Commissioning beyond COVID-19: the foundations
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 overview
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:
- 839,000 adults received long-term care funded by local authorities in England in 2019/20.
- There are an estimated 6.5 million unpaid carers with numbers rising significantly through the pandemic.
- 1.5 million people are employed in social care in England.
- Local authorities spent £23.3 billion on social care in 2019/2020. Councils forecast that COVID-19 would add more than £3 billion extra cost pressure on adult social care in 2020/21.
- People privately purchasing their own care spend in excess of £11 billion. In addition, people receiving state-funded support also contributed £3.1 billion to fees and assessed charges in 2019/20.
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...
Commissioning for better lives and communities - the purpose of commissioning
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:
- Promote better lives for individuals and positive outcomes across communities
- Drive quality and promote innovation
- Promote equality
- Enable people to choose or direct their own care and support
- Facilitate integrated approaches and make the most effective use of available resources.
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:
- Communities where everyone belongs
- Living in the place we call home
- Leading the lives we want to live
- More resources, better used - local councils, their partners and support providers must think about and use resources differently - starting from asking how to support good lives in strong communities not traditional services.
- Sharing power as equals - collaborative 'co-commissioning' with communities
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.
Definitions of commissioning
Most definitions of commissioning have common themes of understanding or assessing needs, designing solutions and using resources effectively to achieve outcomes.
Commissioning is essentially the effective design and delivery of policy, solutions or services. The best commissioners have the confidence to challenge the status quo, take on radical change, collaborate effectively with external stakeholders, gain a deep understanding of the need and target resources effectively to meet those needs.The Commissioning Academy (GOV.UK)
We 'commission' in order to achieve outcomes for our citizens, communities and society as a whole; based on knowing their needs, wants, aspirations and experience.Integrated commissioning and provision (Local Government Association)
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.
Person-centred and outcome focused Open
This domain covers the quality of experience of people who use social care services, their families and carers and local communities. It considers the outcomes of social care at both an indivudal and population level.
- Person-centred and focused on outcomes.
- Co-produced with service users, their carers and the wider local community.
Well led Open
This domain covers how well led commissioning is by the local authority, inlcuding how commissioning of social care is supported by both the wider council and partner organisations.
- Well led.
- A whole-system approach.
- Uses evidence about what works.
Promotes a sustainable and diverse market Open
This domain covers the promotion of a vibrant, diverse and sustainable market, where improving quality and safety is integral to commissioning decisions.
- A diverse and sustainable market.
- Provides value for money.
- Develops the workforce.
- Promotes positive engagement with providers.
The commissioning cycle and commissioning models
The commissioning cycle model originally developed by the Institute of Public Care, describes the main activities of commissioning:
- Analyse: This stage aims to define the change that is needed by identifying the need - the barriers or issues that need resolving - and the desired outcome.
- Plan: Involves designing a range of options that will work to address the issues identified against the desired outcome.
- Do: Making the necessary changes to deliver the agreed outcomes. This could be via community capacity building, market facilitation or by securing or procuring services.
- Review: Evaluating the chosen option(s) to see what has worked well and what can be improved further.
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.
Vision and values of commissioning
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:
- Disabled people have the opportunity to choose where and with whom they live on an equal basis with others and are not obliged to live in a particular living arrangement.
- Disabled people have access to a range of in-home, accommodation and other community support services, including personal assistance necessary to support living and inclusion in the community, and to prevent isolation or segregation from the community.
- Community services and facilities for the general population are available on an equal basis to disabled people and are responsive to their needs.
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:
Local Disabled residents are working together with decision makers to actively identify, design, and evaluate policy decisions and service delivery that affect our lives and remove the barriers we face.
Co-production is just a way to bring everyone together with the same aim of removing the barriers that stop our residents from living as equal residents in our community ... It's about getting people to feel confident – working together and included in changing the things that matter together.
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.
Understanding local needs
Information for good commissioning
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.
Understanding local financial resources
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:
- How much is spent on what types of services?
- How much money stays local or is reinvested in local services or employing local people?
- Do local community groups have the opportunity to draw in funding from elsewhere?
- How does overall council spending help remove the barriers faced by people who may draw on social care, including carers? Are they benefiting from investment in local employment support for example; are new community developments accessible?
- How can more money be shifted away from transactional time and task care to towards outcomes and for people to make their own support decisions?
- How much is available to support innovation? Is this then funded to scale up?
- How can more resources help support people at an early stage?
- What has been the impact of COVID-19 on spend? LGA's Modelling the financial impact of COVID-19 on adult social care is a useful resource to help map this.
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.
Co-production and commissioning
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.
Tips for good co-production Open
- Develop co-production approaches with people - ask what works for them. COVID-19 has meant doing some things differently. Be flexible and use a range of approaches so people can be involved in ways that suit them. Use established groups but don't make that the only way. Some people who find it hard to get to physical events have been able to engage virtually. Others have been excluded due to lack of accessible digital connection.
