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Published: June 2020
Last reviewed: May 2022
This guide gives an overview of the foundations for how good commissioning should work and looks at what we can learn from commissioning approaches during the COVID-19 crisis. It discusses how commissioners can work in true partnership with citizens, providers and the community to resolve issues faced in social care and make positive outcomes a reality. For more detail about the impacts of COVID-19 and commissioning for the future, please see the other guides in this series.
Good commissioning is about working with individuals and their communities to improve lives. The influence and impact of social care, and therefore commissioning, affects millions of people:
COVID-19 has had a huge impact on people’s lives and on society. Despite the challenges, many areas saw an amazing mobilisation and response to the crisis by communities, individuals, the voluntary sector, providers, local businesses and the statutory sector. Many local authorities responded incredibly swiftly and flexibly, re-deploying staff to work differently as needed, providing resources to help maximise the impact of work through community groups, newly established community responses and volunteers.
Whilst a lot of people have been connected in new ways, others faced heightened isolation and fear. Some people missed out on support due to service changes or workers not being available; some turned down care due to fear of catching the virus. Many people have developed new needs that remain unmet, including growing numbers with mental health concerns. Millions of unpaid carers face new and additional pressures. There has been a disproportionate impact on people already experiencing inequality and poorer outcomes related to ethnicity, poverty, ill-health and digital exclusion. These issues have been compounded by a fragile care market and the low status of social care workers.
The challenge for commissioners is…
How do we commission better and learn from what has been done well during COVID-19? Are we clear what we don’t want to go back to? What perhaps should we have been doing anyway?
Better commissioning requires commissioners to act in ways that make most effective use of resources to promote people’s choices, rights, equality and to improve quality. Social care doesn’t operate in isolation – there is higher unmet need in the most deprived areas and amongst groups that already face discrimination. Effective social care is also essential for the NHS to operate effectively, as well as for recovery from the pandemic generally. Good commissioning must consider the barriers that prevent people’s full inclusion in society. Housing, transport, work, community resources and accessible environments all make a huge difference to people’s independence, choice, control and wellbeing.
The Care Act 2014 sets duties on local authorities to shape a sustainable market of quality providers and develop the workforce. It requires a focus on outcomes and wellbeing and to do this in co-production with partners. Commissioning should address gaps and stimulate new approaches to improve locally agreed outcomes. Effective commissioning should help to:
These approaches and outcomes need to be ambitious and move beyond tweaking the existing system. Social Care Future is a growing movement calling for major positive change. The movement identifies five key changes needed to allow everyone to live good, equal lives:
Co-producing solutions with people who draw on care and support and with local communities is essential if we are to develop approaches that are sustainable and are based on what is important to people.
Most definitions of commissioning have common themes of understanding or assessing needs, designing solutions and using resources effectively to achieve outcomes.
Social Care Future talks about good commissioning as using whole-community approaches and fostering positive relationships with providers. Good commissioning is about leadership and facilitation; using local money effectively; using evidence and local knowledge. It is about working in partnership across health and social care and beyond. Essentially, it is about working in true co-production with local people.
In Commissioning for Better Outcomes, the Local Government Association (LGA) describes commissioning that is person-centred and outcome-focused, well led and that promotes a sustainable and diverse market. It sets out nine standards for good commissioning across these three domains, providing a framework for local authority self-assessment and peer challenge.
The commissioning cycle model originally developed by the Institute of Public Care, describes the main activities of commissioning:
SCIE’s Care Act guide on commissioning independent advocacy sets out in more detail the inter-relationships between these four stages and gives practical examples of commissioning resources, including a self-assessment tool.
It is important for local authorities to consider how and why they commission, who is involved and what that means for respective roles and accountability. That also helps citizens, the community and providers understand their relationship with commissioning and how together they can improve outcomes. If commissioning is seen solely as a procurement function then collaborative and strategic opportunities will be missed.
