Commissioning care services for older people: A study of achievements and

challenges in London Penny Banks June 2005

Contents Introduction Defining commissioning

Aims Methodology Contents of this report

Policy background: a new era for commissioning Findings 1: Assessing performance of commissioning: outcomes Findings 2: Assessing commissioning practice Findings 3: Market, policy and resource pressures Conclusion Recommendations Appendices

Appendix 1: Criteria for effective commissioning Appendix 2: Participants at experts seminar, King’s Fund, October 2004

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Acknowledgements The research team from the King’s Fund who undertook this study – Penny Banks, Rebecca Rosen and Alex Smith – would like to thank the special advisory subgroup of the Care Services Inquiry Committee for their invaluable support and advice: Peter Fletcher and Peter Smallridge joined by Juliet Mellish (Assistant Director of Service Improvement Directorate, Brighton and Hove City PCT) and King’s Fund colleagues – in particular, Janice Robinson. We would also like to thank everyone who generously gave their time to take part in interviews and discussion groups in Hillingdon, Kingston, Lewisham, Newham, Southwark and Westminster and all those who took part in an experts seminar to discuss the study findings (listed in Appendix 2).

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Introduction This study was commissioned to inform the Kings Fund Care Services Inquiry, which was set up in response to concerns about the quality, appropriateness and adequacy of care services for older people in London. The King’s Fund wanted to investigate how local authorities with PCT partners were commissioning care services for older people in London, recognising that which services are commissioned and how determines to a large extent what is available in the care market. The King’s Fund also wanted to explore allegations being made in the debate about a ‘crisis in care’ that local authorities could be doing rather better in commissioning. Defining commissioning From the outset we understood that commissioning can take place at two levels: at a strategic level, for populations, and at an individual level. We wanted to focus on strategic commissioning, which has been described as a cyclical process and includes: understanding and forecasting supply and demand factors within the market to meet current and future needs of older people; aligning system partners to agree on what needs to be achieved to meet demand; joint strategy planning to meet these goals; applying resources to achieve strategic goals; and reviewing and evaluating to adjust to changing needs.1 However there is an important relationship between commissioning at an individual level (where services are arranged and purchased for the individual) and strategic commissioning. Strategic commissioning should ensure there are appropriate services for an individual needs-led assessment and that information on needs from micro-commissioning informs local strategic plans. Aims of study This study was set up to examine the effectiveness of current strategic commissioning practice and to assess how local authorities, with their health, housing and other partners are working together to:

• understand the nature of local markets as characterised by different levels of demand and supply

• commission new service developments and de-commission outmoded services

• respond to the needs of a growing population of older people from black and minority ethnic communities

• respond to the needs of older people with dementia • reduce demand through preventive approaches • build capacity in workforce, capital building or refurbishment.

Methodology Six boroughs in London took part in the comparative descriptive study, having been selected for their different demography, geography, local political control and performance assessment ratings. Structured interviews and facilitated discussion groups were held with stakeholders from three key groups: commissioners (social 1 Department of Health (2003) Commissioning and the Independent Sector – A good practice checklist

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services, PCT and housing); providers (independent, voluntary sector and in-house); and services users, and carers. Chief executives of the local authority, local councillors, and non-executive PCT board members were also interviewed. A desktop analysis was undertaken of relevant documents. The aims were to draw out trends and themes in the approaches taken by these sites to illustrate commissioning in London, and to highlight what is helping and hindering commissioning practice across the capital. This study is not offering an analysis for each individual site; nor does it provide an individual assessment of their commissioning practice. Contents of this report Following a short introduction to the policy context, this paper starts with a description of the broad picture of care services and systems across the six sites, noting how far this meets the ideal outcomes of effective commissioning. We then consider how far shortcomings in services might be the result of the way in which services are commissioned – firstly by examining how commissioning is undertaken in practice, and then by looking at policy and market pressures affecting commissioning in London. In the light of these findings, we conclude with a commentary on prospects for the future and propose a series of recommendations to address the issues raised.

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Policy background: a new era for commissioning Commissioning became a central role for local authorities after the 1990 NHS and Community Care Act. This Act made local authorities responsible for arranging (but not necessarily providing) services, and reinforced the notion that care services would be purchased and provided through a market system. A range of government incentives supported this fundamental change, which was seen as a way to keep costs down and improve quality through competition. Despite considerable local authority concerns about this commissioning function (in particular, the perceived dangers of introducing markets where social care users are in a vulnerable situation), by the end of the 1990s residential and domiciliary care services were predominantly purchased from external agencies. A major change had taken place over ten years, and commissioning was established as a key process in the social care market. More recent policy has driven further radical change in commissioning, promoting closer working between health and social care to provide more integrated services for older people. The development of integrated commissioning has been supported through the Health Act 1999, which introduced the flexibilities of pooled budgets, lead commissioning, and integrated provision. A whole-system perspective on local services has been promoted through, for example, establishing local strategic partnerships as integrated planning forums, and developing guidelines such as in Building Capacity and Partnerships in Care (2001). These guidelines particularly focus on how statutory and independent sectors should work together, and emphasise that ‘commissioners and providers are equal partners in delivering services.’ Policies to address pressures on acute health care, including the stimulation of intermediate care developments and the introduction of fines on local authorities for delayed discharges from hospital, have also driven more integrated provision and commissioning. Since April 2003, primary care trusts (PCTs) have been responsible for funding nursing care in nursing homes, which has reinforced their position in commissioning for older people. The recent focus on chronic disease management and the introduction of different models of case management for people with long-term conditions and complex needs also calls for integrated approaches between PCTs and social services. The National Service Framework (NSF) for Older People emphasises integrated arrangements that go beyond health and social care, to promote the health and well being of older people through multi-sectoral approaches. The Local Government Act 2000 provided additional powers for councils to work in partnership with other local agencies to improve economic, social and environmental well being. Two Wanless reports2 highlighted the importance of promoting better health in the population through partnerships across sectors. This is emphasised in the NHS Improvement Plan 2004 which focuses on health and well being, not only on ill people.

2 Wanless Securing our Future Health:Taking a Long-Term View 2002; Wanless Securing Good Health for the Whole Population 2004

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Supporting People funding arrangements for housing related support services (introduced from 2003) and the promotion of extra-care housing have underlined the importance of integrated working between, health, housing and social care commissioners. The Department for Work and Pensions, along with other government departments, and supported by the Local Government Association, is also promoting strategic and operational partnerships at every level to develop an integrated network of services for older people in each area to promote well being, social inclusion and joined-up customer-focused services.3 Policy emphasis on choice and control by service users and the extension of direct payments to older people in 2000 open up possibilities for individuals to commission their own services. This ‘individual commissioning’ will have an impact as yet unknown on strategic commissioning. The single assessment process emphasises practice centred on the individual, and takes an holistic approach to needs as a basis for individual commissioning. In addition to these policies encouraging integrated commissioning and joined-up delivery for older people, the national procurement strategy for local government 2003 and the Gershon review of public service efficiency in 2004 (Releasing Resources to the Front Line) identified ways to find savings from improved care procurement. One proposed way is through regional as opposed to borough-based commissioning. All these recent policy drives thus mark a new era for commissioning. The expectation now is that commissioning should achieve integrated health and care services in people’s own homes, meeting their needs in a holistic way, offering choice and control. This should be combined with community initiatives to improve the quality of life for older people, which at the same time reduce the demand for health and care services. The forthcoming Green Paper on the future of social care is likely to describe this vision in more detail. Commissioning is the vehicle that will bring about change in the shape of care services.

