1. Disability Services Value for Money and Policy Review 29/11/20151 Value for Money and Policy Review of Disability Services in Ireland Presentation to the Irish Association of Supported Employment. 14 th November 2012 Colm Desmond, PO Disability Services Unit, Department of Health Disability Services Unit, Department of Health

2. Disability Services Value for Money and Policy Review 29/11/20152 Background Review commenced in July 2009 Review commenced in July 2009 Scope of the review: Scope of the review: Define and describe the objectives of the disability services; Define and describe the objectives of the disability services; Consider the extent to which existing policies are consistent with delivery of those objectives; Consider the extent to which existing policies are consistent with delivery of those objectives; Assess whether current policies and investments arising from those policies are sustainable in the context of the changing economic climate; and Assess whether current policies and investments arising from those policies are sustainable in the context of the changing economic climate; and Propose the policy changes, if any, needed to ensure that overall objectives are delivered. Propose the policy changes, if any, needed to ensure that overall objectives are delivered.

3. Disability Services Value for Money and Policy Review 29/11/20153 Background (Cont’d) The review comprised two strands: The review comprised two strands: A examination of the effectiveness and efficiency of the current disability services programme; and A examination of the effectiveness and efficiency of the current disability services programme; and A review of current policy in relation to disability services funded from Health Vote A review of current policy in relation to disability services funded from Health Vote

4. Limitations A number of factors limited the ability of the project team to look at the sector in totality: A number of factors limited the ability of the project team to look at the sector in totality: The size & diversity of the sector & time factor; The size & diversity of the sector & time factor; Lack of agreed units of outputs for some services; Lack of agreed units of outputs for some services; Lack of outcome measurement / reporting; Lack of outcome measurement / reporting; Lack of comparable financial data, collected in a consistent manner; Lack of comparable financial data, collected in a consistent manner; Capacity of some agencies to engage with the review notwithstanding their willingness to do so. Capacity of some agencies to engage with the review notwithstanding their willingness to do so.

5. Disability Services Value for Money and Policy Review 29/11/20155 Final report signed off by VFM Steering Group on 5 th June 2012 Final report signed off by VFM Steering Group on 5 th June 2012 Review approved by Government and published in July 2012 Review approved by Government and published in July 2012 Agencies requested to examine recommendations & draw up a plan of action Agencies requested to examine recommendations & draw up a plan of action Implementation planning has commenced in DoH and HSE Implementation planning has commenced in DoH and HSE Current Position

6. Disability Services Value for Money and Policy Review 29/11/20156 Key Message The Review proposes a fundamental change in approach to the governance, funding and focus of the Disability Services Programme, with the migration from an approach that is predominantly centred on group-based service delivery towards a model of person-centred and individually chosen supports The Review proposes a fundamental change in approach to the governance, funding and focus of the Disability Services Programme, with the migration from an approach that is predominantly centred on group-based service delivery towards a model of person-centred and individually chosen supports

7. Disability Services Value for Money and Policy Review 29/11/20157 Key Findings 85% of expenditure is on pay, 15% on non-pay 85% of expenditure is on pay, 15% on non-pay 45% of direct pay is on residential services, 19% on day services, 11% on multi disciplinary services, 9% management & admin, 4% respite, 12% other services 45% of direct pay is on residential services, 19% on day services, 11% on multi disciplinary services, 9% management & admin, 4% respite, 12% other services No national guidelines on rostering practices, skill mix or staff/client ratios, although these are essential components of the cost of providing services. No national guidelines on rostering practices, skill mix or staff/client ratios, although these are essential components of the cost of providing services. Services are heavily professionalised Services are heavily professionalised

8. Disability Services Value for Money and Policy Review 29/11/20158 Key Findings (Cont’d) Past: focus on inputs, outputs and global costs. Past: focus on inputs, outputs and global costs. Future: focus on outcomes and unit costs, but: Future: focus on outcomes and unit costs, but: no common definition of outcomes, and no national measurement or monitoring; no common definition of outcomes, and no national measurement or monitoring; Insufficient information to determine unit costs at individual service user level, consequently no analysis or monitoring. Insufficient information to determine unit costs at individual service user level, consequently no analysis or monitoring.

