Commissioning during COVID-19: Good commissioning overview
Commissioning for better lives and communities
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:
- In England there are 1.5 million people employed in social care.
- Local authorities spent £22.2 billion on social care in 2018/19 supporting 841,850 adults.
- People privately purchasing their own care spent £11 billion.
- There are an estimated 8 million unpaid carers with numbers rising significantly during COVID-19.
The impact of COVID-19
Many areas have seen an amazing mobilisation and response to the COVID-19 crisis including by communities, individuals, providers 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.
However, the measure must be whether these responses result in positive impacts on individuals both now and in to the future.
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 lack of availability of workers and some turned down care due to fear of catching the virus. Others will have developed new needs that remain unmet. Millions of unpaid carers face new and additional pressures. The disproportionate impact on people already experiencing inequality and poorer outcomes related to ethnicity, poverty, ill-health and digital exclusion highlighted challenges faced by so many. This was compounded by a fragile care market and the low status of social care workers.
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 we should have been doing anyway?
Purpose of commissioning
Effective commissioning should help to:
- promote positive outcomes
- drive quality and promote innovation
- promote equality
- enable people to choose or direct their own care care and support
- facilitate integrated approaches and make the most effective use of available resources.
It should stimulate new approaches and address gaps to improve locally agreed outcomes. The Care Act 2014 sets duties on local authorities to shape the market and develop the workforce.
Good commissioning uses whole-community approaches and fosters positive relationships with providers. It is about:
- leadership and facilitation
- using local money effectively
- using evidence
- local knowledge
- working in partnership across health and social care and beyond
- working in true co-production with local people.
Most definitions of commissioning have common themes of understanding or assessing needs, desiging 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)
In Commissioning for better outcomes, the Local Government Association (LGA) identifies that effective commissioning is person-centred and outcome focused, well led and promotes a sustainable and diverse market. It sets out nine standards for good commissioning across the 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 defining the need – the problem that needs solving – 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.
See SCIE's Care Act commissioning page to see the inter-relationships between these four stages.
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 the community and providers understand their relationship with commissioning and ultimately to improving 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 drive commissioning: promoting choice, control, rights and equality. SCIE would argue that good commissioning can only happen when solutions and decisions are properly co-produced.
The COVID-19 crisis has highlighted the inequalities that social care responds to on a daily basis, including the disproportionate effects of poverty, health inequality, race and ethnicity. It has also highlighted those built into its systems that leave people feeling disempowered. The growing call of ‘valuable not vulnerable’ across every sector highlights that everyone has a role to play in society – people are not just passive recipients of care. They are part of families and networks, so holistic approaches are vital.
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. Equality of access, relevant accessible information, and visibility of people all have impacts on people’s life chances. 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. 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, residential 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 says that 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. ‘Nothing about us without us’ means that Disabled people and those who need support, including unpaid carers, must be at the heart of all decision making that impacts upon their lives. Commissioning cannot begin to develop solutions without understanding the barriers and problems it is trying to address. We must also be aware that some of these barriers, and potential solutions, may have changed as a result of COVID-19.
Co-producing solutions makes commissioning sense. 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.
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 co-production 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.