Very early on during the COVID-19 crisis it became clear that commissioners were going to have one of the most difficult jobs.
Perceived to be the gateway to funding and access to everything from personal protective equipment (PPE) to new recruits, commissioners found themselves facing an impossible task, and some difficult questions, including:
Where is the money we were promised for PPE and tests?
My personal assistant is sick, who will replace them?
- Where can I find emerging funding to keep my home open?
- How do I access funds to pay for new recruits?
- We have run out of safe step-down beds, where do we find more?
- How do I access my direct payment?
Aware of these challenges, the Department of Health and Social Care (DHSC) commissioned the Social Care Institute for Excellence (SCIE) to produce new commissioning guidance – Commissioning and COVID-19: advice for social care – and run a series of surgeries to help them navigate this minefield.
While new and focused on responses to the pandemic, many of the problems that are discussed in the guidance predate COVID-19. In conversations which informed the guidance, we were told on numerous occasions that ‘commissioning is stuck’ or ‘commissioning has become little more than procurement’.
This was not the original intention. For the last 20 years, we have heard a lot about the importance of commissioning. It was to be a strategic process which led to service improvement and better outcomes. The best commissioners, we were told by the Commissioning Academy, were to ‘have the confidence to challenge the status quo, take on radical change, collaborate effectively with external stakeholders, gain a deep understanding of the need and target resources effectively to meet those needs’.
So what has gone wrong? Funding cuts have definitely played their part. With each cut in adult social care funding, the scope of commissioners to invest in better ways of delivering care has reduced, but the problems in commissioning are not just about money.
In developing the guidance, we heard that commissioning was:
- Narrowly focused on outputs – time, tasks, hours, beds occupation – rather than on enabling people to achieve outcomes and live better lives
- Deficit-focused, ignoring or failing to build on the wealth of assets and social networks in communities construct
- Directive and top-down, rather than built through collaboration with citizens and providers
- Siloed, focusing on narrow parts of care, like home care or care homes, rather than exploring whole systems solutions
- Focused on the short-term and quick fixes, rather than investing in innovations which will take a while to develop but yield better results over the longer-term
This is not to say that we haven’t seen many examples of good practice during COVID-19. In our guidance we describe excellent examples of good commissioning: of good communication between commissioners and providers; of commissioners finding ways to shift funding to community organisations; of commissioners taking sensible decisions about early payments and flexible contracts; and of commissioners brokering supplies of PPE. These examples are cause for celebration, but much deeper reform is now needed.
Suggestions for action
Firstly, we need commissioning plans which are co-produced and co-designed with local people, providers and partners, ensuring that priorities and service specifications properly reflect the aspirations and needs of local communities. This is the goal in Bristol. Faced with rising demand and a lack of high-quality provision, the council has run co-design events with providers, voluntary and community sector organisations and other partners to re-design both home care delivery model and the way it is applied.
Secondly, we need commissioning based on the achievement of outcomes, rather than narrow service outputs. In Swindon, for instance, this has meant redesigning service specifications which pay home care providers on how well they maintain people’s independence, rather than on how much time and task is delivered. Camden has done something similar with supported living, paying providers on basis of outcomes, discarding traditional output measures and paying for providers to deliver outcomes like getting people into work, improved quality of life and promoting independence rather.
Thirdly, we need to shift money towards innovation. There are many good examples of innovative approaches to care and support that are person-centred and community based, but they tend to exist in pockets and are small-scale. In financially constrained times, it is extremely hard to maintain core services whilst investing in new innovations. But with brave leadership, even this challenge can be overcome. Faced with dire finances, and a need to raise quality, Wigan MBC took the decision to close its day centres, and invest instead in innovative community organisations. The town now boasts some of the best care in the country. Similarly, North Yorkshire CC set up an innovation fund, with the specific goal of making more money to innovate community organisations committed to prevention.
