New funding arrangements for the provision of services and supports for persons with disability are expected to be introduced next year in Ireland, Breda Crehan-Roche, CEO Ability West, told the HMI Conference.
She said there was likely to be a reduction in block funding. Multiple funding sources would be considered and reviewed and there was no doubt that commissioning in some form or shape was on the cards and would be implemented in the next 12 – 18 months.
Commissioning could take the form of direct payments, personal budgets or individualised ringfenced funding.
Speaking on “Transferring Power from the Service Provider to the Individual,” she said that following publication and consultation on the Department of Health’s Policy Review & Value for Money Report, it was intended to have a new policy for persons with disability in place next year.
Multiple funding sources would be considered and reviewed and there was no doubt that commissioning in some form or shape was on the cards and would be implemented in the next 12 – 18 months
In the new arrangements, we needed to ensure that individuals and their families were supported to be active partners with service providers in decisions about their lives. Issues such as self-managed/directed funding, governance, accountability and monitoring of quality and standards would need to be explored and carefully addressed. Priority needed to be given to developing a structure for decision making and the implications of this needed to be considered vis a vis the pending Mental Capacity Bill.
The highly likely introduction of commissioning also required an agreed cost methodology and the formalisation of the role of other sectors in the mainstreaming agenda and self managed/directed budgets.
Research evidence indicated that services and support that encourage self-direction and determination and provided opportunities for inclusion and participation achieved good outcomes in a cost effective manner.
The potential advantages of commissioning were that it would align needs with service provision, provide transparency of costing, open the market to new providers, drive innovation and improvements, provide a greater choice of providers and, through monitoring, address issues such as poor standards of service delivery.
Cherry picking was a real risk, especially in relation to complex challenging services
Potential risks and disadvantages included disruption of services, challenges for the HSE (which will be both commissioner and service provider), a focus on competition and cost (which could potentially lead to compromising the quality of service) and onerous reporting requirements. The sustainability of service providers could be compromised if contract renewal was too frequentand more competition would increase providers and add to the current perception that there were too many providers, too many managers and too many back office functions.
Cherry picking was a real risk, especially in relation to complex challenging services. Competition should be on an equal footing. Current service providers were locked into consolidated pay scales and staffing costs could be up to 85 per cent of budgets. Private for-profit providers might not pay these scales. The absence of mandatory regulations and standards needed to be put on a statutory basis and must be a requirement for all providers, the for profit and not for profit as we could not have a two tier system.
She said that direct payments were cash payments given to the individual in lieu of community care services. The payment was based on needs assessment. In other jurisdictions direct payments were means tested with the individual also contributing to the cost of their support. With direct payments, the responsibility was on individual to employ people and to commission services for themselves. Some services could be contracted out with the funder commissioning a support organisation to assist and enable service users to handle responsibilities of direct payments.
Personal budgets were an allocation given to the service user based on assessment of need with the funding allocated being sufficient to meet their needs. The service user could take their personal budget as a direct payment or choose to engage with a service provider to commission a service on their behalf. Personal budgets could potentially offer a good option especially when the service user did not want to have the responsibilities of a direct payment.
Priority needed to be given to developing a structure for decision making and the implications of this needed to be considered vis a vis the pending Mental Capacity Bill
Individualised ringfenced funding was based on assessment of need. Funding was ringfenced to the service user within the block funding allocation to the service provider. There was a requirement to hold it as a ringfenced fund in the organisations accounts. Individual budgets differed from personal budgets in that they included a multitude of funding streams.
Findings were that individualised funding resulted in better relationships and collaboration between the service provider and service user, greater accountability to the service user and citizens, increased choice and greater control for the service user and increased public participation in decision making.
The introduction of individualised payments and direct funding would seriously challenge service providers in the context of existing and future employment contracts.
In order for individualised funding to become a reality, the person must know what services they wanted and needed and have a clear desire to take responsibility for improving their services. This might not be for everyone, as issues such as interviewing, training, hiring/firing staff, management of financial affairs and all the duties that being an employer entailed might be too onerous for some. In Scotland, less than four per cent of people with intellectual disability chose direct funding.
“All of these issues need to be considered and addressed and where there is a desire to self-manage and self-direct services and supports, the person must be supported to do so. For individuals who did not desire such an option they must be empowered to be active partners with service providers.
“Looking to the future we need to ensure choice, flexibility and innovation, ensure that organisations are fit for purpose. We need to focus on outcomes and really listen to what the service user has to say, for those who are unable to speak for themselves, independent advocacy will be important. Providers need to have individual options in place for the population they serve, especially those deemed complex and challenging.”
Agreed costing methodology urgently required
Crehan-Roche said that the National Intellectual Disability Database Report 2009, stated that there were over 26,000 people with intellectual disabilities registered but this did not include all people with intellectual disabilities in the country. Of the 26,000 people registered, 98 per cent are in receipt of some type of service and 49 per cent of people with intellectual disabilities are over 35 years of age. She added that it is estimated that 85 per cent of intellectual disability services are provided by the non-statutory sector.
With advances in healthcare and lifestyle, people with intellectual disabilities were now living longer and the likelihood of their outliving their caregivers has increased substantially in recent times. This was a real concern for carers as they worried about what would happen to their family member when they did. The changing age profile observed over the past 30 years had major implications for service planning, pointing to an increasing on-going high level demand for full time residential services, support services for ageing carers and the requirements for services specifically to meet the needs of older people with intellectual disabilities. This explained why there was an on-going demand for additional resources in the sector.
The role of other sectors outside the health service in the mainstreaming agenda such as education, employment, housing, income support is vital and a more coherent and integrated approach is required from the State to support people with disabilities. This will underpin the new policy direction.
Individuals with intellectual disability wanted:
- Flexible support to meet individual needs
- To use local services – to do ordinary things in ordinary places
- Get different elements of service from different providers
- Choose and manage their own services
- Families want to be allowed to play their part in supporting their family member.
“They are dissatisfied with the amount of independence they have, the amount of choice they have over the service received from service providers and with the support received from service providers to facilitate inclusion in the mainstream life of the community.
“There are many changes taking place that will challenge both the HSE and the health system. There are still 4,000 people who live in congregated settings, defined as a residential setting of ten or more people. Best practice is four to five or less. The delivery of housing in the community for this cohort over a seven year period will be challenging, but not impossible in recessionary times.