- Invest in peer support and DPOs (disabled people's organisations). Peer support can give confidence and the strength of a shared voice. Ensure there is active communication with user-led organisations and DPOs. They are invested in their local communities and help ensure citizens are at the heart of decision making.
- Build capacity for co-production and share leadership. Invest in training delivered by people with lived experience, resource co-production properly and support the development of a shared understanding of why it is so important to work together. That's as important for staff, councillors as it is for local people. Look at how meetings are convened for example - are they all led by the statutory sector? Community groups need the resources and capacity to lead and the status to secure people's commitment.
- Governance - co-production must feed in to formal decision making channels. It is worthwhile mapping where co-production is taking place, what influence it has and tracking what decisions and changes have resulted.
- Engage with people at different times and in different ways: at weekends, via phone calls and webinars. Use social media, information boards at shops, pharmacies or GP surgeries. Without this, you may miss key voices or particular groups. What has been the feedback via mutual aid groups; are there separate platforms for carers?
- Equality and diversity. Co-production must be inclusive. Some communities are seldom heard - they may not trust statutory services or traditional approaches might not work for them. Can you link through other channels such as advocacy or carer organisations, faith groups or community groups that people trust? Are you missing people?
- Understand the context. People fear losing what they have, even if it isn’t perfect. It needs to be safe for people to give their views. What is available locally will shape what people say they want and ultimately what they choose. You can help broaden horizons by enabling people to share their stories and look at what is happening elsewhere.
- Respect and value people's views. Ask people if you have the questions right. Engage people with meaningful questions that will make a difference. What barriers are people experiencing? What would good support look like?
- Be clear how information will be used - what difference it will make and by when. Show and ask people what has changed as a result of their work.
- Reward and recognition is a key strand of co-production so be clear how this will work and continue to co-produce agreed ways of doing this. Whether that’s paying for involvement in developing specifications, payment for co-delivering training or refreshments for people giving their time at an event. Is there a way of doing this for virtual meetings too?
- Discuss existing co-produced values, for example, TLAP's I statements that people might want to adapt and adopt locally as core principles.
Empowering people and building capacity
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.
Strategic commissioning approaches
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.
Working together - engagement and partnerships
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:
- Bring stakeholders together. Most areas found new digital ways to do this during COVID-19. Providers can showcase good practice and innovation can be shared. It's important too for providers, commissioners and decision makers to hear directly from people and communities impacted by changes – their stories are powerful. Is there a forum to meet with providers and community groups? Does that engage different types of organisations – community enterprises as well as traditional services? This will help stimulate new discussions and help re-balance power dynamics, which usually favour the statutory sector and larger providers.
- Are elected members involved? As well as shaping decisions, they will have a view and represent the needs of their constituents.
- Regular supportive communication with providers has been highly valued during COVID-19. Adopting this as an ongoing way of working will be helpful for building collaborative relationships and more effective solutions.
- Gather information and get views from GPs and pharmacists. They are seeing people regularly and may also have feedback from social prescribing.
- Are there shared agendas through the health and wellbeing board and are partners informing JSNAs (Joint Strategic Needs Assessments)?
- Engage with local community plans, housing plans and equalities plans to address employment, ageing well, access to leisure, community engagement, or tackling isolation and loneliness. Remember, local authorities have duties to promote equality.
- Link with your local Healthwatch, as the independent champion for people using health and social care services to shape and improve services.
- Connect with (and fund) disabled people's organisations (DPOs), carers groups and needs-specific groups. Community organisations, groups relating to identities, and faith groups will also have a view and may be able to offer creative solutions. Recognise inter-sectionality – acknowledging that everyone has their own unique experiences of discrimination and oppression. Consider the multiple factors that can marginalise people or impact upon outcomes and experience (for example gender, race, class, sexual orientation, age and impairment). Disabled, older people and carers are part of that community too.
- Local businesses often want to contribute to their community. People who work or own companies are also carers, Disabled people, family members themselves. Businesses may want to develop corporate social responsibility (CSR) plans.
Market shaping and developing what is needed
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.
Analysing supply and demand
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:
- A stocktake of existing information. Is your market position statement up to date and relevant? Has there been mapping of registered suppliers, the voluntary and community sector and micro-enterprises?
- What do you know about local spend and investment?
- The range of supplier types and contractual arrangements. What is the uptake and how does this reflect the diversity of your local population? What registered or other services are there in the area?
- What are the workforce issues? What have been the challenges during the pandemic and what are the ongoing impacts? How has Brexit impacted?
- What do social care assessments and reviews tell you about the use and effectiveness of support and services?
- What have people told you about the services they use? Has their view and experience changed as a result of COVID-19?
- Providers - what is their honest view of supply, need and sustainability? Do they have waiting lists or vacancies?
- What is the quality of local supply? How do you know this? Through surveys, contract monitoring, CQC inspections, peer quality checking? How does it compare with 'What good looks like?'
