Challenges for the future of adult social care

Commissioning focusing on outputs not outcomes

A widely held view which emerged from the essays, podcasts, roundtable and our wider engagement with the sector on COVID-19, is that commissioning is no longer fit for purpose.

Whilst our recent collection of guidance Commissioning and COVID-19: Advice for social care highlights examples of good commissioning, it also raises concerns about the direction of travel for commissioning and the high level of what people called ‘transactional’ rather than outcome-focused commissioning which takes place.

Commissioning was supposed to be a strategic approach, but has become bogged down in narrow processes. It drifted far from its original purpose.

Commissioner

Originally intended to be a strategic process which enabled resources to be directed towards the achievement of outcomes, we now see a tendency for commissioning to be overly focused on the delivery of outputs, such as the amount of time and task delivered. A radical overhaul of commissioning, it was argued, is now needed.

Lack of support for innovation

There are many good examples of innovative approaches to care and support that are person-centred and community-based. Evidence generated through the Social Care Innovation Network demonstrates that these models are not only cost-effective but improve outcomes and experiences. However, even though these innovations can demonstrate their impact, they tend to exist in pockets and are not yet seen as the core business of social care. Even small-scale innovative community-based organisations who don’t wish to grow large, struggle to survive beyond short-term pilot funding. This needs to change, and there were several contributors who called for national investment in innovation; possibly through some kind of innovation fund, or pioneer programme, which involves authorities being backed to make rapid progress on growing innovations to scale.

I believe, at its core, an innovation must be about moving people closer to what they say they want, which is having a life and not a service – about thriving and not just surviving.

Clenton Farquharson, Chair, Think Local Act Personal

Variability in quality and performance

Though the rules on entitlement to state-funded social care are set nationally, access to social care varies considerably depending on where people live, reflecting what one contributor described as a ‘post-code lottery’. Local authorities have the power to make their own decisions about priorities, budgets and what they commission at the local level, inevitably leading to variation in access. This variability in access is compounded further by the variability in the quality of care, as reported by the Care Quality Commission in its Annual State of Health and Adult Social Care reports:

As we explored in last year’s report, there are parts of the country where relative concentrations of poor-quality care, as shown by ratings, mean that people living there may find it more difficult to access good care.

I think we have a problem not just with how direct payments (DPs) are policed but also with the overall low number of them (4 in 10 working age adults, less than 2 in 10 older people) and the variation between places – in some councils more than half of people have DPs, but in other places it is fewer than 1 in 10.

Simon Bottery, Senior Fellow, The King’s Fund

This problem of quality was much debated through the essays and at the roundtable, with little agreement on the solution. Whilst there was broad support for a fairer funding settlement for publicly funded social care – something SCIE would support – there were differing views on whether Government should be more active in stepping in to address underperformance and variation, or instead that this role should be left to local authorities to support one another with sector-led improvement.

Lack of clear plan for workforce

Participants at the roundtable raised a number of concerns about the workforce. Whilst there was universal praise for their resilience and professionalism during the crisis, there was also real concern the workforce was reaching breaking point. To address these challenges, there is urgent need for a national strategy for the social care workforce, that sets out clearly how low pay and conditions, the lack of progression opportunities, and the lack of training and leadership development, will be addressed.

There were deep issues the 18,500 organisations who offer social care services were wrestling with before the virus. A high turnover rate of 30.8 per cent and increasing year on year. This is compounded by a high vacancy rate, which means that on any given day before the pandemic there were 122,000 vacancies that needed to be filled. Those realities make it more expensive for employers who have to pay to recruit constantly.

Oonagh Smyth, Chief Executive, Skills for Care