Tag Archives: commissioning

Government by diktat: adult social care companies must have decision making powers about NHS and social care commissioning

The quango NHS England has just published guidance on “Expected ways of working between integrated care partnerships and adult social care providers“. This is the latest direction on how to implement the contentious 2022 Health and Care Act, that received Royal Assent in April 2022. The Health and Care Act 2022 is remarkably permissive; this […]

Government by diktat: adult social care companies must have decision making powers about NHS and social care commissioning

Going to market

Vic Citarella, Director CPEA Ltd, looks at the economics of social care and suggests marketing is more than immediate sales but is integral to every provider’s longer-term business strategy.
Describing a market portrays how buyers and sellers do business. There are many kinds of market and several types of player. Social care is a market with changing characteristics and an evolving cast of participants. Knowing and understanding how it works is central to successful transactions – now and into the future – between customers and service provider. In this respect, social care is like any other business.
In economics, it is usual to identify five types of market:

  • Perfect Competition
  • Monopoly
  • Oligopoly
  • Monopolistic Competition
  • Monopsony

Applying the associated features of each to the social care market, it appears that not to be perfect competition because there are not an infinite number of buyers and sellers. There is one buyer who can alter the prevailing price in the market and that is the local authority. Nether buyers nor sellers have infinite alternatives and choice is a chimera.

Patently nor is there a monopoly with just a single supplier of social care and no reasonable substitute. If there were the supplier would be able to charge whatever they wanted and their income would only be limited by whether the customer was prepared or able to pay.

Neither is there an oligopoly in social care where there are just a few dominant providers. If there were they would be able to collude to set prices and to the customer it would seem just like a monopoly.

If the social care market were monopolistic competition there would be numerous competitors but the differences between each would allow them to charge different prices. Whilst each provider may be different there are usually substitutes available.
Lastly the monopsony market in social care would just have a single buyer. If this were the case they could dictate the price.

Two markets
So, what types of market are there is social care? On a national level, there are two markets. Firstly, the public market – about 40% – which is a monopsony. Here the purchasing local authority can keep the price to the lowest level feasible. The only controls are if there is intervention from a regulator or there are unlawful actions. Both forms of intervention are currently being tested. e57799fa-350c-4d90-93dd-ba847d84f20b.jpg

Secondly the private market which displays aspects of all the other types excepting monopsony. Several providers are seeking to differentiate their social care offer. For example, this is the case at the luxury end of the market and in terms of specialism or niche. There are signs of an oligopoly-like cluster emerging as smaller businesses are squeezed and consolidation takes places through mergers and acquisitions. If this trend continues there will need to be a strong regulator to prevent price fixing between providers and the eventual emergence of a monopoly. There are further signs in some parts of the private market that there is genuine competition (if not perfect) which offers the customer some choices at affordable prices.

Questions and Challenges
Selling to the monopsony provider – the local authority – is becoming untenable. Home care providers are handing back contracts and residential care homes are closing or ceasing to operate for the public-sector customer. The return on investment is insufficient to sustain a business even for a not-for-profit provider. There is little scope to attract and retain a skilled workforce. Much vaunted innovation will not take root in a climate of survival of the fittest. Social care is not a business field where rebuilding or paradigm shift can come out of chaos because of the lives at stake. Such change is much needed but careful incubation is a safer approach.
Residential home providers are either shifting to the private market and/or charging in a way that means private customers are subsiding the shortfall on income from the public customers. The former leads inextricably to a two-tier service with characteristics akin to the airline industry where actual customer service is increasingly for the first class only. Whereas the latter seems duplicitous under consumer legislation.
Inevitably providers are cutting costs – some say ‘corners’ – and seeking ways to raise income from extras – some say from ‘basics’. There are too many services not reaching the minimum standards required by the regulator. The regulator is not well enough resourced to enforce standards. And policing a service that cannot comply brings the system into disrepute with a fall-back position that colludes to allow the standards to lapse.

