Adult social care: independent review
The Independent Review of Adult Social Care in Scotland was led by Derek Feeley, a former Scottish Government Director General for Health and Social Care and Chief Executive of NHS Scotland. Mr Feeley was supported by an Advisory Panel comprising Scottish and International experts.
Chapter 9 Commissioning for public good
"If the commissioning and procurement model is to be maintained, there is a need for the introduction of more ethical commissioning models that take into account factors beyond price, including fair work, terms and conditions and trade union recognition.”
Over the course of the independent review there can be few things we heard more people speak about than commissioning, even if only in passing, and the need for it to be radically overhauled. Many people and organisations believed if it was done differently and altogether better that commissioning would provide the bedrock for a fairer, rights based, improved social care support system with a relentless focus on quality, outcomes, participation and collaboration. This would drive up standards and improve outcomes for people using services and supports, and the experience of social care support staff. This is one area where the proposal for a new social covenant rehearsed earlier in this report could bear fruit. The current approach to commissioning and procurement is characterised by mistrust, conflict and market forces. We need to radically redesign commissioning and procurement around the common good and stewardship of public money.
An improved approach to commissioning would change how procurement works. Care planning would be based to a lesser extent on costs and more on a range of factors. These could include, for instance, terms and conditions of the workforce, investment by providers in training and support for staff and in the fabric of buildings, flexibility and adaptiveness of services and people's experience of the quality of care. We were sympathetic to the view expressed by many people that procurement arrangements with providers should include requirements for the investment of a proportion of any profit made in improving the quality of care, and in staff terms and conditions.
Although spoken and written about often, not everyone has a shared understanding of what commissioning is. In Scotland, we used the term strategic commissioning to mean medium to long term planning that determines the choice of services and supports to meet individuals' needs, rights and preferences to live independently or as independently as possible. This must be underpinned by a robust strategic needs assessment of the whole population that is then segmented to understand the range of local needs, such as those of people from a particular geography or care group. This process is undertaken skilfully and expertly in some parts of Scotland but it is not yet consistent and is not always having the desired result on improving care and support because of the translation from strategy to delivery and the continuing dominance of a competitive social care market. Reformed Integration Joint Boards must give priority to making changes in how commissioning and procurement is undertaken supported appropriately by a national improvement programme.
Collaborative commissioning and procurement
As outlined in Chapter 1, commissioning is not synonymous with procurement but procurement can result from the commissioning process, i.e. identify the need to purchase a service from a provider or range of providers to meet identified needs. Over the last 10 years and more in adult social care support, procurement methodology and practices have increasingly driven and occasionally undermined commissioning decisions, where price and a competitive market environment, characterised by competitive tendering between providers, dominates.
We want to see an end to this emphasis on price and competition and to see the establishment of a more collaborative, participative and ethical commissioning framework for adult social care services and supports, squarely focused on achieving better outcomes for people using these services and improving the experience of the staff delivering them. By shifting emphasis in this way we believe Scotland can deliver social care supports more fairly and more sustainably.
We would like to see the split between commissioners and providers narrowed so that we can get the expertise of both, foster innovation, and engage people with lived experience more productively. In return for a seat at the commissioning table, we expect providers to be accountable for new standards of accountability, quality, staff wellbeing and transparency.
Professionals leading commissioning processes are often good at involving people with lived experience, carers, local communities, providers and other professionals to develop the large scale strategic commissioning plans that are statutorily required from Integration Joint Boards, for and with their local populations. We want to see this level of engagement and participation at all levels of commissioning from the strategic planning end of the spectrum through to any procurement of individual services and supports. And we want to see the decisions taken by social workers on people's care needs decoupled in the first instance from questions of affordability. We are not suggesting that it will be possible to meet every need nor that costs do not matter, but we believe assessment should be the product of a full understanding of the individual's needs, rights and preferences, and that when that assessment is translated into a package of supports any unmet needs should be recorded.
People with lived experience told us they want to be more involved, not just in the planning of their own care, but in the planning and design of services and they self-evidently have much to offer in this regard. In some instances peer groups, such as Disabled Persons' Organisations, Collective Advocacy Agencies and other representative groups, can play a very valuable role too.
There are alternative models of commissioning and procurement, including Public Social Partnerships and Alliancing, that are tentatively and selectively being adopted in various parts of Scotland. While these have not been wholly successful in changing prevailing practice, and we heard many have been too complicated and taken too long, we think they, along with other models, offer the opportunity to move away from competitive tendering. In some instances, the whole model of Alliance contracting has not been adopted but the principles have been fully embraced and applied but attention needs to be paid to the timescales for establishing such arrangements and must not take years to set up. New models of procurement need to be adopted more rapidly across services and alternative models put in place across different kinds of services and supports, and across Scotland.
