The Future of Commissioning – 22nd National Adults Commissioning and Contracting Conference 2014

Rosemary Trustam reports on the 22nd National Adults Commissioning and Contracting Conference 2014. (See also her report: Authorities need to consider how to make better use of community resources in this issue of Community Living).

This is a care system which seeks through prevention to keep people as independent as possible with good advice and information, preventative approaches such as reablement and enablement before personal budgets provide as much choice and control as possible for service users and carers. There is a strong momentum for joining up commissioning, and where appropriate, provision with health and other services such as housing” (Wendy Fabbro)

Radical change is needed, Wendy Fabbro, commissioning lead for the Association of Directors of Adult Services (DASS) said. It is shocking that Britain is currently the poor relation among 11 leading Western countries spending only 4 per cent of its GDP on social care.

She did not underestimate the serious additional challenges commissioners face. By March 2014, £2.68bn savings had been lost from council budgets (20 per cent) and while most had been achieved by ‘efficiency savings’ there had been considerable pain involved, with providers changed and squeezed on prices, care packages reviewed and services out-sourced. Although 86 per cent of councils say quality for service users had not been affected, with 32 per cent further cuts in local government funding over the next four years, adult social care will be badly hit.

Currently, £13 billion of the £39 billion spent on local government is spent on adult social care and the new Care Act has a projected £1.9m funding gap, as well as an additional duty to fund supporting self-funders. A survey of councils found many expected services to be of lower quality, with fewer people accessing them, personal budgets to be smaller, and councils to get into financial difficulties and face more legal challenges. In addition, the supply of family carers is estimated to grow by only 13 per cent (compared to an estimated 55 per cent growth in need), while research by Southampton University found a considerable amount of unmet need.

The task for commissioners seems on the face of it impossible. A senior commissioner commented that he had not come into this work to cut budgets beyond what is possible to support and protect vulnerable people.

The Barker report* recommends that England moves to a single ring-fenced budget for health and social care run by a single commissioner. Different sources of funding should be drawn into a single budget, including some disability benefits and funds such as the winter fuel allowance, and NHS charges and exemptions and wealth and property taxation to be reviewed. Single commissioning and a single funding stream would substantially reduce the ‘transaction costs’ of all the separate assessment and funding streams. The proposal that services should be free by 2025 would also reduce all the financial assessment and collection costs. It proposes a holistic assessment of need ending the distinction between health and social care need with critical health and social care needs to be free from the start with a gradual extension of those qualifying so by 2025 those in moderate needs would be included. The costs by then are estimated to be between 11 and 12 per cent of GDP for both health and social care, comparable with what other countries currently spend on health alone.

The £3.8bn Better Care Fund will kick-start the change. This fund aims to move the balance of care to promote more independence from and integration of services. The Health and Wellbeing Boards have to agree the plans and Section 75 of NHS Act allows for NHS and local authorities to take each other’s functions and pool budgets, with 3.5 per cent of the funding contingent on reducing emergency admissions. In addition, the commissioner role of market shaping will be an essential part of the plan and should build on and incentivise informal care. It will be critical for commissioners to have a full understanding of the financial underpinning of services they commission to protect people from market failures. This may need the use of consultants.

This vision for the future is challenging and demands a major change in the balance of services to create a real partnership with communities (such as we see in the Leeds Neighbourhood networks). Marrying the different service cultures also presents a challenge. The alternative of no change in the face of shrinking resources is not to be contemplated and the role and skills of commissioners will be critical.

Changes in procurement law will present further problems. Leonie Cowen, (Leonie Cowen and Associates) said the changes may fetter some of the discretion commissioners have. Currently, for both health and social care the full rigour of Public Contracts Regulations don’t apply (Part B exemptions). For example, they can develop partnerships with social enterprises, their own or others, without having to go to open competition. This has led to many local authorities setting up social enterprises but in future anything above £5-600,000 would be curtailed. They have also been free to contract as they wish – for example, for longer than four years – BUT by Spring 2015 this freedom might be lost; current proposals stop any distinction between Parts A and B and will affect social care contracts above €750,000 (circa £610,000), though the UK has the discretion for a ‘light touch’.

