OUTCOMES MATTER - LGIU · outcome-based commissioning agenda has been patchy, and fraught with difficulty. The use of service outcomes is now well recognised, but the process of paying

OUTCOMES MATTER: EFFECTIVE COMMISSIONINGIN DOMICILIARY CARE

Authors: Lauren Lucas and Jonathan Carr-West, LGiU

“As we set out earlier this year, we want to put an end toundignified care by the minute. We want care that is judged bythe outcomes that matter to people receiving the care.

“We know that some councils and care providers are leadingthe way, but there is still a long way to go. We will continue towork with care providers and people who use the services tobring an end to providing care that undermines people’sdignity and choice.

“I am determined that collectively we develop commissioningskills so that providers are rewarded for improving health andwell-being, promoting independence and increasing mobility."

Norman Lamb MP, Minister of State at the Department of Health

“I welcome the research work undertaken by the LGiU andMears to raise the profile of outcome based commissioningacross social care and support services. In a time ofincreasing pressure on social care budgets, outcome basedcommissioning focuses attention on what is important andwhat can most benefit individuals and communities.

“In the London Borough of Sutton we are actively working tomove away from traditional time and task commissioning tofocus on outcomes and empower commissioners,organisations and individuals working in the social care sectorto collaborate in more creative and innovative ways totransform people’s experience of care and support for thefuture.”

Cllr Colin Steers, Lead Member for Adult Social Services and Health, London Borough of Sutton

“We are pleased that the LGiU is focusing on the importantissue of outcome based commissioning. In Essex ourapproach to contracting follows a number of commercialprinciples, which include; moving away from blockcontracting, allowing the market to regularly compete forbusiness, linking quality and price and focusing on outcomebased payments.

“The recently awarded reablement contract is one example ofa shift away from an output focus, this enables the provider toinnovate and develop new solutions to meet resident’s needsin a more efficient and effective way, delivering outcomes.”

Cllr John Aldridge, Cabinet Member for Adult Social Care, Essex County Council

"Wigan Council has been moving completely away from theold "time and task" approach to providing home care. Thevalue to our residents who experience a more human,personal service, and get better outcomes is fed back to us aswe regularly consult with our service users on the quality ofthe service they receive. Better outcomes for residents alsomeans better value for money. This outcomes-focusedapproach helps to create the right relationship between theprovider and the service user so that they can offer a moreflexible service, able to respond at times when a bit more helpis needed, and reduce appropriately at other times.

“In turn, this reduces the need for detailed specificationchanges and micro management and so improves back officeefficiencies. The services for the future will, we believe, proveto be more cost effective and efficient if they are helpingindividual service users to make the best use of all the assetsthey have as people, and fit services round them rather thanfollow rigid service models of the past."

Cllr Keith Cunliffe, Co-Chair of the Health and Wellbeing Board, Wigan Council

Contents

Executive summary 1

1 Context: resourcing pressures and 5implications for commissioning

2 Where are we now with outcome-based 9commissioning?

3 Challenges for outcome-based commissioning 13

4 The local authority position 20

5 Commissioning approaches 34

6 Recommendations 44

Conclusion 49

Effective commissioning in domiciliary care LGiU

AS A NATION we are living longer, which should be a cause for celebration,but when I speak with people facing old age they worry about what thefuture holds. Our current system of care has moved in a direction whichdemands that care workers clock in and clock out. Unfortunately thisapproach is on the whole, driving service delivery. With demographicpressures and immense financial constraints facing local authorities, there is

a risk that we will see a race to the bottom with care providers competing for who candeliver care packages at the lowest per minute cost.

There is a general consensus that commissioning for outcomes is a positive move, but as aprovider who sees care contracts on a daily basis, we continue to have our hands tied bytask and time contracts whilst true commissioning for outcomes remains somewhat elusiveand out of the ordinary. We believe that while this continues, older and disabled people willhave their dignity and independence eroded and the longer term cost of social care willcontinue to rise for the sake of short-term unit cost savings today. Having spoken to manylocal authorities we understand that they feel the same, but they are struggling with the jointchallenges facing social care and the need to make immediate savings.

It may seem strange for a care provider to be highlighting these practices. Many providersare happy with the status quo, but Mears believes that providers should work together withcommissioners and other providers to improve services; and should be paid on the basis ofthe results they deliver. A task and time system de-incentivises prevention because if anindividual’s care needs escalate there will be more work. Instead of judging our careproviders on their ability to get care workers in and out of a person’s property in 15 minutesshould we not be paying them on whether they have reduced hospital admissions,prevented falls and enabled independence?

So, if personalisation and commissioning for outcomes are almost universally agreed asgood things what is stopping us from getting from the theory to the practice? Mears haveworked with LGIU to explore current practices and the barriers to change. This report showsthat commissioning for outcomes is possible and by rethinking current commissioningpractices we can do more with less.

But we know that real change can only be achieved through working in partnership; privateproviders, the third sector, service users, local government and our health services. Mearswelcomes the opportunity to work with commissioners who want to drive up the quality ofcare, integrate services, provide better value for money and ultimately ensure that olderpeople live their life with dignity, choice and control.

Alan LongExecutive Director,Mears Group

Forewords

LGiU Effective commissioning in domiciliary care

PUBLIC SERVICES face real challenges in the near future. Resources areshrinking at the very time that long term trends such as an ageingpopulation and an increasing complexity of need are driving up demand.

Nowhere is this more true than social care.

A commissioning process, irrespective of your choice of delivery agent, is part of thesolution to this problem – a way of offering efficient, targeted and personalised services.

This process only works, however, if commissioning processes are flexible and responsiveto the needs of the individual. Outcomes are central to this. Defining them, measuring themand contracting around them is the best way to drive innovation, efficiency and results fromin-house teams and external partners alike.

However, although this is widely recognised, cuts to social care budgets have in realityforced councils to ration home care services in ever-smaller chunks of time. In our survey,over a third of respondents paid their providers in slots of 15 minutes or less. Only 7%reported paying providers according to the outcomes they achieved for the individual.

Councils clearly recognise this as a challenge, with 75% saying they see a ‘time-task’approach as their biggest obstacle to commissioning services that promote outcomes.

In this report, we argue that working with providers of all sectors to incentivise the deliveryof outcomes is a priority. If we continue to pay providers according to the time spent with aservice user, we incentivise failure and give unscrupulous providers the opportunity todeliver poor outcomes for the individual, in order to increase their care package.

This is a big ask for local authorities, and requires upfront investment, but there are alreadyexamples of forward thinking councils delivering services in innovative ways to meet thischallenge. We’re delighted to be working with Mears on this report and hope the casestudies will help to share best practice and support authorities to develop their thinkingaround outcome-based commissioning in care delivered in the home.

Jonathan Carr-West Policy DirectorLGiU

1LGiU Effective commissioning in domiciliary care

The concept of outcome-basedcommissioning has been a feature of theadult social care landscape for some time,as a method of delivering personalisedservices based on need. A recent LGiUsurvey has shown that over 70% of localgovernment respondents regard outcome-based commissioning as ‘very important’ tothe future of adult social care.

But what do we mean by commissioning?The renewed interest in in-house provisionshown by some local authorities could beheld to imply a move away from standardcommissioning models. We would arguehowever that ‘commissioning’ describes thestrategic process of designing services andchoosing delivery agents, rather thanproscribing a particular form of provision. Assuch, it remains intrinsic to the system,irrespective of the choice of service provider.Most definitions describe a cyclical process,where possible involving carers, careworkers and service users throughconsultation and coproduction, and includingthe following steps:

l assessing the needs of a population

l setting service priorities and goals

l securing services from providers tomeet those needs

l monitoring and evaluating outcomes.

Appropriately, different communities willrequire different models of service provision,but whether the service provider is ultimatelya private sector organisation, a charity, asocial enterprise, in-house service or a

dynamic mixture of all, the commissioningprocess will remain the basis for decisionmaking about the design of a service.

Despite a general consensus about thevalue of this process, progress on theoutcome-based commissioning agenda hasbeen patchy, and fraught with difficulty. Theuse of service outcomes is now wellrecognised, but the process of payingproviders on the basis of the outcomes theyachieve is less common. The currentpressures of the financial situation have alsoproved challenging, as local publicorganisations attempt to share budgets oncross-cutting outcomes, whilesimultaneously finding unprecedented levelsof savings.

This report sets out to investigate currentpractice in commissioning for outcomes indomiciliary care in England. With risingdemand for adult social care services, at atime of declining resources, the goal ofpromoting independent living and highquality outcomes for the individual has neverbeen more important. Care and support inthe home is at the centre of the debate. Withthis in mind, we undertook a programme ofresearch to identify the challenges,opportunities and examples of innovativepractice that shape council commissioning ofdomiciliary care.

Our initial survey of local government officersand elected members working in social caremade some interesting findings:

l while most respondents reportedthe regular use of outcome-basedcommissioning, a sizeable minorityof 35.9% said that it was only used‘to a limited degree’ in their

Executive summary

2 Effective commissioning in domiciliary care LGiU

authority. More than 70% sawcommissioning for outcomes as a‘very important’ priority for socialcare in future.

l 75.9% of respondents disagreedwith the statement ‘our currentsystems and processes will besufficient to manage our adult socialcare provision in future’, reflectingthe present resourcing challengefacing social care. More than 90%agreed that pressure on resourceswas making them reconsider the way in which they provide socialcare.

l 74.4% of respondents regarded ‘aculture of running services on atime-task basis’ as an importantbarrier to outcome-basedcommissioning in future. However,over 90% still pay providersaccording to the time they spendwith a service user, rather thanoutcomes.

The results of the survey throw up a numberof important questions for local authorities.

l What further steps can we take tobreak down a ‘time-task’ culture incommissioning domiciliary care?

l How can we most effectivelyincentivise providers to deliver highquality outcomes for the individual,to promote independence andreduce the need for care wherepossible?

l How can we ensure outcomes areshared between health, housing,social care and other relevantservices to minimise waste andavoid duplication?

l How can we establish and measureoutcomes that are meaningful toboth provider and service users?

l How can we ensure service usersare fully engaged in shaping theirown care and determining theoutcomes they want to achieve?

l How can we ensure care staff aresupported and empowered to deliverhigh quality services?

Our call for examples of innovative practicein this area highlighted a range ofilluminating case studies, detailed inChapter 5. Wiltshire County Council’s ‘Helpto Live at Home’ scheme rewards andpenalises providers on the basis of theirperformance against outcomes. Wirral’sRapid Access Contract has broken downorganisational boundaries to minimisedischarge times for hospital patients aroundshared outcomes.

Trafford’s Quality Checkers show howsuccessfully service users can be involved inimproving service performance, while EssexCounty Council demonstrates a useful modelof market management and use of paymentby results in reablement.

These examples draw attention to some ofthe challenges and opportunities indeveloping a successful approach tooutcome-based commissioning.

On this basis we have developed a five-pointchecklist for raising our game incommissioning.

1) Are you contracting for outcomes?Establishing outcomes as the basis for acommissioning strategy is important, butexplicitly linking the payment of providers tothe outcomes, rather than the outputs thatthey deliver, is a more powerful tool. Whenproviders are paid on an hourly rate, theyare offered no incentive to reducedependency on services or respond flexiblyto individual changes in circumstance. Givingthem the right target will help to improve theefficiency of the service and result in betteroutcomes for the individual.