3 DWP LGA (2004) Link-Age: Developing networks of services for older people – Building partnerships

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Findings 1: Assessing performance of commissioning: outcomes In order to assess the effectiveness of commissioning, we have established criteria from a review of guidance and good practice in commissioning. (See Appendix 1 for full list of effective commissioning criteria with references.) We would expect effective local commissioning to achieve:

• an adequate balance of responsive services offering a range of local options for older people and strategic innovatory developments that demonstrate shifts in service configurations, from traditional services such as a heavy reliance on residential care to more flexible models and integrated services

• better functioning of the whole service system and a stable market so there are few bottlenecks or crises, and with contingency plans able to deal with unexpected events

• a high degree of user and carer satisfaction in the quality and accessibility of local services, including satisfaction expressed by older people from black and minority ethnic communities and older people with dementia and other special needs

• demand for care services reduced or delayed through a range of broad community services to promote older people’s well being and quality of life, as well as health promotion, rehabilitation services and other types of prevention services

Essentially, effective commissioning should be transforming a care system that in the 1990s was dominated nationally by residential care, instability in the market, and inflexible services. Historically, the balance of care has been somewhat different in London where, partly due to competition for land and high property costs, a larger proportion of homecare services have been commissioned relative to care homes.4 We have therefore understood that any efforts to shift the balance of care even more to home care are likely to be less dramatic in London. In summary, all the sites partially meet these outcomes, but for each indicator there are some serious shortfalls, as described in the following section. An adequate balance of local responsive services? While there is evidence of a shift in service configurations beginning to take place and developments of some flexible and responsive services on all the sites, there are pressing concerns about the quality and quantity of current services to meet local needs. These concerns centre on the more traditional services of homecare and residential care. Progress in transforming services is indicated by examples across the study sites of:

• redesign of existing services such as moves away from traditional day centres to integrated resource centres offering a range of education, leisure and other opportunities alongside access to health, care, information, advice

4 CSCI London Regional Office (2004) Report for King’s Fund Care Services Inquiry Services for Older People

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and other services; better co-ordinated stroke services; and more enabling ways of delivering homecare through specially trained staff working with older people to restore their independence

• introduction of new services such as different forms of extra care housing with separate units for older people with dementia; development of accommodation with latest technology (SMART homes); outreach and specialist support for older people with dementia and their carers; and units for Asian and African-Caribbean people in a care home offering intermediate care and flexible breaks

• whole-system redesign – for example, through the establishment of integrated health and social care teams with integrated budgets, linked to general practices and strategic development of intermediate care services that prevent inappropriate use of acute health services, support people’s return to home, and facilitate a more effective functioning of the whole system of services.

However, these developments are part of a continuum or spectrum of care that is still the subject of considerable debate (see later discussion about a shared vision in findings on managing the market). There is no real consensus about what constitutes an ‘adequate balance’ of services. There are also major worries about the quality of homecare services – the bedrock of supporting people to stay in their own homes. In particular, the practice of 15-and 30-minute slots of people ‘being done to’ (being passive recipients of services) is criticised by homecare providers, and not acceptable to older people and their carers. There are also concerns about the quality of care provided in some residential and nursing homes, such as insensitive care and poor standard of meals. All the sites identified gaps and shortcomings in services to older people with dementia. Gaps were also noted in services to older people with mild cognitive problems, learning difficulties, and very challenging behaviour. Insufficient key support services such as chiropody, occupational therapy (OT) and continence services were also flagged up. The majority of sites voiced concerns about older people who do not meet local eligibility criteria but who need some care and support. One voluntary organisation commented that local day centres were ‘full of ill people, giving carers respite.’ Stable or crisis-driven system? While no site identified an immediate crisis in their local service system, all identified high risk factors. These included: quality concerns that could lead to a closure of service; difficulties in recruiting and retaining staff; and a funding gap that meant ‘if resources and needs continue to be so far apart, there could be a crisis.’ Indeed, two sites described their local system as ‘on a knife edge’. No sites reported any current problems in delayed discharges, and one reported fewer people now going into care homes since the introduction of reimbursement policy. However, we heard feedback across the sites, and from different stakeholders, about pressures on older people and families to accept a place that was not their preference; increased numbers of older people being admitted to residential care and dying within 24 hours; frail older people undergoing several

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moves in a short period of time; and high rates of readmission to hospital. While this is anecdotal evidence, the consistency of these reports by different stakeholders urgently calls for more substantial evidence about this aspect of ‘better functioning’ of the whole system. A high degree of user satisfaction? Older people and carers from all communities provided mixed views on local services in all the areas studied. Independent providers in several areas commented on the gap between strategic and micro commissioning. The strategic level aimed for ‘person-centred’ approaches and services tailored to individual needs. But frontline staff often commissioned standard packages of care or specified the task to be undertaken by providers rather than the final outcome for individual older people. In all places, there was praise for excellent health and social care staff, homecarers who made such a difference to life at home, and proactive services, such as link nurses for those over 75, and health visitors for older people who take a holistic view of people’s needs. Recurring topics of concern included: poor quality of homecare, especially when provided by agencies and the independent sector; long waits for equipment; confusion about new service arrangements following the introduction of eligibility criteria; increased charges for services; worries about the isolation of older people described as an ‘epidemic of loneliness’; local environment problems, including inadequate public transport and access to toilets; and difficulties in being heard, both individually and collectively. A frequent remark was that those who are assertive get help while others miss out. Particular concerns were raised about people with no family or friends to speak up on their behalf. Feedback from black and minority ethnic elders and their carers reflected these general concerns. In addition, many felt money would be better spent on making mainstream services more culturally appropriate rather than developing separate specialist services. Support to local faith organisations and specialist black and minority ethnic providers was particularly welcomed but not always forthcoming. Some communities perceived others to be getting a better deal from local services. Carers from all communities had mixed experiences of services, and worried about the quality – especially the reliability – of services. Many felt that they were ‘invisible’ to services. Others reported that when a carer is known to be involved, very few statutory services are offered, if any. There was mixed experience of carer assessments. Many had not been offered an assessment. Others found this a helpful process. One carer had been given a self-assessment form to complete and although stating she felt near to breakdown had had no response at all from the authority. Reducing demand? All sites are concerned with tackling the prevention agenda, but most have serious difficulties in adequately funding this work. There are also differences in the strategic approach, the breadth of the agenda, and involvement of other partners in this work.

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All sites have examples of low-level community support and health promotion activities, including handyman schemes, keep-fit projects and falls services. There are also some developments in casefinding of older people at risk, as well as other work with PCTs on chronic disease management designed to reduce dependency on health services and improve overall quality of life. At least half the sites studied are trying to progress wider quality of life strategies and proactive ageing-well programmes, supported by departments across the council and championed by elected members. These include action on safe and inclusive neighbourhoods, community support teams, access to adult education and initiatives run by older people. For example, one authority is working on six strategic objectives: valuing older citizens; enhancing financial security; keeping people independent and in event of failing health, providing high quality health and support services; securing a safe environment; ensuring opportunities for lifelong learning; and maintaining personal and wider relationships. Some sites, however, feel there is no clear shared strategy to take forward. There is some dispute about who is responsible for prevention, and a lack of evidence to convince members and some officers to back this as a priority. One authority was taking the topic of prevention to their scrutiny committee to progress the debate and effect change. Summary of findings on outcomes of commissioning • Although there is some evidence of strategic development of flexible and

responsive services and change in the way the service system operates, there are pressing concerns about the quality and quantity of key services to meet local needs. The lack of adequate services for older people with dementia was of universal concern.

• While no one felt there was an immediate crisis in care, every area identified high-risk factors, and at least two areas described their local service system as ‘on a knife edge’.

• User and carer satisfaction was mixed across all the sites, ranging from generally high levels of satisfaction for those with agreed packages of care to widespread concerns around accessing services, charges, waits for equipment, isolation of older people and the quality of homecare services.

• All areas are concerned about prevention, but there are serious difficulties in funding this work ,and there are differences in how this is being tackled in terms of both breadth of approach and the involvement of other players.

