Health and social care leaders: commissioners must be creative

Policymakers and health and social care leaders gathered in Liverpool last month to debate the challenges personalisation and the pursuit of world class commissioning are posing for councils and PCTs. This is an edited account of their discussions

Bronagh Miskelly: World class commissioning sits as one part of a big transformation agenda. As a result, it means a lot of different things to different people. I thought it would be helpful to get some different perspectives from different parts of the chain. So I am going to hand over to John Bolton, strategic finance director for social care at the Department of Health, for an introduction from the policy perspective.

John Bolton: I go around the country and visit a local authority every week. And things are very different. We’ve been looking at two, north-eastern neighbouring authorities very similar demography and very similar grants from government. But they offer very different services because of the way things have historically been commissioned, with different costs for the same type of quality of service. Commissioning is often a long-term task. There will have been councils that were thinking five years ago about choice and they may be developing good opportunities in their communities, while others are still offering very traditional services. Sometimes there are good quality providers but the choice is not there, in part because there is no vibrant third sector.

That’s a real challenge – how we help councils play catch-up. The best councils are those who have been planning for some time, have been working in partnerships with a range of stakeholders and, particularly, engage service users in the planning process.

Bronagh Miskelly: Des Kelly, director of the National Care Forum, will give us the provider perspective.

Des Kelly: I think it was Gandhi who, when asked about western civilisation, said that he thought it would be a good idea. And in a way, I think world class commissioning is a bit like that, from a provider perspective. My worry is that what seems to be happening with the personalisation agenda is the polarisation between discussions about a whole new set of services that will exist in the future and what are now described as conventional or traditional services.

Many providers feel they are not part of the debate, talking about what future services might be commissioned. And that the only debates they seem to be having is around contracts or procurement. The other area we are turning our attention to is how we manage the transition as, despite one or two exceptions, not enough is being done on it. We may create instability in what is in some areas quite a fragile sector because people will exit from the market for one reason or another, if we do not give stronger guidance over what transitional arrangements will be in place for providers.

Bronagh Miskelly: Now Peter Beresford, chair of Shaping Our Lives, is going to give us a service user’s perspective.

Peter Beresford: You can’t have high-quality commissioning without real user involvement. If the user isn’t shaping services, rather than vice versa, how can provision be fit for purpose or match the personalisation agenda? At the heart of this is involving individual service users and service user-led organisations in commissioning. This will require groups of service users having an infrastructure of information, advice and advocacy to ensure equal access for people with self-directed support.

For service user organisations to have a level-playing field to be such support organisations will mean encouraging and providing incentives for small, local, user-controlled bodies and those from black and ethnic minorities. That is going to mean a huge culture shift in commissioning practice. For a period, some service users will want the old service provision. If we are serious about choice, then this provision has to be maintained. But it has to be about upgrading and transforming traditional services – the residential, day and field services – to fulfil the ethos of personalisation.

Bronagh Miskelly: A point that has struck me is about communication how providers, users, local authorities, PCTs form a common language over these issues. Veronica, would you like to kick us off as you have some experience of this in Oldham?

Veronica Jackson: It is our responsibility as councils and PCTs to use the joint strategic needs assessment to identify what the needs of the local population are, to tie that into national priorities and then give the direction to providers about what needs to be provided. Also we need to work with service users and carers. It’s about talking to the larger organisations through the various provider forums but then it’s also about talking to local people. Through the micro enterprise pilot (to foster very small providers) in Oldham, we’re involved with developing local services. It is about communication, information and a common language, so that we can have services from two people from ethnic minorities who provide domiciliary care in their local neighbourhood for two or three families and also one of the largest providers providing traditional nursing home care across England. It’s how you do all of that, which isn’t that easy.

Sian Lockwood: Naaps is managing the two pilots that are using the business support approach to nurturing micro enterprise in social care. One of my jobs is identifying the barriers to the development of micro enterprise and one of the biggest barriers is current commissioning practice. Commissioners tend to find it very difficult not to control, and that gets in the way of innovation by communities. One of the lessons we’re learning, particularly in Oldham, is that communities are very creative and they’re often not actually current providers. Communication should be with communities as well as current providers. The knack is to create an enabling environment for users rather than using a commissioning approach which is defined by the commissioner.

Peter Fletcher: Some of the most creative work involves bringing providers together with the users’ perspective to produce solutions that actually make sense. The commissioner role is to push that process. It is a different dynamic from the one that exists at the moment and I think there’s a lot of work that needs to be done to ensure that dynamic works really creatively.

Sian Lockwood: We’re talking about people who use services and people who provide services as two distinct groups. One of the tantalising things that is happening in Oldham is that we’re starting to get people to use their personal budgets to provide a service for someone else. Solutions come from people.

Janet Crampton: There’s an endless capacity for providers to be creative and move into the spaces that sometimes commissioners may be slow to recognise. I was talking to some providers the other day who were offering family support and what they’ve identified is that in small communities you can have families who have money coming in from a variety of routes – attendance allowance, carer’s allowance, direct payments for disabled children – and the community providers have recognised they can put in a holistic programme for the family.

Kieron Murphy: The Nihme national programme is working on commissioning for well-being. Commissioners must think outside the box of the normal range of services, and talk to people who commission housing and employment services. People’s lives are made of all sorts of things, not just the presenting condition. We’ve known this for a long time and if world class commissioning is going to mean anything it’s that we need to get that right.