Focus on prevention and early intervention
National guidance is in place for effective commissioning and procurement processes, but as with so many other aspects of social care support, an implementation gap remains. We believe that national leadership can support increased pace and urgency to enable bold, long term whole system redesign commissioning decisions. Greater emphasis and focus are needed on prevention, early intervention and de-institutionalisation, which means decommissioning, disinvestment and redesign of current services must become a reality and not just an aspiration. This will help support a move to independent living for everyone or the development of smaller supported community living arrangements.
Alongside this is the vital importance of recognising, valuing and linking people to local community assets, which should be commissioned and appropriately funded by Integration Joint Boards, potentially through grant aid, and working jointly with Community Planning Partners. Even modest resources can make a huge difference and help establish highly effective community supports, planned by local people for local people, where these do not already exist, to ensure availability to local communities, in addition to what are more traditionally considered to be social care services and supports.
Commissioning, procurement and service delivery approaches must factor in how people using services and unpaid carers will be engaged and involved throughout the journey of their care plan, its delivery, review and feedback. Information about identified unmet need must be fed into the strategic commissioning process so that this can be addressed.
Commissioning should become increasingly transparent in relation to how people's rights have been taken into account and eligibility criteria applied, and local plans should include a method statement and commitment describing how organisations and individuals will be and have been involved and respected in the process.
Ethical commissioning and procurement
An ethical approach to commissioning, and as a consequence to any procurement of care and support, will reap benefits for staff and supported people alike. We know there have been some gains already made in the small number of Local Authorities that have adopted the Unison Ethical Charter on social care commissioning, but this approach must be extended and enhanced, and must ensure that Fair Work practices are fully supported by commissioning and procurement for all services and supports across the country.
Adopting an ethical, fair approach cannot be an optional extra: it must form the cornerstone of future contractual relationships, to help improve the experience of the workforce and help create sustainable, high quality provision. Along with the failure of many current commissioning and procurement arrangements, the most frequent observation made to us throughout this review has been that the workforce must be better regarded, rewarded and supported.
We do not underestimate the immense culture change implied by what we have set out above. We firmly believe that without radical change and a more collaborative and ethical approach to commissioning adopted at all levels, we will see the disparity between what people require and what they actually get continue to grow, alongside levels of dissatisfaction and people not achieving their desired outcomes or reaching their potential. Costs will spiral, and services will become less sustainable and quality will decline further, which we can avoid by taking decisive action.
People want choice and control in self-directed support options to be a reality, not a slogan, so that they can be supported to live their lives in the way they determine not the way services or commissioners choose.
The Coalition of Care and Support Providers (CCPS) has been working on alternatives to the way that social care support is planned, purchased and funded in Scotland, in close partnership with supported people and support providers, and drawing on academic research. It has developed a number of "Big Ideas" – one of which calls for a pause button to be pressed on the current procurement system to support the move from a competitive process and culture to a collaborative approach. We think this idea has considerable merit but that it needs close consideration for any unintended consequences and careful planning to ensure it does not impede anyone's care and support. In particular, its success will be entirely dependent on delivering the recommendations for a national improvement programme we set out in Chapter 7. It should be a priority for a new National Care Service.
During the Covid-19 pandemic, a great deal of attention has rightly been given to care homes. A previously creaking and fragile system has been exposed, particularly in regard to infection prevention and control (IPC). We know from research that those care homes that have successfully minimised outbreaks of Covid-19 have been smaller, locally run and staffed services, that are part of the local social care ecosystem, operating in partnership with other local services and commissioning bodies. Arrangements have been put in place in each Local Authority area to directly and indirectly support and nurture improved standards of IPC, with increased clinical oversight provided by Directors of Public Health and Directors of Nursing, alongside professional support from Chief Social Work Officers and IJB Chief Officers to ensure a focus is simultaneously maintained on people's wider wellbeing as well as adult support and protection issues.
The safety huddle tool referred to in Chapter 7 has meant that for the first time ever a standard data set is available in real time about each and every care home in Scotland. This data is available to local systems and at a national level, and is helping to ensure support is provided at as early a stage as possible to care homes to ameliorate and better manage risks for residents, staff or the whole care home, identified through use of the tool. This approach has wider implications and opens possibilities to a more partnership-based approach to improvement in care homes, which is not reliant on the Care Inspectorate using its regulatory powers but instead focuses on the priority we heard expressed that local ownership of improvement work needs to be nurtured and supported.
Generally, care homes are not part of a managed market or commissioned set of services. The care home market is largely led by business decisions made by individual care homes or groups of care homes, some of which are large multinational companies. There is currently no oversight of this market and we believe there is an enhanced role for the Care Inspectorate as part of its regulatory activity to undertake this work, drawing on existing work and expertise. A more actively managed market should be shaped and facilitated to respond to a longer term strategic vision that takes into account the balance of providers in the market and local needs, for example, by requiring engagement with Integration Joint Boards before a service can be registered. In this role the Care Inspectorate would provide information and assurance to the National Care Service and to local systems about care home provision.