Knowledge and Expertise
In short – two markets, two tiers of service, falling standards for the have-nots and a get what you pay for service for the haves. The scenarios are last business standing takes the chaotic market into a monopolistic new order or the state intervenes to prop up a failing market and a centralised monopsony is (re)institutionalised with a choice and/or means tested opt out. Not a pretty picture for providers or genuine investors. Not encouraging for the social care entrepreneur unless jeopardising quality and safety are an acceptable risk for permitting the entry of a cohort of more ‘disruptive’ investors.
Markets and marketing are vital areas of knowledge and expertise for social care providers. In social care, both involve individuals with needs, transactions between organisations and purchasers as well as a strategic understanding of the local and national (and indeed international) business environment.

Ask yourself:

  • How well do you know your market – where are the gaps?
  • Who are the key players in your market – the service users, families, the workforce, the commissioners, brokers, agents or regulators – how well do you know them and do you need support in mapping and understanding your stakeholders?
  • What are the emerging opportunities – do you need assistance in developing them?
  • Who are the customers and why should they buy from you? What’s your plan?

Vic Citarella, Director CPEA Ltd, www.cpea.co.uk 07947 680 588

Lynden Consulting has a proven track record in implementing successful strategies to achieve excellence and tangible results for providers in health and adult social care. Get in touch to find out how we can help.

Developing effective commissioner–provider relationships

Vic Citarella – a post that first appeared on RiPfA website on the 9th March 2017
As everyone seeks to squeeze more out of the social care system, how can strong and positive relationships lead to improved and more cost-effective working practices?
I have recently authored a Strategic Briefing for RiPfA on effective commissioner-provider relationships and facilitated a workshop on the same topic. I will also be leading their upcoming open access webinar ‘developing effective commissioner-provider relationships’ (28 March, 12-1pm, online). As part of my approach to gather evidence relating to this work, I began by asking some initial questions. I found it helpful to test out some of the underlying assumptions, namely that:

  • there is a problem
  • the relationship that matters is the one between the commissioner and the provider
  • such relationships have character – effective, strong and positive – which can be improved
  • there is an answer to the problem.
Problem – what problem?
Clearly social care is experiencing unprecedented financial pressures which is characterised as a problem or even a ‘crisis’. RiPfA identified this as a key issue back in 2012 in the publication: How to maintain safe, effective and quality services with reducing resources.

The underlying assumption is that integral to the problem are poor relationships between commissioners and providers. Community Care and the Guardian certainly think so. The guidance and toolkits say so. If only commissioners and providers got on better, they could make the money go further and people in need would get what they want. Implicit in this assumption, and reinforced in the Care Act 2014 guidance (Chapter 4), is that it is for the commissioner to do something about this problem. They have the money, the power and are the public authority.

But is this in fact the case? Does the responsibility lie at their door? The forthcoming webinar offers an opportunity to check this out.
A many-faceted relationship
Perhaps a more worrying assumption is that the relationship we are talking about involves just the two parties – commissioner and provider. But social care is patently a more complex system involving lots of people, organisations and stakeholders. Relationships between two people are hard enough. Imagine how much more convoluted relationships are in the multi-agency, multi-professional and multi-faceted world of social care.

The webinar session will try to unpick some of these relationship interactions and dynamics, and look at common purpose, co-production and role clarity. We will look at ideas around stakeholder mapping, user-led approaches and person-centred coordinated care.
The character of a relationship
That a strong relationship is a positive one and leads to more effective services is another assumption we can test. From there we can explore what steps can be made to build strength in relationships. How we turn our social care values into commissioning and service providing practice is the proving ground for the customers.

Clearly trust and communication are at the heart of all kinds of relationship building – but what do you actually do to make these things happen? The webinar will also look at how the behaviours of the participants in the commissioner-provider relationship can be (positively) developed, drawing on examples that have been tried involving individuals, groups and organisations in a variety of settings and formats.
A problem demands a solution
Lastly there is an assumption that there is an answer to the problems of poor commissioner-provider relationships. There is no sure-fire formula for success. Like personal relationships, those in business and between organisations require continuous work (and as with personal relationships there are online quizzes to evaluate the partners’ starting point and where they want to go with a business relationship, for example: http://www.growthink.com/content/finding-business-partner-take-quiz). In fact, the similarities between the advice offered by relationship counsellors and business gurus is quite remarkable. Writ large are trust, open communication and respect.