2) Have you considered the localdrivers for need? Service user need can be manufactured bybadly designed services. If we are to dealwith the current pressures on adult socialcare, and continue to meet the needs of ourcommunities, domiciliary care servicesshould be based on the premise ofreducing or stabilising dependence onservice provision wherever possible in linewith service users’ own expressedpreferences.

3) How well aligned is yourcommissioning for housing, healthand social care? Housing, health and social care are thethree pillars of independent living. Identifyingshared outcomes between these three areasand commissioning together will offer moreefficient and integrated services.

4) Do you empower providers? The focus on a time-task method ofcommissioning, along with tight budgetaryconstraints and several high profilesafeguarding scandals, have shifted thecouncil’s role into one of invigilator, oftenleading to a command and control approachto dealing with providers. Commissioning for

outcomes involves putting the onus on theprovider to solve the problem, alongside theservice user. Market management should beabout increasing the range of care productsavailable, rather than simply increasing thevolume of providers in the market.

5) How engaged are electedmembers?Councillors have a crucial role to play inconnecting council processes to theoutcomes they see through their case-workin the community. At present many people inreceipt of care, and older people inparticular, find it difficult to make their voiceheard. Elected members can act asimportant advocates for people in the caresystem, while also holding influence over theinternal processes for commissioning.

Responses to this set of challenges willnecessarily depend on local circumstance:there is no one-size-fits-all model of servicedelivery that will provide the answers. Bysharing practice we can move towards abetter understanding of how outcome-basedcommissioning can help to deliver high-quality, cost-effective, personalised servicesfor the individual in times of great financialpressure.


The UK social care sector is facing aserious funding crisis. Rising demand forservices, combined with shrinkingresources, together present a worryingpicture for the future of care for ouroldest and most vulnerable residents.The sector is facing pressure on bothsides of the equation, and calls forgovernment to address the funding ofsocial care are becoming increasinglyvocal, particularly in the context of therecent White Paper. Nevertheless, whilelocal government alone cannot answerthe funding question, there is still scopefor some aspects of commissioning todeliver better value and higher qualityservices.

Rising demand for services

Demand for social care is being driven bydemographic change. The Office for NationalStatistics states that the population aged 65and over will account for 23% of the totalpopulation in 2035, while the proportion ofthe population aged between 16 and 64 isdue to fall from 65% to 59%. In future thisdemographic change will place additionalpressure on council services, as the gapbetween demand and available resourceswidens.1

These projections have profoundimplications for the delivery of social care.We know, for example, that life expectancyin the developed world is increasing at a rateof two years per decade. However, peoplenow live with chronic illness for an averageof eight years at the end of their lives.

As well as a general rise in demand, we areseeing a growing complexity in the needssocial care services are addressing. Thereare approximately 1.5 million people inBritain currently living with learningdisabilities, and that number is likely to growby 14% between 2001 and 2021 accordingto research by Lancaster University.2

While the focus of attention in social caredebate tends to rest with older people, it isimportant we do not forget the importance ofother groups in receipt of services.

Resourcing challenges

The increased levels of demand andcomplexity are coupled with a reduction inresources. The government’s commitment toeliminate the budget deficit within a singleparliament has major implications for councilbudgets: the October 2010 Spending Reviewreduced central government’s grant to localgovernment by 28% over four years.Although this was offset to some extent byadditional funding for health and social care,there are still major savings to be found fromthis service.

The 2011 Association of Directors of AdultSocial Services (ADASS) budget survey hasfound that adult social care will provide acontribution to savings in 2012/13 of £890m.This represents 6.8% of the 2012-13 adultsocial care budget before savings. Whencombined with last year’s figures, thecumulative reduction in adult social carebudgets is £1.89bn. Over 85% (£688m) ofplanned reductions have been secured

1 Context: resourcing pressures andimplications for commissioning

1 http://www.statistics.gov.uk/hub/population/ageing/older-people2 Emerson E, Hatton C (2009), Estimating Future Numbers of Adults with Profound Multiple

Learning Disabilities in England, Lancaster: Centre for Disability Research, Lancaster University.


through service re-design and efficiency and£77m provided through increased charges.Only £113m – 12.7% – has been saved byreducing services.3

How big is the problem?

Despite the work of adult social caredepartments to preserve frontline services,the picture in the long term is lessencouraging. In June this year, the LocalGovernment Association (LGA) released areport that modelled the funding outlook forcouncils up to 2020. According to the LGA’scalculations, the money to fund popularservices such as leisure and libraries willshrink by 90% as adult social care andother statutory responsibilities soak upalmost all council budgets by the end of the decade.

The report shows that by 2020 a £16.5bnfunding shortfall will exist between theamount of money available to councils toprovide services and the predicted cost ofmaintaining them at current levels. This gapis largely attributable to the rising cost ofadult social care. Estimates suggest thatspending on social care will exceed 45% ofcouncils’ total budgets by 2019/20.4

Some local authorities have drawn a starkerpicture. Barnet Council has recently attractedpress coverage for its ‘Graph of Doom’,which shows that on current projections,within 20 years the council will be unable toprovide any services except adult social careand children’s services.

LGiU research, conducted as part of theLocal Government APPG enquiry into adultsocial care funding, has gathered fundingevidence directly from a wide range of localauthorities on both the growth in demandand the decline in resources. Thisinformation suggests that while the picture

differs across the country, the currentfunding gap is at 4.4% per annum,equivalent to £634m in the next two yearsand rising thereafter.

Safeguarding

Concerns for the future of social careservices are also being driven by a series ofhigh profile human rights violations in carehomes. Reports into institutions such as AshCourt and Winterbourne View havehighlighted the vulnerability of people incare. These concerns are not limited to thecare home sector: the Equality and HumanRights Commission (EHRC)’s Close toHome enquiry into home care reported that“our inquiry has uncovered serious, systemicthreats to the basic human rights of olderpeople who are getting home care services”.

At the same time, the collapse of SouthernCross has demonstrated the potential impactof financial failure on the part of a largeprovider.

Implications for strategiccommissioning

There is no easy solution to thesechallenges and increasing pressure onresources will have important implications forthe way social care is to be delivered infuture. While the social care White Paper‘Caring for our future: reforming care andsupport’ initially deferred a decision on theDilnot Commission’s recommendations untilthe next spending review, it has since beenrumoured that the government intends topush forward with the recommended£35,000 cap on care fees. Nevertheless,although a decision on this issue woulddeliver some level of consistency in the caresystem, the underlying funding questionremains.

3 http://www.adass.org.uk/index.php?option=com_content&view=article&id=813&Itemid=4704 http://www.local.gov.uk/web/guest/publications/-/journal_content/56/10171/3626323/

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However the central funding problems are tobe addressed, there must be a shift in ourunderstanding of how we address the needsof vulnerable people. The long-term gapbetween rising demand and availability ofresource necessitates broader change in theway we provide care.

This cultural shift may include some of thefollowing features:

l greater investment in preventativesupport

l more support for people to liveindependently at home for longer,and commissioning processes thatsupport this;

l breaking down barriers to andsupporting informal care

l better support, information andadvice to ensure that people makegood decisions about their carearrangements.

Local authorities have enormous power toshape the context within which care isrequested and received. It clear that care inthe home is an essential part of the solution.A recent report based on Department ofHealth accredited FACE assessment toolshas identified savings of between £3m and£7.8m for councils with social servicesresponsibilities across England if more isdone to help elderly people remain in theirown homes. This constitutes approximately7.4% to 19.4% of their social care budget forolder people.5 Besides the financial benefits,support in the home is an essential aspect ofa high quality person-centred approach tocare. Most older people express a

preference for living in their own homes foras long as possible.

Underpinning any new model is an effectivecommissioning strategy that brings togetherthe public sector at a local level to deliveragainst shared outcomes for the communityand for the individual. Commissioning is oneof the most important tools councils and theirpartners at a local level have to shape thenature of demand and to determine the wayin which care is delivered. Outcome-basedcommissioning can help to shape efficienttargeted services, but it is also a tool forbuilding a quality person-centred approachthat meets the needs of the individual.

We should be clear that commissioning doesnot imply one form of service provision overanother. The present funding gap, inconjunction with the shift to localism hasgenerated interest in re-developing their in-house provision in some areas of thecountry. Commissioning and in-houseprovision are not alternative forms of servicedelivery, rather commissioning is the processby which a council assesses need andplans, designs and procures its services,whether they are to be delivered by theprivate sector, by charities, by socialenterprise or by in-house teams.

With this in mind, this report will focus onoutcome-based commissioning in domiciliarycare. It will seek to identify current practice,identify challenges and opportunities anddraw attention to innovative case studies.We have seen that councils are facing thetwin pressures of declining resources andincreasing demand for services. In thiscontext, the need to ensure ourcommissioning processes are fit for purposehas never been greater.

5 http://www.thisishampshire.net/news/9814188.Big_social_care_savings_possible/


Commissioning for outcomes has beenan accepted part of the narrative in adultsocial care for some time. While there isstill debate about the types oforganisation authorities shouldcommission, most would accept the corevalues of a commissioning approach interms of process: identifying need in thecommunity, designing service goals andoutcomes, securing services that meetthose needs and monitoring andevaluating outcomes.

Equally, few would challenge the value ofoutcomes as well as outputs. The need toshift thinking from how a service operates,to what it accomplishes is recognised andthe concept of strategic commissioninghas been taken further in children’s andadults’ services than in any other aspectof council service delivery. Neverthelessthere are still challenges that must befaced before a truly outcome-focusedapproach is universally employed.

The development of outcome-based commissioning

One of the biggest factors in shaping thecurrent context has been the evolution of thesocial care market, which is now one of themost developed in the public sector.

l In the 1980s, the government’scommitment to a ‘mixed economy ofcare’ saw an expansion in the caremarket, which became morepronounced from the early 1990sonwards.

l The 1990 National Health Serviceand Community Care Act made it a

duty to assess people for care andsupport, and introduced an internalmarket into the supply of healthcare,making the state an 'enabler' ratherthan a supplier of health and socialcare provision.

l The 2007 CommissioningFramework for Health and Wellbeingrepresented another step in thejourney towards commissioning foroutcomes. It aimed to shift the focuson acute services towardsprevention, and introduced the JointStrategic Needs Assessment as thefoundation of needs basedcommissioning.

l The 2012 Health and Social CareAct establishes a new outcomesframework for the NHS, publichealth and social care, giving localauthorities responsibility for securingtheir identified outcomes.

In the context of the localism agenda someauthorities have started to reconsider theoption of in-house provision. Nevertheless,as the results of our survey willdemonstrate in Chapter 4, the general trendis towards a greater diversity of serviceprovision, incorporating a wide range ofproviders, from in-house provision, tocharities, social enterprise and the privatesector.

The commissioning cycle in which localneed is considered, services designed,providers identified and outcomesmonitored remains relevant irrespective ofthe type of provider involved. We will arguethat the focus of debate should be on thequality of outcomes achieved for the

2 Where are we now with outcome-based commissioning?


service user, rather than the form ofprovision used to deliver them.

More than 90% of respondents to an LGiUsurvey on commissioning regardedoutcome-based commissioning as‘important’ or ‘very important’ to the futureof care. It is clear that the concept ofemploying outcomes as a basis forcommissioning is here to stay. Outcomes,with an accompanying emphasis onpersonalisation and choice, are firmly set toform the focus of future commissioning insocial care.

