Commissioning during COVID-19: Market shaping

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. 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. This also needs to be built on a well-trained, well-supported and appropriately paid workforce.

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) give citizens more choice and control to shape their own solutions. Some innovative approaches such as Shared Lives and increasingly micro-enterprises have a strong evidence base in terms of quality and outcomes, but have not yet scaled to the extent you’d expect given their cost effectiveness.

Procurement may not be needed at all, but if it is, rigid approaches should not drive the agenda or obstruct the development of new, flexible choice-based provision. Procurement regulations very much allow for personalised choice.

Analysing supply and demand

There is a range of data sources that support analysis and market intelligence. Examples include local JSNAs (Joint Strategic Needs Assessments), Equality Impact Assessments, CQC registrations and inspection, Skills for Care workforce data, Poppi and Pansi population projections and ASCOF data and surveys. These are all useful tools for evidence-based commissioning.

Mapping supply

COVID-19 will have brought into focus the effectiveness 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 any ongoing impacts?
  • What do you know about use of services from assessments and reviews?
  • 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 contract monitoring, CQC inspections, peer quality checking? How does it compare with ‘What good looks like?’

Understanding demand

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? Are there new ways people have met their needs during COVID-19? Have new people been identified or have new needs developed?

  • 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?
  • What are people buying with their direct payments or own funds and what care and 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?
  • Identify potential collaboration with health services to predict new local demand due to 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? This needs to inform immediate as well as long term plans – in relation to people needing care and support as well as 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 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 to reach some?
  • What intelligence do providers have? Do you providers have a waiting list? Have they been approached by people they can’t help?
  • It’s vital to understand the role of carers and the impact of 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 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. There is a chance to co-produce options based on new ideas of what can work. These need to address equality and access issues particularly where there has been under-representation of some groups. Providers may have proposals for development, innovative approaches 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 – 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.
  • Ensuring a sustainable market – moving beyond pilots and having secure 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.
  • 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. 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 and trust they’ll be purchased. Who is developing, or wishes to develop, new forms of provision? Early conversations are needed to shape this and build a relationship.
  • 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? 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 smaller groups.
  • 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.

Commissioning during COVID-19
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