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Findings 2: Assessing commissioning practice The question arises as to whether the progress and problems identified in the picture above are a consequence of the way care services are commissioned. In order to answer that question, we start by examining commissioning practice before considering national and local challenges to commissioning. The criteria used to assess commissioning practice are drawn from recent guidance (see Appendix 1). Effective commissioning should include:

• partnership working between local authorities, PCTs and acute trusts, housing authorities and organisations, voluntary sector, private and independent sector providers, older people and carers. These would be partnerships able to demonstrate effective working relationships where, for example, information and data is shared; commitments to take action are honoured by partners; and where risk taking is shared

• user-focused commissioning where older people and carers are involved at every stage of the commissioning process and there are routine ways of engaging older people from all communities – particularly those ‘hard to reach’. This involvement can be shown to influence commissioning strategies and service developments

• an understanding of the market and intelligence gained at population and case levels about local needs and local supply of services, including knowledge of resource allocation, unit costs and local cost analysis of providing care. There would also be means of forecasting supply and demand and the likely impact on the market and service system

• evidence of managing the market with a shared vision for older people’s services; a joint strategy and agreed implementation plan to deliver the necessary changes; budget management and accountability; a mix of incentives used to influence and stabilise the market such as block contracts, and support to providers through training and other measures; ways to review and evaluate implementation of the strategy

• ways of increasing capacity through, for example, pooled budgets, joint working and training across disciplines and agencies, shared occupancy or new use of buildings, shared information systems, joint workforce plans and strategies for recruitment.

In summary, we found varied practice across the six sites, but for each of the processes described above every site met at least some of the criteria. Partnership working Partnerships between local authorities and PCTs All sites demonstrated some degree of partnership working between the local authority and NHS. In every site, local authorities took the lead role with PCTs as their key purchasing partners. Different organisational arrangements supported work between social services and the PCT. Some had established integrated or joint commissioner posts and integrated commissioning teams. In other sites, commissioners from the PCT and social services were co-located to support joint

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working. Some were planning, but did not yet have in place, structural arrangements to formalise integrated commissioning. Agreement on risk sharing between the PCT and social services was partially demonstrated in Section 31 agreements at all sites. The use of this flexibility was limited and mostly related to the use of reimbursement funding, partly reflecting considerable caution by authorities concerned about accountabilities and the complexity of drawing up these agreements. Indeed, partnerships appeared to be at different stages of development. This reflected the limited capacity of some PCTs to get fully involved in the commissioning process where managers had a very broad span of duties; older people’s services being squeezed out by other priorities; and a mismatch between experienced commissioners in the local authority and new roles for commissioners in the PCT. Health commissioners have not operated in a mixed economy with a plurality of providers (statutory, voluntary and private), while social services commissioners have that experience for at least ten years. Strong partnership working was demonstrated in several sites. This occurred, as other research has shown,5 where there was a local history of joint working, strong leadership and where partnerships have been supported at every level – frontline, middle management, senior management and political or non-executive. Supporting factors also included: co-terminous boundaries, co-location of health and social services staff, and an emphasis on communication and building relationships. This last factor can be seriously impeded by personnel and organisational changes – very evident in a few sites where a succession of changes in senior managers had disrupted partnership working. Partnerships with acute trusts All the sites had some form of whole-system planning that included acute trusts. This had been given extra impetus through reimbursement policy. Many reported improvements in tripartite relationships between PCT, acute hospitals and local authority, although they continue to be under pressure from government targets on emergency admissions and trolley waits. Although work together has improved, there remain considerable challenges in redesigning services across community and acute health sectors – for example, in bringing geriatricians out to work in community services. Partnerships with housing Many of the sites noted that engaging with housing partners has been more challenging than engaging with some other partners, but all sites now involve housing in their partnership working. The majority have developed joint strategies in consultation with older people and other stakeholders. These partnerships appear to be exploring a much wider range of options for integrated and community approaches to services to older people – for example, new developments that incorporate extra care for people with dementia, a range of nursing and intermediate care provision, expanding community alarm, telecare and other supportive services to assist individuals in their own homes, and developing schemes that are a resource for all older people locally, including information and advice services. 5 Hardy B, Hudson B, Waddington E What makes a good partnership? A Partnership Assessment Tool Nuffield Institute for Health 2000

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Partnerships with providers In contrast, we heard of very varied relationships with independent providers. Independent providers in half of the areas studied clearly do not feel they are ‘partners’ in any sense other than in contractual relationships, and are not involved in any strategic planning. Underlying tensions are acknowledged in these contractual, and often competitive, relationships but providers seemed to welcome (even be thirsty for) more involvement in strategic discussions about services. In some of the areas studied, independent providers were frustrated by poor communication at every level. For example, they do not get proper case information; are not routinely invited to reviews; experience delays in getting panel decisions; and despair of ‘invoice nightmares’. One provider had over 300 bills outstanding from social services and another had waited 13 months for payment by a PCT. Sporadic local forum meetings in some areas tend to be one-way information giving sessions on contractual rather than strategic matters. In one area a large care home provider was so disillusioned with local relationships that they plan to reduce their dependency on the local authority and rely on the private market. In contrast, in other boroughs, independent providers respected the professionalism, clarity and good communication of the council; some commissioners clearly worked very hard at building relationships with independent sector providers, who appreciated the support and easy communications through, for example, a small central unit, stable workforce, regular forum meetings which allowed for good exchange of information and views, special support teams (for example, with nursing homes) and newsletters. There were also examples of successful partnership arrangements between independent providers, local authorities and the NHS, which had planned and delivered new extra care housing. A number of interviewees remarked on PCT staff being particularly inexperienced at working in partnerships. It was felt in one area that the ‘independent sector have got health where they want it, as we don’t have the capacity nor sophistication.’ Partnerships with the voluntary sector There were also a number of tensions in partnerships with the voluntary sector – not least because this is often a highly politicised sector that is complicated by its diversity and range of roles, including those of service providers, champions and advocates. Most commissioners praised local older people’s organisations and welcomed their work to engage older people. Some authorities have set up longer-term funding agreements of up to five years with these local voluntary organisations. Others have tried to protect and support smaller community groups and organisations without adequate infrastructure to meet training and monitoring requirements, recognising these are frequently service providers to the most hard to reach and excluded groups of older people. Special fees, training opportunities and other developmental support have been provided to these groups in some areas. Some authorities have explicitly adopted a developmental model of commissioning with black and minority ethnic groups to build capacity and move away from short-term funding.

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However, many voluntary organisations offering services have to accept spot contracts or year-long service agreements, which present problems in keeping staff and planning services. Some feel they are patronised (‘It still feels we go cap in hand,’ said one) and are not real partners around the strategic planning table. They are the first sector to be hit when there are funding pressures – the very sector where much of the community support and low-level help at home is being undertaken.

User-focused commissioning All sites supported a range of processes to involve older people and carers, mostly through seats on strategic partnership groups and through wider networks such as local older people’s and pensioners’ action groups or assemblies, and black and minority ethnic forums. In some areas, they have tried to bring these together by, for example, supporting an older people’s reference group involving people from a wide range of networks and communities (also provided with special support). The voluntary sector frequently facilitates these networks and forums. There are numerous examples of involvement in service planning, development, monitoring and evaluation. These range from consultation with user and pensioner groups; older people’s participation in stakeholder events, as mystery shoppers, or in discovery interviews; outreach work with black and minority ethnic elders; through to telephone surveys with older people. All of these have potential to feed into commissioning. Each site gave examples of influence by older people on commissioning service developments. For example, an event bringing together everyone involved in developing new ways of preventing and working with older people at risk of falls led to a new ‘return home safely from hospital’ service in response to older people’s views on going home to ‘a cold flat and empty fridge’. Older people helped draw up the necessary service specification for this new service, and interviewed providers. Several sites had involved older people from black and minority ethnic communities to improve the range and suitability of different meals services and develop local community centres. Carers have also influenced services, such as the development of an Alzheimer’s café providing support to carers and people with dementia. However, some commissioners feel that direct and systematic involvement in commissioning is limited. Indeed, many fundamental issues raised by older people regarding charging and access to services are having little obvious impact (see the later discussion on funding issues). There were mixed views from older people and carers about their involvement in commissioning and their ability to influence developments. Some felt there had been improvements in engaging them at every level, but others were frustrated by the ways in which processes were still controlled by authorities as well as the lack of feedback from their input. Many older people and carers had no knowledge of how they might be involved in the commissioning process. As has already been noted, commissioning for the individual appeared largely to rely on specifying a set time for a particular task. This was often at odds with the strategic vision of commissioners for flexible and tailored services. A large number of services seemed to be commissioned for exactly the same package of care suggesting