Outcome-based commissioningand personalisation

Discussion about outcome-basedcommissioning invariably goes hand-in-handwith debate about choice andpersonalisation. The growth of the disabilitymovement, particularly from the 1970sonwards, challenged the traditional balanceof power in social care and saw thedevelopment of the independent livingmovement.

The mid-1990s saw the introduction of directpayments and was followed by series ofgovernment publications that advocated‘self-directed’ support for service users morewidely. The coalition government hascommitted to a personal budget beingavailable for everyone eligible for ongoingsocial care by 2013.

Outcome-based commissioning is very mucha part of this agenda. Commissioning on thebasis of individual outcomes, rather thanoutputs, shifts the emphasis away fromsystems and processes and onto the qualityof the service and the impact on theindividual. However, personal budgets anddirect payments have had profoundimplications for the structure ofcommissioning. Under care management,services were usually bought in large blockcontracts for particular service user groups.

Service users were then matched to theservice, rather than the service beingtailored to their own individual requirements.

For many authorities, moving towardspersonal budgets has involved challengingthis approach, using some of the followingsteps:

l making a strategic shift away fromblock contracts towards frameworkagreements; umbrella agreementsthat set out the terms (particularlyrelating to price, quality and quantity)under which individual contracts canbe made throughout the period ofthe agreement

l moving service users onto personalbudgets, and, where appropriate,onto direct payments

l taking an active approach tomanaging the market, aiming toincrease the number of providers inorder to maximise choice

l providing high quality advice andinformation for service users (insome cases including self funders)to enable them to make goodchoices about their carearrangements

l developing partnerships, particularlywith health, to try to make the movebetween different services seamlessfor the service user

l seeking opportunities for co-production of services with serviceusers where possible.

Personal budgets have been a success inmany ways, giving people more control overthe outcomes they want to achieve; a recentevaluation report by Lancaster Universityshows that of 14 measures of quality of dailylife, between 57% and 76% of allrespondents reported improvement in 10 as


a direct consequence of having a budget.6

Despite this, we are by no means at the endof our commissioning journey.Personalisation, particularly in relation topersonal budgets and direct payments, stillfaces several challenges that we will explorein the next chapter.

While important steps forward have beentaken towards delivering personal outcomesfor service users, there remains some wayto go and parts of the reform have had farreaching implications that need to beconsidered in more depth.

There are still many important questions foroutcome-based commissioning:

l How much choice do personalbudgets actually offer?

l What does market managementmean in the context of domiciliarycare?

l Does maximising the number ofproviders in the market increasechoice?

l How can we empower care staff?

l How far have we moved away froma time-task approach to servicedelivery?

l To what extent are providersincentivised to deliver outcomes forservice users?

l How can we successfully articulatepositive outcomes and measuretheir success?

l How can we support integrationbetween the services that supportbetter outcomes for individuals, forexample housing, health and socialcare?

Many of these questions relate to therelationship between commissioner andprovider.

In the next chapter we will explore some ofthese challenges in more detail and considerwhat issues must be addressed beforeoutcome-based commissioning can becomea reality.

6 http://www.in-control.org.uk


The need for personalisation and foroutcome-based commissioning has beenthe dominant narrative in social caredelivery for the last decade at least. If weaccept that it is not yet fully embedded,we must ask why we have notprogressed further. What questions mustbe answered before outcome-basedcommissioning can be really put intopractice?

How much choice do personalbudgets offer?

Personalisation has been a very importantaspect of adult social care reform over thelast 10 years. Moving away from a ‘one-size-fits-all’ approach towards individuallytargeted service delivery represents a vitalcultural shift for the sector. Nevertheless,there are still implications to be explored inrelation to the financial impact of a personalbudget approach, and the level of choicethat they offer to service users.

First, the financial impact of person budgetsis still to be fully explored. In 2010 theDepartment of Health’s finance chief JohnBolton announced that personal budgetswere proving to be ‘cost neutral’ overall,whereas previous studies had shown anoverall cost benefit.

In many ways this is a positive finding, but ata time when major savings are being sought,it raises questions about the scope forefficiencies. The move away from large blockcontracts makes economies of scale moredifficult to achieve, as providers take onincreased responsibility for risk, and faceconsiderable uncertainty in relation tovolumes of work, often over fairly short

contracts or framework agreements. Ifsavings cannot be found in this way, othermeans must be sought. For many councilsthis has had a knock-on effect on otheraspects of the service, either in terms ofeligibility criteria, or in terms of the hourlyrate an authority is willing to pay a provider.

Second, there are questions about the realimpact of personal budgets. Many are still‘managed’ budgets rather than directpayments, and there has been speculationabout the real level of choice that is availableto individuals. This will depend very much onthe area in question and the training andsupport offered to frontline staff. In manycases, service users will simply take theservices that are recommended by theauthority or provider. If staff do not have afull understanding of the products available,the service user may simply receive thesame service that they would have receivedin the past.

Even with a direct payment, service usersmay not always experience a greater level ofchoice and control. The use of personalbudgets and direct payments in the contextof young adults with learning disabilities isvery different to their application in thecontext of elderly people. Successful directpayments require the service user tobecome a commissioner themselves, achallenging prospect for many individuals.

Having real choice in the use of a personalbudget is dependent on users understandingthe full range of options available to them, aswell as the consequences of their choices.Unlike shopping for products in asupermarket, shopping for care can be anopaque and confusing process, and it isshaped as much by expectations as it is by

3 Challenges for outcome-based commissioning


the availability of care products. The socialcare White Paper includes a duty forauthorities to make information about localcare provision more easily accessible online,but more information alone does not alwaysmake such choices easier. The way thisinformation is presented determines its valueto the individual, and many will still needbrokerage and advice.

This is not to say the concept of personalbudgets is necessarily flawed: clearlydelivering an approach that empowers theindividual and gives them control over theirown lives is a desirable outcome. But wemust think carefully about what we mean bychoice, and how we make it meaningful forthe service users.

Local authorities unconsciously shapeservice user choices through the servicesthey provide and expectations that theybuild. We should be aware of this influencewhen we approach market management.

What does market managementmean in the context ofdomiciliary care?First, ‘market-management’ is oftencharacterised by councils aiming tomaximise the number and diversity ofproviders in the market place, with a view toincreasing choice for the service-user. Thiscan be an important aspect of marketmanagement, but on its own, increasing thenumber of providers does not necessarilybroaden choice, particularly if they areoffering similar packages of care. Choosingbetween 60 care providers all of whom offerthe same services is no choice at all.

As we noted above, the ability of serviceusers to make informed choices about theircare is often limited by a lack of information,and a poor understanding of what isavailable. Market management needs to befocused on the breadth of service as well asthe volume of providers.

Second, adult social care still has asignificant level of savings to deliver, but asmarkets are becoming more diverse thereare fewer opportunities to deliver savingsthrough the economies of scale generatedby large contracts. Savings must be foundelsewhere.

How should we monitorproviders?

Reducing waste in the system has been oneway in which authorities have sought toreduce their costs. The introduction offramework agreements has provided someof this impetus, by asking providers tocompete on the basis of cost and quality. Insuch agreements, providers are faced with ahigh level of uncertainty in terms of volumeof work and their long-term position in thelocal area. In theory this drives cost downand quality up and providers jostle for pollposition on the framework.

However, there are concerns about thisapproach. If the emphasis on cost isdominant, some providers are encouragedto submit ‘suicide’ bids in which they makeunrealistic cost appraisals in order tomaximise their opportunities for work.Without scrutiny from the local authorityfrom the very start of the tender process,this can have a serious impact on servicequality and in extreme circumstances causethe collapse of the provider. In Chapter 5 wewill see how some authorities have workedto shift the emphasis away from cost andonto quality.

Another trend in cost reduction and wasteminimisation is the renegotiation of hourlyrates for care with providers and theintroduction of electronic monitoring.Electronic systems are used to measure theprecise amount of time the provider is in thehome of the service user, allowing thecouncil to pay the provider for exactallocations of time. This approach hasallowed some councils to cut out journeytimes from payments to providers, and pay


them solely for the time they are deliveringcare. In a time of declining resources thisapproach has allowed some councils todeliver against their saving targets withoutany immediately apparent impact onservices.

There are however, implications for serviceusers in rationing time in ever smaller timeslots. According to a survey conducted bythe United Kingdom Homecare Association,three quarters of all trips to older people nowhave to the completed in less than half anhour, with one in 10 limited to no more than15 minutes.7

Sian Davenport, Regional OperationsManager for Mears commented that:

“Many local authorities now use electronicmonitoring of care workers such as CM 2000or Ezi Tracker. These systems put theemphasis on clocking in and out rather thanservice delivery. As service providers wewould like the flexibility to provide careservices that an individual wants. So forexample an individual may prefer threeweekly visits of 35 minutes than a daily visitof 15 minutes. With care frequentlypurchased in 15 minute slots it is verydifficult for a service provider to deliver apersonalised service. Electronic monitoringcan be a valuable tool for automatingfinance process and for health and safetymonitoring, but it is increasingly being usedas a mechanism to pay by the minute,leading to the system driving the service.”

The use of electronic monitoring in this wayraises questions about the balance betweencost and quality of service delivery.

How can we empower care staff?

The need for savings has also ledcommissioners to re-negotiate the hourlyrate of care with their providers and to pay

for smaller and smaller chunks of time;however, there are limits to how cheaplycare can be delivered by the hour. Careworkers are among the lowest paid insociety.

Research published by King’s CollegeLondon in 2011 has even suggested thatbetween 150,000 and 200,000 care workersover the age of 21 may be earning less thanthe statutory minimum wage. The figure is atleast five times higher than government’sown estimate from the Office for NationalStatistics (ONS).

In their response to the Caring for our future:reforming care and support White Paper,public sector union UNISON identifiedseveral areas of concern in relation tocurrent commissioning practice and cuts tofinance in social care. Some of the issuesthey identified included the following:

l the pressures of cost has increasedthe so-called practice of “e-auctionsrace to the bottom” and “suicidebids”

l the low funding of contracts places asqueeze on workers’ pay and timelimits to visits, creating pressure onboth the care recipient and the careworker

l care workers feel they don’t haveenough time or flexibility in theirwork, causing low morale

l the average hourly care worker ratein 2010 was £6 per hour, which is adrop of 4.8% since 2008 and,combined with rapid inflationincrease, makes an average drop inwages of 7.3%

l poor pay and low reward increaseschurn. The majority of care workers

7 http://www.telegraph.co.uk/health/elderhealth/9379877/Care-routinely-rationed-to-15-minute-slots-to-save-cash-study-shows.html


move to another provider in thesame sector for better pay. Often in health, which is seen as betterpaid and rewarded. The turnoverrates of care workers in April 2010was 21.4%.8

They also highlighted the reduction, or non-payment of travelling times between homecare visits as an important workforce issue.It could be argued that the increasinglyproscriptive approach to commissioningproviders and the growing pressure on thehourly rate in response to savings targets isa central part of this issue.

