Social workers face a tension between supporting people’s choices and helping them to regain independence, a social care finance expert has warned.
John Bolton said that service users sometimes had limited aspirations for themselves because of the limits that services had put on them in the past, meaning their preferred outcomes did not necessarily involve regaining independence.
“There is a question in all of this whether the user is in the best possible position to define their outcomes, their aspirations and whether we should all go along with that as the measure of what happens,” he said. “The critique of that is that many users may lack confidence or aspirations for themselves and may therefore downplay or dampen down opportunities that may be there for them.”
Bolton, a consultant who specialises in helping councils improve the efficiency of their social care operations, is a former the Department of Health’s social care finance chief, a director of social services and a social worker. He made the remarks at Community Care Live Birmingham in delivering a session on outcomes-based commissioning in adult social care.
Bolton said he had recently been impressed to see a social worker in Derby working with a group of people with learning disabilities with a history
of receiving institutional care, to raise their aspirations.
He said she was “helping people redefine their aspirations and was getting amazing results”, adding: “If you had asked those people they would probably have said that they were happy and content. There’s a tension in policy and practice about how we listen to our customers and then help them aspire to what they haven’t had before.”
This tension is embodied in the Care Act 2014, which requires local authorities to take account of people’s preferred outcomes during assessment, care planning and review, but also to arrange services to prevent, delay or reduce people’s needs, and provide people with information and advice on doing so at various stages in the customer journey.
Bolton said that, currently, most local authorities did not commission for outcomes but procured services at the lowest cost. He said that there was a strong case for councils to move towards outcomes-based commissioning as other options for saving money, such as simply cutting the prices paid to providers or reducing social workers, were no longer feasible.
“We can’t take anymore price out of the market; we can’t cut any more social workers,” he said. “We have to look at what outcomes we are delivering and whether we can deliver better outcomes at lower cost. That’s what I believe.”
Bolton set out four different ways councils were developing outcomes-based commissioning in adult social care:
- Building outcomes-based performance indicators into a contract with a provider but not offering a financial incentive for meeting them, as Coventry council has done with its domiciliary care service.
- Agreeing a set of outcomes with the service user following assessment and then calculating a fee for the provider based on the estimated cost of delivering them, to incentivise the provider to do so as cost-effectively as possible. This is the approach taken by Wiltshire for its home care service.
- Giving providers multi-year contracts whose annual value reduces over time, incentivising them to support service users to become more independent. This is being applied by Nottinghamshire council in relation to community support for people with learning disabilities.
- Commissioning a lead provider to be accountable for delivering outcomes for a particular population, sub-contracting work to other providers as necessary. This approach, which Bolton said was being developed in Torbay, transfers accountability and risk to the provider, incentivising them to promote independence within the population in order to reduce cost.
Key role for social workers
- Bolton said there would be a key role for social workers, under the lead provider model, in advocating for service users and ensuring they were not being exploited by the provider.
- “If the customer felt they were being exploited by the provider, the social workers are the people who hold the rein and say to the provider ‘what you have done with this person hasn’t promoted their independence’ and we need to do this and that because that is what the law requires.” Social workers have a key role with a lead provider in advocating for the client.”