The future of commissioning for social care

This is one in a series of commissioning guides focusing on impacts and responses during the pandemic. This guide focuses on the immediate future of commissioning in light of COVID-19. As such, it does not try to address all thinking about commissioning which will be inextricably linked to the future of social care.

Commissioning beyond COVID-19

Commissioning should be about improving lives, so we need to reflect on our work through COVID-19 to consider what commissioners have done well and what could have been better. We have an opportunity to re-focus commissioning for a better future that promotes wellbeing, choice and control and good outcomes for people in their communities.

There are huge challenges, of course – money is incredibly tight; the ‘market’ in many places is not fit for purpose; the vision of the Care Act is not routinely fulfilled; policy decisions are rarely shaped by citizens. However, there are positives to build on – not least the amazing community response and people working better together. Commissioners responded incredibly swiftly to ensure services remained viable during the crisis. Awareness of social care has grown and there is pressure to fix and radically improve things. Despite the challenges, Disabled people have fought to be heard and developed new channels of leadership and influence.

The key message from citizens is that whilst safety is important, approaches must be based on human rights, equality and justice. Change needs to be about independent living, the right to an ‘ordinary’ life, equity of outcomes and choice and control for all people. The voice and experience of citizens must be central and so commissioning for the future must be shaped by their specific concerns and hopes.

SCIE co-production network members said:

We cannot change everything overnight, but the time is right to ensure everything we do is based on supporting people to achieve better lives. In the immediate response to the pandemic, commissioners will need to:

• urgently address approaches in care homes and supported living settings to enable better outcomes
• restore support and choice to those who need it, including carers
• understand the impact on local citizens and different communities, including self-funders and what needs to change – not everyone’s experience has been the same
• ensure joined up plans to address urgent issues – waiting lists for assessments and services, carers at breaking point, mental health pressures
• understand the issues facing providers and plan for immediate risks
• understand the capacity and potential of community responses going forward
• ensure financial planning is linked to better outcomes and local economies, rather than about patching the existing system
• work with citizens and communities to strengthen co-production so plans to address the above are properly shaped by their experiences and an inclusive understanding of what will make a positive impact.

There is a real opportunity for councils to co-produce recovery plans around social justice and equality with social care as a key driver of economic development, quality jobs and full community participation.

The impact of COVID-19 on social care

Disabled and older people with care and support needs have suffered dreadful impacts during the pandemic (see guide on the impact on citizens) – loss of life, emotional distress, curtailed freedom, isolation, lack of access to basic provisions and healthcare. People from Black, Asian and ethnic minority (BAME) communities have been further disproportionately affected – including those working in the sector. People living in deprived areas have experienced considerably worse outcomes too.

Many people, including people with mental health support needs, have not received the support they need to live well due to (temporary) service closures and changes. People with learning disabilities, along with many others, have had packages of support reduced, respite has often been unavailable, thousands suspended their own support due to fear of transmission. Direct payments (DPs) have been flexible for some, but for others there have been limitations such as not being able to find personal assistants (PAs), or not having the right support and advice to use their DP flexibly. Carers across the country are at breaking point.

Positive responses to COVID-19

It’s important not to underestimate the challenges that were faced in the initial lockdown: tens of thousands of people rapidly discharged from hospital, many staff themselves ill or needing to isolate, difficulties and costs in accessing personal protective equipment (PPE) and other supplies. The guide on challenges and solutions sets out the range of ways in which local authorities, commissioners and communities worked to ensure that social care was able to function, that (the vast majority of) people were not left without vital care and that the provider sector could continue to operate.

COVID-19 has raised the profile of social care. It’s shown we can work at pace and presents a chance to do things differently. Positive examples from around the country include:

• Innovative and flexible support services responded well, providing positive sustainable support, valuing individuals and keeping people connected as well as safe, e.g. through Shared Lives, micro-providers, and peer support.
• Commissioners built positive relationships and maintained regular supportive communication with providers, which resulted in more solution-focused ways of working.
• Strong local decision-making grounded in co-production, and really knowing communities and providers has saved lives, including through locally developed testing, early closure of care homes to new admissions, targeted support and contacting all people with care and support needs to ensure appropriate responses.
• Disabled people and communities have galvanised around a campaigning message about rights, social justice and equalities that is focused on the lives people want to lead.
• Communities can deliver and people want to be involved. There is huge capacity, including via local groups, individuals and businesses. This is not about replacing paid roles, but about communities working together to improve lives with local people.
• Collaboration with health has shown that people can move out of hospital quickly and get the support they need to live more confidently at home.

However, the pandemic also highlighted existing issues in social care such as a narrow market, workforce pressures, and the lack of choice and value experienced by people who require support.