The extent to which some privately-run care homes yield profits for their shareholders was raised with us repeatedly as an issue of concern. We have reflected on whether nationalisation is practical, desirable or affordable elsewhere in this report. We nonetheless want to record here that we share the unease expressed by many about whether it is right – in a country committed to health-care free at the point of need to all of its citizens, regardless of age or any other characteristic – that an important part of our care system is largely run on a profit-making basis.
Our principle concern is not with profit itself, which plays an important function in any market economy, but with what we have come to think of as "leakage" from the care system in Scotland. Significant sums leave the care economy, some of which could be better used to raise standards of care and terms and conditions for staff. We therefore recommend that the National Care Service should take these concerns into account as part of its development of a new approach to ethical and collaborative commissioning. National contracts, and other arrangements for commissioning and procurement of services must include requirements for financial transparency on the part of providers along with requirements for the level of return that should be re-invested in the service in order to promote quality of provision and good working conditions for staff.
Care home placements are currently purchased by Local Authorities on an individual basis at a price set through annual negotiations on the National Care Home Contract. This contract is in urgent need of reform so that the focus on the price payable per placement does not undermine the vital focus on achieving good outcomes for people and ensuring high quality care is delivered to care home residents, and staff enjoy the benefits of fair work requirements being fully delivered.
Finally, care homes should be supported fully by primary care and integrated health and social care support teams. Access to the NHS is a universal right in Scotland, provided free at the point of care for everyone. We heard that some care homes have excellent support from local primary care practitioners including GPs, and integrated health and social care support teams, but others do not: there can be no justification for denying healthcare to care home residents on the basis of their place of residence. Addressing inequities like this should be a priority for the new National Care Service.
Care Home Resident
I have been living for several years in a wonderful care home, run by the council in South Lanarkshire. I couldn’t be happier. The staff do everything for me, I don’t need to worry about anything and even during the pandemic I feel so safe because we are so well looked after. We have a hairdressers, a cinema and a lovely café and I am surrounded by friends. The staff are really committed to making sure we have everything we need. I don’t think the staff are paid enough for what they do. They have a really difficult job at times and they never complain, they just get on with it and work so hard, particularly dealing with the Covid situation. They are worth their weight in gold.
I know some people dread the idea of going into a care home but it’s been a wonderful move for me. I would urge people to look into the care and help that is available. Living in a good care home is so much better than sitting at home alone and struggling. Nothing would persuade me to move from here. It really is my home and I love it.
We have identified a range of changes needed in commissioning and procurement practices:
32. Commissioners should focus on establishing a system where a range of people, including people with lived experience, unpaid carers, local communities, providers and other professionals are routinely involved in the co-design and redesign, as well as the monitoring of services and supports. This system should form the basis of a collaborative, rights based and participative approach.
33. A shift from competitive to collaborative commissioning must take place and alternatives to competitive tendering developed and implemented at pace across Scotland. Commissioning and procurement decisions must focus on the person's needs, not solely be driven by budget limitations.
34. The establishment of core requirements for ethical commissioning to support the standardisation and implementation of fair work requirements and practices must be agreed and set at a national level by the new National Care Service, and delivered locally across the country.
35. To help provide impetus and support to the adoption of a collaborative and ethical approach to commissioning, the idea from CCPS of pressing pause on all current procurement should be fully explored in the context of a National Care Service, with a view to rapid, carefully planned implementation.
36. The care home sector must become an actively managed market with a revised and reformed National Care Home Contract in place, and with the Care Inspectorate taking on a market oversight role. Consideration should be given by the National Care Service to developing national contracts for other aspects of care and support. A 'new deal' must form the basis for commissioning and procuring residential care, characterised by transparency, fair work, public good, and the re-investment of public money in the Scottish economy.
37. National contracts, and other arrangements for commissioning and procurement of services, must include requirements for financial transparency on the part of providers along with requirements for the level of return that should be re-invested in the service in order to promote quality of provision and good working conditions for staff.
38. A condition of funding for social care services and supports must be that commissioning and procurement decisions are driven by national minimum quality outcome standards for all publicly funded adult social care support.
39. A decisive and progressive move away from time and task and defined services must be made at pace to commissioning based on quality and purpose of care – focused upon supporting people to achieve their outcomes, to have a good life and reach their potential, including taking part in civic life as they themselves determine.
40. Commissioning decisions should encourage the development of mutually-supportive provider networks as described above, rather than inhibiting co‑operation by encouraging fruitless competition.
41. Commissioning and planning community based informal supports, including peer supports, is required to be undertaken by Integration Joint Boards and consideration of grant funding to support these is needed.
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