The devil's in the detail: tackling the complexity of commissioning for outcomes

25 April 2013

Closing care homes, like closing hospitals, is not simply about the business case; and providing extra services to keep vulnerable people in their own homes is not just a matter of budget. Blair McPherson considers some of the complex issues faced by service commissioners

When a commissioning approach was introduced to social services nearly 15 years ago it was trumpeted as the vehicle for transforming services. The reality has been somewhat different.

Like many senior managers, I found myself in front of elected members answering questions like: "If the number of old people is increasing why are you planning to close homes for elderly people? "

This is a commissioning question. The answer? That the intention is to support people in their own homes by commissioning more home care, day care and respite care, decommissioning residential care and commissioning new services like very sheltered housing. The outcomes being sought are the greater independence, privacy and choice that come from having your own front door.

The next question was much harder to answer: "How many beds will you need?"

Commissioning is presented as a scientific approach based on good intelligence about local need. In fact, we have never been able to answer the question with the level of certainty it implies. Commissioning plans have in reality been driven not by detailed information about local population needs, but on available budget, benchmarking against the best performing organisations and what is politically do-able.

Shifting the balance of service provision is harder if the budget allows little scope for investing in commissioning of new services. In local authorities commissioning has often had to take place within the context of budget savings. New services could only be commissioned by stopping doing something else. Closing homes, like closing hospitals, is not simply about the business case. Most councils have had to deal with high-profile media opposition and the threat of judicial review.

Decommissioning is political. Politicians tend to sign up to the strategy based on a sound business case, but oppose its implementation in their own area based on representing the view of their constituents. Even government ministers have not seen any contradiction in this.

Commissioning less residential care will force some homes out of business. Commissioning has to ensure that it's not the quality providers that go out of business. Commissioning has to ensure that there is still choice in each locality. So commissioning has to manage the market.

If commissioning can't be based on detailed knowledge of population needs because that information is not available, it is often based on performance targets. If the best performing local authority is admitting X number of people per 10,000 population into residential care, then that becomes the admission target and determines how many beds will be needed. Likewise, if the best performing authority is supporting Y number of people in their own home, that then becomes the target and determines the amount of home help hours to be commissioned, day care places and respite care beds.

Need is not abstract, it's open to interpretation. For example, it's generally accepted that the level of dementia in the population is one in five people over the age of 80. However, in commissioning services for people suffering from dementia there is still a local political decision to be made about the level of need that will qualify someone for help.

Dementia ranges from the early onset of a loss of short-term memory right through to disorientation, disinhibition and being unable to function without a high level of support and supervision.

Due to their budget position, most local authorities only provide help to the most dependent and vulnerable so dementia services would not be commissioned on the basis of one in five over 80.

A commissioning plan for people with dementia would need to identify not only how many specialist long-term beds would be required, but how much day care and respite care would be provided to support carers and the extent to which the local council believed very sheltered housing would be appropriate for people with dementia.

In practice, since the number of older people living beyond 80 is increasing – and consequently the number of people suffering from dementia increases – local authorities commission more of all these services. But how much more depends on the available budget and the competing demands of other groups.

Blair McPherson is a writer and commentator on the public sector






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