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standard rather than individualised care plans. A number of providers also commented on the widely varying assessment practice of staff responsible for commissioning for the individual. At one end of the scale were sensitive holistic assessments of needs. At the other were assessments that were at odds with information and understandings obtained by providers working closely with the older person and their family. There are some examples of advocacy services for older people living in care homes and in their own homes, and of carer support and advice services provided through centres and specialist workers. These do not appear to be widely available. Many older people and carers noted the difficulties in finding out information, whether paying privately or not, and the random access. One said, ‘Everything has to be asked for, and if you don’t know what to ask, you don’t get.’ Direct payments offer potential for control by older people of the services they use, but the majority of sites are at very early stages in introducing this system. One site had 100 older people using direct payments, and one carer talked of it ‘changing her life’. Another site had offered service users the alternative of direct payments at the time of transferring homecare providers. At most sites, discussions uncovered mixed feelings about the benefits of direct payments. Homecare providers fear that this is being used to reduce costs, and consider that the level of payments do not cover standard fees. Others worried about the potential risks to older people using providers rejected by local commissioners and who may be seeking business through this route. Some reported that social workers are not promoting this option. Older people had mixed views, and many had no knowledge of this option. Understanding the market Understanding local needs Practice varied widely in understanding local needs, with some sites acknowledging they were at early stages in bringing together information from a ‘shanty town of databases’ while others used a comprehensive range of sources at population and case levels, as well as commissioning special research into specific areas of need and undertaking collaborative service mapping exercises. Some recognised that they knew the demand for individual services but had an inadequate picture of overall need. All recognised the challenges of finding out the needs of isolated households and people in privately-rented accommodation and developing a full understanding of the needs of some local areas that consist of a series of micro-communities. Understanding supply Levels of understanding of the local supply of services partly reflected the closeness of working relationships with care providers. In some areas, providers felt that stereotypical views about the private sector were causing problems in communication, and blocked the sharing of valuable information on needs and service supply. Other areas had put considerable resources into developing one-to-one relationships and had a good knowledge of local providers. Brokers have been introduced in some areas to liaise with local providers and act as a link between strategic and micro-commissioning.

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Tensions in relationships between in-house and external providers was a recurrent theme. One borough had no in-house provision, while the rest had purposefully retained a mix, to help lift standards, act as a safety net and, in some places, to meet a gap in the market – especially in the provision of nursing care homes. Tensions were described where in-house staff, often homecarers, received higher pay and conditions, and thus attracted staff away from the independent sector once they had been trained. Several authorities had no internal service-level agreement with their in-house providers but were in the process of developing these. Relationships between in-house managers and commissioners varied, and in some areas managers had dual responsibilities for in-house and external providers. Levels of understanding of how the whole system works appeared mixed, and while all had examples of work on different care pathways and relationships between services, most acknowledged the complexities of dealing with the ‘big picture’ and the difficulties in forecasting the impact of changes in one part of the system on other parts. Redesign of services and locating expertise out in the community was seen as crucial but difficult to implement. Forecasting was acknowledged as a major challenge by most, and while some had used different capacity planning and other models, some sites found these of limited use. Planning in the short to medium term was felt to be more realistic than any very long-term projections. Managing the market Is there a shared vision? All sites are seeking to promote older people’s independence; ensure people are not ‘catapulted’ into a level of care service that they do not need in the long term; improve the quality of services across the spectrum; and develop a range of service options. Some study participants had a clear vision that began with older people as citizens with access to all health and community services, and where older people were not automatically seen as dependent. One commissioner described a ‘hub-and-spokes model’, where services are developed in the neighbourhoods in which people live and connect to mainstream services. This focus on outreach and partnerships will generate a range of models, including older people-led services, which are very visible to the local community and ensure older people are fully informed. Across all the sites, there was debate about components of the vision, including: • the best balance of services There is some uncertainty about the most

appropriate balance between residential care and care in people’s own homes. While most strongly support care in people’s own homes, a number of people voiced worries that in practice, this can leave people isolated and in the current situation, the ‘quality of life for older people and dignity is being sacrificed.’ There are also different understandings of extra care housing and uncertainty as to how far this option could ever be any real substitute for residential and nursing home provision.

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• the best approaches for black and minority ethnic elders Debate around this issue included recognition of the importance of very detailed understanding of each local community, sub-communities and their needs.

Mixed views on direct payments Some sites did not appear to have a clearly specified shared vision, nor a partnership-commissioning strategy, with an implementation plan identifying steps to reconfigure services or shift current provision within the whole system of services for older people. Many written strategies for older people’s services are primarily ‘mission and position’ statements for older people’s services, largely reflecting the delivery of the NSF. Other plans focus on individual services. Several sites had quality of life strategies adopted across the council. From a review of documents supplied, most offered limited evidence of needs assessment and capacity planning to influence local commissioning intentions. For example, demographic information may be described, but no connection is made between this and commissioning strategies; no reference is made to service use or referral patterns; and there is no gaps analysis and little financial data, or use of this, to inform commissioning. While written strategies may by themselves be an unreliable indicator of strategic work, there appeared to be a contrast between the ‘live’ documents, written as part of an inclusive process and in use by partners, and some papers written by outside consultants. The latter, while often impressive in their scope and vision, did not appear to be owned by all the stakeholders. In one borough, a consultant was employed to develop a commissioning strategy for homecare, but found this difficult to progress in the absence of a strategy for other services within the health and care community – which would obviously impact on homecare, and vice versa. Analysis of documents submitted also show some marked difference between the content and aspirations of some of these written strategies and the actual experience, practice and issues being expressed by local stakeholders. A number of people noted the lack of support and training for middle managers who play a key role in translating strategies into practice. Some reported, too, that strategic partnership groups are not given the capacity, support or clarity of role to deliver.

All sites demonstrated elements of market management aiming for sustainability not crisis management. They had taken steps to stabilise the market through tendering processes, moving away from selecting the cheapest provider to offering higher fees to reflect (as far as budgets allowed) quality service costs, and awarding a number of block contracts. Some areas were cautious about the timescale and conditions of new block contracts, having previous experience of being locked into lengthy block contracts with providers offering less than ideal or modernised services. The sites studied offered varied levels of support to providers, including joint training opportunities, one-to-one dialogue with providers, and developing fee scales related to different dependencies. Each site took a different approach, depending on their local situation and history. For example, one site had just gone through a tendering process to reduce the very large number of homecare providers, from over 40 to 14,

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and move to a locality-based approach. Another site was consulting providers on reshaping homecare services so that their internal service could concentrate on the initial assessment of people requiring homecare and provide the first six weeks service in a way designed to increase independence. Although sites had good strategic intentions, implementation and follow-through appeared problematic in some places. This might have been due to problems in information systems and supporting organisational infrastructure. For example, in one area, aims to generate healthy competition to raise standards through tendering processes were welcomed by service providers, but having gone through a long and expensive process, they claimed they had been awarded contracts based on inaccurate figures, and have consequently lost workers through not being able to offer the hours they had promised. Monitoring appeared to rely on a mix of feedback from care managers, service-user surveys and contract monitoring. Some authorities appear to have highly specified contracts with regular monitoring, but in others it was not always clear how intelligence from different sources was shared and collated. One commissioner talked of the need for a ‘better feedback loop between operational and strategic commissioning.’ Commentary on commissioning practice Commissioning practice varied across the six sites, partially reflecting experience and expertise in this area. In some local authorities, commissioning has only been acknowledged as a key role in the last few years, and senior posts are relatively new. Some authorities are finding it difficult to appoint and retain senior people with the necessary skills and experience. PCTs are also relatively new organisations, and although all those interviewed defined commissioning as a process beyond contracting and procurement to include service development, many acknowledged that they are new to this role. They have limited experience in partnership working, and have a very wide brief on which to deliver making it difficult to fully undertake the needs analysis, relationship building and other important components of care services commissioning. Organisational arrangements to support the multi-faceted commissioning process also appear very mixed. Some places appear to have a well-led and managed team of people with clear roles and responsibilities within the social services department and with other agencies; others have integrated commissioner posts in name but with responsibilities clearly focused on their employing organisation; others see integrated commissioners acting as a focal point for older people’s services, working across numerous boundaries in more of a roving role, and with a very wide brief. Many social services operational managers carry a mix of responsibilities for in-house and external services, and have differing relationships with strategic commissioners. Some argue that this mix of strategic and operational responsibilities works well, as it provides a link between commissioning at the front line for individuals with an overview of needs and supply for planning purposes. Others, moving towards integrated commissioning, argue for a clear distinction between commissioners and providers so that in-house services are commissioned on the same basis as external providers.