These comments were reflected in theNovember 2011 Equalities and HumanRights Commission’s Close to Home: aninquiry into older people and human rightsin homecare. It found that ‘somecommissioning was driven by quality, andreferred to human rights standardsthroughout the process, while otherpractices focused foremost on price. Costpressures lead to shortened care visits andincrease the risks to older people's human rights and to the quality and safetyof their care’.9

“We need adequate time and flexibility tomake sure that we meet the needs of ourclients. Our support improves our clientsconfidence and encourages them to keeptheir independence... this wouldn't bepossible if we had to stick to rigid 15 minutetime slots.” Gloria Yearwood, Care worker forreablement service, Chiswick

As the funding gap in social care opens up,we will be forced either to deliver the sameservice to a dwindling number of people, orto seek more fundamental change to theway we deliver services. While the problemof the funding of social care cannot be

resolved without major decisions on the partof central government, some of thechallenges do relate to the way in which wecommission.

How far have we moved awayfrom a time-task approach toservice delivery?Commissioning is built on a foundation ofoutcomes, but they are not usually carriedthrough into contractual arrangements. Inmost cases, service providers are stillcommissioned to deliver particular tasks,often within a set period of time, rather thanto achieve specific outcomes for theindividual.

This is particularly evident in a domiciliarycare setting. Even in a personalised service,providers in domiciliary care are usually paidto deliver specific tasks for an individual,within a specific allocation of time. In mostcases these tasks are decided on the basisof the outcomes the service user needs toachieve, but ultimately the provider is paidaccording to whether or not the tasks aredelivered, rather than whether or not theoutcomes are achieved.

If the outcomes have not been achieved, notonly is the provider still paid, but there isevery likelihood that they will receive anothercare package to continue the additionalsupport that is necessitated by their failure.

Translating outcomes into contractualarrangements with providers is an importantchallenge for care services. When providersare paid by the hour, it gives them a falseincentive to maximise the number of hoursthey spend with a service user, rather thanpromoting their independence, andsupporting their recovery where possible.This is a problem for two reasons.

8 http://www.unison.org.uk/acrobat/A13845.pdf9 http://www.equalityhumanrights.com/legal-and-policy/inquiries-and-assessments/inquiry-into-home-care-of-older-people/close-to-home-report/


First, consultation with people approachingthe care system invariably shows that they want to remain as independent aspossible, for as long as possible: they donot want to be reliant on care when they do not need to be.

Second, when we give providers anincentive to maximise their number of hourswith a service user, we are, in effect, payingthem to fail. In many ways, the currentsystem creates a false incentive forunscrupulous providers to increase the levelof care an individual requires. Besides beingcounter-productive for the individual, this isalso financially inefficient.

Service user needs change all the time, butpaying a provider on a time-task basismakes it difficult for the support plan to adaptquickly, resulting in some people continuingto receive services they do not require.Payment by outcomes ensures that the typeof support provided will adapt in whateverway will be most effective in attaining theoutcome.

Given the pressures on social care budgetsdescribed in Chapter 1, the need to findmore effective models of commissioningbased on outcomes is now urgent. If wewant providers to deliver against outcomes,we must build their incentives aroundoutcomes.

This will not only benefit those in directreceipt of services from the council, but willin time open up similar approaches to selffunders in the care system.

“It’s quite challenging for us ascommissioners and for providers to focus on outcomes rather than inputs and processes – we’re increasingly trying to capture individual experience and what it’s like to receive care and support commissioned by the local authority” LGiU survey respondent (assistant director for commissioning)

How do we establish andmeasure outcomes?Deciding what outcomes you want toachieve is the first challenge for outcome-based commissioning. For many, this is anopportunity to use coproduction, theinvolvement of service users in shapingservice design, as a way of setting theobjectives of a service and determining whatthe outcomes should be.

Defining and differentiating outcomes for theindividual and outcomes for the service isnotoriously difficult. Linking them together,establishing causal links and demonstratingcost savings where applicable is more so. Aswe can see from the local authoritycomments from our research, this isregarded as an obstacle for many councils.

What do you see as the mainbarriers to effective outcome-basedcommissioning in the future?

“Outcomes are difficult to measure andresource intensive.”

“Lack of understanding of outcomesand how they can be measured toprovide evidence of effective servicedelivery and value for money.”

“The inability to develop outcomebased specifications that can bemeasured which can deliver theappropriate level of service.”

Respondents to the LGiU’s survey of local government social caredepartments

Nevertheless, innovative approaches toaddressing this problem have been made.The New Economic Foundation proposed a‘public benefit’ model of efficiency usingSocial Return on Investment (SROI)


principles.10 SROI measures the broadersocial and environmental impacts of aservice, assessing the effectiveness ofoutcomes in terms of their benefit to usersand the wider community. The model aims tobuild the ‘triple bottom line’ into publicservice contracts, incentivising providers tomaximise their wider impacts wherepossible. SROI has been important indrawing the focus away from a narrowinterpretation of cost, offering an advocacytool that shifts the emphasis onto the socialvalue of wider service outcomes as well asfinancial cost. However in the currenteconomic climate, the emphasis is oncashable savings, which are more difficult toattribute. In a social care context, manyindividual outcomes are also hard tomonetise.

A more recent model, focused specifically onadult social care, is the Adult Social CareOutcomes Toolkit (ASCOT), developed bythe Personal Social Services Research Unit.It establishes ‘social care related quality oflife’ over eight domains (accommodation,cleanliness and comfort, control over dailylife etc.) and enables commissioners tomeasure the benefit of social careinterventions on that quality of life. Serviceusers can prioritise the factors according totheir personal importance, and theachievement of outcomes can be consideredas part of a cost-benefit analysis.11

Some authorities may choose to use thesemodels as a basis for developing their ownoutcome frameworks. Two of the mostimportant principles when establishing

outcomes in a contract are that they must beattributable to the performance of the serviceprovider, and they must be consistent for thesake of comparison. We will see both ofthese principles at work when we come toexamine Wiltshire’s Help to Stay at Homescheme in Chapter 5.

How can we support integration between theservices that support better outcomes forindividuals?

Health, social care and housing are mutuallysupportive in delivering personal outcomesfor the individual. While ClinicalCommissioning Groups and the shadowHealth and Wellbeing Boards have thepotential to shape the relationship betweenhealth and social care, there is still a longway to go in many areas of the country. Therole of housing in social care is increasinglyrecognised, as demonstrated by theinclusion of provisions relating to diversity ofhousing provision in the social care WhitePaper. However, as our research in the nextchapter shows, there are still broaddifferences between the culture ofcommissioning in social care and housing,raising questions about the future ofintegration between these services.

To explore these issues in more depth, weundertook a survey of local government,focusing on their domiciliary carearrangements. This was followed up with aseries of qualitative interviews with leadingcouncils to discuss their commissioningstrategies. The next chapter outlines ourmain findings.

10 http://www.neweconomics.org/projects/social-return-investment11 http://www.pssru.ac.uk/ascot/


Commissioning in social care hasprogressed significantly in recent years,but there is still progress to be made inturning outcome-based commissioninginto a reality. To test our assumptionsand form a basis for further research, weundertook a survey of local government,focusing specifically on domiciliary careservices.

We received 210 responses to our survey, ofwhich roughly half were officers and halfcouncillors.

Key findings include:

l while most respondents reportedthe regular use of outcome-basedcommissioning, a sizeable minorityof 35.9% said that it was only used‘to a limited degree’ in theirauthority. Seven out of 10 sawcommissioning for outcomes as a‘very important’ priority for socialcare in future;

l three-quarters of respondentsdisagreed with the statement ‘ourcurrent systems and processes willbe sufficient to manage our adultsocial care provision in future’,reflecting the present resourcingchallenge facing social care. Nineout of 10 agreed that pressure onresources was making themreconsider the way in which theyprovide social care

l three-quarters of respondentsregarded ‘a culture of runningservices on a time-task basis’ as animportant barrier to outcome-basedcommissioning in future. However,

more than 90% still pay providersaccording to the time they spendwith a service user, rather thanoutcomes

l the types of organisations beingcommissioned as providers isexpected to diversify. Moreauthorities identified in-houseprovision as a method of delivery in future, while the number ofcouncils commissioning socialenterprise providers is expected todouble.

Budget position

55% of social care respondents reportedoverall budget reductions of more than 5% inthe last financial year, with the majority ofthese seeing reductions of between five and10%. Just under 20% reported that theirbudgets had remained the same, or evenincreased (see Chart 1).

We asked respondents to identify wherethey had made their savings (see Chart 2,overleaf).

The most common choices werenegotiation with providers, and back officerestructures. However, there were anumber of individual responses whichincluded:

l re-tendering services

l charging for day care

l tightening eligibility criteria

l reducing other rates in the contract(other than the hourly rate)

4 The local authority position


l increasing level and scope ofcharges and reducing level andscope of concessions

l increased use of reablement and extra care housing

l sharing services with health.

This confirms that while many authoritiesare finding innovative ways of deliveringsavings without affecting frontline services,the ultimate funding position is such thatauthorities are struggling to meet demandwithout raising eligibility criteria for services.

Providers

We asked respondents who they currentlycommissioned as domiciliary care providers,and who they planned to commission infuture (see Chart 3, overleaf).

The majority of councils expected to retain ahigh level of private sector delivery, with over90% of respondents reporting that they willcontinue to commission private sectorbodies.

The most significant changes were the risein prominence of social enterpriseorganisations (a massive increase from35.1% to 74.2%), and the number of

Increased

Remained the same

Reduced by less than 5%

Reduced by between 5% and 10%




Reduced by more than 30%

Don’t know

0% 10 20 30 40 50%

Chart 1: How was your adult social care budget affected in the last financial year?

Per cent

12.2

6.7

6.7

2.2

8.9

16.7

31.1

15.6


authorities planning to take a proportion oftheir services in-house.

Whereas no one reported currently havingin-house provision, 16.1% of respondentssaid they would provide some level ofprovision in this way in future.

Nevertheless, it is also clear that mostcouncils intend to retain at least someaspect of commissioning third parties,perhaps pointing to a greater diversity ofproviders (including some in-house options)going forward (see Chart 4).

The number of organisations that authoritieswere commissioning varied considerably.60.5% of respondents had more than 10providers delivering domiciliary care, withroughly two out of 10 having more than 30providers in total (see Chart 5, overleaf).

Approaches to commissioning

Survey respondents reported a high level ofengagement with providers prior to letting acontract. 81.4% of respondents said theyengaged with providers in advance of allcontracts. 67.5% said the same for service

Negotiating with current providers

Restructuring back office functions

Moving to personal budgets

Shifting the servicetowards prevention

Introducing a frameworkagreement

Re-tendering to reduceyour hourly rate

Reducing your residential offer

Sharing services withother departments

Reducing other frontline services

Sharing services withother councils

Don’t know

0% 10 20 30 40 50 60 70 80 90 100%

Chart 2: Where appropriate, how have you made your savings in adult socialcare? Please tick all that apply.

Per cent

66.0

79.8

83.0

61.7

24.5

22.3

13.8

52.1

37.2

28.7


Private sector

Social enterprise organisations

Other public sector bodies

Large national or regional charities

Local voluntary and community sector groups

All our services are provided in-house

0% 10 20 30 40 50 60 70 80 90 100%

Chart 3: Who do you commission as adult domiciliary care providers? Please tick all that apply.

Per cent

10.6

35.1

93.6

45.7

52.1

Private sector

Social enterprise organisations

Other public sector bodies

Large national or regional charities

Local voluntary and community sector groups

In-house provision

0% 10 20 30 40 50 60 70 80 90 100%

Chart 4: Who do you expect your domiciliary care providers to be in future? Please tick all that apply.