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:
- What do local people want and need? How do you know this? What do your local surveys tell you? What are the views and ideas of front-line staff? What information is there from assessments and reviews?
- How are people using existing services? Has this changed? Are there impacts on longer term support needs if people have missed out on reablement during COVID-19 or had medical treatment delayed?
- What are people buying with their direct payments or own funds and what care or support would they like to access, but is not currently available? Has this changed during the pandemic, and if so will this become a longer-term change?
- Work with health services to predict new local demand due to long COVID or delays in accessing healthcare or elective surgery. This could have long-term impacts on people’s independence and support needs.
- What demographic information is available? Census data, JSNA and POPPI and PANSI data should show how many carers and people with needs there are in an area, age profiles and ethnicity.
- How have people been impacted during COVID-19 in relation to equalities? People from black, Asian and minority ethnic groups have experienced higher death rates and have poorer access to healthcare. This needs to inform immediate as well as long-term plans - both for people needing care and support, and the workforce.
- How many people are known to statutory services? Lack of integration across the whole system can make this difficult to quantify, so utilise channels across health, mental health and social care. What additions from the COVID-19 responses can and should be added?
- How does the use of services compare to expected demographics? People from black, Asian and minority ethnic (BAME) are less likely to access support services. Is there lack of uptake by particular communities or age groups? Might you need targeted campaigns?
- What intelligence do providers have? Do local providers have a waiting list? Have they been approached by people they can't help?
- It's vital to understand the role of unpaid carers and the impact if they were unable to continue. Are there trends that indicate particular pressures on carers and their ability to carry on caring? How many new carers have been identified during COVID-19 or existing carers who now need support?
Developing what is needed
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:
- Ensuring genuine choice through a wide range of provision and types of provision. This range needs to address equalities, preferences and specific needs that require particular knowledge and approaches. People (including self-funders and direct payment users) also need to be aware of what is available and how much it costs. This should go well beyond traditional care services and include community resources, access to personal assistants, good support for direct payments, and innovative provision.
- Ensuring a sustainable market - moving beyond pilots and having sustainable contracts where appropriate (including via ISFs) and meaningful monitoring by residents and families that facilitate wellbeing outcomes. Sustainability planning will need to address challenges in rural areas to ensure the viability of low volume services. See the Somerset case study about how micro-enterprises have provided more choice, better outcomes and great local work opportunities.
- Investing in quality and developing what works. This may include scaling up and encouraging quality providers to diversify.
- Workforce, including attention to remuneration and turnover. Staff are key to quality so linking providers with workforce development plans to collaborate on training - including by disabled people and carers - can help. This needs to also be inclusive of personal assistants. Innovative approaches will attract a workforce from a wider range of skill sets and backgrounds. This is increasingly vital given the challenges to recruitment and retention. For example, Shared Lives arrangements are delivered by people from all walks of life, self-managed teams attract people wanting to work in non-hierarchical and solution-focused ways.
- Articulating to providers the likely demand and the types of services that people say they want, and a shared local understanding 'what good looks like'. This may be via co-produced market position statements.
- Provider-led developments. Many providers or investors crack on with their own developments, confident that they will be purchased by authorities or by self-funders. Who is developing, or wishes to develop, new forms of provision? Early conversations are needed to shape this and build a relationship - not least to avoid the development of models that don't extend rights, quality or choice.
- Fostering a climate that facilitates the development of flexible services that are truly personalised and strengths-based. This includes whole-family and integrated approaches building on community assets and local business opportunities. This can also be through technology that supports independent living.
- Facilitating innovation, social enterprise and community-based models. Small charities and social enterprises may be put off by formal tendering processes but be able to offer tailored, innovative support. Be creative about how these can be engaged and funded.
- Supporting DPOs, carers organisations and direct payment organisations that can help build capacity, support individuals to develop their own solutions and offer peer support.
- Wider support such as advice services many of which have been vital during COVID-19.
- Identifying organisations at risk. Are they worth saving in the long term? What is their impact? A close relationship is needed with CQC for market oversight, but it is also important to understand the impact of risk on population groups where numbers may be small but the impact high.
- Decommissioning services where there is not the need or demand or the service is unable to adapt to what is needed. This should still be co-produced and handled sensitively, and be accompanied by clear plans about how resources will be better used.
- Financial planning to shift spend and the use of resources to what works.
Next steps for commissioning?
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.
Find out more Open
Market shaping (Institute of Public Care)
Integrated commissioning for better outcomes (ADASS / 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)
Asset Based Commissioning (Bournemouth University)
Workforce shaping for commissioning and better outcomes (Skills for Care)
Adult social care market shaping (Department of Health and Social Care)
Top tips for market diversity (housinglin.org.uk)
COVID-19: adult social care commissioning practice resource (Local Government Association)
Support from SCIE
SCIE's COVID-19 hub contains more relevant information including safeguarding, Mental Capacity Act and infection control. It can be used when working and supporting people who are isolated or vulnerable through COVID-19, and can also be shared with community groups.