The long-term impact on demand and delivery is not yet known making long term planning difficult. The funding proposals in the ‘People at the Heart of Care’ white paper leave social care short of the amounts needed to meet growing needs and the transformation required. Campaigners and lead organisations caution against assuming business as usual and have called for a rethink rather than a reboot. Discussions in response to the white paper may offer an opportunity to co-produce a new vision, revisit what is wanted and to begin developing community alternatives to traditional services.

Market issues

The Care Act requires market shaping to ensure a wide range of high-quality services and different types of support, so people can choose local support that is right for them. Too often, there simply isn’t the range of flexible and responsive support, or the infrastructure, to empower people to truly shape and organise their own care and support arrangements. In many areas, the commissioning focus on markets has resulted in high-scale and low-cost delivery models. It is these, such as large care homes, which have seen the worst impacts from COVID-19 (see guide on hospital discharge and preventing unnecessary admissions). Market issues include:

• Private markets (the basis of much social care delivery) require economies of scale to extract profits. The ownership basis of many of the large care companies mean profits leave the sector and the area – sometimes off-shore. Many providers say they are no longer financially viable due to COVID-19 challenges, workforce issues and rising costs.
• During COVID, care home occupancy rates fell from an average of 87.3 per cent nationally to just over 79 per cent. There was wide variation in admissions funded by local authorities, but self-funded admissions reduced significantly. Small care homes and smaller independents that lack the scale to cope with occupancy loss are at particular risk.
• Competitive tendering often reinforces larger-scale delivery by focusing on unit costs – hours of care, cost per bed – rather than on outcomes and more collaborative support.
• Cutting spend on staff is the main way providers reduce costs, resulting in low wages, insecure jobs, and poor terms and conditions. This added to COVID-19 transmission with staff working across multiple sites and many unable to afford the time off to self-isolate.
• The result in many areas is a very narrow market of care homes and home care. There can, of course, be good private care, but scale can impact on quality: larger homes tend to have poorer CQC ratings. Supply-wise the trend is towards larger high spec homes commanding higher fees – overall, homes registered since 2015 quote premiums of 22% for nursing care and 28% for residential care.
• COVID has highlighted the limitations of congregate living and use of physical space. It has meant a struggle between resident freedoms, quality of life, family relationships and protecting people.
• Time-limited funding has offset some COVID-19 costs but pressures will continue as measures become standard and local authorities may also face pressures of inflated fees, negotiated in a rush when the NHS was paying for people discharged into care services.
• Evidence shows that innovation and local flexible support options deliver better outcomes and are more cost effective. They also provide more attractive and more sustainable jobs. However, most commissioners have not yet scaled these alternatives.

Workforce challenges

Workforce challenges and the related equalities issues are largely linked to these market issues. There are 120,000 vacancies in social care (and rising), with many workers earning only the legal minimum per hour, 25 per cent on zero-hour contracts and many holding down multiple jobs to make ends meet.

Workers suffered and faced considerable risks during the pandemic (see guide on the impact on citizens), and the longer-term workforce impact is yet to be understood. It is possible some workers are burnt out and will leave the sector. Others who lost out on work because some home care provision was reduced, may not return. Black, Asian and minority ethnic (BAME) workers faced greater risks with disproportionately higher mortality rates. The sector offers little career progression for care workers, skills aren’t maximised, and it pays less than supermarkets. Shortages will be amplified by Brexit and immigration policies.

Commissioning for the future will need to address these workforce challenges. A shift away from transactional delivery will help. More innovative approaches such as micro-enterprises, Shared Lives and self-directed teams attract from a wider pool, use values based recruitment, offer sustainable jobs with better terms and conditions and are consequently much better at retaining workers. Investment in support for personal assistants will also be key to ensuring more people can benefit from direct payments.

Lack of choice and value

The overall impact of how we currently arrange care – there are of course many flexible and positive approaches – is lack of value, with people treated as passive recipients of care. Citizens are not routinely involved in shaping policy decisions. This has been exacerbated by COVID-19 responses with people viewed as ‘vulnerable’ and to be protected even if that means limiting freedoms, choices and relationships.

COVID-19 has had a devastating impact on the lives of older, Disabled people and people with mental health support needs. Those with the least choice have suffered the most – excess deaths in care homes, lack of access to healthcare, people not seeing family and friends for months on end, and support ending or reducing for some.

The increase in unmet need, including for carers, since March 2020 will need to be understood and quantified in each area. Many people did not receive the support they need due to reductions in services or people declining care or not requesting it. Some people were not discharged to the right place when there were rapid discharges from hospital, they may have missed out on reablement and be in a care home when they could have been at home, or were placed a long way from family.

There were already an estimated 1.5 million older people not getting the support they need (Age UK). In May 2022, ADASS estimated that over 500,000 people were waiting for assessments, reviews or care to start.