Per cent

16.1

74.2

92.5

55.9

72.0

16.1


1 to 5

6 to 10

11 to 15

16 to 20

21 to 30

30 or more

0% 5 10 15 20 25 30

Chart 5: How many care providers do you have for domiciliary care?

Per cent

14.3

25.3

14.3

14.3

12.1

19.8

The reputation of theprovider/CQC reports

The provider’s track recordin customer satisfaction

The hourly rate

Overall contract cost

The ability of the provider to invest in the service

The provider’s ability to reducecosts through prevention

Your relationship with the provider

The size or capacity of the provider

The geographical location of the provider

0 1 2 3 4 5

Chart 6: How important are the following considerations in tendering for adomiciliary care contract? Please choose the top 5 considerations (1 being the most important)


users. Nevertheless, a sizeable minority of30% said that a ‘lack of trust’ betweencouncil and provider was proving anobstacle to better commissioning.

This assertion has also been publiclychallenged by providers. In their evidenceto the recent Local Government APPGenquiry into social care funding, social careprovider Mears expressed concern aboutthe level of local authority engagement withthe sector.

“Providers can do much more to integrateservices as we are doing at Mears. Localauthorities should commission outcomebased broad independent living contracts,which encourage providers with differentskills to collaborate and integrate theirservices together. The problem we face isgetting real dialogue with local authorities, atthe right level, to encourage this type ofthinking.”Alan Long, Executive Director of Mears

We asked respondents what their mostimportant considerations were in choosing

providers. The most popular responseswere ‘the reputation of the provider/CQC’,‘the provider’s track record in customersatisfaction’ and ‘the hourly rate’ (see Chart 6).

It was noted by several respondents that amove towards personal budgets and directpayments requires individuals to becomecommissioners themselves, and the role ofthe council has shifted to facilitating thisprocess.

Domiciliary care contracts were typicallyquite short. 12.9% of respondents reportedcontracts that were less than two years longand the majority (84.7%) were between twoand five years (see Chart 7). Many of thesewill be on framework agreements rather thanblock contracts as was formerly the case.

While this provides flexibility for councils, itcan also cause instability for providers whomay find it difficult to invest in services whenthere is so little certainty in terms of volumeof work, and the renewal of the agreementgoing forward.

2 years or less

Between 2 and 5 years

5 to 10 years

10 years or more

84.7%

2.4%

12.9%

Chart 7: How long is a typical domiciliary care contract in your authority?


Service user surveys

Complaint levels

CQC reports

Audits

Electronic monitoring

Time sheets

User panels

0% 10 20 30 40 50 60 70 80 90 100%

Chart 8: How do you monitor your domiciliary care providers? Please tick all that apply.

Per cent

78.4

80.7

85.2

65.9

50.0

26.1

23.9

Not at all

To a limited degree

In most cases

In all cases

35.9%

2.2%

15.2%46.7%

Chart 9: In your view, to what extent does your authority practice outcome-based commissioning in adult social care?


This may have a particularly adverse effecton small providers, but equally makesbusiness planning and service investmentmore of a challenge for providers of all sizes.

“Commissioning defines shorter periods, andplaces greater risk onto the provider. Oftenthis puts off new and smaller companies inbeing involved with local authority work at all.This is such a growth business, that localauthorities are in danger of not finding enoughproviders of sufficient financial and staffingstrength to give real local competition.”County Councillor from East Midlands

Monitoring

A variety of approaches were taken tomonitoring domiciliary care providers, themost important being service usersatisfaction surveys and complaint levels.This indicates a level of service userinvolvement in monitoring processes.However user panels were much lesswidely employed, with less than a quarter ofrespondents reporting that they were usedat all (see Chart 8).

Electronic monitoring was undertaken by halfof respondents. This reflects the importancegiven to ensuring providers are meeting theirobligations in terms of the time spent with aservice user, and are paid for this time only.

Outcome based commissioning?

There was a mixed view on the level towhich outcome-based commissioning is acurrent feature of the council-providerrelationship. 15.2% stated that it was used inall cases. Roughly half said it was used in‘most cases’. However, over a third said thatit was only used ‘to a limited degree’ (seeChart 9).

The benefits of outcome-basedcommissioning were largely represented interms of their impact on the individual andthe ability to deliver personal outcomes. Sixout of 10 saw it as an opportunity to reduceservice costs. However, less than halfregarded it as a way of increasing thecapacity of the service and less than 10%regarded it as a way of transferring risk tothe provider.

by the minute?

by the quarter of an hour?

by the half hour?

by the hour?

by another mechanism?

13.1%23.8%

7.1%

26.2%

29.8%

Chart10: Are your domiciliary care providers paid...


By contrast, more than 90% of respondentsreported that they pay their providers on atime-based rate. A substantial minority paysthem by the minute and the largestproportion by the half hour: only 7.1% wereusing other means of paying their providers(see Chart 10).

This is particularly interesting in the contextof earlier views on commissioning. Can aservice in which payment is made on thebasis of time, not outcomes ultimately bedescribed as ‘outcome-basedcommissioning’?

There was clearly a high level recognition ofa need for review in the current system.Three quarters of respondents saw ‘a cultureof running services on a time-task basis’ asa barrier to outcome-based commissioningin future.

Bearing in mind the predominance of thetime-based rate as a method of payingproviders, this finding raises questions as towhy these models of commissioningpersist. Possibly part of the problem lies inthe complexity of measuring outcomes andin building them into a contract in ameaningful way.

Monitoring an outcome-based contract is alsoa more difficult challenge. Ensuring aprovider is fulfilling a duty to attend a serviceuser for a set period of time in a day isrelatively straightforward to monitor. Ensuringthey are delivering outcomes for theindividual is less easy to assess. Payment byoutcomes is also complicated by the rise ofdirect payments, in which the service usertakes on the role of commissioner.

Working across boundaries

We asked respondents about theinvolvement of other local services insupporting the care agenda. While healthwas seen as being very active, there was

clearly scope for increased involvement ofsome of the other services (see Chart 11).

The interface with housing is of particularinterest. The draft Care and Support Billreflects this in its proposed duty for localauthorities to work towards joining upadaptations and home repair services withcare and support.

The NHS Future Forum reports that theNHS spends £600m each year treatingpeople due to severe hazards in poorhousing, mostly as a result of falls.12

Health, social care and housing needs areclosely interrelated and a lack ofcoordination between the services can havea profound impact on service level andindividual outcomes. If the interface is notworking, a service user can be faced with amultitude of visits; someone to discussdomiciliary care, someone to discusstelecare and someone to discussadaptations.

Roughly half of respondents to our surveysaid that housing was ‘very active’ in thesocial care agenda, suggesting there is stillroom for development in this area. Tounderstand this issue better, we undertookan additional survey of housing departments,focusing on repairs and maintenance. Wereceived 163 responses, of which 43.8%were officers and 56.2% councillors.

The survey demonstrated that while bothsocial care and housing were engaging withthird parties to deliver services on theirbehalf, there were considerable differencesin their methods of managing this process.The two main contrasts relate to thedistinction between a ‘contracting’ and acommissioning approach.

l Number of providers/contractorsIn social care, 60.5% of respondentshad more than 10 providers

12 NHS Future Forum, Integration: a report from the NHS Future Forum, 2012


delivering domiciliary care, withroughly two out of 10 having morethan 30 providers in total. Thepicture in repairs and maintenancewas very different, with 70% ofrespondents having five or fewerorganisations contracted to deliverthese services.

l Length of contract Domiciliary care contracts weretypically much shorter than those inrepairs and maintenance. 12.9% ofrespondents reported contracts thatwere less than two years long andthe majority (84.7%) were betweentwo and five years. In repairs and maintenance by contrast, nearly40% of respondents said theirtypical contract was five years or longer.

Repairs and maintenance and social careare very different service areas, with verydifferent models of service delivery.However, they are both ultimately services

which deliver outcomes for individuals, andare both essential in supporting people tolive independently at home for longer andsupporting them to achieve personaloutcomes.

It is therefore worth considering whethersocial care commissioners and housingcontract managers could learn more fromone another’s methods.

The future

The survey revealed a level of concern inthe sector regarding the future of adult socialcare. Over three quarters of respondentsdisagreed with the statement ‘our currentsystems and processes will be sufficient tomanage our adult social care provision infuture’.

More than 90% agreed that pressure onresources was making them reconsider theway in which they provide social care.Interestingly, by contrast, 78.8% of housingprofessionals said that they already had ‘the

Leisure

Housing

Health

Transport

Advice services

0% 10 20 30 40 50 60 70 80 90 100%

Chart 11: To what extent would you say the following services are activepartners in the adult social care agenda in your local area?

Fairly active Very activeNot at all active Not very active

Per cent

5.7 27.3 43.2 23.9

4.4

37.8 46.7 11.1

14.4 48.9 36.7

3.3

19.6 77.2

13.0 40.2 46.7


right systems in place to manage repairsand maintenance effectively in the future’.(see Chart 12).

These responses acknowledge the growinggap between demand and resources in adultsocial care. They suggest that peopleworking in the sector recognise a need forchange as a result of some of the driversoutlined in Chapter 1.

Despite this, there was little consensusabout the best way of changing the systemto make it sustainable in the future.

Respondents regarded a whole range oftools as important in addressing theresourcing gap. Outcome-basedcommissioning was regarded as ‘veryimportant’, as were reablement, partnershipswith health and preventative services.Payment by results and electronicmonitoring were only seen as fairly importantby comparison (see Chart 13).

Barriers

Finally, we asked respondents what the mainbarriers to effective outcome-basedcommissioning were.

The most significant reason highlighted was‘a culture of running services on a time-taskbasis’, with nearly 75% of respondentsidentifying this as a barrier.

However, a number of other issues wereidentified in the comments section includingthe following:

“Commissioning defines shorter periods, andgreater risk onto the provider. Often this putsoff new and smaller companies in beinginvolved with local authority work at all.”

“Difficulty in measurement and resourceintensive.”

“Working with council lawyers.”

“The inability to develop outcome-basedspecifications which can deliver theappropriate level of service that can bemeasured.”

Elected members

The survey was targeted at electedmembers with the portfolio for adult socialcare, or those with scrutiny panelresponsibilities for this area. Nevertheless, asignificant proportion of councillorsexpressed a lack of understanding of thedetail of social care commissioning; the typeand number of providers in the market, thecommissioning approach taken by their localauthority and the way in which providerswere engaged to deliver services on behalfof the council. Social care is a complexservice area and perhaps this isunderstandable, but it does highlight a need

Pressure on resources is making us reconsider the ways in which

we provide adult social care

Our current systems and processeswill be sufficient to manage our

adult social care in future

0% 10 20 30 40 50 60 70 80 90 100%

Chart 12: To what extent do you agree with the following statements?

Agree Strongly agreeStrongly disagree Disagree

Per cent

2.2

6.7 36.7 54.4

23.0 52.9 24.1


for training to ensure that elected membershave the appropriate skills to both lead on,and scrutinise work in this area.

“I have no knowledge of the state of themarket. As a back bench opposition memberI have limited information as to the issuesinvolved in what is a radical change instrategy.” LGiU Survey Respondent (adult social careand health scrutiny panel member)

Implications

The results of the survey reinforce some ofthe concerns highlighted in earlier chaptersin relation to commissioning challenges.

l There are concerns in localgovernment about current systemsof commissioning. The ‘time-task’approach is seen as a serious

challenge for the future of outcome-based commissioning.

l True outcome based commissioningis by no means universal. The vastmajority of councils still pay theirproviders on the basis of the timethey spend with a service user (anoutput), rather than the outcomesthey deliver for the individual.

l Market management for manyauthorities means increasing thenumber and diversity of providers inthe market, rather than focusing onthe range and diversity of serviceson offer.

l In many areas there is still acommissioning disconnect betweenrepairs and maintenance servicesand care and support.

