenham and Redbridge
| Category of savings              |
|----------------------------------|
| undertaking work in this area    |
| Other                            |
| Outsourcing services             |
| Residential care and meals on    |
| wheels                           |
| In 2012/13 25 per cent of        |
| efficiency savings were          |
| classified as 'other'. In        |
| 2013/14 this is due to           |
| decline to 22%.                  |
| Closure of in-house residential  |
| care                             |
| Externalising community          |
| supported- living services       |
| (Learning Disability services)   |
| New approaches                   |
| Review of Transport              |
|                                  |
| Remodel supported living schemes |
| Review of Day Care               |
|                                  |
|                                  |
| Developing more extra care       |
| housing (as an alternative to    |
| residential care)                |
| Getting the resource allocation  |
| system right                     |
| Community /Voluntary Sector      |
| Engagement                       |
| Advice to self-funders           | Calderdale/Coventry/Luton/ Southend Lincolnshire Lincolnshire Durham/Croydon/Solihull/ Warrington/Kingston Croydon Croydon/Durham/South Tyneside/ Torbay/Waltham Forest/ Warrington/Tameside Calderdale Coventry/Cumbria Calderdale Barking and Dagenham and Redbridge/ Poole

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