Commissioning social care for people with dementia living at home: Findings from a national survey

To explore the complexities, circumstances, and range of services commissioned for people with dementia living at home.


| Measures and data analysis
Measures of commissioning were used to evaluate the joint arrangements between health and social care agencies. Three of the five measures relate to the process-joint plans and planning, joint specification, and overseeing of contracts and a single lead commissioner. Two measures relate to the management of finances-the pooling of both ring-fenced monies and total agency budgets. Joint commissioning arrangements of services provided to all older people and those dedicated to older people with dementia are included with Pearson's chi-squared test conducted to assess differences.
Four measures were used to cluster the commissioning arrangements of local authorities, contributing to the infrastructure available within a locality to support people with dementia living at home.
Commissioning of services at both the level of the individual service user (care planning and support) and at the strategic level (joint commissioning, nonstatutory sector contribution, and dementia service premiums) are included.
1. Care planning and support-At the level of the individual, commissioning arrangements for older people, including those with dementia, involve 1 negotiating the most appropriate means to achieve the goals identified in the assessment and 2 securing the necessary services to meet them. 10 2. Jointly commissioned services-Joint commissioning between health and social care agencies is a means to promote integrated care and support with the aim of joining up services for the benefit of users and carers. 10 Evidence of joint commissioning in five dementia specific services (care at home, overnight respite, day care, telecare, and occupational therapy) at the strategic authority level was measured.

Key points
• Little is known about the specialist support available for people with dementia living at home or how it is commissioned.
• There is more evidence of commissioning social care at the level of the individual compared with the commissioning of services to meet their specific needs at a strategic level within localities. Exploratory cluster analysis was performed to identify groups of authorities whose local commissioning practices shared similarities, compared with other authorities whose commissioning practices formed other distinct groups. There were three steps in this process. To determine the optimal number of clusters, the Bayesian Information Criterion (BIC) fit statistic was applied. Individual, anonymised, authorities were selected from each cluster grouping to provide exemplars and convey the dominant characteristics of each group. Cluster assignment was then compared with the range of services delivered in localities dedicated to support older living at home with dementia.
Differences in the dementia specific services delivered between cluster groupings were tested with Pearson's chi-square. (c) Differences between clusters were assessed in terms of local area character- Chicago, USA) software was used in these analyses. Table 1 compares local joint commissioning arrangements for generic older peoples' services with those for specialist dementia services.

| RESULTS
Joint commissioning across four of the five practices was most evident in generic services; though, the pooling of total agency budgets was slightly more prevalent in dementia specific services. The P values in this table indicated that neither generic nor dementia specific services were associated with any of the five approaches to joint commissioning. Across all services, processes related to joint commissioning activities were more frequently implemented than those activities relating to joint management of finances. The proportion of authorities employing joint plans and planning processes in both generic and dementia specific services was just under half (46%) whereas just over one quarter (28%) employed these in neither service. With regard to joint specification and overseeing of contracts, just over one quarter (27%) of authorities employed these in both generic and dementia specific services, just under half (47%) employed these in neither.
About a third (36%) of authorities had a single lead commissioner for health and social care in both generic and dementia specific services.
With regard to financial arrangements, 30% of respondents pooled ring-fenced monies, and 10% pooled total agency budgets in both generic and specialist services.
The exploratory cluster analysis, of 100 local authorities, identified four distinct groups (Table 2)  Cluster D-The distinguishing attribute of this cluster group was the absence of services from the nonstatutory sector (eg, respite) in the provision of dementia specific services. Joint commissioning with health was also least evident within this group with the lowest average of 1.4 dementia specific services. In the exemplar authority, none of the dementia services were jointly commissioned with health partners, commissioning practices were linked to individual service plans, and a dementia premium was not paid for the provision of home care.
The associations between cluster membership and other measures, reflecting the services delivered to those living with dementia at home, are shown in Table 3. Levels of dementia care planning and support services were highest in Cluster A, as was the provision of dementia specific telecare and assisted living technologies and hospital discharge services.
Cluster B had the highest levels of authorities providing respite care (through family placement opportunities) for those living with dementia.
Due to relatively small cluster sizes it was anticipated that Chi-square tests would reveal that specific services delivered were independent of cluster membership. However, the total number of these specialist services provided was related to cluster membership (P < .05); Cluster A authorities provided significantly more. Table 4