Fourthly, we need to connect commissioning to practice. This means that in addition to providers and people who use services, commissioners need to work closely with practitioners to develop commissioning strategies and specifications. Why? Because as more and more local authorities adopt strengths-based practice – which focuses on identifying people’s strengths, or assets, as well as their needs – practitioners increasingly have a rich picture of local needs, aspirations, but also about how services can be improved and build on community assets.
The COVID-19 crisis has tested social care to the limits – including commissioners. But this is no time to retreat to the status quo, which we know was no longer delivering the outcomes people deserve. Let’s make this summer the turning point for commissioning, returning it to its founding propose – a collaborative way of working which harnesses resources to deliver better outcomes.
Ewan King is chief operating officer of the SCIE
Case study 1
Princess Homecare: Collaborative working and maintaining quality
Princess Homecare is a small domiciliary care agency in a rural part of Wiltshire, supporting ten older people. The council has assisted by doing things like providing video calls between clients and families; providing technology to ensure those staff who can work from home are able to, boosting motivation and support; making sure that there has been a regular supply of PPE; and continually checking latest guidance and best practice to ensure they have been working as safely as possibly.
Princess Homecare feels that since the start of the COVID-19 crisis Wiltshire CC has been proactive, supportive, as well as approachable and responsive to questions. They have acted as a sounding board for enquiries, or have signposted them for further information, which has been crucial – particularly at the break of the crisis. Their support extends to areas such as making sure that the organisation is financially sustainable, as well as helping out with training and video links.
Princess Homecare has kept a log of actions and activities taken due to COVID-19 to make sure they knew what happened and when. They were able to keep in touch with the service users’ families with regular updates on top of their video calls. Because of this, they say they were able to easily reference resources they had found, reasons to have taken actions and to provide accurate information to families for peace of mind.
Of course there have been challenges. COVID-19 has thrown up many, including how to keep up-to-date with the amount of information being released daily, and being able to translate it in a practical way to staff, service users and families. The fact that the information is not organised in one place has added to the difficulty, as some days they received several emails from different sources with similar information.
One key lesson learnt is how much more can be achieved working collaboratively. They have been linking to other small providers in the area and then they have supported each other emotionally and professionally. The level of collaboration between small companies has been incredible.
Case study 2
Sustaining intergenerational initiatives – Liverpool City Council
Sewing, crocheting, baking and bike repairs. These are just some of the life skill activities that socially isolated older adults are teaching to parents and children in Liverpool. Those older adults plan the session in advance among themselves, supported by Community Interest Company, IIIN. Older adults report feeling valued and respected in society once again; and in return the younger generations share skills, often digital, supporting the older adults to become proficient in any areas they thought were inaccessible to them, like IT.
The Inter-generational Sustainable Skills Exchange, funded by Liverpool City Council, see these sessions empowering the older adults and enhancing their feelings of self-worth and value. The sessions also show parents and children how to reduce, reuse and recycle items and clothing that many would normally throw away. And the sessions allow parents to devote a large amount of time and attention to their children, which can improve the relationship between parent and child. Also, the sessions can help older adults make and maintain friendships with members of their community.
When the pandemic hit Liverpool, all intergenerational sessions were halted, as the majority of the older adult participants were required to shield, unable to spend time with anyone or leave their homes. Initially, significant support was given around meeting essential needs, such as food shopping. But soon ‘virtual tea’ saw the older adults eating a meal with each other via video conferencing. This alleviated some of the isolation the older adults were feeling. This widened to having ‘Virtual knit and natter / crochet and chat’ sessions. IIIN feel it is vital that contact between all the groups was maintained.
One huge obstacle has been access to the internet. Many older adults who were able to use smart phones and iPads would use communal wifi areas (such as in sheltered accommodation) to go online. During lockdown these areas were often placed out of bounds by housing providers. Many older adults who used their own internet had low data plans.
The online sessions drastically reduced the older adults’ feelings of social isolation and loneliness. Parents reported children were thrilled to maintain contact with their older adult. Children found the activities a nice break from the online homework tasks. Older adults have reported their relationships and friendships with parents and children have become deeper.