There is lack of recognition and support for millions of unpaid carers – the numbers of which have increased significantly during the pandemic – and many are at breaking point. There is limited access to breaks and to useful information and advice. Nearly two thirds (63.5%) of carers of people with dementia say they have no or not enough support. Carers face agonising decisions as they are unable to balance work and care. Huge numbers of people with care and support needs, as well as carers, already face financial hardship. This will be further amplified by rising living costs.

Despite the pressures on supply, people who need early support are often over-supported rather than getting strengths-based support to rebuild skills and networks. Digital exclusion and barriers to community participation, further highlighted during lockdown, disproportionately affect older and Disabled people, limiting opportunities for resilience and adding to the inequalities experienced.

The control exerted on people’s lives – even those using direct payments (DPs) – is keenly felt. Some areas eased restrictions on DP use during COVID-19 (restrictions that perhaps shouldn’t be in place anyway) advising DP users that their decisions would be supported and the level of scrutiny reduced.

SCIE co-production network members said:

Added to this, many people are not aware of how the funding system works, so are shocked when they realise they have to pay towards the cost of their care. This causes distress and means many do not continue with the support they need. Hammersmith & Fulham are now the only council in England not to charge for community-based care.

Moving towards better commissioning for the future

Reflecting and learning

Commissioning should be about improving lives – working creatively with communities to understand needs, shape responses and meet ambition. However, some commentators see commissioning as being out of touch, too complex and slow-moving. This may especially be the case when much of a commissioner’s role is driven by contract-focused work, mainly dealing with contract end dates, extensions, tenders and governance processes. This takes time and ties up resources, which means they have less capacity to properly co-produce and strategically plan with communities.

It’s a good time to re-think commissioning, to learn together and move forward. Whilst commissioners played a key role in ensuring delivery of services and support to providers during COVID-19, the ultimate impact on individuals was variable. Good practice must be spread to move beyond the current postcode lottery of choice and outcomes for local citizens. That will mean commissioners using and sharing evidence about what is working elsewhere to gain improvement ideas. What can we learn from the best including from international learning?

Members of SCIE co-production network suggest commissioners should ask themselves:

Reflecting on market shaping

Commissioners have an opportunity to take stock with communities as to whether local ‘markets’ improve people’s lives. They should also consider gaps or risks to positive support, and to what extent current approaches promote the Care Act principles of individual wellbeing, choice and control by ensuring a range of high quality services to enable people to live better lives, including those who buy their own support.

To commission effectively and shape the market, we should know what people want and need from services. We need varied channels to properly listen to people who use services, their families, communities, frontline workers, managers, and providers. People who use services often point to basic quality standards – respect, courtesy, communication and reliability. There is a message to commissioners and providers ‘to get the basics right’. These should underpin all services so people can focus on the detail of support that is right for them.

As commissioners, we need to understand what the market is prepared to do. Some care providers will only be there while there are profits to be made. It doesn’t mean they can’t offer good support, but there should be realism about the drivers. We need honest consideration of how to incentivise providers to promote independence and reduce inappropriate reliance on paid support and move from prevailing contracts systems which pay based on contact time or beds being filled. This affects how money is used and how decisions are made. Commissioning plans need to shift control, decisions and the money to individuals to make choices that are right for them.

Commissioners also need to consider who shapes the market and how, and whether the balance serves local people well. This may have shifted during the crisis. Shapers may include:

• providers or investors with good marketing plans
• people who use services – via self-funding or direct payments. If so, what are they buying and are they aware of the choices? Why are people choosing residential care when they could afford alternatives?
• assessors who lean towards services they know and trust
• innovators or community groups
• commissioners via contracted provision or shaped by market position plans.

Commissioning for outcomes – the future of commissioning

• A valued and sustainable workforce
• Growing genuine self-directed support
• Supporting local people and local economies

There are various messages to consider in looking to the future of commissioning post COVID-19. Priorities will be different in each area, but the following are consistent themes for development:

• Make a reality of co-production and the power of lived experience. This will ensure that insight and ambition shape future commissioning and the broader community and health agendas that impact upon people’s lives. Peer support and empowerment, including through Disabled people’s organisations (DPO), are important enablers.
• Support what works by mapping strengths, gaps and evidence to identify what should be sustained. Set out plans to decommission care that constrains independence and re-invest in more asset based solutions. This requires a shift from ‘time and task’ to more relational practice moving money and control away from block contracts to individuals and communities.
• Invest in sustainable innovation that improves outcomes but also delivers fulfilling work within communities, better resilience and better value for money.
• Community mobilisation has been a real positive – the voluntary and community sector (VCS) and mutual aid groups need to be central to the planning for recovery as well as the longer term.
• Carers are essential to recovery plans. Carers must have access to support for their own health and well-being including employment and financial advice. Reach out to identify carers – many are hidden including those of black, Asian and minority ethnic communities and those caring for people who fund their own care.
• Build on collaborative and integrated work with health so people get the right support and funding without navigating complex systems with multiple hand-offs.
• Invest in enablers that help people live well and be connected, such as digital devices and skills, accessible design and assistive technology. Some people may need targeted support with this or access to alternatives to ensure benefits are inclusive.

