Service design and commissioning

Introduction

This module is primarily aimed at local authorities, commissioners, directors of children’s services, directors of public health, and those leading the service design and commissioning of family hubs.  

Reading this module and reflecting on the questions posed should give readers: 

  1. An overview of service design and commissioning in relation to family hubs, why it’s important and who needs to be involved. This will help service transformation leads to work in partnership to design and transform local services to create family hubs that improve outcomes for children, young people and families 
  2. Practical tips in line with the family hub development process and the understand-plan-do-review cycle. 
  3. Case studies giving examples of good practice. 

Parent and carer participation advisors from the National Centre for Family Hubs (NCFH) team have informed the design of this module in partnership with: 

  • Essex County Council
  • Westminster City Council 
  • Early Intervention Foundation (EIF) 
  • Andrea King, Director of Clinical Division, Anna Freud Centre 

Why is this important to family hubs?

Effective service design and commissioning is crucial for better outcomes for infants, children and families – particularly in the context of budget pressures. Designing effective family hubs is about responding to what children and families say they need; and building on best practice while addressing the gaps and who is being missed. 

From the beginning it needs to be clear what difference leaders want to make to local families before any design begins. The outcome changes desired – the differences leaders want the service to make for families – becomes the golden thread against which to check and balance the strategic design and transformation. 

What is this module about?

Service design and commissioning are mechanisms to achieve effective whole-system change using the available resources in the most efficient way. Family hubs are a unique opportunity to design 0-19 services (and services for young people up to 25 with special educational needs and disabilities) in response to local community need. 

In the 2021 Budget, the Chancellor announced £300 million of funding to create a network of family hubs in 50% of local authorities. 

Those leading service design and transformation locally should consider the following questions in relation to the need, strategic picture of provision and the co-design: 

  • Understand the need (both quantitative and qualitative)
    • What do children and families say they need, what are their day-to-day challenges (please read the co-production module for more information on how to do this)? 
    • What does the data and evidence say is the local need for these families (please see our family hub development process module)? 
    • Who are services reaching and who is being missed (applying equity, diversity and inclusion)? 
  • Consider the strategic direction of provision
    • How can family hubs build upon and embed key services (for example, they should have a comprehensive Start for Life offer for parents, carers and babies at their core, and enable access to targeted/enhanced services for those with higher/specific need), while integrating with others e.g., supporting families, social care, and child and adolescent mental health services (CAMHS)? 
    • What partnership services already work well and what is their impact on outcomes for children and families? For example, are special educational needs and disabilities (SEND) services, the Peep Learning Together Programme, and maternal mental health services integrated? 
    • What are the gaps – what’s missing locally, who do existing services reach and who isn’t reached, and why is that?  
    • What is in development through new transformation work? When will that be ready? How it might relate to, or integrate with, family hubs? 
    • Consider what contracts or service provisions are time-limited or subject to review. 
  • Seize the opportunities presented by integrated care systems
    • The Health and Care Bill will place integrated care systems (ICSs) on a statutory footing from July 2022.  
    • Integrated care boards (ICBs) will bring together the local NHS and will take on the commissioning responsibilities previously owned by clinical commissioning groups (CCG). Have ICB commissioners been engaged in the development of the family hub?  
    • Integrated care partnerships (ICPs) will bring local partners together across the ICS area, to integrate care and improve outcomes for their population. ICP service transformation and family hub service transformation would ideally be aligned to improve outcomes for children. 
    • The ICP is responsible for producing an integrated care strategy for the ICS area, covering health, public health and social care. Are the objectives of the family hub aligned with the objectives in the integrated care strategy? 
    • For many ICSs, the footprint will cover several local authorities. Can family hubs within an ICS area collaborate to identify opportunities for join up, such as in workforce planning? 
  • Co-design and plan to achieve the aims
    • How can leaders create a partnership vision for the future of family hubs that describes the difference family hubs will make to local babies, toddlers, children, young people and parents and carers? 
    • What impact on outcomes will family hubs make for local families? How can service designers understand the relationship between the specific difference they want to make and the quality of design and commissioning?  

Joint commissioning and pooled funding 

In a review carried out by EIF, joint commissioning of services was seen by those developing family hubs as key to enabling multi-agency working. This is consistent with practice findings from a range of studies of multi-agency systems which suggest that joint funding and commissioning arrangements are associated with better joined-up systems of support. 

With a complex array of providers involved in each local family hub network, joint commissioning bridges the gaps between organisations and provides clearer pathways for families to journey through the network of services. 

Through joint commissioning, local partners can execute their vision and strategy for integration within their family hubs approach.    