| Commissioning to meet individual needs
In this study, the commissioning of services to meet the specific needs of older people, including those with dementia, at the individual level is apparent. Most authorities include care planning and support activities within their overall commissioning arrangements; however, the cluster analysis reveals a group that this is absent ( Table 2, Cluster C). These care planning and support activities, core tasks within care management for older people, involve the negotiation of services between service users, carer, and provider agencies. More recently, with the intention to provide a more personalised service with a more flexible response to need, service users and their carers have the opportunity to take more control in the planning and organisation of their own 10 via self-direct support and personal budgets. This has the potential to increase the complexity of commissioning at the operational level. 13 However, it has been suggested that, particularly for older people with dementia, there will be a preference to minimise their responsibility in decisions regarding the purchasing of services and equipment and the creation of complex care packages. 14 In this context, the responsibility for care planning and support activities for individuals with dementia will continue to lie with care managers. 12

| Strategic commissioning arrangements
Some evidence of strategic commissioning of dementia specific services was evident. However, the cluster analysis highlighted variation in extent to which this was undertaken, particularly in terms of the joint commissioning of services with health partners. This was illustrated in Table 2 (Cluster A compared with Cluster D). The importance of involving health organisations to improve the commissioning of social care services has long been recognised. 15 Successive legislation and guidance 10,16,17 has required NHS organisations and local authorities to increase their partnership working, and it is now a statutory duty, facilitated by the introduction of flexibilities to promote joint working. Joint commissioning has been identified as a means to ensure better outcomes for populations in an area. 10 The importance of this for people with dementia has been articulated previously. 18 Historically it has been noted that despite the volume of policy and guidance attempting to increase and improve joint working only limited progress has been made. 19 However, this survey provides more recent evidence of joint commissioning in respect of services for people with Brown-Forsythe test applied as assumption of homogeneity is not met.
dementia (see Table 1). Furthermore, potential links between joint commissioning and the provision of a higher number of specialist services were suggested (

| Specialist services for people with dementia
There is little evidence of a shared understanding of the form and content of specialist services for people with dementia. Within this survey specialist services were defined as those offered only to people with dementia, generic services were available to all older people. However, the nature in which these two service types differed, other than service user group targeted, was not specified. In terms of specialist services, care delivered within the home was the least reported with respite care and day care, services provided outside the home, were the most frequently reported (Table 3). In other research, specialist day care has been identified also by activities (sensory activities, such as ball games) and diet (high calorie food, soft in texture). 21 Similarly, care delivered within the home has been characterised as available only to those in the later stages of dementia and providing care reflecting care specific to the condition (eg, in support of therapeutic goals, such as the reduction of problem behaviours) around the clock as required. 12 It has been suggested that commissioning arrangements should promote such diversity in service provision. 22 In this study, there was also no evidence of a link between the availability of specialist services and different approaches to commissioning (Table 3). It may be that how services are commissioned is less important than the manner in which they are delivered. An appropriately skilled and trained workforce is vital in the delivery of specialist care for people with dementia living at home with their carers. In residential settings, training has been shown to improve a carer's knowledge of the disease and increase their confidence to manage the challenging behaviours associated with the condition. 23 However, it has been reported about half of people affected by dementia thought that home carers were not adequately trained to understand their specific needs and that a third have not received appropriate training. 24

| CONCLUSION
This typology suggests that joint working between health and social care organisations results in a greater range of services specifically for people with dementia, complementing services available to all older people. However, the joint commissioning of services is not widely reported in this study. Nevertheless, as the population with dementia ages and physical health needs increase joint commissioning of services for people with dementia and their carers will become increasingly important, informed by the experience of existing service users and their support planners. This will be important in the provision of tertiary prevention, ameliorating difficulties and enhancing well-being, for people with dementia in achieving the goal of living well. 24 Given the study has identified different approaches to commissioning, future work could examine the extent to which this affects outcomes for patients and their carers.