Fairly important Very importantNot at all important Not very important

Outcome-based commissioning

Electronic monitoring

Rolling out personal budgets to allour domiciliary care service users

Using payment by results in our contracts with domiciliary

care providers

Extending re-ablement

Developing closer partnershipswith the health sector

Developing preventativeapproaches to delivering

social care0% 10 20 30 40 50 60 70 80 90 100%

Chart 13: How important will the following be in adult social carecommissioning over the next five years?

Per cent

1.1

25.3 70.3

3.3

2.2

20.0 51.1 26.7

1.1

27.0 43.8 28.1

3.3

18.7 78.0

1.1

18.3 80.6

2.216.1 81.7

1.1

32.6 65.21.1


While councils are innovating to addressthese challenges and prevent an impact onthe frontline, there is clearly concern that thecurrent systems and processes they havewill be inadequate to deal with demand forservices in future.

This throws up a number of importantquestions for local authorities:

l What further steps can we take tobreak down a time-task culture incommissioning domiciliary care?

l How can we most effectivelyincentivise providers to promoteindependence and reduce careneed?

l How can we ensure outcomes areshared between health, housing,social care and other relevantservices to minimise waste andavoid duplication?

l How can we establish and measure outcomes that aremeaningful to both provider andservice users?

l How can we ensure service usersare fully engaged in shaping theirown care and determining theoutcomes they want to achieve?

l How can we ensure care staff aresupported and empowered to deliverhigh quality services?

With this in mind, we undertook interviewswith local authorities about theircommissioning approach, to help us build apicture of practice at a local level and toidentify areas of innovation.

In the next chapter we will draw on some ofthe case studies to illuminate the ways inwhich some councils are working to answerthese questions.


In the previous chapter we examinedLGiU survey results that highlightconcerns in local government about thesystems and processes associated withcommissioning home care services.Councils are facing a serious set ofissues in relation to capacity andresourcing in adult social care. Managingoutcome-led commissioning processesagainst the backdrop of significantsaving targets, rising demand and publicsector reform is complex andchallenging. While in the long termcommissioning for outcomes is moreefficient, and better at avoiding wastethan commissioning on a time-task basis,it may require a level of up-frontinvestment that is difficult to secure atthe present time.

Nevertheless, many local authorities areworking to find new ways of delivering these

services and improve the quality of servicefor the individual. We interviewed a numberof councils to collect examples of innovativepractice in delivering home care servicesacross a range of themes:

l Incentivising providers to deliveragainst outcomes

l Breaking down a time-task culture

l Sharing outcomes acrossorganisational boundaries

l Shifting the emphasis away fromcost and onto quality

l Working with service users to designservices and establish outcomes

l Supporting care users to makeinformed decisions

5 Commissioning approaches

Incentivising providers to deliver against outcomesand breaking down the time-task cultureWiltshire County Council: Help to Live at Home

When Wiltshire County Council reviewed their domiciliary care arrangementsas part of their transformation programme they realised that the serviceneeded to change. It was over-complicated, with over 100 different contractswith providers. Service users reported that they couldn’t understand thesystem, and care package length was increasing to an extent that could not beexplained by rising demand.

Consultation with service users showed that they wanted social care servicesto support their autonomy and to give them the skills and technology to liveindependently where possible. What they did not want, was increased reliance


on services, but the figures showed that this was what was happening. Thecouncil decided to address the challenge through their relationship withproviders, by moving away from a time-task culture. With this in mind, theychanged their commissioning strategy and established the Help to Live atHome scheme.

l They established eight geographical areas in the county, each with aseparate contract for care with one provider. This provider wasguaranteed all the initial support plans assessed by the council in thisarea, but they were also obliged to take everything they were given. Initialsupport would not be means tested and would aim to give the customertime to consider what care and support they might need in the long termwhere appropriate.

l Providers were asked to salary their care workers, rather than payingthem an hourly rate. This was seen as an important step in driving upquality in the service.

l They established two rates of payment: standard and specialist. However,while these rates would be used to cost a package, the amount of timespent with a service user would not be the basis of payment.

l They established a framework of standardised outcomes against whichthe provider could be expected to deliver. These had to be observable (asopposed to a self reported level of wellbeing for example) and directlyattributable to the work of the provider. ‘I can’ formed the basis for eachoutcome: ‘I can cook a meal for myself’, ‘I can use the bath withoutoutside help’ etc. The outcomes fell into two broad categories:‘reablement’ and ‘maintenance’ outcomes.

l The outcomes for a particular care plan are developed from a person-centred assessment of the service user, and must be accepted by theservice user, the provider and the local authority before they areapproved. A proportion of them are termed ‘payable outcomes’ and theprovider receives a penalty for not delivering against them.

l Contract monitoring is managed using a new online system, developedspecifically for this purpose. Everyone involved in the process has accessto an online dashboard that shows progress against each outcome, alongwith other measures of performance including service user feedback.

l The initial support package is free and is reviewed by the council at itsend. The provider is then asked to draw up and cost the next plan, whichmust be for a maximum of six months. The council approves it and offersit to the service user, at which point they can either accept the plan, ortake the monetary value of the plan as a direct payment.


The London Borough of Sutton: payment by outcomes inthe Substance Misuse Service

When Sutton re-commissioned their substance misuse service this year, theydecided to review their commissioning approach: many of the services hadbeen commissioned on service level agreements up to 10 years ago, and therewas a need to ensure these arrangements were brought into line with thecouncil’s corporate commissioning strategy.

As a result of both national and local drivers, the council decided to use apayment by outcomes approach for the service to encourage the focus ondelivering outcomes for all clients and to share financial risk with providers. Anoutcome was described as the benefit the person has gained from contact withthe service, and a set of outcomes were agreed as part of the commissioningstrategy. A market-testing day was held with potential providers to getagreement to what is deliverable and how the outcomes might be measured. Itwas agreed that 75% of the funding would be offered on the ability to deliver toset standards, while 25% would be retained and paid against the achievement ofagreed outcomes. The council hopes to roll this approach out to other servicesonce it has been trialled in substance misuse.

Payment by results in reablement – Essex County Council

Essex County Council is currently engaged in a long-term programme to shifttheir care and support provision away from a time task approach. They havearticulated their new approach in a Market Position Statement, which sets outtheir vision for commissioning social care in the future. As we describe later onin this section, they have already moved towards a best value rankingframework which emphasises both cost and quality. Their next challenge is towork with providers to develop a performance-based system, which pays foroutcomes, rather than activities, and which promotes independence for serviceusers wherever possible.

With this in mind, they have embarked on further consultation with providersand re-tendered their reablement service. Formerly, providers were paid for six-week packages at a set price. Under the new model, they will be paid in twoways. They will still receive a set price for the package, but will also receive abonus payment if, at the end of the reablement plan, the service user does notrequire any further support.

The council intends to move away from setting an arbitrary number of weeks forthe package, which will be shorter or longer than six weeks depending on theneeds of the individual service user. Ultimately they aim to move all their homecare provision onto a performance-based model. For service users with learningdisabilities, they are working specifically on developing whole life budgets withan emphasis on pathways to independence.


Wigan’s home care transformation

Wigan Council has been moving completely away from the old "time and task"approach to providing home care.

It believes that there is both a human and a financial cost to providing serviceswhich simply fulfil routine tasks rather than responding to the real needs of theresident. Adopting an outcomes approach gives residents a more personalservice, and with home care forming one of the biggest bills for a local authority,it also makes financial sense - there is a real cost to delivering services in waysthat do not give customers the chance to improve, or to stop things that don'thelp their lives.

The council has transformed its services by creating a re-ablement team as partof a holistic local offer to people - anyone who first contacts its services isoffered a package of support for an initial six weeks to help them recover theirindependence. This includes re-ablement home care, assistive technology andoccupational therapy assessment.

The next step was to try to make this approach to supporting people'sindependence universal. Having decided to set the same challenge to all itscommissioned home care providers, the council met regularly with them andactively developed organisational development and quality standards for all itshome care services. It co-designed improvement standards for home care withthe providers, asking them to self assess regularly and evidence improvementoutcomes.

Wigan has also changed its assessment process to one which is entirelyoutcome focused, and established a team of brokers who are able to use theoutcomes that customers have agreed they want, as the basis of helpingsomeone plan their support. Along with this, an indicative allocation of money iscalculated. So the request for home care is not, for example, based onspecifying the number of visits, time of day and tasks to be done, but theoutcomes the customer has agreed they want delivered for them personally andthe indicative amount of money available to provide the service. Proposals fromproviders can then be reviewed and agreed based on the best offer that thesocial worker and customer feel will meet their need.

Wigan has now procured an on-line market place where providers will be able toadvertise their services, prices and options.


Sharing outcomes across organisational boundariesWirral Rapid Access ContractWirral PCT wanted to reduce its hospital discharge times and develop moreseamless referrals between health and social care. The referral system wascomplicated and was resulting in people remaining in hospital for longer thanrequired. This had an impact on the patient’s health and recovery time, and wascosting the service money and creating a bottle-neck for bed allocation. Toaddress this problem, the PCT formed a partnership with the local authority, andfour social care providers to deliver a ‘rapid access’ contract that aimed to getpeople discharged within 24 hours.

Previously when a ward manager discharged a patient their case was referred toa broker, who tried to find a home care provider who could take on their case.Under the new arrangement, when an individual is deemed medically fit fordischarge but does not have a package of home care in place, care plan and riskassessments are completed by a multi-disciplinary team at the hospital. Mearsreceives referrals from this team. Previously the referral could take up to sevendays to put in place and the person would have to remain in a health andwellbeing bed until the assessment and package was in place. This cost anaverage of £250 per day.

Mears is one of four providers on the approved list who will accept a rapidaccess package. Within 24 hours the client will receive a home care package,this will continue for a maximum of 14 days when the care transfers to adomiciliary care provider. There is an agreement between the providers that norapid access client will be kept on as a domiciliary care package by the sameagency.

So far 280 clients have been allowed home from hospital on the rapid accesscontract, all within 24 hours.

Hertfordshire County Council and reablementHertfordshire County Council is committed to ensuring that individuals are ableto maintain their independence whenever this is possible. To support this allindividuals requiring ongoing support and services are finding that 80% can besupported through a reablement pathway with a view to optimising theirindependence and reducing their level of dependency on ongoing care packages.

This service has been commissioned from a single provider contract to ensurethat they have equity to coverage and a targeted and dedicated enablementworkforce. To date the success of this service has seen about 52% of thoseentering the service requiring no ongoing care package after six weeks ofsupport and a further 21% requiring a reduced ongoing package.


Integrating home care and housing maintenance in Wigan

Traditionally if a care-services worker spots a trip hazard or other problem in acustomer’s home they report it to their supervisor. They in turn let their managerknow. The manager should contact social services, which in turn, make a reportto the landlord. The landlord will then put in a request to a contractor for anadaptation or repair.

Mears is working in Wigan to make services for older people more efficient. Ithas combined care-services with housing maintenance teams. This has meantthat responses to problems are virtually immediate. Care workers are uniquelyplaced to identify potential problems or hazards that could cause an accident.