There are clear principles that should underpin all commissioning: promoting choice, control, rights and equality. SCIE would argue that good commissioning can only happen when solutions and decisions are properly co-produced. As set out briefly below, Independent Living, the social model of disability and valuing the strength of individuals and communities all provide a strong framework for effective commissioning. These values and principles also help commissioning to make more effective use of public money and community resources.
The COVID-19 crisis highlighted the inequalities that social care responds to on a daily basis, including the disproportionate impacts of poverty, health inequality, race and ethnicity, and digital exclusion. It also highlighted systems barriers and difficulties accessing services that leave people feeling disempowered. The growing call of ‘valuable not vulnerable’ rightly highlights that we all gain from more inclusive societies. People are not passive recipients of care – they are a vital part of families, networks and communities, so holistic approaches are essential.
Building on the strength of communities is a vital pillar for good commissioning. There is so much to learn from the impact of and response to COVID-19. For people to retain, and in many cases regain, control over their lives, they need to be able to connect with the things and people that are important to them and to participate in their communities.
Independent Living is the equal right of all Disabled people to live in the community with choices equal to others. The term “Disabled people” is inclusive of older people who may need support, people with mental health support needs, people with learning disabilities and people who are neuro-diverse. Disabled people face significant societal barriers, and are more likely to experience worse outcomes in a wide range of life chances including poverty, work, housing, health and social relationships.
Social care is often experienced as ‘doing to’ rather than empowering people to live how they want with the support they need. Independent Living is about taking effective measures to ensure full inclusion and participation in the community by ensuring that:
The Social Model of Disability describes how people with impairments are ‘disabled’ by the barriers in society that exclude and discriminate against them. The exclusion and discrimination people face is not an inevitable consequence of having an impairment, but is caused by the way society is run and organised. The task then is to tackle the attitudes, structures and systems that create these barriers.
Co-production improves outcomes. There is more about co-production later in this guide, but is covered briefly here as a key pillar of values-based commissioning. ‘Nothing about us without us’ means that people who may need support, including unpaid carers, must be at the heart of all decision making that impacts upon their lives. Co-producing solutions makes commissioning sense – there is no point developing services that people don’t want or don’t value. It needs to be based on an ongoing relationship not a series of one-off activities. There are a number of definitions of co-production including:
A way of working whereby citizens and decision makers, or people who use services, family carers and service providers work together to create a decision or service which works for them all. The approach is value driven and built on the principle that those who use a service are best placed to help design it.
A relationship where professionals and citizens share power to plan and deliver support together, recognising that both have vital contributions to make in order to improve quality of life for people and communities.
Hammersmith & Fulham have a council-wide commitment to co-production and are taking a strategic approach to bring to life their priority of doing things with residents, not to them. They talk about co-production as:
The principles of equality, diversity, accessibility and reciprocity are core values underpinning co-production. These, along with other co-production resources, are set out in SCIE’s co-production guide.
The DHSC Ethical framework for adult social care commits to the Care Act principles of personalisation and it asserts that ‘Genuine co-production in equal partnership will ensure the best possible decision-making and the best possible outcomes for both citizens and the workforce’. It is underpinned by the TLAP Making it Real ‘I statements’ that powerfully set out the expectations of citizens who may need or use services.
Commissioning cannot begin to develop solutions without understanding the needs, barriers and problems it is trying to address. Some of these barriers, and potential solutions, may have changed as a result of COVID-19.
To develop a full picture of what is needed, commissioners must gather and make sense of information from a range of sources including responses to and impacts of COVID-19. Understanding local aspirations, experiences and needs is vital to deliver support or approaches that will make a difference. Understanding supply – what is available and how it is used – is another essential commissioning task. This includes provision that’s off the radar because it is not commissioned by the local authority, or because it is small-scale or not described as care. Commissioners also need to look at what is working well elsewhere.