What we will examine during the webinar is ways for commissioners and providers to work together, how to make the time, and some methods that have been found to work. We will consider approaches to procurement and contracting as procedural processes to cement relationships, to record agreements where the players may change and to cater for endings and failures as well as success.
If you are a commissioner or service provider (of any kind – registered/not registered/large/small/private/voluntary), please do join us at the webinar on 28 March. As we are looking at relationships between commissioners and providers in social care then it would be beneficial if people who have worked together in these roles could participate jointly (although this may of course not be possible). People who use services and/or directly commission for their own needs are very welcome to attend.

If you have any thoughts or questions, please email me in advance at vic.citarella@cpea.co.uk– although I am not offering relationship counselling!

About the author
Vic Citarella is a qualified social worker and a former Director of Social Services. He now works with local authorities, NHS bodies, private and voluntary social care providers, to help them improve standards and quality of services.

Related resources

Workforce retention?

Richard Banks looks ahead to this year’s Skills for Care conference where the focus will be on recruitment and retention of the social care workforce.
David Mowat MP, the Parliamentary Under Secretary of State for Community Health and Care, voted as did most Conservative MPs, against guaranteeing EU citizens rights to stay in the UK ahead of the ‘Article 50’ negotiations. If passed the amendment would have ensured that all EU citizens legally living in the UK on 23 June 2016 (the date of the EU referendum) would have their right to stay and work protected.
Across the UK EU nationals comprise around 4.95% of the staff in NHS trusts and Clinical Commissioning Groups, and 5% of the UK social care workforce[1]. In England, there are 1.43 million people in the social care workforce[2]The Cavendish Coalition[3]estimate that there are 90,000 EU nationals in employment – this is around 7 % of social care workforce. [4]
So, 90,000 people working in England in social care are now uncertain of their future as social care workers and as residents, along with their families, of the UK.  Horrible for them and how can any of us imagine how we might reassure our relatives supported and cared for by these people?
The social care sector in England has difficulty in recruiting and retaining staff; there are about 90,000 job vacancies[5].  All indications are that the need for increased levels of social care support will require a continued growth in the workforce.
Dodging responsibility
Respect and support for the social care workforce might be the least one might expect from the Parliamentary Under Secretary of State for Community Health and Care sadly this has not been the case.  Recently, in attempting to dodge responsibility for the Government’s social care funding crisis, David Mowat blamed uncaring families. In doing so he not only insulted families but also implied that social care was an unskilled occupation that any family member might do.  With the EU amendment vote last week he went further and completely dismissed the importance of 90,000 social care staff.
So, it will be interesting to hear what messages David Mowat will have when he speaks at the Skills for Care Conference entitled Recruitment and retention: the road to success (Thursday 9 March in Liverpool).  Social care conference participants are remarkably unmoved by banal government representatives (almost as if they expect no better). Let’s hope that on this occasion David Mowat can explain how he has a plan to support social care recruitment and retention. He might even manage to show some respect for the social care workforce who surely are an example for the Conservative slogan of being for ‘hard working people’ 

[1] researchbriefings.files.parliament.uk/documents/LLN-2016…/LLN-2016-0039.pdf
Of the overall percentage, the detailed breakdown shows geographical variances:
·         22,000 staff in London – 12% of workforce;
·         23,000 in the south east – 10% of workforce.
·         There are a higher proportion of EU nationals in regulated professions, e.g. nursing, than managerial posts.
[5]Skills for Care 2017 Conference information