John Dixon: You’re not a competent commissioner if you are not sitting down with the people who are mainly providing services. You’re not a competent commissioner if you don’t help reduce the barriers to people providing good services. In the current credit crunch this can mean doing things as simple as paying bills within 10 days. And removing the regulatory barriers, which commissioners have more power to reduce than providers, particularly tiny providers. It’s about providing a good environment for people to get on and do what they have to do.

Martin Routledge: There’s a lot of discussion going on about what are the practical things that need to be done to deliver Putting People First and what’s the commissioning element of that. We put out a think piece called Commissioning for Personalisation (www.communitycare.co.uk/csipframework) and we’ve had a good response. We’re receiving a good picture of what needs to be done and we need to form a plan of action.

Jon Glasby: I’m nervous that at a national level we do have a tension in the system, between an NHS that’s being asked to focus very strongly on world class commissioning and an adult social care system that’s being asked to focus very strongly on personalisation and I think there’s a genuine question over the extent to which those frameworks are compatible.

I’m not sure that at a national level they are. It may mean at a local level developing a framework for services with an agreed vision that allows you to receive some of the national policy developments and make sense of them in a way that works for the people you serve.

Marianne Griffiths: The whole commissioning for quality agenda is moving forward for PCTs and that corresponds with the personalisation agenda. It’s about making sure you get user and carer experience sorted along with your priorities. And in the PCTs that are piloting personalised budgets, things are a lot better. I think it synthesises brilliantly actually.

John Dixon: The only place where things get synthesised is at the level of the individual – that’s where we live our lives. I’ve begun to wonder to what extent we, at a local level, can expect government to join up beyond a certain amount. It’s the job of local authorities to be joining up things for individuals and communities.

Anita Marsland: I agree with what Marianne said about the synthesis between personalisation and world class commissioning. As someone going through the world class commissioning assessment, it’s not an end in itself, it’s a process. For me, personalisation must be the outcome. If world class commissioning doesn’t provide good quality services in the best possible way, driven by service users, it will fail.

Jeff Jerome: Picking up on what Jon [Glasby] said I think there is a mismatch. One of the things I was thinking about when I left Richmond is that we were giving out £250,000 a month to service users, so the dynamic of the use of money was changing very quickly. In local authorities, if that continues, the role of commissioning is quite different, it isn’t using your financial weight, it’s about finding out what people want, what your partners want. There will be a slight mismatch because the NHS is going to use its monetary clout. It’s quite a complicated process.

Jon Glasby: Throwing my health services management centre hat into the ring, most of the PCTs we work with are really struggling to engage in this debate, not that they wouldn’t want to, but because they are so focused in the day job on the world class commissioning competencies and the assurance framework. Those organisational issues are occupying the bulk of their time. It may just be the PCTs that I meet, but it’s about how we can have this kind of debate across a locality without some of that baggage getting in the way.

David Colin-Thomé: What world class commissioning will identify is that some people’s mindsets aren’t up to this new task. Rather than world class commissioning being the issue, we’re going to find out that a lot more different skills among our managers and their staff are needed. If they’re saying “we’ve got to get these tick boxes right” then they’ve failed, and we’ve failed in the ways we’ve developed the process.

Julie Jones: Where are the golden threads that take you through all of these processes to a successful self-directed support arrangement for an individual or family? Do we know what we’re looking for? If we don’t, this won’t make sense to anybody, least of all our workforce. We’re not engaging with the different parts of our workforce in a way that brings the story together. I think it’s one of our responsibilities at the Social Care Institute for Excellence to capture these emerging good stories about what works and why and put them out there in language people can understand.

Anita Marsland: I’m in a very privileged position because I live and work in a very joined-up world. It seems to me that what we are very good at is making simple things very complicated. To turn all this on its head and say, this is not our money, this money is the people of Knowsley’s, it’s not the NHS’s money or social care’s money – holding that mirror up helps. I’m sad to hear there are PCTs about the place who are so consumed with world class commissioning as a process that they can’t talk to anyone. They are not the conversations I have with PCT chief executive colleagues. They talk with lots of passion about wanting to work closely with their colleagues in local government. My glass is always half-full, I’m an optimist.

David Behan: I’ve sat round in meetings like this discussing commissioning since 1993. There’s a sense of frustration that we’re still here having these conversations.

Why are we posing this as it’s world class commissioning or personalisation? Because it’s both. [Turning to Jon Glasby] Will you tell these PCTs to talk to the local authority rather than telling you, as if it’s some kind of Roman Catholic confession. The leadership responsibility here is to connect this stuff and make sure people are having these conversations and not to collude with this almost adversarial stuff.

I’m a fan of world class commissioning – it applies equally to local government. I’d like any of the curriculum development courses to be as accessible to directors of adult social services as they are to PCT chief executives because people who train together end up doing stuff together and it begins to make a difference. Where there is a tension is that choice in the NHS has been about “where” and choice in personalisation is “how”. There’s work to be done on personal health budgets and the link with personal budgets.

But I’m with my friend Anita, which is let’s keep it simple and the only way we’re going to meet the needs of our populations is if we do it together.