Meeting needs in the best way
Commissioning is a broad concept with various definitions. A helpful summary is provided by Oxford Brookes University (2016):
Commissioning is.… the process of identifying needs within the population and of developing policy directions, service models and the market, to meet those needs in the most appropriate and cost-effective way.
In essence, commissioning combines effectiveness and efficiency, achieving the best possible outcomes within the resources available. Procurement is one way of achieving this.
Although the statutory DASS guidance does not provide a definition, it essentially sets out the components of the commissioning cycle. The Care Act 2014 introduced duties for councils in England to facilitate and shape a diverse, sustainable and quality market in adult social care and support.
Adult social care commissioning is usually a high-profile activity in councils, with millions of pounds of public money being spent and services being shaped that affect the lives and opportunities of local people.
Commissioners must observe and respect the democratic decision-making processes of their council and, as a DASS, you should periodically check that commissioners continue to observe the Nolan Principles when conducting their duties, to ensure public funds are used with integrity. Risks and their mitigations are also co-ordinated through organisational forums, including cabinet, full council and adult social care scrutiny.
Adult social care is the biggest spend area within overall council provision and given the increasing shift from central to local taxation, councillors will want to ensure efficiency and effectiveness when considering impact on council tax levels.
Commissioners have an important role in assuring councillors that the services provided meet the needs of the local community in the most cost-effective and efficient way. As a DASS, you should facilitate the development of the council’s adult social care commissioning functions, ensuring the breadth of required activities, from effective population-needs assessments (usually working with public health colleagues) to quality and contract monitoring arrangements are delivered. You also must foster effective partnership working with providers through regular forums, communications and visits.
Co-production within the commissioning cycles and processes is seen increasingly as a key component to capturing the views of people with lived experience of receiving care services, as well as securing insights from provider partners (see more Co-production: building better care together).
Working to maintain a culture of ‘outwards focus’ for the commissioning function is vital, as without this approach, commissioning divisions can be criticised for being out of touch with local needs and working in a ‘back office’ without reference to partners’ or communities’ insights. Missing opportunities to meet needs in the most effective way, to embed preventative approaches and to directly influence or to initiate appropriate developments in the market can lead to spending on higher-cost services. This is avoidable.
Most DASSs have established commissioning functions under their direct control and indications are that this is the strongest organisational model for effective oversight and delivery of commissioning activities, their impact and outcomes.
If you do not have commissioning within your department or directorate (for example, if the council has a separate, centralised commissioning department), it is important you establish exactly the influence you have to ensure your DASS statutory responsibilities, as well as the council’s Care Act 2014 duties, are delivered. You do not want a function that you are accountable for being outside your span of control.
Application of the ‘commissioning cycle’ is a process that applies to all services, whether they are provided by the local authority, NHS, other public agencies, the private sector or civil society. Key points of a strategic commissioning cycle can include:
- Assessing the needs of a local community, now and in the future.
- Setting priorities and developing commissioning strategies to meet those needs in line with national statute and policies, and local and national targets.
- Designing and securing services from providers to meet those needs and targets.
- Monitoring and evaluating outcomes.
- Consulting and involving a range of stakeholders, including people who draw on care, partners and communities in the whole process.
Put simply, strategic commissioning enables councils and their partners to procure services that will deliver the priority outcomes set out in their strategic plans.
Alongside this strategic commissioning cycle, frontline social work staff work with individuals to identify and secure the right level of support from providers. This support may be drawn from a ‘block’ contract that has been procured via strategic commissioning, making available capacity of a specific service (e.g. 20 beds in a care home) that staff can arrange access to. Alternatively, support may be arranged via ‘spot’ contracting, which means setting up a contract with a provider to meet the specific needs of an individual.
This activity at the level of individual support is sometimes called ‘micro’ or ‘tactical’ commissioning and it can be seen from this description how quickly it can become complex to maintain an oversight of the complete picture of procurement activity and trends, especially when the separate activity relating to direct payments arrangements is factored in.
