‘How outcomes-based commissioning could meet the challenges facing domiciliary care’

By John Bolton, visiting professor at the Institute of Public Care, Oxford Brookes University

Three years ago, I visited Wiltshire to observe and write about the council’s approach to outcomes-based commissioning of domiciliary care – ‘Help to live at Home’. There has been much interest in the journey Wiltshire has subsequently taken and many discussions between their commissioners and other councils in the UK.

This interest is likely a result of the current pressures on the domiciliary care sector. There is growing criticism of the traditional task and time model and, as councils and providers try to reduce costs, stories of low pay, poor training opportunities and zero-hours contracts are never far from the headlines. But can outcomes-based commissioning tackle these issues?

‘Natural evolution’

There is growing evidence that the way an older person is initially helped when they need care and support can make a significant difference to their longer-term outcomes. This is supported by the evidence for reablement and it seems that outcomes-based commissioning is a natural evolution for councils seeking improved outcomes for their service users.

This is certainly the view of Wiltshire, where the council and providers are absolutely committed to further developing this model.

Wiltshire’s model starts with an assessment of the older person’s needs, which focuses on outcomes that might help them to become more independent. The provider and the older person then develop a service that enables those outcomes to be delivered.

The costs of the care package is agreed between the council and the provider and providers who help older people to regain their independence accrue rewards. Reablement is also an integral part of the response that every service user receives.

‘Teething problems’

Wiltshire has found that around 60% of older people need no further care as a result of this approach – but some may have received help for six weeks and others for six months before that help is either reduced or stopped. Customer satisfaction rates have improved year-on-year and the council has procured four providers to help develop the approach.

However, it has not been without its teething problems. Recruiting a strong team of local care workers to deliver the required care and support has been a challenge. Wiltshire also intended the approach would be based on a more professional approach to care, with salaried workers guaranteed at least the living wage. This has been achieved in parts of the county.

At a time when resources for publicly-funded care are reducing, one of the key questions is also whether this approach will actually increase or reduce the overall cost of services.

‘Worth consideration’

Personally, I think there is a compelling logic for pursing outcomes-based commissioning. It has enormous potential to deliver improved outcomes at a lower overall cost. It addresses some of the immediate challenges for the traditional task and time model – there is a strong focus on getting the best possible result for the customer in the way that suits them.

Every visit also has a clear purpose and a focus on achieving greater independence for the older person wherever that is possible. There is some evidence that the task and time model increases a person’s dependence on care and this new approach avoids that.

Outcomes-based commissioning also places a clear responsibility on the providers to get care right. In these times of severe austerity, any approach that can achieve this must be worth serious consideration.

Emerging practice in outcome-based commissioning for social care