Creative commissioning in the face of budget cuts

Mark Stables is dealing with a £3 million cut to his budget but he is still determined “to make things happen”, he told Seán Kelly.

Two friends of mine were discussing job vacancies recently.  One of them expressed an interest in applying to be a commissioner for services for people with learning disabilities.  The other one said, “Who in their right minds would want to be a commissioner now? All you would be doing is making cuts, dismantling services and apologising to people”.

It’s a point I put when I met Mark Stables, Operational Commissioner for Services for People with Learning Disabilities in Portsmouth. Why would anyone want to do his job?  Mark’s answer is that he has a budget and that means having “not exactly ‘power’… but you can do things. You can create things”.  Straight away he accepts that it is ‘a poisoned chalice’ because you don’t have enough budget. “But you can still make things happen”, he says.

Mark is part of a what he says is a ‘great’ integrated learning disability team that combines social work and health professionals.

Say-so

Mark was previously an area manager and manager of in house services in West Sussex and before that worked as a social worker in day services and residential care . He loved being a provider but says, “Providers never have the ultimate say-so”.  He is quick to say that he is part of a team with strategic commissioning and he picks out the Contracts Manager in Portsmouth for praise as someone who doesn’t just sit at a desk but goes out and visits providers. “Rather than go for big contracts to reduce costs we have a small framework of providers and aim to relate to them well. We pop in and see them”. This seems to fly in the face of the usual desire for cost reduction through increasing scale but Mark says it can lead to jointly planned efficiencies. “We save an awful lot of money through knowing our market well and developing relationships with them”. Mark says in Portsmouth they are deliberately creating a degree of security in the market so that providers feel safe enough to take risks. It’s not completely cosy though. “We often do challenge people but they don’t mind that because it’s in the context of a relationship”.

Mark says it’s not all about cost.  Recently Portsmouth has agreed that supported living providers on the ‘framework’ can increase their hourly rate by up to 10% in submitting tenders. “We don’t want to commission services we are not happy with. What’s the point?”

As you would expect Mark has had to deal with huge reductions in budget which he describes as extremely challenging. “We have saved significant amounts over the years from reducing costs, being more efficient and asking more of providers.  But you can’t keep that up for ever and we are focusing on changing the way we do things in accommodation and support, respite and day services”.

Mark is currently involved in a transformation of Portsmouth day services. “It’s not a review – too often that just means having a look, scratching your head and going away”.  Without transformation he says that the alternative would be just providing the same service model but continually reducing what people get. Mark aims to change the service in a way that develops community connections and work and independence. “The only long term savings solution is for people to be more independent, more part of their communities or using their Individual budgets to buy low or no cost socially inclusive solutions.  And actually, you know what, that makes Portsmouth a better community”.

The in-house day service will reduce from supporting 170 people to about 50 people which will free up money for the new services as will de-commissioning of independent sector providers who are not successful in tendering. Mark recognises the disruption and distress that this inevitably causes. “I am not flip about this Seán because it’s a very painful process for staff and providers but in order to do the new things we have to stop some of the old”.

Vocal parents

He also challenges the belief that family carers will not accept change. “The interesting thing is that some of the most ‘vocal parents’, vocal in inverted commas, are our best allies. The people you’d think might be the most resistant are actually saying, “We get this and it’s long overdue”.

The plan is to create a community connections service, health and independence services, a work service and a friendship service with Gig Buddies. There will also be social enterprises, along with the reduced in-house buildings-based service for people with complex needs.

Outcomes for these services will be based on the four SEND (Special Educational Needs and Disability) Preparing for Adulthood Outcomes which should help provide continuity for young people going into adult services. “The thing I like about the SEND reforms is that from the age of 14 you stop thinking about what is ‘wrong’ with someone and you start thinking about what they want to do in terms of work, independence, relationships, community and health. In essence that’s the five accomplishments”.

“One of the criticisms of the approach is that it is very prescriptive. What if people don’t want to do anything about health or independence, work or community?  And my answer is, well, that’s what day services do. Too often day services are confused about their purpose with the result that people start to see them as respite services”.

Mark accepts that this is making assumptions about people with learning disabilities, that they would want the kind of life that he himself would choose. “But if you say someone doesn’t want a purposeful day, and they don’t want to make any friends, they don’t want to be healthy, and they don’t want to learn anything then I’d say really you are describing someone who is very depressed. Ultimately it’s just about recognising our common aspirations and people’s potential”.

