Commissioning is dead? Long live…?

By Martin Routledge

Professor Donna Hall, former CEO of Wigan Council and current chair of the New Local Government Network recently declared in a Twitter exchange “Commissioning is dead”. Donna of course knows that so long as there are people and organisations responsible for stewarding public service resources, some form of what we currently call commissioning will happen. Clearly, therefore, she was calling for big change in how this is done.

People who use social care are also calling for change. Through the period of Covid 19, Social Care Future have been part of many discussions where people using social care have engaged with politicians from the main parties and with the formal leadership of social care. These include regular meetings with the social care minister Helen Whately and a meeting with the Leader of the Opposition and Labour Health and Social Care team, including shadow social care minister Liz Kendall. We have also spoken to people leading not for profit support providers covering more than half of the country. In addition, we are seeing the emerging results of systematic attempts to capture people’s experience including via the Be-Human register led by In Control and Disability Rights UK and SCIE’s work looking at commissioning during the pandemic for DHSC. TLAP have recently rounded some of these up in an initial analysis.

Pretty clear patterns of experience are emerging – good and bad, about people’s experiences in different council areas. Largely these reflect and sometimes amplify the good and bad experiences pre-pandemic. They are experiences around communication, relationships, levels of flexibility, responsiveness and bureaucracy. People’s local pandemic experiences seem to largely mirror their pre-pandemic ones depending on the council involved. The bad news is that the majority of reported experiences are not positive. The better news is that, as SCIE have discovered in their recent work for DHSC, there are good practice examples in pretty much all the areas of concern – begging the question if some can do it why not others and flagging the possibility of action for improvement.

But beyond better or worse commissioning practice within the existing ways of doing things, it is increasingly clear that those ways themselves don’t really work. I recently co-convened a Social Care Innovation Network set on commissioning with Kate Sibthorp who is a member of Think Local Act Personal’s National Co-production Advisory Group. At the start of one of our sessions Kate painted a picture of the commissioning practice she and her daughter experienced, along with others from her network. The things Kate said pulled our group of commissioners, people with lived experience and progressive support providers up short. It revealed something basically indecent. Kate described, for example, pen pictures of people describing what the council authors saw as their deficiencies put out for local providers to bid for. Basically a trade in people. Which of us would find that acceptable for ourselves or our loved ones?

Kate wrote a blog called “Commissioning, if you always do what you’ve always done.” Reflecting on a challenging presentation from Andy Brogan she wrote, about some of the cruder approaches to commissioning for outcomes:

“ I’ve come across this personally, when I secured funding for one of my daughter’s PAs to go to college to get a Certificate in Care. She decided to abandon it after just two weeks. She was being told that she had to record in writing, every day, exactly what they’d done – how many drinks, how many visits to the loo etc. She told the course tutor that I didn’t want to know these things. I wanted to know if my daughter had had a good day – was she happy, had people been friendly, would she enjoy going back to wherever they’d been or seeing a film again. The tutor said that the PA should still write everything down to ‘cover herself’ in case of a problem situation. It was all process, not relationships or happiness. The only way anyone could measure what matters for my daughter would be to count smiles and laughter. The relationship between me, my daughter and her PAs is built on trust. Sometimes the PA might do something I wouldn’t have done, but if it’s coming from the right place, the heart, that’s fine. And anyway, who’s to say the PA’s ‘wrong’ and I’m ‘right’? I’m happy for them to try things and see whether my daughter likes them or not”.

The really positive thing was that following Kate’s pretty devastating introduction we didn’t get a defensive reaction from the commissioners present. They were up for a serious discussion around the questions Are we ok with this? and If not, what can we do?

Social Care Future has been involved with the Social Care Innovation Network (SCIN) to see if we can support a big shift in how commissioning happens. We are not kidding ourselves that all places and public service leaders will immediately embrace this or that we have all the answers. However, over the past year as part of wider networking we have had sit down conversations with quite a few Directors of Adult Social Services – inevitably ones that might be seen as more “progressive”. We have asked them what they want to change and what they think they might be able to get key local partners to start to converge around. As you might expect their ideas ranged widely around promoting independence and helping people avoid unnecessary use of long term care, supporting strong inclusive communities, shifting from institutional models of care and support, broadening options and choices where people need long term support. Perhaps the most common urge was to shift from life and limb time and task “homecare”. More recent conversations have raised the question of the future of residential care, and the right balance of forms of long-term accommodation with support.

There are, of course big issues about how to create the national and local conditions for a paradigm shift. There are issues about resources, models and strategies. It seems to me that to date we have struggled on all fronts: to make a persuasive case for resources, being largely stuck on making a moral case for more money for existing ways of working; getting clear and setting out what models of support and practice can achieve sustainable improvement; setting out how we can drive change locally. And these struggles are compounded by a continuing “sector” narrative that undermines rather that underpins public support for investment. Changing this requires collaborative and effective action on a series of fronts and at different levels. One element is to support those local places and leaders ready to try to make big change, to do it and hence provide a growing number of exemplars that can offer impact and evidence of value to be used as part of a broader strategy for wider change.

So, as part of phase-two of SCIN, people with lived experience of social care, families, commissioners and innovative support providers came together for two full day sessions to consider what changes to commissioning in adult social care might help localities move towards the goal of becoming (in a bit of jargon we will need to change) an ‘asset based area’. Based on the real world session discussions and issues raised, we started to build a possible framework to guide changes to commissioning in order to make this shift. This outline was shared and some feedback taken (limited given the arrival of coronavirus). Our third session was intended to be a strategy session considering who could do what at different levels to create the conditions for big change and start to drive it. We plan to take this forward virtually over the next few months.