Most people with care and support needs put their own arrangements and solutions in place through self-funding, unpaid care from family and friends or through a mixture of both. This is vital to the full picture so commissioners should seek to understand how people are co-supported by their own networks, how people are utilising direct payments and what self-funders are doing. Pro-active links with individuals, community groups and providers will help commissioners plan and shape the market as a whole. Reaching self-funders will become even more of an imperative as and when the care cap is introduced.
Understanding the impact of COVID-19 responses on citizens describes people’s experiences during the pandemic and how these should shape thinking about what’s needed both as an immediate response and for the future.
Detailed understanding will help shape the right support and responses. This must be informed by a clear analysis of equalities and different needs to identify gaps and opportunities. High-quality individual assessments should be empowering and helpful in themselves to the individual. They should record the rich detail that will help understand specific needs, diversity, aspirations and barriers. Aggregating intelligence from assessments will help to inform planning and give clearer messages to providers about the needs, outcomes and preferences they should be supporting.
The financial context for social care is insufficient budgets, growing need and demand, and lack of resources to invest to do things differently. It’s important that this doesn’t result in us getting stuck. Commissioners need to understand these challenges and how they impact locally, so they can plan in an informed way and use resources to best effect.
ADASS surveys show increased demand for social care services and growing levels of unmet need, people waiting longer for assessments, and more people missing out on vital care and support due to lack of resources. There is an impending crisis in the recruitment and retention of social care staff, which is exacerbated by Brexit, the pandemic, and labour shortages elsewhere. Recognition and reward to staff is key for a sustainable future.
Investment in earlier intervention and prevention and new ways of working is key to longer term solutions. However, much of the voluntary, community and social enterprise (VCSE) sector faces viability risks over the next years. It is from the VCSE that much innovation and prevention would come – funding for its future is vital to local and affordable solutions.
The 2021 white paper sets out a vision of choice, control, quality, fairness and accessibility. This will be funded in part by a new “health and social care levy” that came into force in April 2022. There are concerns that this is far from sufficient to maintain the sector and support the changes to deliver the vision.
The white paper also sets a lifetime limit of £86,000 on how much individuals have to pay towards their care costs. This is due to be implemented from 2023 and will create considerable operational demands on local authorities to track people’s eligible spend.
As well as understanding budgets and pressures, commissioners need to understand what difference the money is making. What are the local financial pressures, why do they exist? Sharing financial information with partners and through co-production can bring in wider views about how to achieve better value for money. Providers may have ideas, people who use services too. Questions for commissioners to address include:
Ultimately commissioners need to develop plans so money is supporting better lives. This will mean freeing up money from traditional or more restrictive services to fund more cost-effective, community-based support such as Shared Lives, micro-enterprises and direct payments that deliver better outcomes. It also means investment in more preventive and enabling support or appropriate technology, including support for carers.
Relevant approaches and provision can only be developed when truly shaped by the people who will use them. Immediate responses to the pandemic required fast and urgent action. Areas with co-production already embedded in their decision making were able to respond in more collaborative ways aligned to community values. The multiple pressures faced by individuals and across social care mean it is more important than ever to build solutions with people. Building relationships and varied co-production platforms offer valued and efficient ways of communicating and understanding people’s views. It is vital to understand the current impacts of COVID-19, how people’s experiences and ideas of what does and doesn’t work may have changed and to shape effective responses. Areas with established approaches to co-producing will find this easier: a position of ‘this is how we do things’ with residents at the heart of decision making.
See Nothing about Disabled people without Disabled people practice example from London Borough of Hammersmith & Fulham.
Commissioning must promote equality and be responsive to the diversity of people and their situations. Information and advice are significant enablers: the provision of such is a duty under the Care Act. Access to relevant information about local practical support, financial advice and benefits has been vital during COVID-19. Videos and stories can be more relatable and have a real impact.