Support the workforce don’t blame the families

Richard Banks makes the case for investment in the social care workforce
David Mowat the Parliamentary Under Secretary of State for Community Health and Care recently questioned why it was that care of older people is not seen as naturally the role of families in the same way as care of children is viewed.  Whilst this raises several issues, it particularly appears to show limited understanding of the nature of social care for older people. Actually, social care is provided only to people with very particular needs that for the majority of families are beyond their capacity to deal with.  David Mowat seems under a delusion that social care is in crisis because resources are spent on simple support tasks.  The reality is of physical frailty and dementia that are beyond the capacity of even the most dedicated and caring family.   He did go on to show some understanding of the numbers of ‘informal’ carers and their position particularly in relation to employment.   Clearly the comments were based on his struggle to say some thing, any thing, in the face of the government created crisis facing social care and the NHS. 
Defending the Indefensible
The demographic issues of our population, the lack of any proper response to the resource needs and the position of carers have been known for the last two decades. David Mowat MP for Warrington South occupying a post that has been down-graded from Minister of State is the current defender of the indefensible.  
Part of this problem is that government(s) in England has resisted any attempt to recognise the social care workforce. If he had any knowledge or respect for the skills, knowledge and understanding of social care staff he would not have made such a crass statement. 
Things are not perfect in other parts of the UK but at least the importance of the workforce is recognised The Welsh Government have announced that social care workers will register from 2020, Northern Ireland have confirmed similar plans and Scotland made it compulsory for care home staff to register, with a register opening for domiciliary care workers in 2017.  The administrations of the other parts of the UK clearly see registration as an import part of establishing social care work as a valued professional activity.  Sadly in England social care has remained as a low skill, low pay occupation not worthy of registration and as a result it struggles to recruit and retain staff.  While employers and programmes promoted by Skills for Care (such as apprenticeships) are making progress in recruiting people they do so against a background of confused and incoherent policy from Government that leaves staff underpaid and cut off from establishing a professional status. 
It is now more than 16 years since the Care Standards Act 2000 provided for the registration of social care staff in residential and home care services for children, adults and older people.  England now stands as the only part of the UK that does not use registration to support the professional competence of care staff and to contribute to the safeguarding of people who depend on care staff.  Labour, Conservative-led coalition and the Conservative administrations have all failed to create a registration system for the 1.7 million staff working in social care. Yet the Government has just announced a spend of up to £16m between now and 2020 on what will be the third registration authority in 20 years for the 90,069 (01/12/16 HCPC) social workers 
Social care is a big employer.  It employs more people than construction, the food and drink service industries and several recognised large sector employers.  It is strange then that the workforce is either ignored or patronised by government.  Even stranger since it is one of the few areas of growth in employment.  The social care sector has about 6.4% of total English workforce and staffing demand is set to rise over the next 30 years.  The debate about the rise in the minimum wage (and change of name to ‘Living Wage\’) and effect of social care again illustrate the complete lack of understanding in government about how social care is organised.  They make no provision for the increased wage bill only latterly allowing local authorities to increase local tax in two piecemeal fuddled policy changes. That increase will not cover the existing funding gap identified by the Local Government Association or the increasing costs of supporting the NHS that fall on to social care budgets. 
Recruitment crisis warning
There is a warning from the last decade when there was a narrowly avoided crisis for adult social care. Recruitment of staff became almost impossible in some areas due to better conditions offered by other industries.  Residential care homes could not fully open and home care services could not recruit or retain sufficient staff to cope with demand. Services to people in need began to suffer as they are again currently. The availability of staff from the new members of the EU saved the day in terms of numbers (there were issues about skills and language).  There were additionally staff from overseas recruited by employment agencies (that had previously provided staff to the NHS).
By 2009 the redundancies related to the economic crisis had ‘freed’ more people looking for work and the crisis of recruitment subsided. There is now again a crisis of recruitment but this time amplified by the start of the well-predicted increase in need as our population ages. This time with Brexit related fear about the status of EU nationals working in this country and other tighter restrictions on immigration there may be further collapse of social care provision due to lack of staff. 
In parts of London over Christmas the home care sector was unable to support the discharge of older people from hospital. The predicted social care crisis preventing the discharge of patients and the lack of support services to prevent the need for hospital care in the first place is now happening.  The problem is not just of numbers but of skills – it takes time and investment to train and qualify social care staff able to work safely and to create personalised support for people.
All of the problems with social care funding and workforce have been communicated to Government over many years but there has been no policy and no action. Rather than attempting to shift responsibility David Mowat needs to start working to invest properly in the social care workforce. This requires proper pay, funded training and setting up a register that ensures we have a safe and competent workforce for the future. 