Joint commissioning means organisations collaborating and sharing responsibility for family hub services and their outcomes. To facilitate effective joint commissioning, there should be a joint commissioning plan between the local authority and partners such as health commissioners for the services accessed through the family hub network. This should be extensive, routine, formally agreed, and cover the majority of family hub services.  

Leaders will need to decide whether to align services and budgets, or to pool budgets. Pooled budgets combine funds from different organisations to enable them to fund truly integrated services. A well-developed family hubs approach will involve the pooling together of budgets from a range of funding sources such as the local authority, health commissioners and potentially other public sector, voluntary, community and faith sector (VCFS) and/or philanthropic partners.  

Pooling resources requires investment decisions from a range of different stakeholders. In the context of financial pressures, each participating organisation will need to consider costs and benefits, as well as risks and rewards, and how these will be shared. 

The Social Care Institute for Excellence has developed a checklist for pooling budgets:  

  • Consider and agree the aims and objectives of the pooled budget, using documents such as the local joint strategic needs assessment.
  • Establish which partner organisations should be involved and clarify the role of each one. 
  • Clarify the services in scope and develop business cases with clear outlines of cost and benefit realisation over time. 
  • Based on the business cases, identify how the initiatives are to be funded and how the pooled budget will be managed. 
  • Develop a detailed and shared understanding of the associated risks, both for individual partners and the programme as a whole. 
  • Develop a joint funding agreement with documentation that outlines: 
    • aims and outcomes, and the relevant functions covered 
    • expected benefits and how they will be measured, realised and shared 
    • key risks, and how they will be managed, shared and – where possible – mitigated on an ongoing basis 
    • respective financial contributions and other non-financial resources provided in support of the joint initiative 
    • how the pooled budget will be managed, with associated governance and reporting arrangements 
    • the duration of the arrangement, including the provision and mechanisms for annual review, renewal or termination 
    • technical matters, such as treatment of VAT, legal issues, complaints, dispute resolution and risk-sharing. 

Who needs to be involved?

It’s important that local leaders ensure shared ownership of family hubs from the outset. Partners involved should include local community leaders and families in active co-production alongside children’s strategic partnership leaders (local authority-led) and the partnership leaders overseeing ICS-led local transformation planning (LTP). It is also helpful to talk through the governance for family hubs with the local health and wellbeing board. The foundation built at the start will be crucial to the success of the programme. 

Family hubs embed relational practice and co-production throughout. Engaging community leaders, faith sector leaders and local people in co-production at the beginning is key. School and education networks (including early years and further education) are particularly valuable – head teachers, chairs of governors and local networks of groups of schools, colleges or early years settings. VCFS partners are critical to involve from the start. 

Please be sure to think about Equity, Diversity and Inclusion early on. Including diverse voices and viewpoints is vital to delivering the right services at the right time – the more representative you are, the better the family hub design.  

It will be helpful to have a core strategic partnership which includes commissioners from the local authority, CCG, ICS and public health and partnership strategic leaders; alongside a wider stakeholder reference forum. 

Engage adult services leaders at an early stage to discuss the likely needs of parents and carers who family hubs will serve and explore potential for integration, as well as considering transition, for when children progress to adult services at the end of the family hub cohort.  

How

The understand-plan-do-review process is a helpful approach to commissioning and can be mapped onto the family hub development process. 

Understand

Compare the findings from the joint strategic needs assessment (JSNA) and local transformation plan needs analysis, with the feedback from co-production and local ethnographic research. Pay particular attention to the voice of local families in this process. 

Consider which infants, children, young people and families are being reached and who is not. This is a chance to prioritise the groups that are not being reached. Consider how qualitative multi-agency audit findings (Safeguarding Children Partnership arrangements) help to understand local gaps in provision. Ensure that the Supporting Families early help system guide self-assessments are also used to inform understanding of the strengths and gaps in existing multi-agency partnership working, data sharing and governance. 

This is in line with step one of the Family hub development process – building consensus on the need for change. 

Plan

Identify the impact on outcomes for infants, children and young people that are desired. Step two of the family hub development process – specifying a family hubs approach – can help with this. This will help all involved in the service design to develop a shared understanding of the model the partnership wishes to aspire to along with the outcomes.  

Map proposals against the Start for Life and family hub objectives and respond to any gaps. 

Review the evidence of what works and is of impact to inform family hub design, while retaining the permission to innovate, building on local strengths to deliver improved outcomes for children and families. 

Scope the service provision that will be adopted within the family hub model and commission the services that are responsive to local gaps and unmet needs. 