To keep the different components of ‘strategic’ and ‘tactical/micro’ commissioning well managed, and to embed joined up working and oversight, you must build and support a good working relationship between the commissioning functions and the social work team / community team functions (including where this has been transferred to an integrated trust). This enables managers and practitioners to share with commissioners the identified need for new service developments. This ensures provider-related quality insights identified from social worker annual reviews are also shared with commissioners.
Embedded, effective joint working also means when there are urgent resilience and emergency management situations, such as a major provider failure, there are already joint response plans in place that can be followed.
To maintain the quality and performance of commissioned services throughout the commissioning cycle, the commissioners should co-ordinate a range of activities and then triangulate, review and appropriately act upon the information.
Performance and evaluation measures must also be developed and agreed at the point of commissioning services, ideally with providers and people who draw on that support, to make sure we are measuring what matters. Through these insights, commissioners identify meaningful measures of success and leading indicators to use to monitor progress, as well as assess if outcomes have been achieved.
The range of other oversight and monitoring mechanisms are tailored to the specific commissioned service. Example activities include quality monitoring visits to providers, contract monitoring meetings, analysis of impact on relevant ‘adult social care outcomes framework’ (ASCOF) measures, ‘customer’ surveys, group meetings with people who have direct experience of the support provided, and company information reviews (including financial reports) and information from individual annual reviews by social workers.
The evaluation process considers how to measure the return on investment, both qualitative and quantitative, and how your commissioners ensure that you identify any lessons learned to inform future commissioning.
The Care Quality Commission plays a part, through its inspection and quality ratings for regulated providers, but we must also hear the views of people with lived experience of the services in the quality assurance process.
While regulator ratings are an important indicator of quality, it is not unusual to hear people describe having received good services from providers with both ‘good’ and ‘inadequate’ CQC ratings. This is a key insight into the difficult balance of navigating between people’s preferences and the statutory responsibilities associated with delivering safe, regulated services.
As a DASS, you should support your head of commissioning to make good judgment calls when it comes to the question of whether or not it is appropriate to continue a contract with a particular provider.
Given the establishment of integrated care systems, and the advent of Integrated Care Boards (ICBs), your council, through adult social care commissioning functions, plays an increasingly important role within the leadership and management of the system (for more on working with the NHS and partners see Partnership with the NHS: working together for the public good.)
Joint commissioning and market management with ICB colleagues can offer real opportunities in a challenging social care market from which continuing health care teams also commission, often from the same providers.
Although written before the establishment of integrated care systems, the collaborative publication ‘Integrated Commissioning for Better Outcomes: A commissioning framework’ is a helpful set of standards on how commissioning should be conducted to support the ambition of achieving better co-ordinated care, ensuring sustainable care and health systems, and to match people’s expectations.
As you look to the future, the key principles to consider for local joint commissioning arrangements are:
- Supporting independence by better prevention and early help approaches, leading to increasing self-reliance and community resilience. This results in both improved outcomes for people and reduced demand on services.
- Developing shared values, including the commitment to inclusion, tackling inequalities and closing gaps in outcomes caused by social disadvantage.
- Focusing on sustainable outcomes through commissioning and working in partnership, rather than commissioning on activity and then over-relying on contract management.
- Working with local and regional partners to foster relationships, jointly commission services and make best use of resources across the system, recognising and using the interdependencies.
- Implementing joined-up approaches that strengthen safeguarding and embed the responsibilities of ‘making safeguarding personal’ to support the individual and the whole family.
- Driving for efficiency within a best value context in line with The Public Services (Social Value) Act 2012. This is about making sure we get the biggest gain for local people from the budget available.
- Listening to and acting on adults who draw on support and services, as well as their families, including carers.
Success is dependent on colleagues at all levels within adult social care, and across the wider health and care system, believing that a good understanding of people, communities and localities will ensure the right support and services are commissioned to improve lives, and acting upon this assumption.