Re-designing commissioning

Social Care Future is bringing together a wide range of people interested in driving major change in the way people can be supported to live a good life in their local community. Over the past year, we have been working to develop a vision of the future, encapsulated as:

“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”

We are pleased that the Social Care Innovation Network (SCIN) has been set up to help change a situation where, despite great efforts, and accepting that there are many positive developments, the general picture remains one where state resources are mostly spent on systems, practices and services that could still be characterised as belonging to a “professional gift” model. The primary models of service have changed little in decades and are increasingly out of sync with what people and communities should be able to expect in the 21^st Century. This is despite, in recent years, the development of attractive alternative forms of support and ways that people and communities can support each other. Though the dramatic cuts of the past ten years are a big part of the problem, there is clearly an issue about what money gets spent on, not just how much money there is.

TLAP and partners have described, at high level the “Asset Based Area” as a desired goal for localities, setting out elements that need to be in place to underpin radical positive change, and some of the approaches that experience is suggesting can help.

The SCIN has been set up to explore and find ways forward in unfreezing this position, helping better ways of doing things to come in from the margins in order to support places to shift in the direction of the Asset Based Areas.

After the first exploratory stage of the Network, the second phase is focussed on three linked areas:

1. Developing the Asset-Based area model in more depth
2. Re-designing commissioning so that it supports innovation
3. Taking self-directed support back to its roots so that it affords authentic choice and control and enables people to connect and contribute

I am co-leading the commissioning element of phase two, alongside Kate Sibthorpe from the National Co-production Advisory Group and supported by Natasha Burberry, TLAP Policy Advisor. In short, we are using our three sessions to consider and plan a range of things we can do within the network and beyond in respect of commissioning, that can help localities progress towards being asset-based areas. Across the three meetings of the learning set we are starting with “living well at home, contributing and connected to our communities” as a key desired area for change in social care, then we will move on to other key areas of commissioning including accommodation with support. One aim will be to develop some practical frameworks, models and resources for localities or collectives to use in taking forward change.

In our first session we started from a place that has a ten-year history of aspiration and developing action to shift how adult social care and other public services operate in the direction of the asset- based area. Thurrock Adult Social Care leaders, Les Billingham and Ceri Armstrong helped us to explore the detail of the shifts involved in moving towards being an asset based area; the new kinds of outcomes they are co-developing with local communities; the practice and support elements they are bringing into place to move closer towards these outcomes; the infrastructure and system changes needed to underpin the shifts and the practical strategies/tactics required with a range of players and partners.

Les and Ceri offered an outline of key high-level developments in recent years that have positioned them to make a sustained and systematic effort towards the asset-based area:

One important opportunity and element of their strategy has been to work in two specific local areas, Tilbury and Chadwell, taking developments and learning from the last decade and bringing them together to develop a new model for the areas. This, in turn, is to provide learning that will be used to spread and scale up a model across Thurrock as part of Better Care Together Phase 2.

In the session we interviewed Les and Ceri in order to explore the key elements they are seeking to put in place in Tibury and Chadwell to drive their desired shifts and to understand their learning about the necessary “market development” and commissioning changes likely to be needed to achieve their goals and to spread them across the whole of Thurrock.

Some of the questions we asked were:

• Can you give us a sense of the direction of travel? The strap line of your recent report is “Improving life not just services” – can you put a little flesh on the bones? - what are the key shifts you have been trying to make, with partners?
• Now can we ask you to offer us some detail about the components or pieces of the jigsaw that you are looking to put into place which you think are likely to drive different outcomes (we understand these to include Local Areas Co-ordination, Community Led Support, technology enabled support, Wellbeing Teams, Hubs, micro enterprises, time-banks, etc.)
• What would you say are some of the key things that can enable this range of elements to have the joined up impact you are hoping for (key infrastructure, flexible use of DP’s, risk approaches etc., workforce approaches, outcome measurement?)
• What will have to change in what we currently call the “market-place” in order to respond to your direction of travel?
• Regarding Better Care Together Phase 2, there is reference to commissioning redesign to go from making a case for change in a specific geographical area to scaling across Thurrock. You have mentioned that to date you have been trying to make the changes within the existing commissioning system. Do you see commissioning as a key enabler or obstacle to the spread or scaling, if so what do you think are going to be the key issues you will need to address?

In addition to these questions, we had the opportunity to explore a specific and significant goal, which was to make a paradigm shift in what is currently called homecare. Les and Ceri spoke about their aim to move to a very different approach to supporting people at home, that is less transactional, broader than simply “life and limb” care, activating and using resources well beyond “hours of care” and expansive in looking to support real well-being. In addition, they want to change and improve the experience of those providing the support. They spoke about their current work with Wellbeing Teams (WBT) and we asked Helen Sanderson who leads WBT to speak about the key elements of the approach being explored with Thurrock – including the implications for commissioning.