The Social Care Institute for Excellence, in partnership with TLAP and Shared Lives Plus have now published our commissioning “starter for ten” along with other materials from SCIN phase two and along with a short guide to relevant materials and resources (see below). We hope that those seeking to embark on such a journey of change will find it helpful and will help develop and improve it via critique and contribution.

Here is a little glimpse:

New vision, new practice

We all want to live in the place we call home with the people and things that we love, in communities where we look out for one another, doing the things that matter to us

The Social Care Future (SCF) vision calls for big change in how public service resources are used alongside citizen and community assets. Think Local Act Personal with partners developed the community-centred support ‘rainbow’ along with the Directory of Innovations in Community Centred Support to show what the future could look like. This now forms the practice basis of the Social Care Innovation Network’s framework for developing Asset Based Areas.

If we agree that paying focused attention to these things will help us change how we use public services for the better, we still have the question – how can commissioning enable this paradigm shift?

Commissioning, but not as we know it

Whilst there is no lack of general backing for the SCF vision we still seem to be somewhat stuck in buying a limited menu of “services” where the largest part of budgets are spent on the same things they have been for many years. We will find some of these are increasingly unappealing to people and they often don’t use resources in ways that maximise wellbeing and independence and can offer a sustainable future.

It is now obvious that we need to commission differently if we want a different future. This is absolutely not to decry the hard and creative work of many commissioners around the country working in tough financial circumstances (and more recently a global pandemic) Indeed it is because, despite massive constraints, many are also breaking new ground in their practice that we have glimpses of a different future that we can now build on. Recent responses to Coronavirus in many places have shown what can be done and quickly. This both shows the way forward and demonstrates that change is possible in even the most difficult of circumstances. It also undermines the negative caricature of all commissioners and commissioning as an immovable straight jacket, instead showcasing what could be done

Of course, we are also not starting from a blank sheet of paper so as well as thinking about where we want to be, we do need to think about how to get there from here. We and others have been looking for better ways that people and communities can be supported in ways that could move us towards the SCF vision. These better ways are far from mainstreamed and some need to be further developed. However, much is already known about what works and how to bring about the change. This is explored below.

Asset based commissioning

Perhaps the key resource in this area is Asset Based Commissioning by Richard Field and Clive Miller. Their comprehensive book is full of useful ideas, resources and examples. It traces the history, theory and practice of commissioning and considers how it needs to and can change to a new paradigm.

A core argument is that public sector resources should be used to “enable citizens to pool their assets to achieve personal and shared outcomes, e.g. community safety…education, employment, health, that are best achieved through collective means”. The authors suggest that the conventional approach to commissioning reflects what has been called the “professional gift model” whereby citizens pay taxes in return for services and supports designed by organisations that provide them free or via part payment. They argue that this model is increasingly inappropriate and unsustainable for a range of reasons including the changing nature of need, demand and expectations. Given this they propose that a more appropriate public service model will be based upon “asset-based practice”:

“Asset-based practice aims to make more effective and efficient use of the total assets of people, communities and organisations. It does this not by reducing the role of the state and transferring the burden to people and communities. Instead, it redefines the role of the state and its relationship to people and communities. It explicitly recognises the roles that people and communities play in achieving outcomes both as co-producers alongside organisations, and through personal and community self-help. As co-producers, people and communities are involved as equals in day-to-day decision-making. This changes what both practitioners and people and communities do to co-produce outcomes”.

Though the authors note interesting and positive developments from the model of commissioning introduced in the late 1980’s they argue it can’t enable the step change needed, with core challenges including: deficit based model, inefficient use of the range of resources in places, narrow focus on specific sector outcomes, failure to make use of supplier innovation and the creativity of people using support.

“Hence, overall, the conventional model of commissioning overlooks the potential for redesigning commercially provided services and state funded services and support to complement what people already do, and would wish to do, for themselves and others. Failing to recognise and properly value the contribution people make, causes inefficient and ineffective use of the assets of people, communities and organisations”

They argue for a shift to Asset Based Commissioning defined as:

‘Enabling people and communities, together with organisations, to become equal co-commissioners and co-producers, and also, via self-help, make best complementary use of all assets to improve whole life and community outcomes.’ 

In thinking this through with people and places showing “glimpses of the future” we came up with some key change processes and then gathered together lots of examples of the glimpses of these ways of working around the country.

  1. Establishing a clear strategic direction starting from the goal of playing a part in improving lives and communities. The focus is on redesigning services to maximise well-being and sustainability including enabling community and individual self-help. This is a shift from a narrow focus on only improving specific service responses to perceived need within public service resources and silo delivery areas – towards a broader and more sustainable vision and direction
  2. A determination to release all local assets – public services (specialist and universal), citizen, community, commercial etc. With a broader strategic vision, it is necessary and desirable to look much wider than existing public service resources, exploring a wide range of assets and considering how synergy and alignment can be achieved. How can public service capacity support and help unlock other assets?
  3. A starting aim to use public service resources to support, enable, build from and add to citizen and community initiative and action. Shifting from the “professional gift model” to add to community action rather than replace it, use professional skills in support of it and to play appropriate roles
  4. Co-produce and deliver a range of activity to support wellbeing and sustainability. Including action at all commissioning levels with communities, citizens, professionals/workers and support providers. This includes desired results, how to achieve them, making them happen, learning. Building from the broad strategy and using a wider range of assets to take specific coproduced actions at different levels to achieve positive change. 

If you want hear more and to check out the materials – they are available free here

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