A familiar theme for some

Quality strategic commissioning will be crucial if people are to
be able to purchase the services they need, as envisaged by the
adult services green paper. In the final article in our series on
the proposals our panellists gauge the gap that commissioners will
need to bridge if the vision is to be realised

John Dixon, Association of Directors of Social
Services’ disabilities committee
“The green paper is fundamentally a document about
commissioning. Its radical idea is to give people control over
their own care by giving them individual budgets – that is,
to become their own commissioners. And, for that change to happen,
a range of supporting commissioning activity is essential at other
levels.

As we have known for years, with care managers doing individual
commissioning, unless strategic commissioners do their work well,
services will not be available for purchasing. Or there will be no
choice; or they will not be of necessary quality, or safe or
reliable. Strategic commissioners are responsible for the
infrastructure on which all the individuals depend.

It will be for strategic commissioners to listen closely to what
individuals are saying they want, to aggregate their needs and
drive service development. From all that we have heard from service
users, that will mean a further push towards the development of
services in people’s own homes and locally in their
communities and away from intensive and institutional
interventions.

So where will the money come for all this? In the longer term,
there will be a transfer of resources from institutional to
community settings, and towards funding barrier-free access to
universal services. That will mean less acute NHS care too,
especially for older people with longer-term conditions. But anyone
who thinks that the NHS is in any position to support a significant
funding transfer to social care is dreaming. If we wait for that,
the green paper reforms will take much longer even than the
pessimistic forecast of 2012.

We need to work closely with the Department of Health to support a
funding bid for transitional monies in this year’s
settlement.”

Angela Greatley, chief executive, Sainsbury Centre for
Mental Health
“I welcome the emphasis the green paper places on
strategic commissioning. It has to strike a balance between
well-being, independence and support or treatment. It has to drive
towards new markets in health and social care. Commissioning has to
build community and voluntary capacity. However, the major question
is whether commissioning is anywhere close to being strong enough
to address this agenda?

Experience in mental health over the past 10 years has not been
encouraging. There are examples of good commissioning for specific
mental health services and there are effective health and social
care partnerships. There are examples of innovation in the way that
pooled budgets and integrated funding have been used. However,
interagency commissioning expertise remains patchy and, despite
encouragement, new ways of using money jointly are few. The aims of
the green paper cannot be achieved until effective commissioning by
health and social care becomes the norm.

There is an argument that the situation will only change when
individual service users are the commissioners – when they
choose their own services, supporting some providers and driving
others out of the market. This does not seem to be a likely
scenario, at least for some time.

If the situation is to change in the longer term, health and social
care commissioners have to engage fully with service users. These
partners have to advocate for services delivered outside hospital
and use their combined muscle to challenge the entrenched position
of acute hospitals. They have to shift the balance towards
promotion and prevention and they have to do it now. This is the
only way that money can be shifted to support diversity and choice
in the market for mental health care and support a real shift to
individual service user and consumer choice.”

Heléna Herklots, head of policy, Age Concern
England
“Realising the individualised services that the
green paper proposes requires two elements to be in place: a system
of strategic commissioning involving the key players – social
care, health, housing, the voluntary and community sectors and
users – and the funding to make it happen.

We’re not starting from a strong position. Government
spending pledges for social services for 2004-8 are only 2.7 per
cent annual growth in real terms. Current trends are for the costs
of social care to increase significantly above inflation. And
that’s before we seriously address ageism in the system.
Improving the situation for older people must not be at the expense
of other groups – so more funding is urgently needed.

Into the mix we must add the requirements of the Gershon review.
The Department of Health has to make 10 per cent of its £6.5bn
savings from social care commissioning by 2007-8. This puts into
perspective initiatives such as Partnerships for Older People worth
£60m over 2006-8.

Greater investment in preventive services would help improve the
quality of life of thousands of social care users.

The proposed local strategic commissioning framework is a good
approach. It will be a challenge to ensure that commissioning is
sensitive to and reflects individual choices. And there is the
question of how to decommission services that people no longer
want. All users of social care must have informed choice so they
can exert their needs and wishes in the social care market. And
they will need to be sure that, if they reject services that
don’t meet their needs, they will be able to find services
that do.”

Jo Webber, policy manager, NHS Confederation
“We have lived through joint commissioning and are
wondering how the new system will address the issues when previous
attempts have had such variable results.

One thing is different: we have a ray of hope that local area
agreements and local public service agreement targets will build a
more binding model of commitment, quality and ‘stretch’
into local partnership arrangements.

More of a problem may be the use of the term
‘commissioning’ at all. Ask 20 health and social care
managers what this means and you will get 20 ideas: anything from
procurement, contracting and needs assessment to service redesign
will be included. Perhaps a redefinition (or at least local
agreement on what it really is) is the first step.

We need a more meaningful dialogue about where to develop the
budget pooling. How can we use payment by results to have money
moved around the system to pay for shared care packages? And how
can we develop care pathways which reward models delivered close to
home in an integrated way using the most appropriate resources,
without wrangling about who contributes what?

No one partner will come up with the magic wands of funding or
expertise to support this change. Money will always be tight for
all partners and strong strategic planning, informed commission
decisions and a good understanding of each other’s pressures
will need to be a basis of a shared future working
together.”

Jeni Bremner, programme director, education and social
policy, Local Government Association
“The vision for adult social care will be delivered
by a range of providers, predominantly from the independent,
voluntary and community sectors. In reality, this provision is a
complex combination of small and large providers providing services
through contracts both with the local authority and increasingly
with service users themselves using a direct payment or, in the
future, individual budget.

Within this context local government needs to develop commissioning
processes that include both service users and providers in
developing the local vision. The process must be effective in
procuring safe and high-quality services, not overly bureaucratic
and easily understood by service providers. Increasingly at a local
level local government and the NHS are developing integrated
approaches to commissioning by aligning or pooling budgets.

The government is almost alone in its belief that the
implementation of the green paper will be cost-neutral. Carrying on
providing services in the way we do now will cost more, as the
pressures on services continue. To deliver the pattern of services
set out in the green paper may deliver some cost savings over time
but will require upfront investment in new models of service.

Since the development of community care in the 1990s, social care
has been playing financial catch up. Derek Wanless’s review
of funding for older people’s services, commissioned by the
King’s Fund, is eagerly awaited. The excellent report from
the Joseph Rowntree Foundation on long-term care looks at different
international models and options for funding. No ‘silver
bullet’ solution is found.

Yes, local government argues that the green paper is not
cost-neutral, but we also believe that we need to work with central
government and partners to develop sustainable solutions to the
funding of adult social care.”

Independent view
Lord Victor Adebowale, chief executive, Turning Point
“The strategic leadership roles of local authorities
could bring benefits to the commissioning process. I welcome the
flexibility this grants at a local level. 

But more work is needed to better organise services around
particular groups of service users with complex needs. Strategic
commissioning is a cross-boundary process that needs to draw on
clinical, social and user expertise. It was important that the
paper considered partnerships in the broadest sense, meaning both
partnerships between statutory and voluntary sectors as well as
those between health and social care and other agencies such as
housing and employment. 

A clearer definition of roles needs to be backed up by better
training and support for commissioners to ensure a more strategic
approach.

Moreover, the voluntary and the statutory sectors need to be
treated as equals by commissioners.

But structural reform will only take effect if a skilled workforce
is developed and if different agencies work together to meet the
shared values, principles and desired outcomes set out in the green
paper.”