We recorded the key elements of the description of goals and key elements emerging from the interviews, including thoughts and ideas about key issues of change strategy and tactics.

Bringing the other members of the set in, we then built upon the issues raised by Les, Ceri and Helen and invited people to explore the specific commissioning issues that they saw as thrown up by Thurrock’s radical goals and by their own local experiences. These were broadly divided up into issues that might be reasonably easily addressed at a local level if there is a good level of focus and determination to make change and those that were considered to be deeper, more challenging issues.

We then invited Andy Brogan from Easier Inc. to offer a possible framework for action to explore and test the potential for approaches to commissioning to help enable the shift to an asset-based area. Andy and colleagues are calling this ‘Commissioning 2.0’. As part of this, Andy offered principles that might underpin approaches to achieving the kinds of shifts being sought, in the context of the clarity of purpose, focus, innovation required, partnerships and the co-production needed to achieve them.

STOP - put operational issues and pressures to one side in order to step back and see the bigger picture. What could you be capable of achieving together? How can you frame a common purpose?

LISTEN - what really matters to each other about how this purpose is delivered? Why? What would make partners anxious and what would each need in order to feel safe in exploring a different way of working together?

LOOK - what is happening today and why? How does this relate to the common purpose that you defined together and how does it relate to what really matters to each other?

TEST - how can you take practical steps together to test new ways of working? At what scale? With what urgency? How will we discover through action how to deliver your common purpose while looking out for and looking after each other?

RESPOND - what have these tests of change revealed about the potential to work differently? What has made this harder than it needs to be? How can you now make some strategic adaptations in order to scale, spread and accelerate the benefits?

Participants then gave us some steer on what they felt to be the key issues that we needed to work on, within the Innovation Network and beyond, in order to support those seeking to move towards the asset-based area.

We agreed that as a next step we would use both the outputs from the session and some work which has already taken place in mapping relevant commissioning work. This ranged from ideas from think tanks, publications, through development activity and skills development programmes to start to build a framework for commissioning for the asset-based area which could then be expanded on into a very practical resource. This would need to address the key commissioning challenges, support on the ground action and experimentation in localities that are part of the network and beyond.

As a first step we will test thinking at the upcoming February 4^th Social Care Future gathering and then build the first version of the framework for further development at our Network session in March – watch this space!

Andy Brogan’s presentation was thought-provoking to say the least and, I sensed, quite challenging for some people in the room.

He argued that commissioning for outcomes in social care is a bad idea. What?! Let’s be clear here; he’s not saying we don’t want to achieve outcomes, but that the process of commissioning for outcomes leads us to measure the wrong things, things that don’t make a positive difference to people’s lives.

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.

As Andy Brogan explains...

Populations don't experience outcomes. People do.

In this context, Andy Brogan’s approach makes good sense to me. He says that great results in social care are achieved through relationships between people. If we accept this, then commissioning needs to evolve into a process that secures the right underpinning values, attitudes and relationships that will deliver good, meaningful lives. I hear people talking a lot about moving away from the time and task approach. The question is, how do we commission the underlying conditions that will enable human relationships to flourish and enable great outcomes to emerge?

It seems to me that Andy’s view of commissioning is far more dynamic than what currently tends to happen. It recognises that we don’t always know exactly what outcomes we want (human lives are messy) and people who access services are endlessly diverse. So commissioners need to work with people, communities and providers in a way that figures out what to do as we go along, running with what works and abandoning what doesn’t. It means that commissioning would have to become a more continuous learning process, more open and flexible, more iterative - not a straightforward specify/deliver/measure approach. There would have to be continuing conversations between commissioners, people who access services and providers to share how things are going and think about what’s working, what’s not working and what else to try. It couldn’t be anything other than place-based and co-produced.

There are lots of challenges associated with this. Not least, and something I’m interested in exploring, is how we enable people in communities, including people who access services, to evolve from being passive customers or recipients to authentic co-production. There are some excellent examples of co-production, the relationship between Think Local Act Personal and the National Co-Production Advisory Group being one. But most people I know don’t get it; in my experience, there isn’t a latent majority of people who access services ready and willing to co-produce. We need to nurture co-production.

This approach takes guts, leadership, collaboration and heaps of trust. It feels like a real opportunity and I’m hoping that the Social Care Innovation Network will generate some interest in giving it a go!

You can read Andy Brogan's blog here