Social Care Commissioning - Need An Outcome Based Approach
Daria Kuznetsova examines how commissioning practices must develop to improve quality of care and ensure it is sustainable.
The challenge in social care is twofold: the first is how do we secure the resources to meet rising demand across all user groups and the second is how do we transform services in a way that uses existing resources to achieve better outcomes. New NLGN research, produced in collaboration with the Adults with Learning Disabilities Services Forum (ALDS) and Learning Disability Coalition (LDC), explores the latter. In a world with the largest reductions in expenditure in the last 40 years we examine how commissioning practices must develop to improve quality of care and ensure it is sustainable. Whilst the research focused on people with learning disabilities, the key principles of commissioning outlined in the report are applicable across all user groups.
In examining how commissioning practices will evolve to meet the challenges ahead,
we conclude that 100 % personal budgets by 2013 won’t be the answer. Although personal budgets and direct payments have the potential to transform people’s lives, the 100 % target has a number of risks attached, both in terms of quality and cost. New NLGN analysis shows that from 2001/02 to 2009/10, each new direct payment added an average of £17,000 to the cost of caring for someone with a learning disability.
These inflationary pressures are mirrored by a recent Dutch decision to scale back their availability of personal budgets. The increased expenditure is in part due to the lack of business streamlining demonstrated by double running of contracts and the slow adaptation of the market to changes in user demand. A number of recent reports have further reported that personal budgets are not giving individuals the choice and control intended as they are often unaccompanied by the necessary support services and availability of information. Personal budgets are often treated as a tick box for personalisation yet a personalised approach within the local authority is necessary in the first place to guarantee their success.
A broader shift in commissioning towards outcomes will therefore be needed to drive forward the personalisation agenda. Although there are a number of sophisticated outcome measures used by providers and local authorities, the current system is characterised by duplication and inconsistency.
Embedding standardised outcome measures such as the Social Care Related Quality of Life (SCRQoL) into commissioning decisions will be essential if we are to achieve value for money in social care services. SCRQoL measures developed by the Personal Social Services Research Unit (PSSRU) allow for comparisons of outcomes with and without the use of care services as well as throughout an individual’s care pathway. Collecting this type of information on the outcomes of assessment and review processes will help commissioners compare the cost effectiveness of services. Commissioners can then devise their own methods for deciding how much they are prepared to spend to secure a particular outcome (similar to NICE QALY guidelines).
A focus on outcomes opens space for innovation, allowing users and providers to use their expertise to design higher quality services. Although the social case for community based initiatives and a mixed market of providers is an obvious one, commissioners will need new tools in making the economic case for investing in new and innovative initiatives. Contracting for outcomes rather than for hours or days of care is going to be key in transforming the system and changing the culture in social care. Such approaches could help avoid the human rights breaches reported by the Equality and Human Rights Commission this week. It could further lead to the development of commissioning strategies currently unused in social care such as payment by results and social impact bonds.
Commissioners will have a key role in developing a mixed and vibrant market to meet the needs of users. As in every other market, the role of the government is to mitigate market failures such as information asymmetry. If services are held directly accountable to users, commissioners should facilitate co-produced ratings of all independent providers within a local area. Furthermore, as the social care market is undergoing rapid change in the type of service provision demanded, strategic market analysis and publically available information on opportunities for market development will be key in ensuring services can be developed to meet the needs of service users.
The question of quality assurance is becoming pertinent as the regulatory structures are in a period of change. The consumerization of the local social care market and the recent problems faced by residential care providers further demonstrate that local authorities and service users themselves need to be involved in provider oversight. New tools to monitor outcomes at a local level will be needed to help ensure continuity of service for those reliant on care services. As most national guidance usually targets the service manager or the head of services, outcome metrics that also reach lower levels of the workforce will be most effective.
In addition to shaping markets, social care commisisoners will only achieve long term outcomes if they are to play a role in shaping places. As a third of support plans in personal budget evaluations identified leisure as a key use of funding, a strategy for increasing access to universal services is needed in each local area: this involves tackling the issues of discrimination and bullying often encountered in the use of universal services like leisure, libraries, education and transport. The Adult Social Care Survey revealed that only 41.9 % of care users in England have as much social contact as they would like. Facilitating community networks through schemes such as time banking, peer support and homeshare could greatly improve social cohesion and lead to improved quality of life for people. There is an increasing evidence base for the cost effectiveness of community-based approaches that allow people to live more independent lives and therefore these initiatives should be scaled up.
Embedding outcome measures into commissioning processes has the potential to join up services around people with learning disabilities in a way that wasn’t possible before. A strategic outcomes framework combined with an understanding of the actual costs of care across departments along an individual’s care pathway would help in aligning commissioning practices. Contracting for outcomes could further facilitate joint working between independent providers as they will need to collaborate to achieve those outcomes.
The current fiscal climate will be a key opportunity for commissioners to embed new outcome measures into delivery of services. Accompanied by “place shaping” and “market shaping” such an approach will drive quality improvements and ensure these are sustainable in the long term.