Plenty to play for

The white paper maps out strong commissioning arrangements with the creation of a new lead role: the director of adults’ services. It also points to the development of commissioning by service users themselves, writes John Dixon

We should be cautiously grateful for the major opportunity the white paper gives us to exercise creativity. For make no mistake, this is still a vision rather than a blueprint. It still leaves a huge amount to play for in articulating the vision and in delivery arrangements. There are of course the sensitive issues of resources and charging, which are left to await the reviews of Wanless on the funding of older people’s services and Lyons on the future of local government.

But more immediately within the remit of the commissioners of services are all the arrangements for translating government policy into practice. The Department of Health has avoided the temptation of structural prescription as a means of achieving delivery, and instead is looking for a partnership between local authorities and primary care trusts as commissioners.

Achieving the high-level policy objectives around delivery of the seven outcomes in the white paper will require a bridge to be constructed between the DH and operational local authorities and PCTs, none of whom on their own have adequate capacity. The Association of Directors of Social Services has been working hard in recent months to create that bridge, working with the Care Services Improvement Partnership, which is emerging as the social care delivery arm of the DH. In doing this, we have been working closely with the Local Government Association and the NHS Confederation, and many of the lead national voluntary and private sector organisations, which have come together in an interagency group for this purpose.

 The white paper is strong in its support for the key elements of commissioning at both a strategic and local level. At the strategic level there is the new statutory lead role of the director of adults’ services to assess the needs of the local population and to commission to meet those needs. Importantly, this is a joint responsibility, with directors of public health. The paper then commends local area agreements (LAAs) as mechanisms for constructing strategic objectives in response to those needs. The ADSS has recently produced with the LGA and the NHS Confederation a document advocating just this: The Future of Health and Social Care: A Partnership for Well-being. And if LAAs are increasingly the vehicle for the shared objectives for commissioning by public authorities in an area, the governance to support and performance manage that should be through the public service boards or local strategic partnerships which oversee those LAAs.

The white paper asks whether these governance arrangements should be underpinned by a duty to co-operate, such as there is for children’s services. While the strategic commissioning arrangements will always be the primary driver for achieving co-operation, the ADSS would support the DH in having such a legal duty.

Two years ago, in All Our Tomorrows, the ADSS set out a vision of “inverting the triangle” of care, promoting well-being, self-care and access to universal services in preference to dependence on intensive (and expensive) models of care wherever feasible. Both green and white papers have followed through on this. The challenge for the directors of adults’ services and strategic commissioners is the new requirement to plan for the needs of the whole population, not just those who will qualify for state-funded care. If this requirement is to mean anything other than strategic identification of needs, and result in, say, a brokerage service for all-comers, this will require a fundamental redesign of access arrangements and care management. It will also beg questions about resources on which the white paper is silent.

The ADSS, in its work with the interagency group, is exploring these issues. We have been working up a model of a single access door for all non-emergency public services in an area; not owned by any one agency, but with the local authority probably supporting it as part of its infrastructure responsibilities. From this single front door the logical next step is to have co-located (or at least virtually integrated) service outlets for the new adults’, children’s, and local PCT services. It is essential that local authorities understand and engage with the development of practice-based commissioning.

Which leads onto the potentially revolutionary change, the development of commissioning at the level of the individual. Individual budgets should hand control over commissioning for the needs of individuals to those people themselves. This means that high level commissioning really must be driven by an aggregate of individual preferences. If not, unwanted services will have been commissioned and not taken up.

For those who are anxious about the impact of individual budgets on finances – which could include the Treasury – the good news from the small scale but very similar experiences of the In Control pilots is they do not have to break the bank. In West Sussex, none of the In Control care packages came in at more than previous local authority arrangements, and many cost significantly less, despite being bespoke for individuals and their carers. But they, like direct payments packages, produced a quite different and generally non-standard pattern of services.

This creates a challenge for commissioners and Eproviders alike.

For commissioners, this front-end activity is very intensive and the procurement activity which it generates is much more difficult to aggregate into blocks. While there will undoubtedly always be a significant demand for the more traditional residential care (and it will need to be brought into the scope of individual budgets in due course, for equity reasons), this also drives commissioners into a neglected area: how to support small scale services, such as personal assistants and family-based placements.

Indeed, all the evidence is that such services have been squeezed out of the market because of commissioning neglect and disproportionate regulation (after all, an NVQ in management cannot really be essential if you are a sole operator). So the ADSS is working with the Commission for Social Care Inspection, Care Services Improvement Partnership, the National Association of Adults Placement Schemes, the Association for Real Care, and others to explore how commissioners can support small scale services (such as by regulating schemes rather than individuals). And we also welcome the new emphasis from the Commission for Social Care Inspection of turning the focus of attention as much onto the quality of commissioning as of provision.

The green paper represented a new deal between people who need support for living and the state. The white paper takes that sea change one step further. But it will take a new partnership to be forged between the government, commissioning authorities, providers, and the “new commissioners” – previously relegated so often simply to the role of “service users” – to realise the vision.

John Dixon is director of adults’ services for West Sussex Council, and also co-chair of the ADSS disabilities committee.

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The white paper is welcome in confirming the vision of the green paper, but has a long way to go in setting out arrangements for implementation. A bridge needs to be formed between government and commissioning authorities to create the capacity for this. Commissioning to deliver the white paper needs to take place at the strategic level, led by the director of adult social services with new statutory responsibilities, and delivered through local area agreements. 

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