Commissioning in Practice – can social care commissioners step up a gear to meet the challenge?

Guest Blog from Doug Forbes, Director, Institute of Commissioning Professionals

Commissioning is everywhere in the public sector. New Clinical Commissioning Groups in the NHS, the white paper proposal that a local authority becomes a commissioning organisation and Justice Commissioning. In children’s services, the area of youth services, the inspectorate OFSTED has said, “In the less effective practice, the process of commissioning was poorly understood; confusion between procurement and commissioning impaired planning.” (August, 2011.) The Institute for Commissioning Professionals’ experience suggests that commissioning is poorly understood within local authorities. Apart from in a few areas, it is not being seen as a tool for leaders to use to reshape provision. It is often seen as a support service which follows process. Clearly, OFSTED would like to see a change and no doubt, the Winterbourne View and Southern Cross issues in health and social care will herald a clamour for change.

At the IoCP, our goal is to improve commissioning standards, an objective shared by Dame Barbara Hakin, National Managing Director of Commissioning Development at the Department for Health. If asked, what is commissioning? It is simply, ‘What to acquire?’. How it is acquired is open to a wide range of routes including, in the NHS, the right to provide and in local government, soon the right to challenge and form a community-based mutual.

The UK Government is making moves to simplify the onerous EU procurement directives and is entering into negotiations with the EU: to free up frameworks which lock out suppliers; eliminate processes which discriminate against small to medium-size businesses; and award contracts to new community based mutuals for 3 years before undergoing a test of competition.

If commissioning is to be objective, it needs to be further professionalised and develop leadership. Currently in Social Care, it is a function for which the Director of Social Services as budget holder is responsible. In the NHS, the National Institute for Health and Clinical Excellence (NICE) is working hard providing evidence based research to determine in care pathways, what should be commissioned. We see no evidence that Social Care Institute for Excellence (SCIE) is performing a parallel task on Social Care.

Without a professional focus on what should be commissioned and a drive to improve the understanding and the practice of commissioning, then the current reforms will become discredited. More importantly in the Winterbourne View situation, where actual harm was caused, it has not been perceived as a failure of commissioning, it has been seen as a failure of regulation. Our view is that it was primarily a failure of commissioning as ‘who pays the piper calls the tune’. No one from the commissioning bodies seemed to be listening to the very expensive tune.

The major challenge in social care and health is how to meet the needs of a growing aged population with limited resources. So where is the leadership in social care commissioning that will challenge existing practice and learn from other sectors which have integrated the client and delivery side of the business at substantial savings? In social care terms, this already happens in aids and adaptations where the Red Cross, for example, can assess and deliver. What it would mean is to put the purchaser provider split under the Director of Adult Social Services and integrate assessment and care management, contracting and the provider arm, probably with a social landlord. How much bureaucracy and cost would be eliminated in that move? We ask where are the social care commissioners who are willing to initiate an employee-led mutual to deliver this vision.

So leaders have a choice, to use commissioning as a tool to deliver more appropriate services and use it to rise to the economic and sector-led support challenge or keep it as a low level support service with a focus on procurement. I know which I’d prefer and I think the inspectorates and tax-payers will think the same.

Governance and Gloss – Castlebeck

Guest blog from Richard Banks

How did we get into the Winterbourne View mess? On the heels of that genuinely heartbreaking May Panorama expose of abuse of patients at Winterbourne View, all of the residential/hospital services owned in England by Castlebeck Care were re-inspected. As well as individual examples of poor practice, the Care Quality Commission found a number of company-wide problems across the group: lack of staff training, inadequate staffing levels, poor care planning, failure to notify relevant authorities of safeguarding incidents and failure to involve people in decisions about their own care.

This exercise has found Castlebeck Care was actually not compliant with ten of the essential standards providers of such services are required to meet. Thus, managers did not report major incidents; planning and delivery of care did not meet patients\’ individual needs; insufficiently robust systems to monitor quality; failure to identify/manage risks relating to the health, welfare and safety of patients; failure to respond to/consider complaints; investigations into the conduct of staff were not adequate; reasonable steps to identify and prevent abuse had not been taken; the company had not appropriately responded to allegations of abuse; management did not protect against excessive use of restraint, did not operate recruitment procedures in relation to persons who were not fit to work in care settings and failed to provide appropriate training and supervision to staff.

That’s quite a list. Yet, before all this came out, the supplier produced, as part of the NHS ‘Quality Accounts’ process, glowing reports of its performance last autumn. Its then Chief Executive, Jon Mann, identified key points of note such as his company building on a long history of outcome measurement to establish a syste “which will consistently measure outcomes for service users across all Castlebeck services”. It had enhanced the use of the so-called “SHARED Approach,” “our person-centred model of care and support”. It had piloted and rolled out a new system to “strengthen local Clinical Governance to complement centrally managed approaches”; it had re-structured its Risk Management Committee, with a revised Risk Policy and a new framework for assessing risk; it had recorded “high levels of patient/user satisfaction with our services” and responded quickly when people were dissatisfied. Great organisation, you’re thinking.

Mann had also reviewed his company’s Medicine Policy to improve the prescribing and administration of medication, including of controlled drugs, had introduced a more accessible system for obtaining service user feedback, including for those with communication difficulties, etc.

The list goes on and I think you will appreciate the point – this was a firm telling the world it was on the top of its game when vulnerable people were being mistreated by the same organisation that the report commends.

Puzzled as to how these Accounts and the CQC audit can be about the same organisation? It would appear that not only was Castlebeck misleading clients, the NHS, relatives and the public; it also ended up misleading itself. To be charitable this kind of disparity between PR and reality is not uncommon in organisations where the need to present a positive, achieving image ends up not just providing a gloss but actually being completely unrelated to reality.

It’s one thing to see this gap in say, how a holiday company talks about a resort and the building site you actually stayed in, or the difference between a bank’s claims about customer service versus your experience of it.

That sort of deceit is never acceptable but it certainly can never be tolerated in the social care and health context. That’s because we’re talking about people’s lives, their safety and their dignity.

This is why governance in social care is so important. Information about the quality of care services is important but the quality and accuracy of that information is also paramount – and that how that information is gathered, analysed and presented also has to be properly and truthfully managed. Governance must start with the people who use the service and spend time and resource ensuring that reports are authentic to their experience.

Whoever is the auditor of the NHS Quality Accounts may want to have another look at how they go about their activity. The SCIE Social Care Governance framework has much to offer settings like those offered by Castlebeck.

Thus we can make the gloss and the governance resonate with each other.

WORKFORCE DEVELOPMENT SCIE GUIDE 38 – Social care governance: a workbook based on practice in England

Author Sally Curtis and a working group developed a definition of social care governance: Social care governance is a framework for making sure that social care services provide excellent ethical standards of service and continue to improve them. Our values, behaviours, decisions and processes are open to scrutiny as we develop safe and effective evidence-based practice. Good governance means that we recognise our accountability, we act on lessons learned and we are honest and open in seeking the best possible outcomes and results for people.