From strategic intent to procurement of adult social care and support in Scotland. Report 2, Analysis of current experience and ideas for improvement
Creators: name: Hendry, Anne
name: Gibb, Stephen
Publisher: name: Zenodo
Year: 2024
Subjects: social care
procurement
commissioning
integrated care
change

description: This report is the second output from research on commissioning and procurement of adult social care (ASC) support and services in Scotland, conducted on behalf of the Coalition of Care and Support Providers in Scotland (CCPS) between March and June 2024. The research was undertaken in advance of the Scottish Government publishing its draft amendments to Stage 2 of the National Care Service (NCS) Bill.  The reports build on previous publications by CCPS, including a series of interviews with representatives of third sector providers.[1] 

Report 1 provides a brief summary of the context for strategic planning, commissioning and procurement of ASC in Scotland and the results of a scoping literature review of published evidence and guidance on ethical commissioning.

Report 2 (this report) presents the results of qualitative interviews with a sample of national and local stakeholders involved in commissioning and procurement of ASC support and services in Scotland. It describes how current commissioning and procurement practice relates to the strategic planning intent of Integration Authorities (IAs) and considers the enablers and barriers for ethical commissioning. The results are clustered around six themes and related sub-themes, each illustrated by stakeholder quotes, examples of what is happening now, and suggestions by the interviewees on actionable ideas to improve the experience and outcomes for commissioners, providers, people and communities.  

Stakeholders spoke about the multiple disconnections between adult social care policy, funding, regulation, planning, commissioning, procurement and service delivery levels. Participants voiced their frustration with the current complex commissioning and procurement system and described how they are striving to work around the many barriers and constraints. This complex, cluttered landscape undoubtedly needs simplified but there seems little appetite among commissioners for more top-down directions, whether from national government or from a future National Care Service board. 

Directions are the mechanism through which an IA tells the NHS Board and local authority about the functions and the associated integrated budget required to improve the quality and sustainability of care and support as outlined in its strategic plan. Most integration joint boards (IJBs) will issue directions to delivery partners at the point of agreeing their budgets for the following financial year. However, as decisions about service change, redesign, investment and disinvestment are generally iterative, issuing of directions can take place throughout the year.  

Statutory guidance was issued in 2020 to support improved practice in issuing and implementing directions.[2] However, implementation experience suggests directions are not sufficiently detailed, nuanced or dynamic to address the complexities of commissioning for different care groups and communities. Rather than a call for more detailed top-down directions, commissioning teams called for greater empowerment to commission collaboratively with local people who have lived experience and to build relationships with providers. Indeed, the sample of commissioners and providers interviewed shared common frustrations and are keen to work together to seek local solutions to improve outcomes for people and communities.

The procurement leads interviewed acknowledged the distinctive nature of procurement of adult social care. Commissioners reported awareness of flexibility within the current legislation to procure social care differently from other services, but acknowledged some colleagues lack confidence in the art of the possible. This knowledge gap should be tackled urgently, as commissioning and procurement decisions being taken now can support transition towards a National Care Service. Current Commissioning Plans should be reviewed to align with ethical commissioning and procurement principles and use of the Light Touch Regime.[3]

National bodies are slowly engaging with local commissioning realities but are not keeping pace with the need for local transformation or the nuances of place, particularly in remote and rural settings where interdependencies require highly integrated workforce models and commissioning practices. The limitations of national procurement frameworks were clearly articulated in this context. There remains a fundamental issue with the language of the NCS that does not explicitly recognise the duality of healthcare and social care aspects of integrated care for wellbeing and population health.

There is evidence of local innovation, but innovative commissioning and procurement practice is not being shared or generalised well at present. Sharing experiential learning and converting personal wisdom into guidance for others is a critical enabler that should be supported now and aligned with a further drive on implementing Self Directed Support (SDS) to enhance experience and personal outcomes. However, lack of social care data on personal outcomes limits the potential to use routine data to drive improvement. Coordinated action must be supported by social care data that includes personal and reablement outcomes and is informed by the voices of people with lived experience.

