Four ways to make providers accountable for service users’ outcomes

Outcomes-based commissioning could benefit service users and local authorities but requires a clearly thought out approach, says John Bolton

Professor John Bolton, visiting professor at Oxford Brookes University’s Institute of Public Care

For the last decade, budget pressures have meant many councils’ procurement strategy for adult social care is to drive down the price for services. The aim has been to maximise the amount of care a person can get at the lowest possible cost to the local authority.

John Bolton will be speaking about the application of payment by results in social care and exploring different initiatives at Community Care Live.
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It is now widely recognised that this approach is unsustainable because it threatens the existence of the service providers.

A new approach – outcome-based commissioning – looks at holding service providers accountable by focusing on the outcomes rather than the activities delivered. There are four approaches that councils have adopted so far.

number-1Approach one

This is the simplest approach to outcome-based commissioning. It sets clear outcome-based performance standards for each contract and the provider is judged on whether they deliver on those outcomes. It is the most straightforward method because the payment system is unaffected, Instead, the providers are held accountable for the outcomes by the council continuing to award the contracts, or withdrawing them.

This approach is probably easier to undertake with a limited number of providers and it requires the whole system to understand the model. Coventry City Council use this approach for the delivery of its reablement contract.

2Approach two

In this one, the outcomes are set for each service user and the providers are measured against these outcomes. It is a model that can work for most individuals needing support, but it requires a major mind shift from the assessment and care management teams.

Each assessment needs to include agreement with the individual about what the potential outcomes might be. Clearly, the outcomes should focus on those that will assist the person in being more independent over time.

The agreed aims are then linked to the payments made to the care provider who should be incentivised to deliver the outcomes in the best time scale. This is the approach adopted by Wiltshire Council.

3Approach three

This model involves setting the budget for a service that reduces over time to reflect the outcomes achieved by the provider. Each year, they help people achieve greater independence and so need less assistance and, therefore, the budget reduces.

It works best when the service users are likely to need longer term support of some sort, but will benefit from a period of help to focus on promoting their independence. This might be through rehabilitation, recovery or skills training. It is particularly suited to adults with learning disabilities.

The approach clearly incentivises the provider to deliver improved outcomes to reduce demand for the level of service in the longer term. Nottinghamshire County Council has developed this model.

4Approach four

Finally, there is the option of commissioning a lead provider to deliver services to a sub-set of the population. The cost is calculated based on an optimum performance where the provider delivers improved outcomes. It assumed that a percentage of people will require less or no care over a given period of time.

This puts much of the onus onto the provider. It is not the cost per hour that counts but the outcomes that are delivered.

It can be cost effective if more people are helped to remain at home without the need to go into residential care and the proportion of those requiring only short-term care increases.

This is the most radical of the approaches and likely to produce the best cost options for both providers and councils.


In all of these models, there is an opportunity to both deliver services at a lower cost whilst achieving better outcomes for customers. To be successful, a new approach requires courageous commissioners and ambitious providers, keen to improve what they do.

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