A. Ray James, President, Association of Directors of Adult Social Services.
The Association of Directors of Adult Social Services (ADASS), and its predecessor the Association of Directors of Social Services (ADSS), have both had long histories in contributing substantially to the growing wisdom lying behind commissioning. This, not just on our own, but alongside a wide-ranging number of stakeholders and partners.
A good example of the breadth of interest and involvement is the commendable initiative the Care Quality Commission (CQC) has taken of organising an event on the sustainability of the sector. This will bring together commissioners, providers, representative bodies, government officials and – probably for the first time – banks and lenders too.
Everyone at a recent CQC symposium on the topic was made very much aware of the moral imperative we all share to improve the sustainability of the sector. My own contribution was to stress the commissioner’s role as bringing people together to co-produce a transparent and shared understanding of the outcomes desired and the issues and risks associated with that. Everything from a fair and true cost of care through to our importance of social care to the wider economy.
Increasingly, our role is to create the conditions within which others (citizens) make their purchasing decisions and transactions. We can increase the focus on outcomes, on securing value chains and encouraging transparent and open book approaches to cost.
Further evidence of our involvement comes from Sandie Keene’s initiative, during her ADASS presidency, to produce the Top Ten Tips for Commissioners. It’s surely no accident that we have recently instituted a specialised commissioning network, chaired by Calderdale’s Bev Maybury, to join its other key policy areas.
More recently, alongside Department of Health, Local Government Association (LGA) and Think Local Act Personal (TLAP), we co-sponsored the seminal Commissioning for Better Outcomes from the Health Services Management Centre in the University of Birmingham. Both initiatives have stressed the importance of sustainability. This latter document was launched last autumn and is already being piloted and tested within the LGA’s Peer Challenge initiative. Its essential task has been to lay down 12 vital standards of good commissioning, and to provide commissioners with the means to test themselves against the demands they make.
It will be a long time before the last word is written on the topic; but it’s well worth reminding ourselves of just what those 12 key standards are, representing as they do current state-of-the-art thinking on the issues.
- Focuses on ensuring diversity, sustainability and quality of the market.
- Is person-centred and focuses on outcomes.
- Promotes health and wellbeing for all – including physical, mental, emotional, social and economic wellbeing.
- Delivers social value – for the whole community not just the individual, their carers, the commissioner or the provider.
- Is co-produced with people, their carers and their communities.
- Promotes positive engagement with providers.
- Promotes equality of opportunity.
- Is well-led by local authorities.
- Demonstrates a whole system approach.
- Uses evidence about what works.
- Provides value for money.
- Develops the commissioning and provider workforce.
The key point running throughout these standards is co-productivity – an essential stress on the fact that commissioning is not an isolated task carried out behind the walls of a single local authority bastion. It is one that is essentially outward-looking, wedded to the wider needs of communities, individuals and providers and one which acknowledges the skills and qualities that everyone engaged in the process can bring to the table. In an age where integration of services is going to be the sine qua non of all our care services, those principles cannot be ignored, overlooked or mislaid.
The current picture
Well, that’s the ideal. How far away from it are we? How far are we down the road of creating an ideal paradigm in which local authority commissioners and their providers are achieving their fullest potential in pursuing the interests and wellbeing of people who need and use our services?
As Bev Maybury put it at a recent joint ADASS and Social Care Institute for Excellence seminar, ‘Have we got the right commissioning skillset or are we still dealing with the same old emperor just dressed up in a set of new clothes? And in process terms, do we have the right systems and tools to be agile enough to respond to future demand and variance in quality?
‘Are Market Position Statements (MPSs) providing the basis to shape our markets differently? Or are they merely aspirational? We all need, all the time, to consider tighter investment in our business relationship capacity to help move us away from reliance on traditional commissioning, procurement and contracting roles.’
We undoubtedly have a common purpose, and one which is heavily underlined by legislation bringing together a jigsaw of social care legislation, regulation and guidance. What are its core principles? They are for us ‘to prevent, postpone and minimise people’s need for formal care and support…built around the simple notion of promoting people’s independence and wellbeing…people should be in control of their own care and support.’
The independence and wellbeing we promote must:
- Be personalised: people who use our services must have choice and control over what really matters to the quality of their lives.
- Increase the voice and influence of citizens and carers over their own lives and their communities.