Older people who use the service have said they feel safer knowing trip hazardsare repaired quickly and they like the fact that the repair worker visits arecoincided with visits from the care worker that they know and trust so they feelreassured that the workman is genuine.

Shifting the emphasis away from cost and on to qualityEssex County Council: managing the domiciliary caremarket

Essex County Council no longer sets an hourly rate for domiciliary care. It assesses all providers on the basis of cost and quality (50/50 weighting) andthen ranks them on a framework. Quality is assessed using a range ofmeasures, from CQC assessments to service user feedback.

While the cost of running the service has increased slightly (as providersmust be re-assessed every six months) the new system has generatedsavings overall. By letting the market set the hourly rate through competitionbetween providers the council has found that the price has dropped withoutdirect intervention on its part and has now stabilised. As a result of thisstabilisation, there is far less change in the price element of the criteria, andthe emphasis has shifted to quality. Providers are now competing primarily onthis basis.

Bracknell Forest

Bracknell Forest Council has taken a different approach. It has set a singlehourly rate for all its domiciliary care providers. The council feels that takingcompetition around pricing out of the equation has allowed providers to focuson quality over cost.


Working with service users to design services andestablish outcomesSurrey County Council

Surrey County Council has produced a ‘Framework For Working With TheVoluntary, Community And Faith Sectors’ that identifies the overarchingapproach to involving the VCFS sector, along with users and carers. It now hasa common method of co-production that applies to all commissioningprocesses in adult social care. Its aim is that commissioning processes involveservice users, carers, relevant partner organisations and the market in order tohelp shape, co-design and co-produce.

It has a protocol for each of its four stages of commissioning (analyse, plan, do,review) which sets out the roles of the users and carers, and those of providers.

Staffordshire County Council’s Green Paper on CareQualityStaffordshire had retendered its domiciliary care services in response to theneed to make savings, using block contracts across four geographical areas.However, it found that the strong emphasis on cost was affecting servicequality and relationships with providers. The council invested £1.25m in theservice and started to move providers onto a framework agreement. In July this year it launched a Green Paper to set out its vision for a revolutionin care quality as a basis for consultation. The recommendations in the paperinclude:

l Working with providers towards an accepted and transparent working wagefor those working in the sector as well as further ‘professionalising’ workingin the care sector to drive up care quality.

l Taking steps to reward excellent quality, via financial and other means; witha proactive ‘zero tolerance’ to poor quality.

l Introducing a raft of measures for more transparent information sharing withthe wider community, for example, publishing the details of the minority ofproviders that aren’t achieving the expected quality standards.

l Investing in more front-line quality monitoring and more targeted trainingand development for providers to drive up quality standards.

Staffordshire is also beginning to challenge geographical limitations in careprovision, working closely with Derbyshire County Council to share providersacross council boundaries.


It has several examples of how this has worked in practice, particularly inrelation to people with a sensory impairment. A commitment to co-productionthroughout the development of the sensory impairment commissioning strategy,from people telling commissioners what was missing through to writing servicespecifications, has led to the provision of lip reading classes for people who arehard of hearing. Co-production continues through the Surrey SensoryPartnership, where the membership review services and monitor contracts.

Trafford Quality Checkers

Five years ago Trafford Council was experiencing problems with the variablequality of their social care providers. In response to this it initiated animprovement partnership that included providers and user groups. Thepartnership was launched with a home care conference to which all the partnerswere invited.

At the meeting a series of general principles were discussed and agreed, whichproviders were afterwards invited to sign up to. As the council wanted to placeservice users at the centre of the improvement programme, it began to train ateam of citizen assessors to think about future proofing services. Working withthe new citizen assessors, it held quarterly user-led audits of each provider. Theuser groups established an improvement plan for each provider, as well as anoverall plan for the service as a whole.

The citizen assessors are now known as Trafford Quality Checkers. They are alltrained to complete quality audits and are now taking on new responsibilities,such as reviewing the cost of care.

Supporting care workers to make informed choicesHertfordshire County Council’s e-marketplace

Hertfordshire has established an e-marketplace described by the council as an‘Amazon for care’. The web portal, which will be launched this year andultimately will allow council employees, members of the public, family carersand service users to buy home care or day services either directly or using theirdirect payments or personal budgets. It is being delivered in partnership withSerco, and is part of a wider review, which will help towards the council’s widerefficiency requirements. Hertfordshire has also been working on a helpline,HertsHelp, which brings together more than 130 community groups andorganisations in the county, and allows the public to access the services theyneed through one point of contact, preventing them having to try multiple routesand is particularly useful for GPs and other professionals who want to be able todirect their patients to a trusted source of support for a wide range of supportservices and voluntary organisations.


The innovation demonstrated by the casestudies in this section show the extent towhich commissioning practice has diversifiedat a local level and the ways in which localauthorities, with their partners, are arriving atdifferent solutions to address the uniqueproblems that they face.

There are significant challenges in movingtowards a commissioning approach that notonly incentivises providers effectively, butshares outcomes across boundaries andhelps service users to have real choice inthe care they receive. Each of theseexamples demonstrate that change requirescommitment and vision, with a view to how

the whole system of care will fit together.The most challenging examples haverequired a willingness to accept risk inexchange for the benefits of innovation.

While different local authorities will findsolutions that suit their own individualcircumstances, there are themes thatemerge from this practice; questions thatcommissioners and elected members withresponsibility for domiciliary care can askthemselves when they review theseservices. The next chapter deals with someof the lessons arising from the casestudies, and draws out a series ofrecommendations.


We have seen that local authorities have concerns about the challengesahead in social care, and are ambivalentabout the success of outcome-basedcommissioning. We have also seen thata time-task culture is still regarded asan important challenge in deliveringhome care.

The case studies in the previous chapterhighlight a number of examples ofinnovation in commissioning foroutcomes. While the solutions todomiciliary care issues will differ fromauthority to authority, there are somebroad lessons that could help to informpractice. These recommendations takethe form of a checklist of five questionswhich commissioners, cabinet membersfor social care and councillors withoverview and scrutiny responsibility forthis area should consider in relation totheir domiciliary care provision.

Checklist: five questions to helpto raise the game ofcommissioning1) Are you contracting foroutcomes?

To incentivise providers to deliver outcomes,it is important that we distinguish betweenincluding service-level outcomes in thecommissioning process and commissioningfor outcomes for the individual.

The former involves identifying the service level outcomes you are aiming toachieve (potentially using coproductionmethods), including them in commissioningstrategies.

Commissioning for outcomes, however,means explicitly linking the payment ofproviders to the outcomes they deliver,rather than their activities.

Fewer than 10% of authorities reportedpaying their providers on this basis in oursurvey. When providers are paid on anhourly rate, they have very little incentive toreduce individual dependency on services.Giving them the right target to aim for willhold providers to account, reduce waste,help to improve the financial efficiency of theservice and result in better outcomes for theindividual.

This is by no means straightforward andrequires significant planning and preparation.As we saw with Wiltshire’s Help to Live atHome scheme, there are several questionsthat need to be addressed before outcomescan form a more central part of the wayproviders are engaged.

What outcomes will you use?In Chapter 3 we outlined some of the workundertaken by the New EconomicsFoundation in relation to Social Return onInvestment and the Personal SocialServices Research Unit in relation to theASCOT toolkit. Wiltshire establishes itsoutcomes for the individual based on aperson centred assessment which iscompleted by the service user and consistsof five questions.

When shaping the responses into theoutcomes against which providers will bepaid, the council uses what it has termed‘Payable Outcomes’. While Wiltshire hasdeveloped its own set of outcomes as partof its needs eligibility assessment, it usedthe ASCOT toolkit as a starting point.

6 Recommendations


“ASCOT gave us confidence to believe thatwe could define outcomes suitable for asystem of payment by results with enoughprecision and objectivity for payment byresults.” James Cuthbert, head of performance improvement

Each ‘Payable Outcome’ must beattributable to the actions of the provider andcomparable against other outcomes on thesystem. Not all the individual outcomes inthe care plan will be payable outcomes. Asin the ASCOT toolkit, the Wiltshire outcomesare of two kinds.

First there are improvement outcomes,where the provider is asked to help acustomer gain or regain some skills or ability.Second there are maintenance outcomeswhere the provider is asked to deliver moreconventional care, but to include the use ofTelecare and other forms of assistivetechnology.

Either kind of outcome can be used in initialor ongoing support plans, depending whatthe customer needs and wants. Someongoing plans can include a lot ofreablement, while other initial plans areabout maintenance only.

How will you monitor your outcomes?Knowing whether or not outcomes havebeen achieved is more complex thanknowing whether a provider has spent agiven period of time with a user.

In Wiltshire, the council reviews each careplan retrospectively to determine whether ornot the outcomes have been achieved. Theprovider speaks to the service user abouttheir progress on a regular basis and, shortlybefore the planned end of each supportplan, uploads this information onto the online‘Carefirst’ social care case managementsystem, to which both providers andauthority have access. The progress reportis checked by the council as part of itsstatutory review of the customer’s needs.

What will happen if a service user is toreceive a direct payment? Wiltshire puts every new entrant to the caresystem onto an “initial” support plan thatnormally includes some reablement,Telecare and assistive technology but maybe as simple as temporary domiciliary careduring a period of convalescence. ‘Initialsupport’ is not means-tested. It allows thecustomer time to recover and to considerwhat care and support they might need inthe long term.

At the end of this time, if the customer needsmore care, the provider is asked to producea new ‘ongoing’ support plan with outcomesfor the longer term and an estimate ofweekly costs. This estimate is thecustomer’s personal budget. The value is notbased on the Resource Allocation Systembut on the provider’s estimate of the cost ofmeeting their needs in a support plan Theservice user can either accept, or take thecost of the package as a direct payment.

In this way the council has helped topreserve competition while the councilcontracts exclusively with four providers. Thiswill differ from one authority to the next, butwe should recognise that the council hassignificant buying power. If they begin to usea more outcome-based approach it is likelythat this will have a broader impact on themarket and the services providers will offer toself-funders and those on direct payments.

What impact will this have on providers?Providers must be a part of any processwhich restructures their approach to the caremarket. In Wiltshire the council ceased totrade with a significant number of providersas they moved from a large volume ofproviders on a framework agreement to eightgeographically based contracts. Thisapproach would not be appropriate for everylocality, but in the Wiltshire example it didoffer the providers the certainty they neededto invest in the service, particularly in relationto training, recruitment, salaries and termsand conditions.


How will you engage care workers in theprocess? Part of the Help to Live at Home contractasked providers to place care workers on asalary, rather than paying them on an hourlyrate. This aims to dissuade providers fromrationing care worker time with an individual;by making the provider’s income depend onattaining outcomes, they must train, pay andorganise their workforce in a way thatreduces the risk of penalties for failure.

The council was able to do this through thecertainty they could offer the provider interms of volume of work and length ofcontract.

The Wiltshire model will not be suitable forall authorities. To implement this model theyceased trading with a large number ofproviders, and made a significant upfrontinvestment in electronic systems designed tomonitor outcomes, which may not bepossible in every local area.

Nevertheless, it highlights a number of thequestions we must answer if we plan tomove towards a more outcome-focusedcommissioning model.

‘Help to Live at Home’ reconciles threecompeting aims of social care reform:personalisation, recovery andprevention.