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However experienced or well supported commissioners highlighted the complexity of the task and challenges of:

• forecasting future demands for and supply of services. It is difficult to predict future generations’ aspirations and to plan far ahead – particularly where there may be no consistent patterns in service usage. For example, one borough commissioned a study about population trends and future nursing care but found no clear forecast of how many homes might close and new providers enter the market and how far extra care housing might impact on the need for nursing care home provision. One area modelled for residential provision based on government predictions of a turnover of 30 per cent of residents, but in practice this has proved to be very different. It is also difficult to plan for transient populations and for unknown impacts of medical advances

• whole-systems working – which requires capacity ‘to work on all of it all the time’ and difficulties in anticipating consequences of actions elsewhere in the system for example, the impact of extra care housing

• bringing together health and social care cultures where people are seen to ‘think and operate differently’, particularly evident where Fair Access to Care operates, and in relationships between the acute sector and care providers

• dealing with a pluralistic and fragmented market where offering choice for older people from all communities through contracting with a large number of small organisations may be costly and offer less stability than dealing with a few large providers

• progressing new developments and building relationships where communication up, down and across organisations is crucial but very time consuming, and where internal communications can suffer if time and energy is directed at outside relationships

• decommissioning services which may involve dealing with a range of competing and political interests – for example, in closing down traditional day centres in preparation for new types of day opportunities; as well as the need for pump priming to support change

• cross-boundary issues where some services are hosted across several boroughs and work to develop these is inevitably at a very slow pace. There are also pressures on the care home market in inner London from the high cost of property and lack of available land. These mean inner-London boroughs have to pay premium prices to secure places, forcing up prices in outer-London boroughs. There is some collaboration between neighbouring authorities to tackle strategic commissioning issues as, for example, developments across east London to address issues relating to elderly homeowners with experiments in sheltered housing for sale

• political support which is crucial to any radical change and risk taking. Members interviewed were either champions or leads on older people’s services, and some were evidently strong advocates for change, and worked hard to bring other councillors and key players on board. While most people interviewed supported the partnership approach and closer work between the council and NHS, some expressed concerns about competing priorities and different accountabilities. Some PCT non-executives were noticeably less

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engaged in the agenda for older people, and had only very recently taken up the role of champion

• demand management where public expectations may be difficult to meet – for example, where local residents have high expectations of council provision based on earlier relationships of landlord and tenants, and where older people expect support ‘from cradle to grave’. Government emphasis on choice and control has highlighted tensions in managing the escalating continuing care budget; tensions between people making decisions and statutory authorities and independent providers fears about risk taking; and where people paying higher charges might expect ‘hotel’ rather than rehabilitation services.

Summary on commissioning practice • All sites are taking a partnership approach, and the strength of these partnerships

between health and social services are heavily dependent on local history of joint working and strong and stable leadership. Partnerships with independent providers are very varied, and in some places providers talk of feeling ‘a bit like Cinderella not invited to the ball’. Relationships with the voluntary sector are mixed, and some also feel on the outside of strategic discussions.

• Service users and carers have some involvement in the different processes of the commissioning cycle but this does not appear systematic, and their influence is limited. Commissioning at the individual level frequently appears to result in standardised packages of care at odds with the strategic vision of flexible services tailored to individual need.

• There are different levels of understanding local needs and supply, and some areas are grappling with inadequate information and data collation systems. All areas are experiencing problems with predicting the impact that new service developments will have on the system as a whole.

• All areas are taking steps to manage the market through different types of contracts – where possible, raising fees to providers – and through training initiatives. However, there is some debate about the vision for older people’s’ services, and there is not always clarity about their integrated strategy and implementation plan for change. There are also some difficulties in delivering strategic intentions – particularly where support for middle managers may be less than adequate.

• The extensive role of commissioning has only been accepted fairly recently in some boroughs, and is new to many PCTs. Organisational support and structures for this role are varied and appear to still be under development in some areas as health and social services establish ways to work together more closely. Capacity is limited for building and maintaining the wide number of relationships needed in working across health, housing and social care sectors

• However skilled and experienced they are, commissioners face considerable challenges in forecasting, whole-systems working, managing fragmented markets across numerous boundaries, decommissioning and managing demand.

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Findings 3: Market, policy and resource pressures While some commented that ‘the biggest challenge is our own capacity to make the changes’, most study participants identified external challenges to commissioning and making progress in developing appropriate quality services. Funding shortfalls Unsurprisingly, funding shortfalls are at the top of the list of challenges. Councils talk of trying to keep a ‘finger in the dam’ of rising prices. And while extra money has been diverted in the last year to older people’s services in at least three of the sites, there remain serious cost pressures in the market. Two of the boroughs studied dispute the Government’s grant allocation in 2003/04 – one claiming an underestimate in the census population, and the other for being categorised as an outer borough but experiencing inner-borough needs. In contrast, one borough has been helped through increased government allocation. Council tax restrictions and the way central funding awards a large percentage to education leaves other services competing for relatively small resources. Most of the boroughs studied see what one participant described as ‘growth for adults crowded out by risks in childrens’ services.’

Short-term special funding can also be problematic, and while it can help kickstart initiatives, it is also difficult to find local funding to continue with these; for example, one borough faces a loss of over £1m of specific grants. Cuts in Supporting People funding are an added funding pressure. However, all sites felt they had benefited from extra funding linked to reimbursement policy. PCT partners report very little room to manoeuvre because of historic patterns of funding, largely in the acute sector, which take up the majority of resources. They also face dilemmas about the sustainability of funding very expensive continuing care packages (as well as ethical issues about equity of access to these). All of these restrictions and pressures mean that authorities are having to strictly target services, and in some areas suppress demand, through very tight eligibility criteria. These funding difficulties work against the aspirations of offering choice for older people and supporting an innovative market. Funding pressures also make it almost impossible to divert resources from care services for people with severe and crisis needs to services that support a good quality of life for older people and that prevent their health and situation deteriorating. It may also be difficult to find bridge funding to disinvest in one service and move on to invest in a new service. Recruitment and staff retention problems Closely linked to funding pressures are problems of recruiting and retaining staff at every level. The competitive labour market in most of the areas studied makes it difficult to recruit and retain staff. ‘Homecare is currently based on students,’ said one participant. There is a lack of skilled staff to work in the community to care for people with highly complex nursing and support needs. Boroughs are competing for social workers and occupational therapists. There is less availability of part time staff

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because of Criminal Records Bureau checks. The resulting use of agency staff is highly problematic for continuity and quality of care. There is also a large turnover of senior staff in some areas, which some attributed to pressures of star ratings and a plethora of policy initiatives. This inevitably exacerbates communication problems with independent providers, middle managers and frontline staff. Managers of care homes also see people being driven away by regulations and other government requirements that they feel have changed the nature of their jobs. Most of the areas studied are taking a proactive approach to recruitment, for example through campaigns in schools and apprenticeship schemes. However a shifting workforce and reliance on temporary and poorly skilled staff, coupled with a lack of stable leadership, poses a very real threat to the effective implementation of local commissioning strategies.