- Build individual and community capital/ resilience.
- Create a safe, sustainable system or market with a diverse range of choices of good quality affordable care and/or support.
The Care Act, too, is symptomatic of an unprecedented degree of co-operation which has emerged within the sector during the past five years. Yes, there are still fault lines, but the old adversarialism is long gone, a thing of the past long put into a box from which we hope it will not easily spring again.
The Commissioning for Better Outcomes publication is one example of that and there are many more. However, it is within the development of the Care Act that we have seen taken forward a vision for social care long championed by local government. This sustained engagement of the entire sector – including providers – has been pivotal in shaping the legislation and underpinned the preparation for implementation of Phase One.
There is no doubt that adult social care, despite being some £4.3bn adrift of the total cash it has required over the past near-five years, engaged in, welcomed and provided substantial input to the Act. As far as Phase Two is concerned? We know that the delay until April 2020 will have some major impacts on the lives of our citizens and on the markets within which we all operate.
We know that, by then, profound and irrevocable changes will have been made to the landscape in which all care – health and social, voluntary, private and independent, family and community – is delivered. Despite this, we have welcomed that delay because of the possibilities – I stress ‘possibilities’ – it provides of having additional funding to attend to current services which are in urgent need of further, pretty well immediate, investment.
Despite the welcome co-operation I’ve spoken of, there are still outstanding ‘stress points’ – key issues which commissioners and providers equally share and need to resolve. MPSs, for example, should underpin active dialogue with providers and the delivery of innovative, person-centred, quality care and support services.
What does your supply and demand picture look like? Have you established with your colleagues an appropriate market balance? Has that been calculated and addressed within a strong relationship with your clinical commissioning group?
Crucially, what about the overall financial profile in your locality, your joint appreciation of the importance of local land and property values, and your assessment of labour market and labour supply issues?
This latter point will be pivotal in the growing, keenly felt competition there will be – very keen in some parts of the country – for labour. Commissioners and providers are obliged to work together to secure a sufficient, properly remunerated and trained workforce. We know there are acute problems arising from the Government’s commitment to a National Living Wage by 2020.
There are obvious connections with the current state of social care funding, the position of the training agencies and the exposed position any negotiations prior to a referendum on membership of the European Union could have on the movement of labour within the Union. As with negotiations over fair prices for care, it is absolutely vital that commissioning is seen as the joint pursuit of a common interest in the wellbeing of our service users.
We really do need a golden thread of national policy and funding so that if the Chancellor backs up his encouraging words about raising the minimum wage to £9, with a transparent and agreed sum of money to do so, that money ends up in the wage packets of those frontline social care workers who make a difference to the lives of over a million people in our country, every minute of every day.
Frankly, a failure to remunerate and recruit, train and retain a confident and secure workforce is tantamount to a failure to care properly for the people we expect them to care for. Diversity and sustainability in the market is a shared endeavour built on an agreed fair cost of care. No opportunity should be lost to emphasise this point to people who have to make decisions concerning social care funding – particularly in the light of the forthcoming four-year Spending Review.
Equally frankly, the close collaboration between commissioner and provider will never be more important – and perhaps tested – when it comes to fulfilling our statutory duties with regard to potential or actual market failure.
Redefining social care
Scoping what sometimes appears to be a menacing, if not hostile, horizon there are some major shifts which again are forcing social care to redefine itself. As CQC Chief Executive David Behan might put it, those old tectonic plates are shifting again, and if they crunch up against each other they will make a very unpleasant noise indeed.
Precisely what proposal for deeper integration of health and social care might emerge from the Spending Review is anyone’s guess. But emerge they shall, and it will be in the joint interests of commissioners and providers to keep a weather eye on developments there. They will not be entirely divorced from constitutional alignments which will take shape around devolution – Cornwall-style or Manchester-style (DevoManc).
These changes, and the sorts of ‘tri-borough’ experiment seen in London and elsewhere, will continue as part of the convulsions set in motion by the wider economic turbulence in which we have been placed these past five years or so. It will make providing more complicated. It will make commissioning more complicated. All the more reason, then, for both providers and commissioners to seize the new opportunities that are arising and help keep social care at least on top, and even at the cutting edge, of a seemingly never-ending chapter of public sector reform.
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