In order to exert choice and control, people need to be empowered; they need to understand what is available, what might work for them, how to access support, how to fund it and feel confident to do so. Peer support can be powerful at building trust and confidence. Advocacy is essential for some people to be involved in decisions about their own lives, to uphold their human rights and to access support. Advocacy must continue to be available to those who need it and used to best effect during COVID-19 and beyond.
Effective commissioning cannot be achieved in isolation. It needs to be co-produced with local people and by close collaboration with adults and children services, public health, housing, NHS partners, and the wider community. Broader engagement is needed to understand and tackle the daily barriers people face such as access to healthcare, shops, transport, leisure, education and community services and sustaining employment. These are all issues that impact on people’s needs, independence and resilience, and their potential need for care and support.
Asset-based commissioning considers all the resources in a community and how areas can achieve more when they combine the expertise, time, creativity and resources of citizens, communities and organisations. This includes making systems-based changes and valuing the skills, knowledge, connections and potential in the community, to redress the balance between meeting needs and nurturing the strengths and resources of citizens.
Stakeholders may be interested in different outcomes, so it is important to be clear about the respective benefits and measures. Knowing partners’ plans and priorities will help identify opportunities across a wider platform and will support cross-system working. Commissioners will want to ensure that collaborative approaches to immediate issues translate in to effective long-term work. Identifying relevant reporting mechanisms and outcomes measures may help. How does this work contribute to the local Adult Social Care Outcomes Framework (ASCOF) and the Public Health Outcomes Framework (PHOF)? What reporting is of interest to the local clinical commissioning group (CCG) and mental health trust? Are there other measures related to employment that provide a focus, for example?
Building in a strategic approach to co-production, with clear lines of influence in governance structures, will help ensure citizens are shaping the decisions that affect them.
Local authorities and health services have legal duties to develop integrated approaches for the benefit of individuals. People should not have to navigate multiple ‘customer journeys’, nor be subject to multiple assessments requiring the same information. Integrated care systems (ICSs) are partnerships between the organisations that meet health and care needs across an area, to coordinate services and to plan in a way that improves population health and reduces inequalities between different groups. Commissioning knowledge and understanding of local needs will be key to this. Commissioning should ensure that joint funding and integrated approaches improve people’s experience of services, maximise outcomes and make the best use of everyone’s time and resources.
Engagement across organisations helps foster collaboration and enables a broad picture of needs and potential solutions. It enables us to understand respective skills – what each partner brings to the table, so we can respond more appropriately.
The value of partnership has been demonstrated during COVID-19 and needs to inform next steps. Providers, along with the voluntary and community sector and mutual aid groups, are essential partners. Commissioners need to know when to take a facilitative or fixing role: when they should lead or co-ordinate and when to stand back. Commissioners need to ensure stakeholders can feed in and value their ideas across wider agendas. Some approaches to support engagement are as follows:
The Care Act 2014 sets duties for local authorities to facilitate and shape a diverse, sustainable and quality market from which local people can choose how best to meet their care and support needs. Local authorities have a responsibility for promoting the wellbeing of the whole local population, not just those whose care and support they fund. This extends way beyond a local authority’s own purchasing to strategic approaches based on influencing, co-production and collaboration.
There needs to be sufficient capacity and variety available to enable choice for all those who need care and support, including unpaid carers. A well-trained, well-supported and appropriately paid workforce is key.
The ambition is for local authorities to influence and drive the pace of change for their whole market, leading to a sustainable and diverse range of care and support providers, continuously improving quality and choice, and delivering better, innovative and cost-effective outcomes that promote the wellbeing of people who need care and support.
Care and Support Statutory Guidance, Section 4.2
Supporting the use of direct payments and individual service funds (ISFs) gives citizens more choice and control to shape their own solutions. This in itself shapes the market. TLAP set out the key elements to support the effective use of direct payments – good information and advice, confident practitioners, and well-resourced direct payment support services.