The aim is to create a range of smaller and more specialised services that people can choose to buy from. Mark makes the comparison of a high street with a shoe shop and a fish shop and a grocery shop. At that point it makes sense to have an Individual Budget. “Having an Individual Budget before that is all set up is like being given £200 worth of WH Smith vouchers, when you don’t like anything in WH Smith!”

His sharp observations make me laugh. For instance, he declares that going bowling is the new workshop. “Bowling makes me laugh. People say you can always learn stuff. I say like what? Counting from 10 downwards? And learning to tie your shoelaces? That’s basically what you learn at bowling. How long do you want to go on with that?”

‘That flipping social worker!’

Another of his observations is that social workers appear to have lost confidence as a profession. “One of the flaws of the whole Individual Budgets narrative was the feeling that ‘Do you know what’s getting in your way? It’s that flipping social worker.  He’s just a tool of the department’. When I was a care manager I thought I was an advocate for the person I sat next to. I didn’t go into social work because I loved Norfolk County Council!  It should be about collaboration that values both the service users’ aspirations and the social worker’s assessment skills”.

He points out that Individual Budgets were created to deliver better outcomes but we can become obsessed with the process: “Getting the RAS right, getting our numbers up. But are the packages looking markedly different? Sometimes we re-double our efforts but lose the point and take a reductive view”.

An example is the way having an independent life often gets reduced down to having your own flat. I get Housing Benefit which helps the local authority budget and I pay a bill and get called a tenant… doesn’t mean anything.  In fact, it’s a very Western materialist type of agenda that what makes you happy is having your own flat.  No, it isn’t: what makes you happy is having a purpose and feeling loved and actually you can feel very unloved in your own flat and very aimless. There is a big difference between having a tenancy and feeling that where I live is MY home”.

Mark feels that a similar reductionist approach often applies to ‘choice’. He recalls going to residential homes as a social worker. “People would take me to a bedroom and they’d do all this thumping on the door even though they knew no-one was in there. And they would say, “I had to ask permission”.  And then we would go into the bedroom and they’d say, ‘He chose his own curtains and duvet cover’ and I’d say, “That’s terrific but actually I didn’t choose my curtains or my duvet cover and I don’t feel too disempowered!”

Meanwhile, he has been surprised at sometimes getting good feelings from old-style places. “One day I went on a visit with the contracts officer. He said ‘You won’t like this. It’s got 28 people in it and it’s really old fashioned’. I went in and people are beaming. They were sharing rooms and loving it. The manager walks into someone’s bedroom ahead of me and doesn’t even knock!” Mark says he believes wholeheartedly in knocking! But he liked the feel of the place. I suggest that he is proudly going retro. “No, no, but it’s not about reducing it down to ‘I’ve got my own flat: tick!” He remembers walking into an early group home and being shocked. “It  felt like their home and I felt like a visitor – it was great. Now you can look back at that model and you think like, ‘group homes, it’s not really cutting it is it? But it’s not all about the model”.

At the same time he has been to supported living services where the staff answer the front door and are clearly in charge and tenants have token ‘choices’ about what to have for tea. Mark says, “Some supported living services are more like residential homes than the residential home. They can trot out the Reach standards but it still feels like the staff’s home”.

Perhaps as a result of some of this thinking, and also of financial pressures, Portsmouth is moving back to what he says are “slightly more congregate” living arrangements.  Mark accepts that this is a compromise but says they have made a kind of rule: “No more than eight” and in really improved accommodation developed, he says, “with a brilliant housing department”.

Support planning

Portsmouth is also developing its own Support Planning Tool. “This, along with the introduction of a named worker for every service user, will help us to work together with people, help focus on key outcomes and help us manage limited money better”.

Mark is clear that as people who work with people with learning disabilities we need a combination of vision and pragmatism. “The world can be full of people with great theories. It’s all very well being visionary but I think one of the skills you need (I am not saying I have this) is pragmatism and a determination to make things happen”.

So that’s how you do the job of commissioner. You need to be both idealistic and pragmatic and in the end maybe you can actually change things. Mark says, “Thankfully, in Portsmouth there are a lot of people who can make a plan, are by nature collaborative and determined to ‘make it happen’ ”.