Land and property at a premium in London Commissioning is also thwarted by difficulties in new build where land and property is at a premium. It is also difficult to find premises to co-locate staff; high property prices do not attract the independent sector into the market; and there is insufficient key worker housing to attract nurses and care sector staff into London. Government agenda The National Service Framework for Older People is seen as a supporting factor and has provided a ‘good starting point’ for improving services to older people. Supporting People, too, has been seen as a very positive move. But given the wide scope of the current agenda, there are some fears as to what will happen next, and that any grand new vision will destabilise plans in progress. There are concerns that government targets do not always serve the needs of older people, offer weak incentives for shifting to prevention, and are not coherent across health and social care. For example, while the single assessment is a key priority in social care, it is not a top deliverable for the PCT. While many now see reimbursement policy and the accompanying funding as a useful driver for joint working, it is equally criticised as a ‘bureaucratic nonsense’. There is also a strong warning that the jury is out on its impact on the lives of older people (see earlier comments about assessing outcomes of commissioning and stability of local systems). Unresolved national policy issues The unresolved issues of funding long-term care present a major barrier to progress. This includes continuing care, which one commissioner described as ‘the biggest mess we have had to live with’ and causes widespread despair at the time and resources used on dealing with retrospective complaints, as well as public confusion about the criteria. Also widely criticised is the highly bureaucratic nature of assessment for nursing care in care homes and the diversion of expensive staff. As one joint commissioner remarked, ‘We are trying to make a dodgy system work as well as we can.’

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Relationships with regulators and inspectors The government push on quality supports commissioner’s work to drive up standards, but relationships between authorities and regulators are not yet fully worked out. Some commissioners reported scarce or even unhelpful dialogue with inspectors of care homes. Care home providers report very mixed experiences of inspections, some claiming it ‘takes the joy out of work’ and saying that after an inspection ‘we feel like criminals’, while they praise those inspectors taking a developmental approach. In the domiciliary care sector, the introduction of standards and regulation is still very new and as a first step there were a number of pleas to unravel the gobbledygook of NVQ jargon. Ageism Deep-rooted ageism threads through much of the feedback, and a challenge for commissioners seeking changes in planning priorities where ‘older people are not seen as a “sexy” issue locally’; in encouraging new approaches to active ageing and quality of life where older people feel ‘once retired you become a second class citizen’; and in improving service delivery where ‘older people are talked down to’. However, there is some evidence that the increasing vocal and politicised lobby of older people is supporting attitudinal change locally, and involvement of older people in service development is beginning to influence opinions. For example, as one participant explained, ‘the lights went on at a falls conference’ in which older people took part and made clear that the issues important to them needed a corporate approach and lighting, transport and pavements are all part of the falls agenda. A number of local councillors are also championing older people’s issues and their rights as local citizens. However, this was not evident across all the sites studied, and in some areas groups were constantly lobbying to get older people on the agenda of local politicians.

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Conclusion How effective is commissioning in London? The overall picture of care services for older people suggests that local authorities with PCTs still have some way to go to achieve a transformation in services. Some authorities are well underway in tackling this, through commissioning processes. But from the evidence in this study, services have not changed substantially for a number of older people in London, particularly those with dementia – an area in which there was unanimous feedback about the gaps in services. Some older people are having to accept poor quality homecare and residential services – an area of concern to commissioners and families alike. Others are having to move into care homes at some distance from their home community. There are older people who are only just managing to live independently but fear for the future if their health and social circumstances deteriorates in any way. Some are living very isolated lives, and even those using services may spend the majority of their day without any personal contact or without being around people who speak their language and share their way of life. However, from our discussions with commissioners and providers, there appears to be a strong commitment to improve services and systems and, most importantly, there is evidence of change taking place. Some older people are using care and support services that make a significant difference to their lives, assisting them to live at home with confidence. There is evidence of some effective local commissioning demonstrated by the development of a richer tapestry of flexible and integrated services, and a degree of stability in local service systems. There is progress in work across health, social care and housing sectors to plan and develop care and housing services for older people, ensure better care pathways between services, and introduce different ways of proactively supporting older people with complex needs. Corporate work to improve the local environment and ensure opportunities and inclusion of older people is also underway in some areas, and is linked to developments in integrated services for older people. But this process of change and development is far from complete. Local authorities and PCTs are in the early stages of integrated commissioning, and there are some uncertainties about the merits of particular forms of integration, and fears about risk management in a climate of serious cost pressures and performance ratings. Some steps are already being taken to address the varied commissioning practice in London and build skills in commissioning through learning networks, training and consultancy. However, there is clearly more to be done to ensure that there are enough people with expertise in commissioning for the future. What are the prospects for the future? A range of external factors are likely to make it even more difficult for commissioning in the future, and they will affect how commissioning is carried out, and what and how much can be commissioned. These relate to market conditions and pressures in

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London, underlying policy and resource problems, and potential long-term challenges. London pressures Pressures from high land and labour costs in London are unlikely to ease. These pose major challenges to the speed at which local authorities, with their PCT partners, can decommission outmoded services and develop a full range of flexible services. Reduction in Supporting People funding is also likely to slow down new developments in extra care housing. As a city with a younger population, more fragmented households, extremes between poorer and richer communities, and a higher proportion of migrant labour than elsewhere in the country, competing interests for limited resources is likely to continue. This issue is particularly challenging where there is a forecasted rise in the proportion of over 85s in the older population in London and an increased proportion of elders from black and minority ethnic communities who will require services that are accessible and responsive to their needs. Underlying external problems There are also several underlying external difficulties that threaten progress in commissioning:

• unresolved problems in funding long-term care and the question of who pays for care

• staffing shortages in health and social care • delivering on national targets that do not always appear to support a shift to

prevention and radical change • a reduction of care homes able to be accredited to provide a service for

people with dementia, since the introduction of national care standards • ageism • public expectations and debates about the responsibilities of the state, older

people and their families. Longer-term challenges A potential array of other challenges are being stacked up for the future, including the collapse of pension schemes, a lack of affordable housing, the impact of a current culture that does not prioritise saving, and graduates with significant debts. Also, with fewer and larger care providers starting to dominate the markets, it is likely to increase the power of care providers and limit the influence that commissioners can bring to bear on the costs of services. Opportunities in the short term However, in the more immediate future, there are developments in the health and social care system that may offer opportunities, as well as challenges, for commissioning. Local authority developments In local authorities, new arrangements to bring together education and social services in childrens trusts are unlikely to decrease historically higher budgets for children’s services. This will be an added incentive to ‘lever in’ resources from elsewhere to increase budgets for older people’s services. Thus pooling resources

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with the NHS will be even more crucial. However, older people’s services will be competing with services for younger disabled adults and people with learning disabilities, so work to raise the profile of older people and alert councillors and NHS boards to the political risks of ignoring this agenda needs to continue. More positively, the envisaged increase in numbers of older people using direct payments offer real opportunities for major change in services to older people, as older people have control over the services they choose to use. However, the impact on commissioning of this shift by social services and PCTs to direct payments is not yet clear; nor is the cost effectiveness of this change. Safeguarding the quality of provision is likely to be a challenge. There are also opportunities offered by the introduction of single assessment to improve person-centred assessments and thus commissioning at the frontline. However, much will depend on how this policy is implemented; the training given to frontline staff and ongoing support; the ability to really take a needs-led as against a service-led approach; and the provision of good IT systems to facilitate the sharing of information across organisations. NHS developments In the NHS, devolving some commissioning responsibilities from PCTs to primary care practices could support moves to care that is tailored to individuals needs, such as care managers for people with complex needs and community teams. Practice-led commissioning provides incentives to GPs to be more engaged with PCTs, and may also strengthen the ability of the wider health system to reorganise healthcare delivery around primary care. However, there may be tensions between on the one hand, the role of PCTs engaged in strategic planning for the local population of older people with their local authority partners, and on the other, the freedoms awarded to primary care teams to set their own agenda. Much will depend on how local schemes are developed and whether they are in partnership between the PCT, practices and social services. Similarly, the impact of foundation hospitals on commissioning partnerships between the NHS and local authorities is also dependent on how these new players see relationships with other partners in the health economy and beyond. Likely moves by foundation hospitals to offer community services and outreach work could impact positively on whole system working if the locus for this work is primary care. If the locus is the hospital, there is the potential to destabilise new developments to integrate health and social care services around primary care and the possibility of further fragmentation of local service systems. There are dangers also of further fragmentation in the health and social care system with the introduction of third-party providers for chronic disease management, such as Evercare, although these have been introduced to co-ordinate services for individuals with complex needs. Much will depend on how these new providers (or any locally grown models) are introduced, and how far the whole system is mapped out to ensure their role is coherent with other forms of care and case management for older people.