Assessments are person-centred andfocus on outcomes, especiallyoutcomes that leave customers betterable to live well with less care. We aimfirst to help people recover theirindependence and then to stop theirneed for care growing. In Help to Liveat Home, reablement is not a specialkind of service; it is the aim of all ourservices.

Help to Live at Home pays for results.Results are outcomes that improve orpreserve independence. The council

applies financial penalties whencustomers’ outcomes are not achievedand rewards care providers whencustomers recover faster than planned.Wiltshire Council believes that buyingoutcomes instead of hours is acommercial incentive to improve thepay and skills of the care workforce.’

Wiltshire County Council

2) Have you considered the localdrivers for need?

We tend to think of the need for services,and the services we provide in a fairly rigidway, influenced by establishedcommissioning models. On the one hand,need is an established fact about anindividual’s requirements. On the other, wemust design services that meet those needs.

What we often neglect to consider is the wayin which the two are contingent upon oneanother. Need can easily be manufacturedby badly designed services, for examplewhen reablement is neglected following ahospital discharge, ‘creating’ a long-termcare requirement.

Need is also about the way in whichindividual expectations are managed. If apatient is told by a GP that they needresidential care, their expectations about theservices they should consider will be shapedby this recommendation.

Services should of course be commissionedon the basis of need, but we must alsoconsider how the types of services wecommission influence the pattern of need. Ifwe are to deal with the current pressures onadult social care, and continue to meet theneeds of our communities, domiciliary careservices should be based on the premise ofreducing or stabilising dependence onservice provision wherever possible.

47

This is illustrated by Wirral’s Rapid AccessContract, in which health and social care areworking together with providers to develop amore seamless service for patients beingdischarged from hospital. As well as offeringa higher quality service, it also releaseshospital beds sooner and reduces demandfor long-term care services as much aspossible by employing a vigorousreablement approach and adapting thehome to suit the needs of the service user.

3) How well aligned iscommissioning in health, social care and housing?

Housing, health and social care are thethree pillars of independent living: identifyingshared outcomes between these three areasand commissioning jointly will offer moreefficient and integrated services.

Health and Wellbeing Boards may forgebetter relationships and facilitate joint-commissioning, but do not holdcommissioning power themselves. As oursurvey demonstrated, housing services andsocial care have very different cultures inrelation to commissioning and contracting,with housing tending to establish longercontracts with a smaller number of providers.

There are benefits to be realised from betteralignment between these two departments,and opportunities to coordinate theircommissioning arrangements moreeffectively to offer more seamlessinterventions for service users.

This is recognised in the draft Care andSupport Bill, which gives new duties to localauthorities to ensure that adult social careand housing departments work together withthe aim of joining up adaptations and repairswith care and support.

The solution to this commissioning problemdoes not need to be resolved by the councilalone. Local authorities should put the onuson providers to work together to deliver

contracts that meet both housing and socialcare needs.

“Within several days of me talking with myoccupational therapist, a member of Mears'Safe at Home staff called me to arrange forone of their team to visit me to assess whatneeded to be done and to supply and fitthese rails. I didn’t have to get anything –everything was done for me, with no fuss ormess. I am so grateful to the Safe at Homestaff and to my occupational therapist. I willalways want to remain living in my homewith my family although sometimes myhealth problems make everyday tasksdifficult. This service enables me to call foradvice and help – this is so reassuring formyself and others in similar situations andhas completely improved my quality of life.”Mark P, a service-user from Churchdown

4) Do you empower providers?

Market management is now an importantaspect of a commissioner’s role in socialcare. Because providers represent the careworkers on the frontline of service delivery,they are often best placed to work withservice users to find innovative ways ofaddressing their problems, and should bechallenged to find the best ways to achieveoutcomes for individuals.

The focus on a time-task method ofcommissioning, along with tight budgetaryconstraints has shifted the council’s role intoone of invigilator, leading to a command andcontrol approach to dealing with providers.Energies have been primarily targeted atensuring that providers do not cut corners interms of activity and the time spent with aservice user. Commissioning for outcomesinvolves a culture shift, which allows theprovider to solve the problem, alongside theservice user. Providers are paid on the basisof achieving outcomes, and they areresponsible for finding the best way ofdelivering them. With or without payment byresults, providers can be more successfullyincentivised to deliver outcomes if the

LGiU Effective commissioning in domiciliary care


authority is willing to let go of their closecontrol of support planning and to be clearthat their role is to be focused onassessment and quality assurance.

Market management does not simply meanmaximising the number of providers in themarket. It also means influencing the contextin which these providers operate. Givingthem the space to innovate is likely toexpand the range of products available inthe market more broadly, offering care usersin both the funded and self-fundedcategories a better choice of qualityservices. Local authorities must always beaware of their safe-guarding responsibilitiesand ensure services are adequatelymonitored. But monitoring should focus onoutcomes and quality rather than time basedmeasures. Making providers responsible forattaining outcomes rather than outputs willimprove service quality and help to shapethe market to meet the needs of the future.

The other dimension to this issue relates tofrontline workforce. In the current systemcare workers are often paid on an hourlyrate to match the authority’s commissioningapproach and reduce cost. Besides theimpact on the care workers, this can putpressure on them to deliver services in away that does not meet the personal needsof the service user and can drive downquality. Councils have enormouscommissioning power: if they have a clearview of what they would like to see in theirproviders, they can support this through theircommissioning practice. Paying byoutcomes rather than time-slots givesproviders the incentive and ability to invest inthe service and their frontline staff. Of course

there are implications to this approach. Forproviders to invest in the service they needstability, which is unlikely to be offered byshort-term contracts on a frameworkagreement.

“The economic situation is currentlyimpacting negatively on what was previouslya very good partnership relationship basedon trust with our providers.”Third tier manager in unitary district council

5) How engaged are electedmembers?

Councillors have a crucial role to play inconnecting council processes to theoutcomes they see through their case-workin the community. At present many people inreceipt of care, and older people inparticular, can find it hard to make their voiceheard. Elected members can act asimportant advocates for people in the caresystem, while also holding influence over theinternal processes for commissioning.

Through proactive casework with excludedindividuals, and their role in budget settingand scrutiny they can take on a vital role inclosing the gap between processes andoutcomes. However, it is essential thatcouncillors have an appropriate level ofunderstanding of these processes if they areto lead on, and more particularly, toscrutinise this area of work. Responses toour survey revealed a significant level ofconfusion among some councillors withscrutiny responsibilities. Offering the righttraining and support will be important inensuring elected members can take a moreprominent role in this agenda.


Councils recognise that a time-task culture indomiciliary care is still a barrier to trueoutcome based commissioning, but breakingdown this culture is easier said than done.Reliance on a time-task approach has leftmany authorities nowhere to go in makingsavings but to cut down the hourly rate theypay to providers and use tools such aselectronic monitoring to minimise paymentoutside contact time with service users.

While such tools have a value, there arelimits to the extent to which savings can bemade in this way without affecting the qualityof the service and the conditions of workersin the care sector, and damaging therelationship with providers.

Councils should be asking for more fromtheir providers. At present in many areas ofthe country they are required to spend timewith service users in allocated slots of time,but have no direct incentive to deliver care inan innovative way that promotes betteroutcomes for that individual. While manypeople will find they need more care as theyget older, we should always try to build acare system which incentivisesindependence and rehabilitation. Paying foroutcomes shifts the freedom andresponsibility for finding better solutions tothe provider.

Of course this is not a simple choice tomake, or more authorities would alreadyhave made it. Contracting for outcomesdemands a shift in the way councils

commission and requires an investment oftime and thought in re-designingcommissioning processes. Providers mustbe able to invest in the service, and this isproblematic in the context of short-termcontracts and agreements. Care workersmust be empowered to spend time with aservice user and this is difficult when theyare paid on an hourly rate rather than asalary.

However, these problems are notinsurmountable. As the case studies inChapter 5 demonstrate, councils across thecountry are finding their own local solutions,and developing innovative ways of shiftingthe emphasis of service delivery onto qualityoutcomes for the individual.

We hope the case studies in this report willhelp to promote discussion betweenauthorities, and between partners at a locallevel about the ways in which they can makethe best use of their commissioning power toproduce the outcomes they want forindividuals and communities. Models ofcommissioning will necessarily vary indifferent areas of the country, but thequestions that need to be answered will bethe same.

By working together to find better solutionsto the commissioning problems we face wecan build systems and relationships thatdeliver the personalised, outcome-focusedservices we need to address the challengesof the future.

Conclusion

Thanks to:

Jonathan Gardam, Policy Officer, ADASS

Glyn Jones, Director, Adults, BracknellForest Council

Elizabeth Saunders, Assistant Director,Commissioning, Central BedfordshireCouncil

Paul Groom, Head of Commissioning,Central Bedfordshire Council

Cllr Anne Naylor, Cabinet Member for Health and Wellbeing, Essex County Council

Craig Derry, Director of Strategic Planningand Commissioning, Essex County Council

Will Patten, Commercial Director, AdultsHealth and Community Wellbeing, EssexCounty Council

Jess Lievesley, Assistant Director,Community Commissioning, HertfordshireCounty Council

Sarah Pickup, Adult Care Services Director,Hertfordshire County Council

Abigail Lock, Head of External Relations,Mears Group

Alan Long, Executive Director, Mears Group

Bernadette Walsh, Director of Care, MearsGroup

Nick Hann, Business Development Manager (Housing), Mears Group

Paul Cooper, Business Manager (Care),Mears Group

Sian Davenport, Regional Care Manager,Mears Group

Zoe Campbell, Business DevelopmentManager (Care), Mears Group

Jennet Peters, Pilot Implementation Lead,Justice Reinvestment, Doncaster andPeterborough PbR pilots, CommercialDevelopment Group, National OffenderManagement Service

Mark Deadman, Assistant Director, The Somerset Care Group

Kim Curry, Interim Commissioner for Health& Care and Director of Joint CommissioningUnit, Staffordshire County Council

Anne Butler, Assistant Director,Commissioning, Surrey County Council

Jane Bremner, Project Manager, Adult Social Care, Surrey County Council

Adi Cooper, Director of Adult Services andHousing, London Borough of Sutton

Anne Higgins, Corporate Director, Adults,Trafford Council

Kieran Topping, WLA Senior CategoryManager – Adult Social Care, West London Alliance

James Cuthbert, Head of InformationManagement, Wiltshire County Council

Acknowledgements

The LGiU is an award winning think-tank and localauthority membership organisation. Our mission is to strengthen local democracy to put citizens incontrol of their own lives, communities and localservices. We work with local councils and other public services providers, along with a wider networkof public, private and third sector organisations. The LGiU convenes the Children’s Services Network(CSN), which provides policy briefings, reports andevents for children’s services professionals.

www.lgiu.org.uk

Mears is the leading social housing repairs andmaintenance provider in the UK and a major presencein the domiciliary care market – bringing the higheststandards of care to people and their homes.

Partnering with clients, 13,000 Mears Groupemployees maintain, repair and upgrade people’shomes, care for individuals and work in communitiesacross the country – from inner city estates to remoterural villages. For more information, please contactAbigail Lock at [email protected]

www.mearsgroup.co.uk

22 Upper Woburn PlaceLondon WC1H 0TB020 7554 [email protected] October 2012

Documents

OUTCOMES MATTER - LGIU · outcome-based commissioning agenda has been patchy, and fraught with difficulty. The use of service outcomes is now well recognised, but the process of paying