Two directives passed by the European Parliament in January 2014, due to be implemented within two years, still have no full detail. The government could introduce some reserved contracts for social enterprises and have a negotiated competitive tender. The statutory exclusion for local authority controlled companies would control the extent to which it can trade outside the ‘local authority family’. Leonie Cowen suggested that too often councils aren’t business-like enough to survive, so that this model might only work as a pathway to independence; for example, towards becoming a charity or social enterprise after three or four years. There are also other relevant laws, including the Localism Act, which gives communities the right to challenge, and the Care Act 2014, which introduces a responsibility on commissioners to ensure contracts help well-being and social value, not just value for money (VFM). She referred to the recent Abbeyfield – Newcastle City case where, even though other providers had caved in to an imposed cut rate, Abbeyfield took legal action and won – the judgment was that the price set should have had some legitimate mechanism. This case also showed that the local authority’s dominant position meant it was not a proper market. Hence, if local commissioners don’t know what the market can manage, they need to start the consultation early and ensure they evaluate and road test.

Karen NewBiggin of the Health Services Management Centre at Birmingham University, brought ‘hot off the press’ the signed-off draft standards for commissioning, commissioned by and co-produced between Local Government Association (LGA), Association of Directors of Adult Social Services (ADASS) and Think Local Act Personal (TLAP), still to be consulted on from late autumn. They found scant evidence of the impact of commissioning and, apart from the financial pressures, some of the difficulties included:
• co-production was an aspiration but challenging;
• integrated commissioning is struggling with different approaches, systems and cultures;
• there were tensions between personalisation and population-focused commissioning; and
• the was a need for more intelligent use of information and data.

The purpose of the standards she suggested are to emphasise continuous improvement, to strengthen and innovate to get better outcomes for all.

The standards developed were that good commissioning should be:
o Well led by local authorities, demonstrating a whole system approach and using evidence about what works.
o Person-centred so it focuses on what people say matters most to them, promotes health and well-being for all and delivers social value.
o Inclusive – ie. co-produced with people and their communities promoting positive engagement with providers and equality.
o ensuring a good quality sustainable and diverse market, providing value for money and developing the commissioning and provider workforce.

Andrea Sutcliffe, Chief Inspector of the Care Quality Commission, outlined their new approach to services inspection which is asking five key questions: is the service safe, effective, caring, responsive and well-led? More rigorous inspections mean putting people at the heart of all they do. Increasingly, therefore, their inspection teams include ‘experts by experience’ who are family carers and service users. She said the plan is to eventually have them on all inspections.

Andrea was at the recent summit meeting when the service user representatives from Change presented their proposals to the Minister. Asked when we would see change in the commissioning of assessment and treatment centres she said that Simon Stephens, head of the NHS, had clearly been affected by people’s stories of their experiences. In the past week she’d heard him speak about this twice on conference platforms.

Although from April 2015 they will have a statutory duty to ensure the financial viability of services and provide early warning of market failure, they will not have a right to refuse to register services that meet the registration requirements. Leadership is a key issue in services, as it is in commissioning standards. It is up to commissioners, she said, to ensure the appropriate services and models are in place. They can’t hold commissioners to account for inappropriate practices, such as sending people miles away and not developing appropriate local infrastructure but Andrea feels that NHS England has started to take the issue more seriously.


 

Full conference downloads @ http://www.psconferences.co.uk/
http://www.ncctc.co.uk/presentations/october-2014/

*A New Settlement for Health and Social Care – the final report of the Independent commission on the Future of Health and Social Care in England chaired by Dame Kate Barker CBE – http://www.kingsfund.org.uk/publications/new-settlement-health-and-social-care)


 

What does the Care Act say?
• Must ensure that the wellbeing of patients and carers, and that outcomes enable people to stay independent as long as possible
• Must facilitate markets to continuously improve quality, innovative services including fostering a competent workforce
• Must comply with Equality Act 2010
• Must develop markets for care and support
• Must step in to ensure continuity of care if a provider fails
• Must encourage a variety of providers and services
• Must ensure sufficiency of provision
• Must facilitate information and advice to support choice
• Must have regard to co produced guidance on integration