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Efficiency drives Requirements for social services to make 3 per cent efficiency savings are encouraging a serious look at ways of achieving savings through greater London-wide procurement. However, commissioners stress the importance of distinguishing procurement of easily specified goods from commissioning care services. This issue is about ensuring service quality and service development, which calls for an in-depth knowledge of local needs, strong links with micro-commissioning (commissioning for the individual) and a shared local vision for services between social services and the PCT. For these reasons, regional procurement is seen as inappropriate for care services other than for services to small groups with specific needs who may live across different localities. Indeed, it is questionable how much room there really is for savings. This study suggests that current commissioning practice scores reasonably well in terms of several indicators of cost effectiveness. Prices paid for care services are kept low; there is a mix of services commissioned and, where possible, a shift away from highly expensive options; and contracting processes are being streamlined and steps taken to rationalise the number of contracts with local providers. There is still much to be learnt about the most cost-effective processes while ensuring diverse markets that offer genuine choice and appropriate services for older people from all communities. There are also tensions between policy on patient choice and payment by results and proposals for regional commissioning. Regional collaboration, however, may be useful to standardise some elements of contracting. What needs to happen? The policy and market environment will continue to change, and while there are important opportunities in some of the forthcoming developments, overall the future looks even more challenging for commissioning. We are unlikely to see substantial improvements in care services for older people until these policy contradictions, resource and market problems have been resolved. The progress we have seen in changing services through commissioning may well stall unless, as a priority, government clarifies the vision for services to older people and reviews funding for social care to ensure this vision can be realised. As well as addressing these policy issues, government should continue to support developments to build commissioning skills. It is unreasonable to expect that a full shift to integrated commissioning and a complete transformation of older people’s services could have been achieved at this stage, given all the policy, market and other pressures. Every support is now needed from the centre to build commissioning skills and through collaborative work across London disseminate best practice. Regulation and inspection also have a role to ensure all London boroughs and PCTs reach the highest standards in commissioning that some already are well on the way to meeting.

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Recommendations Clarify the vision for services to older people. The forthcoming national strategy for older people and the vision for adult services should acknowledge and accommodate the urgent and growing needs of older people with dementia and those older people with considerable health and support needs often at the end of their lives. There must be coherence between policies to promote well being and citizenship, to improve services to people with long-term conditions, and to offer choice and control to older people and carers from all communities. Review social care funding. Underlying funding pressures call for a review of social care funding that should properly relate to the new vision of care services for older people. This review should seek to ensure a level of funding that addresses staffing shortfalls and puts services to older people on a par with services to other people, such as young disabled adults. Incentivise the involvement of key players to drive change The Commission for Social Care inspection (CSCI), in its reviews of services and performance of councils, should routinely assess the level of involvement of older people and carers from all communities in commissioning, and should assess the outcomes of their involvement. The CSCI should also assess the involvement of providers from all sectors, including independent and voluntary, to see how far they are directly engaged in the redesign of services and local systems, and how far this involvement leads to better outcomes for older people. Strengthen partnerships with specific aims All local authorities should be audited as good places for older people to live, building on lessons from the Audit Commission pilots. Such audits will strengthen partnerships between local authorities and other public services, such as transport, to progress community and prevention strategies. Local authority departments other than social services have a key role in spearheading work on the health and well being of local older people. Collaborative working across boroughs and PCTs should be supported by the Association of London Government, Greater London Association of Directors of Social Services, and strategic health authorities in London, working together to develop strategic frameworks for best practice in commissioning, best value approaches and models of collaborative commissioning. Ways should be agreed to engage councillors and non-executives of PCTs across London in supporting change, such as setting up a special task force comprising councillors and non-executives to champion developments and support new collaborative frameworks for commissioning.

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Build commissioning skills and infrastructure to support best practice. • While there have already been some important developments to help build

commissioning skills, other means should be considered, such as standards for commissioning and qualifications and courses for commissioning teams and leads.

• More robust leadership development to support commissioning in a whole system

is also important to ensure leadership in driving the vision and putting in place the infrastructure to translate strategic intentions throughout the partner organisations. Strategic health authorities have a role to play in supporting work to develop the necessary infrastructure.

• The CSCI and the Healthcare Commission have a key role in reviewing

commissioning in their inspections, and the infrastructure in place to support the process. This will include assessing: – clarity about roles and accountabilities within and across organisations – good information, data sharing and communications systems – supervision and performance systems to translate strategic intentions

throughout the organisations involved – progress in implementation of single assessments and support to frontline

staff in undertaking assessments and commissioning for individuals that focuses on outcomes for older people.

• Priority should be given to the development of information systems for social care

that effectively link with current national developments on health information systems.

• Further research is needed to study market forces, including monitoring the

development of monopolies and forecasting potential trends in market development, and to evaluate the effectiveness of different prevention approaches. This may be best undertaken through the establishment of an intelligence unit.

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Appendix 1: Criteria for effective commissioning Expected progress Criteria (what we would expect to see) Working in partnership

• Joint working between: – social services – health (primary care and acute trusts) – housing authorities and organisations – other council departments (such as transport and

leisure) – voluntary and community sector – private and independent sector providers – older people from all communities – carers from all communities

• Working together through, for example, planning structures, formal and informal meetings and forums

• Engaging with a diversity of stakeholders in each of the above sectors (for example, small and larger providers, older people from black and minority ethnic communities)

Effective partnership working

• Engaging in open communication where information and data is shared (having an information and communications strategy in place)

• Acknowledging interdependence • Honouring commitments to take action, including

financial investment • Sharing risk taking • Making consensual decisions rather than limited

consultation • Agreeing ways to resolve conflicts, plus a fair

arbitration process • Agreeing on intervention and protocols for helping any

provider business in difficulty • Supporting involvement, such as reimbursing costs,

including for independent sector partners where appropriate.

• User-focused commissioning

• Ensuring user involvement at every stage of the commissioning process

• Setting up effective processes to routinely engage with users from all communities, particularly those who are ‘hard to reach’

• Focusing on quality and user outcomes evident in strategic vision, plans, monitoring and evaluation processes

• Including a requirement within contracts for providers to seek service users’ views.

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Expected progress Criteria (what we would expect to see) Understanding the market and obtaining intelligence: local needs (demand)

• Collecting data about needs as well as qualitative information, at population and case levels, including: – population projections – feedback from users from all communities – views of carers – information from needs assessments – information on housing and accommodation needs – views of frontline staff – prevalence rates and trends information from

providers. • Understanding of needs of populations falling outside

current eligibility criteria • Regular formal and informal communications with all

stakeholders to obtain market information, including the Commission for Social Care Inspection and other regulatory bodies and users and carers.

Understanding the market and obtaining intelligence: mapping current service provision (supply)

• Mapping and understanding current supply and providers of services: – in-house, independent sector, other providers – volume and trends in provision – quality of services.

• Mapping and understanding budgets and resource allocation and unit costs, informed by: – local cost analysis of providing care with the

independent and public sectors working together – knowledge of specialist provision by regional and

national service providers – comparison of performance against national

benchmarks and indicators.

Understanding the market and obtaining intelligence: forecasting supply and demand

• Using capacity planning models and other models • Working with partners to assess influences on future

supply and demand and the likely impact on market and service system. This will include identifying gaps in services and accommodation, oversupply, shortfalls and trends. Also, assessment to include not only numbers of beds required but also type of service needed, housing and accommodation, and mix and balance of local services

• Using research, evidence and good practice to inform plans (including involvement in learning and other networks).