We hope this report will help policy makers, national and local organisations and providers understand what can be done now to enable more ethical commissioning through a stronger focus on collaborative leadership, culture and relational practice. However, the elephant in the room remains the scale of the financial challenge to achieve equity of pay for over 212,000 workers in the social care sector, as set out in the Accounts Commission’s recent publication on IJB finance and performance.[4] This must be a clear focus for the NCS if it is to be an exemplar of Fair Work.

Ideas for improvement

These ideas were proposed by interviewees and are collated by six themes. 

Resolve Ambiguity

Ø  The Scottish Government should provide greater clarity on the scope and principles of ethical commissioning in the context of the NCS legislation. 

Ø  The Scottish Government and Public Health Scotland should work with HSCPs and providers to address the gap in adult social care data, including for reablement and transitional care activity, and enhance analytical capacity to assess needs and outcomes for individuals and for populations. 

Ø  Shared values and principles are welcome, but we need to move beyond these to an agreed set of outcomes for ASC and how they contribute to a refreshed set of national health and wellbeing outcomes.

Ø  The Care Inspectorate should have a more innovative and consistent approach to regulation and inspection of emerging and hybrid models of care. 

Reduce Complexity

Ø  Simplify the commissioning and procurement landscape and current bureaucracy.  

Ø  Flow adult social care funding directly to IJBs with some ring-fenced funding to the NCS national board for specific regional and specialist services – e.g. support for people in prison.  

Ø  Stop slicing funding for care and support services for the same individual. Align budgets across funding streams to enable wrap-around funding and support for individuals on an outcomes-focused and place-based basis. 

Ø  Enable IJBs to directly employ adult social care planning, commissioning and procurement staff so these functions are better aligned and there is less disconnect with local providers. 

Ø  Reduce the reliance on competitive tendering and make more use of direct awards and grant funding options where appropriate.  

Refresh Practice

Ø  Embed SDS and Independent Living values and practice within commissioning and procurement education and continue to promote uptake of SDS in practice by all involved in planning, commissioning, procuring and providing adult social care. 

Ø  Create and support a national network for commissioning and procurement professionals from statutory, independent and third sectors to learn and grow. 

Ø  Ensure this network involves people who use adult social care, and their unpaid carers, to ground learning and development in the reality of lived experience. 

Ø  Introduce an accredited learning qualification and career pathway for commissioners. 

Rebalance Power and Relationships 

Ø  IJBs should build relationships and trust at all levels and with all involved in delivery of adult social care, including people with lived experience. 

Ø  Reform the commissioning role as relationship manager and system steward and value time spent in building relationships and trust and in facilitating the market.  

Ø  Structure and systematise shared decision making through open and honest conversations on investment choices. 

Ø  Value providers as equal partners and cede power – get out of the way of people who know what they are doing. 

Ø  Change the culture through branding of partnerships within and across collaborations at all levels of the workforce.

Respect Place 

Ø  Develop guidance on balancing financial pressures with a focus on place, outcomes, community-led support and best use of all local assets and resources.  

Ø  To create sustainable services, NSS should help local authorities with procurement of equipment and housing adaptations in remote, rural and island settings. 

Ø  The NCS legislation should be open to the potential for Single Authority type governance models for island authorities, across community planning partners. 

Realise Value 

Ø  The Scottish Government’s Prevention, Care & Wellbeing Board should provide guidance on the vital contribution of adult social care to prevention and making best use of collective assets and resources. 

Ø  IJBs should be supported to rethink how they measure the value of investing in adult social care, including the wider social value. 

Ø  IJBs should view their accountability for investment decisions and realising social value as fundamental to their role as system stewards. 

Ø  Commissioning and contract managers should simplify reporting and monitoring and apply the same monitoring standards to in-house and commissioned services. 

Ø  The funding level of contracts awarded by IJBs should be sufficient to ensure Fair work and to sustain the local provider.  

Ø  Pay systems should value and reward roles equitably with parity of esteem, pay and terms and conditions for social care workers, regardless of employer.