In the immediate recovery from COVID-19, support needs to be stabilised and switched back on so people get the help they need. Plans should address the possible risk of further lockdowns and ensure more individualised approaches for those affected. Services need to ensure their delivery is safe and improvements are put in place – for example, better use of space in care homes, residents and people living in supported living accommodation to have better freedoms, connections and quality of life, and building people’s digital skills. There is a need to address urgent pressures including support for mental health and the rights of people with learning disabilities to live in the community. Many people have faced genuine trauma. Help with that, as well as bereavement support, needs to be available across communities.

A valued and sustainable workforce

A well supported and remunerated workforce is a key element of effective market shaping. Adult social care leaders called for the development of a workforce strategy with fair national care wages and career progression across social care, social work and the NHS. This is partly addressed in the 2021 white paper but many are concerned that proposed funding is far from sufficient. We know that so many staff are highly committed and have untapped and unrecognised skills. Workers themselves have been at risk and equalities issues prevail. A corresponding change of skills is needed to support genuine connection and enablement. Increasing numbers of people will need support in the future, and different ways of working help attract a more diverse workforce, e.g. Shared Lives carers and micro-entrepreneurs are from wider sectors of the community.

Costs and evidence: growing genuine self-directed support

There is strong evidence of how community-based, innovative and flexible support delivers far better outcomes and value for money than traditional home care or residential care. Doing things ‘with’ rather than ‘to’ citizens enables people (together with their workers) to find their own solutions. Peer support can further strengthen this – sharing ideas, information and growing confidence. These also bring more sustainable, rewarding jobs. These services have performed well during COVID-19, responding in human ways, being agile, problem solving and keeping people at the heart of their communities. It’s time for more commissioners to follow the evidence and develop plans to support and scale what works including:

• Shared Lives
• direct payments – and the necessary support to use them to best effect
• self-managed teams such as Wellbeing teams
• micro-providers
• individual service fund (ISFs) arrangements for accountable flexible support
• flexible and holistic support for carers.

Supporting local people and local economies

Social care has the potential to be a key driver of inclusive economic recovery, bringing green jobs, and diverse local quality provision. It is already a major sector of the economy employing 1.5 million people in England. Its influence and impact affects all of us. Post-crisis the attention for the country will be preventing unemployment as well as addressing workforce gaps, improving health and wellbeing, and supporting more connected, resourceful and powerful communities. Social care can be key in delivering this – supporting people to lead the life they want, regardless of age or disability whilst also adding social value and promoting equality.

Mapping shows that a care-led recovery can bring double the amount of jobs than similar stimulus spending on construction. Improving wages and seeing care as a skilled job, such as in Denmark, can be part of bringing long-term financial recovery, as well as affordability and sustainability.

Co-producing a shared vision for the future

Be human, be visible

Sometimes the complexity of procurement-focused commissioning – its rules and regulations – prevents commissioners from being open and talking to people on the ground. We need to reflect on what we are doing and why, and who are we doing it for. For example, people with learning disabilities, supported by FPLD, are leading a call to action to commissioners to move beyond the decades of policies that have failed to ‘level up’ rights and outcomes. We need to know if what we are doing works. We can only know that by listening to people, by being visible and accountable to local citizens.

Be inclusive

The message from citizens is to reach out and be inclusive. Co-production is right and it is more efficient too. Don’t commission or plan things that people don’t want. Ensure there are varied and broad ways for people to be involved in decision making. Hammersmith & Fulham in their commitment to ‘doing things with residents not to them’ have developed a commissioning checklist that they are starting to test. They expect that early and open conversations will shape things differently. By asking a different question or an open question, people will identify different solutions. It is citizens who live with the consequences of commissioning decisions, so they are strongly invested in getting things right.

Support a vision for better lives

We need to ensure that commissioning supports and underpins people’s rights to full citizenship. The future for social care needs to be built on equalities and social justice, and all people being able to play a full and valued role in society. The message from citizens is for change – not just to improve what is already there or to get more money to bolster the current system. It has to be about building choice with people.

*Social care future

The task for commissioners is to enable citizens and others to co-produce the vision. Commissioners then need to translate what’s needed locally and agree the steps to get there, helping to remove the barriers. Adhering to good commissioning principles will enable commissioners with communities to be more ambitious.

It’s about …