There is a strong evidence base demonstrating how innovative approaches such as Shared Lives and micro-enterprises deliver better quality and outcomes. However, these have not yet scaled to the extent you’d expect, given their cost-effectiveness. Commissioners need to consider why not, and to change this so more people have access to these options.
Procurement is just one approach to ensuring choice and supply. Where procurement is needed, commissioners should ensure that rigid approaches do not obstruct the development of new, flexible choice-based provision. Procurement regulations very much allow for personalised choice as well as ways to contract with small, voluntary and community sector and user-led organisations. Local authorities have a duty to promote equality and Social Value requirements should be used to maximise local benefits from contracts.
There is a range of data sources that support analysis and market intelligence. Key sources include local JSNAs, Equality Impact Assessments, CQC registrations, inspection reports and insight reports, Skills for Care workforce data, ADASS reports, POPPI and PANSI population projections and ASCOF data and surveys. These are all useful tools for evidence-based commissioning.
COVID-19 brought into focus the effectiveness or limitations of local supply. Commissioners need information from a range of sources to properly understand this. Remember, much support is not funded or arranged by statutory services. Good supply mapping will look at:
Commissioners need to understand the demographics of demand as well as the needs and trends. Information from engagement, co-production, equalities data and assessments will form a key part of this. What services do people trust? What are they prepared to use? Have people found new solutions or different ways to meet their needs during COVID-19? Have new people been identified or have new needs developed?
National data (ADASS surveys) show an increase in people waiting for assessments, growing unmet need, an increase in people being offered care and support such as residential care that they would not have chosen. There are concerns (ADASS activity survey 2021) about increases in people presenting with mental health issues; seeking help for domestic abuse or safeguarding; and more rough sleepers needing support. The key for commissioners is to understand their local picture by asking:
Commissioners along with providers and communities need to understand the gaps – the difference between supply, availability, demand and quality compared with ‘what good looks like’ to respond to what is needed.
It is important to analyse and reflect, rather than just to switch back on services post COVID-19. This is an opportunity to co-produce options based on new ideas of what can work. These need to address equality and access issues. Providers may have proposals for development, innovation may have scope to grow and there may be wider agendas and strategic opportunities to embed effective approaches.
A good approach to market shaping will include the following:
Commissioners will be asking this question now. Many have noted that in a real emergency it has been possible to make changes to practice, systems and processes very rapidly. Some of these changes had previously been talked about for years. These changes, where shown to be effective, could be the catalyst for a shift to new ways of commissioning that focus on making a positive difference with individuals and with communities.
The Social Care Innovation Network have been exploring why the framework of provision and models of support and practice in social care have changed little in decades, and innovation has remained marginal. The network of commissioners, people with lived experience and innovatory providers have been considering the potential role for commissioning in shifting this position. They have produced a ‘starter for ten’ framework called Commissioning for a Better Future as a resource for those places interested in exploring how to shift the current ‘frozen’ position via asset-based commissioning.
There is considerable work to do to continue meeting existing and urgent needs, and more work is needed to plan the right things for the longer term. The other commissioning guides in this series set out more detail about the impact of COVID-19, the challenges and responses. They include examples of positive approaches and practical considerations for commissioners, to support a better future social care. Commissioners must ensure what they do really does help improve people’s lives.
Market shaping (Institute of Public Care)
Integrated commissioning for better outcomes (ADASS / LGA)
Commissioning and market shaping (LGA)
New Developments in Adult Social Care (Institute of Public Care)
Commissioning for outcomes and co-production (New Economics Foundation)
The Commissioning Academy (GOV.UK)
Integrated Personal Commissioning (NHS)
Asset Based Commissioning (Bournemouth University)
Workforce shaping for commissioning and better outcomes (Skills for Care)
Commissioning (ADASS)
Adult social care market shaping (Department of Health and Social Care)
Top tips for market diversity (housinglin.org.uk)
Ten Tips for an Asset-based Area (TLAP)
COVID-19: adult social care commissioning practice resource (Local Government Association)