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Expected progress Criteria (what we would expect to see) Managing the market: strategic planning with partners

• Developing a joint commissioning strategy with an agreed vision and priorities promoted by leaders from all partner agencies

• Agreeing the plan for change – decommissioning some current services and developing new services in line with strategic vision, specifying timescales, lead responsibilities, financial allocations, and arrangements

• Drawing up clear plans to minimise disruption for older people where services are to be decommissioned

• Putting in place plans to manage cross-boundary or regional commissioning where appropriate

• Setting up initiatives to stimulate the number of minority ethnic providers.

Managing the market: applying and monitoring resources

• Clarifying management accountability for budgets • Agreeing systems to monitor budgets to ensure use of

funds is developing the market and ensuring best user outcomes (link between quality and prices)

• Using a mix of rewards or incentives to influence market

• behaviour – not only fee levels (investment/block contracts/ longer timescales for contracts)

• Employing a range of contracting methods to fit commissioning objectives and ensure market stability and availability of appropriate quality services.

Managing the market: reviewing and evaluating implementation of strategy and development of new or reconfigured services

• Setting targets in a strategic plan with agreed ways to monitor progress

• Ensuring user involvement in agreeing performance criteria

• Agreeing a method to review cost effectiveness and value of services

• Making sure all stakeholders monitor performance • Monitoring contracts • Using findings from best value reviews • Carrying out regular reviews of the range and quality of

services, along with performance evaluation.

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Expected outcomes What we would expect to see Strategic and innovatory developments: shift in service configuration/ provision

• Measurable/demonstrative progress on plans to reconfigure services

• Shift in expenditure from traditional services to more flexible models and integrated services, including housing options – very sheltered/extra-care housing

• Development of preventive services to reduce demand • Increased numbers of older people supported to live at

home • Increased choice of options for older people • Older people not being accommodated outside of

borough unless specifically requested by the older people themselves.

Strategic and innovatory developments: support to innovation and services promoting independence and self determination

• Service improvements undertaken by staff at all levels who are supported as part of the overall strategy

• Innovations and short-term initiatives that inform strategic plans and are not simply fragmented projects

• Support to care providers to introduce innovations (for example, training, low interest loans, help with business planning).

Strategic and innovatory developments: better functioning whole system and stable market

• Few bottlenecks or crises within the service system • Reimbursement/financial penalties rarely imposed • Contingency plans able to deal with unexpected

events.

Quality services as defined by older people from all communities

• Commissioning strategy making explicit references to services for black and minority ethnic older people

• Contracts include quality standards as defined by older people

• Ethnic monitoring information collated and used to inform

• commissioning • Services that meet the needs of local black and

minority ethnic communities • Quality services for older people with dementia and

those with special needs.

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Expected outcomes What we would expect to see Increased capacity: resources maximised (staff, property and financial resources)

• Joint working and training across disciplines and agencies

• Shared occupancy or new use of buildings • Harmonised/compatible IT • Shared information systems • Shared client records • Pooled budgets and budgets managed and monitored

to ensure strategic objectives are being met • Proactively levering in resources such as private

finance • Joint workforce plans, including strategies for

recruitment, induction, ongoing training, integrated health and social care workers

• Ways of reducing transaction costs and eliminating unnecessary bureaucracy

Demand reduced • Preventive services, rehabilitation and intermediate

care services.

Sources used to draw up the criteria Appleton N, Porteus J (2003). Extra Care Housing for Older People: An introduction for commissioners. London: Department of Health. Audit Commission (2002). Tracking the Changes: Joint review team sixth annual report 2001/2. London: Audit Commission. Audit Commission (1997). Take Your Choice: A commissioning framework for community care. London: Audit Commission. Department of Health (2003a). Implementing the NSF for Older People Falls Standard – Support for commissioning good services. London: Department of Health. Department of Health (2003b). Discharge from Hospital: Pathways, process and practice. Joint Unit and Change Agent Team. London: Department of Health. Department of Health (2003c). Commissioning and the Independent Sector – A good practice checklist. Health and Social Care Change Agent Team. London: Department of Health. Department of Health (2003d). Changing Places. Report of the work of the Health and Social Care Change Agent Team 2002/03. London: Department of Health.

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Department of Health (2003e). Making Partnership Work for Patients, Carers and Service Users – A proposed strategic partnership agreement between the Department of Health, the NHS and the voluntary and community sector. London: Department of Health. Department of Health (2002a). Out in the Open: Breaking down barriers for older people. London: Department of Health. Department of Health (2002b). Improving Older People’s Services – Policy into practice. The second phase of inspections into older people’s services. London: Social Services Inspectorate, Department of Health. Department of Health (2002c). Developing Services for Minority Ethnic Older People: The audit tool. Practice guidance for councils with social services responsibilities in support of ‘From lip service to real service’. London: Department of Health. Department of Health (2002d). A Catalyst for Change: Driving change in the strategic commissioning of non-acute services for older people. London: Department of Health. Department of Health (2001). Building Capacity and Partnerships in Care. An agreement between the statutory and the independent social care, health care and housing sectors. London: Department of Health. Department of Health (2000). For the Benefit of Patients – A concordat with the private and voluntary healthcare provider sector. London: Department of Health. Department of Health (1995). An Introduction to Joint Commissioning. London: Department of Health. Department of Health Joint Unit (2003). Capacity Planning Model for Social Services for Older People. London: Department of Health. Fletcher P, Risborough M (2003). Preparing Older People’s Strategies: Linking housing to health, social care and other local strategies. London: Department of Health. Hardy B, Hudson B, Waddington E (2000). What Makes a Good Partnership? Partnership assessment tool. London: Nuffield Institute of Health. Health and Social Care Joint Unit (2001). A Guide to Contracting for Intermediate Care Services. London: Department of Health. NHS Modernisation Agency (2002). Improvement leaders’ guides, available at: www.modern.nhs.uk/improvementguides (accessed 22 April 2005). Poxton R (2003). Working with Particular Reference to Joint Commissioning. Briefing paper. Health and Social Care Partnership. Institute for Applied Health and Social Policy. London: King’s College London.

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Stevenson J, Spencer L (2002). Developing Intermediate Care: A guide for health and social services professionals. London: King’s Fund.

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Appendix 2: Participants, experts seminar, King’s Fund, Oct 2004

Penny Banks Fellow, King’s Fund Jane Bearman Principal Manager for Older People & Health

Services, Kingston Community Care Services Mark Brangwyn Head of Health and Social Care Team, ALG Alan Clark Director, Strategic Commissioning Project Janet Crampton Change Agents Team, Department of Health Claire Crawley Section Head, Department of Health Zaid Dowlut Manager, Joint Commissioning Team, Hillingdon Social

Services Peter Fletcher Care Services Inquiry Committee Member, and Director,

Peter Fletcher Associates Julien Forder Strategy Unit, Department of Health Julia Gosden Associate Director, Acute and Older People’s

Commissioning, Kingston Primary Care Trust Marian Harrington Assistant Director, Community Care and Health,

Westminster Social and Community Service Peter Hindmarsh Manager, Commissioning Unit, Lewisham Social Services Julie Jones Director of Social and Community Services, Westminster

City Council Penny Marshall Policy Officer, Health and Social Care, Commissioner Older People’s Services, Brighton and Hove City PCT Ann Netten Professor of Social Welfare and Director at Kent PSSRU Susan Pascoe Joint Commissioner (Older People), Hillingdon Primary

Care Trust Fran Pearson Single Assesment Project Officer, Westminster Primary

Care Trust Edward Roberts Assistant Director, Newham Social Services Janice Robinson Senior Adviser, Health and Social Care, King’s Fund Rebecca Rosen Fellow, King’s Fund Lucianne Sawyer President, UK Home Care Association Barbara Scott Associate Director (Older Adults), Lewisham Primary

Care Trust Pam Seymour Group Manager, Policy, Partnerships and Communication, Lewisham Social Care and Health Peter Smallridge Care Services Inquiry Committee Member, and Chair,

Ashford PCT Alex Smith Researcher, King’s Fund Nigel Walker Director of Homecare, Housing 21 Care Options

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