Lessons will be learned

Margaret Flynn and Vic Citarella – authors of the Winterbourne View Hospital serious case review – reflect on what has followed the screening of the BBC Panorama \’Undercover Care: the Abuse Exposed\’ five years ago in May 2011.
The serious case review was published by the South Gloucestershire Safeguarding Adults Board in August 2012. In response to the findings and recommendations, politicians asserted that lessons will be learned and that they would set in train a number of continuing efforts to ‘transform’ services.[1]It was apt that they should deploy such terminology since, for us, the lessons have been stark:
Now it is evident that the number of people with learning disability referred to assessment and treatment facilities stubbornly refuses to reduce. The lesson? Stop registering these facilities and stop using public money to fund placements. Neither do we need yet another review to confirm that the act of commissioning a review only begins to address the heart-felt search of families for justice and healing. It\’s what comes after a satisfactory review that matters;
Change is a hard, slow process. Transformation programmes, such as the Winterbourne View Hospital Programme Board, are known to fail two-thirds of the time:  A long, drawn-out project executed by an inexpert, unenthusiastic, and disjointed team, without any top-level sponsors and targeted at a function that dislikes the change and has to do a lot of extra work, will fail;[2]provides an extreme caricature of what has happened. The lesson? Spend scarce resources on making sure the dice is loaded towards the converse – or better still towards prevention;
Sustained austerity and cuts in services for people with learning disabilities and their families cannot address the support needs of children, young people and adults whose behaviour is bewildering, troubling, challenging and even criminal. The lesson? The NHS spent a lot of money on commissioning harmful and inappropriate services at Winterbourne View Hospital.  The expenditure continues and should now be unequivocally channelled towards user and family controlled organisations. The stakes are high and soaring;
There appear to be many professionals who believe that ‘full-body restraint’ is a necessary skill for health and social care workers supporting people with learning disability. They should be directed otherwise. The lesson? This form of restrictive physical intervention leads to death, physical and emotional pain and severe injuries. Although Castlebeck’s restraint policy seemed OK, it was wholly ignored by its employees!
Health and social care practitioners are punished for their poor practice. In contrast, service commissioners and business owners seem to have an unassailable alliance to misuse public money intended for the care of people with learning disabilities. The lesson? Even though negligence and manslaughter are corporate crimes, there were surely offences under trades descriptions legislation and unfair trading practices committed by the owners of Winterbourne View Hospital and by the commissioners as the agents of the consumers. Yet thus far, no money has been returned and our recommendation that the costs of the serious case review should be met by Castlebeck Ltd has been ignored.
In a private health and social care market, inspection of practice has to be complemented by the use of regulatory powers in the boardroom and beyond. The lesson? Winterbourne View Hospital has taught us that in such a market an enforceable code of practice in ethical investment is essential. Consumers have rights. Company directors have duties. Investors have responsibilities.   It cannot be a matter of profit or loss or pressure to meet impossible financial targets because these overwhelm restraints against dishonesty and are incompatible with the delivery of humane care.
Winterbourne View Hospital is a case study in institutional abuse. Its name is synonymous with all that we must never let happen again to people with learning disability and with associated programmes of \’transformation\’ and \’improvement\’. Regrettably however, the serious case review remains a blueprint for many lessons still to be learned; particularly in respect of the conflicts of interest that can arise from the commercial provision of services.

[2] Harvard Business Review, October 2005

Health+Care Exhibits Integration

Last week I and a number of CPEA Ltd colleagues went to big Health+Care event at the Excel Centre. Seminars, exhibitors and networking from right across both the health and social care worlds. The emphasis was on integration and commissioning but there was something for everybody – safeguarding, home care, residential, meals, telecare – you name it.

A couple of things struck me along the way:

First the exhibition was a microcosm of the true market place out there for customers – the health services of all types well displayed and social care providers more reticent. People need to see and hear about the choices available. They need to understand how they interact and how one option can prevent the need for another. People need the space to test and taste what is offer before they make decisions. Critically they need to be engaged in the value and emotion of services and not just the cold facts of how they work. This is how we can all make best use of our money both individually and as communities.

Second Health+Care demonstrated complexity and gave some indication of the type of approach that can be used simplify things for customers. Provision across health and social care is characterised by its plurality. The economy is a mixed one and likely to get more so. However fragmentation is not inevitably a bad thing if opportunities are made and taken to collaborate. Some of the networking witnessed and partaken in at the exhibition will serve me well. I noted how thoroughly this aspect of the event was enabled by layout, timing, presentation and a number of navigation formats. Again there is a lesson here in how our real health and social care markets can develop and learn from commerce.

So a welcome addition to our calendar at CPEA Ltd. There are reasons for optimism about the way forward for health and social care commissioners and providers if this type of message can be replicated locally and in the market place.