Identify what’s included in the family hub design, building on services that meet the brief and innovations that demonstrate positive impact on outcomes for children and families. Agree together how the gaps in services will be resourced. In this thinking consider finance, workforce, IT and facilities, safeguarding and the child/family experience. 

Undertake an equality impact assessment (EIA) and depending on the model proposed consider whether public consultation is required. 

If capital investment is required anticipate the necessary approval likely to be required for capital development. Likewise, if the leasing of buildings is required, start to plan for this as early as possible in the process to allow for completion of required negotiations on lease terms within required timeframes. 

As partnership leaders, develop a strategic and operational risk log and start to mitigate these risks. Consider what the strategic and operational unintended consequences of family hub integration might be. 

Consider where and how the services within family hubs will be hosted, including the benefits of co-location. Plan their integration and the agreements that will be required to support this integration. 

Decide if the approach will be to align services and budgets, or if it will involve pooled budgets. 

Do

Seek governance approval for, and support of, the proposed model. If the family hub model is built upon informal partnership alignment use local governance structure and memorandums of understanding (MoU) to record these agreements. If pooling budgets is preferred, undertake legal and financial agreements at the earliest opportunity.  

Design and follow an implementation plan and ensure oversight of this plan by the strategic partnership governance group, and broader accountability of this plan to the wider reference group. 

Where capital expansion is required, initiate this development at the earliest opportunity. 

Regularly review and update the strategic and operational risk mitigation; be alert to unintended consequences. 

Step three of the family hub development process – planning implementation – will help with this part. 

Review

Review the impact of family hubs against the original aims and outcomes for infants, children, young people and families. It is important to give permission to the service design team to adjust the implementation in response to this impact review. 

Critically analyse reach to infants, children, young people and families. Where gaps are identified, partner with leaders in the local community or subject experts to address these gaps. 

Pay close attention to the strategic and operational risk management measures and retain sensitivity to the unintended consequences of their implementation. 

Qualitatively audit and review the practice of family hub delivery, and any associated safeguarding features. 

Undertaking a review of family hub arrangements after 12-24 months of operation is strongly recommended. It is important to understand the impact of the arrangements and the reach they are achieving. Review and reflection measures can help facilitate analysis of both the intended and unintended consequences of systems transformation, and how effectively the local offer is working for children, families, and other intended audiences. 

Practice Example: 

Essex family hubs have been operating since 2017. The local authority commissioned Virgin Care (now known as the HCRG Care Group) to deliver in partnership with Barnardo’s the ‘Essex Child and Family Wellbeing Service (ECFWS). The local authority has allowed flexibility for the commissioned partners to subcontract further providers to meet local needs. Commissioners used an integrated outcomes-based commissioning model which gave providers freedom to suggest a suitable delivery model with the community at its heart, based on consultation, evidence, and desire to improve children’s outcomes. 

Essex wanted to encourage a culture in which health, early learning and family support provision are equally regarded. They focused on creating genuinely integrated multi-disciplinary teams to support the full pre-birth to 19 age range, prioritising and enhancing the skill set most relevant to the needs of families and working across this age range, rather than being limited by traditional roles. They also wanted to promote the development of community assets through early learning, peer support, peer learning and proactive engagement, to tackle the loneliness or disconnection from peers that families described feeling.  

In Essex, family hubs have multi-disciplinary healthy family teams, with one based in a family hub in each of their 12 districts. A further 28 family delivery sites across the county provide local community-based access to services. The model offers three tiers of support: universal services are open to all families who are initially referred through health visiting appointments. Families in need of more targeted support, including family support interventions (universal plus and universal partnership plus services) are identified through the universal provision.  

Across the county, health visiting, school nursing and family support services are integrated within the family hubs. In West Essex only, the West Essex CCG has also jointly commissioned the family hubs to include children’s community health provision (i.e., community paediatrics, speech and language therapy, allergy, incontinence, physiotherapy, occupational therapy, and specialist community nursing). 

To facilitate the significant systems change this commission required, the local authority and West Essex CCG entered into a seven-year contract, with the option to extend for up to another three years. 

These changes are having a positive impact on both the workforce and services being delivered, for example: –  

  • A whole family approach can be implemented, with one practitioner supporting the family regardless of the ages of the children, rather than splitting them into separate (for example) 0-5 and 5-11 services. This can also help to facilitate support from other agencies in a more coordinated way. 
  • Staffing resource can be more effectively deployed, for example in some cases (based on assessment of need) mums who are on their 3rd baby don’t necessarily need as much support as a first time mum  
  • The outcomes commissioning approach makes it much easier for the provider to seek alternative service delivery / intervention options as required 

Resources

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