9. Disability Services Value for Money and Policy Review 29/11/20159 Employment - Key Findings The provision of Health supports plays a vital part in enabling a person with disabilities to access education and employment. The provision of Health supports plays a vital part in enabling a person with disabilities to access education and employment. Most people accessing specialist disability services are not in employment in the open labour market. (Expert Reference Group reported that 2,389 of 25,302 people using day services could be considered to be in the workplace ) Most people accessing specialist disability services are not in employment in the open labour market. (Expert Reference Group reported that 2,389 of 25,302 people using day services could be considered to be in the workplace (9%) )

10. Disability Services Value for Money and Policy Review Employment – Recommendations 1 Indicators should be developed to measure the effectiveness of the disability services in promoting personal progress through access to day services and supports Indicators should be developed to measure the effectiveness of the disability services in promoting personal progress through access to day services and supports. The health sector should continue to be responsible for providing health-relatedsupports to facilitate access to mainstream services in the following areas: education, employment, housing, transport, healthcare and community inclusion e.g. personal assistance supports for adults who live in the community or therapy supports for children attending schools etc. The health sector should continue to be responsible for providing health-related supports to facilitate access to mainstream services in the following areas: education, employment, housing, transport, healthcare and community inclusion e.g. personal assistance supports for adults who live in the community or therapy supports for children attending schools etc.

11. Employment – Recommendations 2 In the absence of day service standards being set and monitored by HIQA, the HSE should establish a framework whereby they can satisfy themselves, within the context of the SLA process, of the outcomes and quality of day services through dissemination of quality assurance guidelines, self-evaluation and continuous quality improvement protocols.

12. Disability Services Value for Money and Policy Review 29/11/201512 Challenges Capacity of the system to implement the recommendations Capacity of the system to implement the recommendations Need to increase efficiency of current system pending migration to new model and achievement of target cost per place Need to increase efficiency of current system pending migration to new model and achievement of target cost per place Implementation of standardised assessment method for services and needs Implementation of standardised assessment method for services and needs Change-over to provision of services based on identified need and personal choice Change-over to provision of services based on identified need and personal choice

13. Disability Services Value for Money and Policy Review 29/11/201513 Opportunities Current financial climate will provide an impetus for innovative solutions Current financial climate will provide an impetus for innovative solutions Opportune time to make changes to staff mix and embedded rostering practices Opportune time to make changes to staff mix and embedded rostering practices Desire amongst many service users and their families for greater choice, control, independence and social inclusion Desire amongst many service users and their families for greater choice, control, independence and social inclusion Realisation by service providers that the landscape has changed and they must change with it Realisation by service providers that the landscape has changed and they must change with it Innovative practices already evident on the ground Innovative practices already evident on the ground

14. Implementation Framework for implementation will depend heavily on new structure of Health Service Framework for implementation will depend heavily on new structure of Health Service Options are currently being considered for a national implementation plan for VFM Options are currently being considered for a national implementation plan for VFM Would welcome feedback and input from sector to the report and to implementation Would welcome feedback and input from sector to the report and to implementation

15. Disability Services Value for Money and Policy Review 29/11/201515 Implementation Priorities Strengthen national disability function Strengthen national disability function Initiate demonstration projects to drive migration towards person-centred model Initiate demonstration projects to drive migration towards person-centred model Put in place commissioning and procurement framework Put in place commissioning and procurement framework Develop national resource allocation model which will provide a framework for individualised budgeting & ‘money follows the patient’ Develop national resource allocation model which will provide a framework for individualised budgeting & ‘money follows the patient’ Establish strategic information requirements Establish strategic information requirements

16. Disability Services Value for Money and Policy Review 29/11/201516 Immediate Actions Streamline SLA process Streamline SLA process Standardise financial reporting Standardise financial reporting Each agency to examine VFM findings and draw up plans for: audit of rosters, review of skill mix, critical examination of cost base, reduction in average cost per place (for a range of service types and support needs) Each agency to examine VFM findings and draw up plans for: audit of rosters, review of skill mix, critical examination of cost base, reduction in average cost per place (for a range of service types and support needs) Introduce unique identifier to support a move to individualised resource allocation and service provision Introduce unique identifier to support a move to individualised resource allocation and service provision

17. Disability Services Value for Money and Policy Review 29/11/201517 Conclusion Report sets out a clear direction for the development of disability services Report sets out a clear direction for the development of disability services Policy direction is in line with the findings of various public consultations and recent HSE reports (Adult Day Services, Congregated Settings) Policy direction is in line with the findings of various public consultations and recent HSE reports (Adult Day Services, Congregated Settings) Broad welcome for the policy expected from people with disabilities and families, and disability agencies, but concerns about continuity of service pending migration to new model, and also the effects of the country’s current financial difficulties. Broad welcome for the policy expected from people with disabilities and families, and disability agencies, but concerns about continuity of service pending migration to new model, and also the effects of the country’s current financial difficulties.