Focusing on ‘basic needs’ is the worst thing a commissioner could do, argues Mark Stables. Bold approaches in the face of budget cuts are the only way to provide sustainable services
Are we “living in troubled times”? I was once asked by someone wanting a meaningful discussion. In terms of social care, anyone would agree that we are.
We would probably also agree that a big part of this is there is not enough money. It is so tough that we get a mention on the news along with health and education.
Peter Gilbert, a great advocate of social work, wrote: “Our task as social workers is to look, see, think and speak positively and beat the predictions of pessimism.”
To be hopeful is not about wishful thinking. It is about being clear about our response to problems and being determined to try always and never give up.
Glen Garrod, the president of Association of Directors of Adult Social Services, has encouraged commissioners to have “more swagger” and he is right if he means we need a confident approach. This requires us to be clear about our role in addressing the situation we are in and upholding the values that underpin what we do.
Big picture
Commissioning is about putting things in place to meet people’s needs. This can mean drawing up contracts, working on the big picture and plans for day opportunities or housing and support. It also covers the work that social workers do with users and carers to achieve certain outcomes.
That sounds straightforward but it is often misunderstood. Now, more than ever, we need to be clear about commissioning and what we should and should not do.
Statements set out everything that people find difficult so they can get support in these areas. A need is not something that I can’t do. A need is what gets in the way of achieving an outcome. As part of the SEND reforms, statements of need have been replaced by education, health and care plans. Statements set out everything that people found difficult in order to get support in those areas. EHCPs from 14 years focus on outcomes in work, health, relationships and independence, making what they want clear and offering support to realise their goals. The Care Act 2014 talks about the role of social care in delivering these outcomes.
What does this mean for commissioning? It means “need” cannot be reduced to something a person cannot do or cannot do without.
When funding falls, it means we cannot think of our role as keeping body and soul together and meeting basic personal care needs. It means we should not reduce day services across the board or ration them.
The role of social care is to support people’s human rights, which means assisting people to have the outcomes they want – those that they have often been denied the opportunity and support to realise. You cannot ration human rights; they do not apply only some of the time.
Being presumptuous?
Commissioners need to design stuff that will deliver outcomes. In Portsmouth, we decommissioned 70% of day services and used the money freed up to support services and activities that provide opportunities in work, health, independence and relationships.
The approach was met with some criticism. It was seen by some as presumptuous: how did we know this is what people wanted? We were absolutely clear that people with a learning disability wanted to focus on these outcomes because they are what we all want. It will mean different things for different people but no one wants to be ill, have purposeless days, have no friends or be dependent.
The transformation has been remarkable. The services now feel as if they belong to the people who use them, and their confidence has grown across the board.
Many more people are in work settings, social enterprises are flourishing and people who were often passive recipients of support are now active contributors to their communities. Projects have been developed by service users. A recent sign of success was that the police approached a local service because they knew this was a group that helped people.
One project, Art Invisible, was set up to support artists with a learning disability. One result of this is that artist Raki Chowdhury has become more communicative, confident and happy. He had previously spent his days in a large day centre, where he wore headphones, had limited engagement and communication, and occasionally became upset.
Art Invisible linked him with Outside, a national organisation supporting outsider artists. This year, Chowdhury took his work to the International Outsider Art exhibition in Paris and, more recently, exhibited in Sotheby’s in Bond Street. His portrait of Jarvis Cocker was sent to the musician who, in a great moment, turned up at Sotheby’s.
Focusing on strengths, designing support to build on these and connecting with the wider world makes the difference.
Plans into practice
Our housing plan has two main themes: changing shape and size; and changing culture and practice. We have done a lot of the first and more than 67% of people are in supported living.
What does this mean in practice? Service users and families have told us that “owning” your home means far more than having a tenancy. It means that, when people come they feel like a visitor, and it does not feel like a staffed service. It means people take responsibility for their homes. We are delighted to be engaging with Gr8 support to make sure people are supported well.
In Portsmouth, we are clear that it is not enough to develop good services and support if the integrated team are not making good referrals.
We have introduced “named workers”, who work with the people they serve to identify what they want to achieve then support them to achieve it. The named workers are proactive – they don’t go away. A named worker may be a nurse, social worker, occupational therapist or speech and language therapist but all work in the same way. Far from creating more work, this has greatly reduced duty activity.
Importantly for commissioning, it enables the market to grow. Very few people ring in a state of crisis saying they are desperate to work in a coffee shop. However, as named workers get to know people and explore their ambitions, they identify goals so providers can take risks and make arrangements to expect referrals. This reduces the need to guarantee funding to a provider to get a service in place. In Portsmouth, we have redesigned support plans and assessments so they all focus on outcome and this is reflected in how services respond.
The relational approach with service users and their families should apply also to providers. That thought will inform how big commissioners want frameworks to be. Like users and carers, providers want engagement. Regular contact and visiting, investing in support and encouraging providers to meet and work together has been of great benefit.
Sometimes, I think we fear over-engagement may compromise our position, but there is no contradiction in being challenging and engaging. Good providers love challenge.
Valuing social workers
In the 1980s, people talked optimistically of social work as a profession. However, more recently, it has become unclear about its core skills and role. At worst, social workers are viewed as people who get in the way. A reductive approach has been taken to assessment.
Service users will benefit from rediscovered clarity and confidence. Social workers need to understand and agree on what make a good assessment and process. They need consistency on what is meant by need, and to unashamedly declare themselves as advocates of the people they support. Only then can they be effective commissioners. When we talk of valuing people, it is good to remember that social workers are people too.
Commissioners and social workers do not divest themselves of responsibility by issuing a direct payment. The information should be pulled together and what is needed should be developed. Otherwise, it would be equivalent to giving each of us a share of the national defence budget to buy our own rifle -….not a good idea.
Services should be put in place only if they have been designed to deliver the outcomes set out in support plans.
In Portsmouth, people often took a direct payment as a way of buying something not very good to avoid having to accept something even worse. We have found that people have no problem with a support plan being drawn up centrally as long as they are involved, own it and there is a range of options that enable outcomes to be achieved.
We are at a critical time when commissioners may be tempted to take the wrong action to meet targets Ð build bigger living units, ration services in a way that ignores individual assessment and think of their role as meeting basic needs to make ends meet. This is a time to assert confidently that we are about supporting people to live fulfilling lives as directed by the Care Act and Valuing People. Focusing on assets of people and their communities and designing everything to support people to use and develop their strengths are the only sustainable ways to deliver savings.
As you might expect, commissioners spend a lot of time arguing for more money. When they do so, they must be clear that, far from undermining efficiency, focusing on independence and being part of community is the only way to deliver sustainable savings.
Mark Stables is service manager for the Integrated Learning Disability Service at Portsmouth City Council
