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The right approach

On paper, the benefits of outcome-based commissioning are clear for all to see. For social care, it means a co-ordinated approach, combined budgets and more person-centred services, with a focus on preventing ill health and, in turn, reducing or slowing a need for longer-term care.But in practice, outcome-based commissioning in adult social care has proved tricky to implement. One of biggest challenges for councils, according to John Bolton, independent consultant in social care and visiting Professor at the Institute of Public Care at Oxford Brookes University, is the payment structure.In his discussion paper, Emerging practice in outcome-based commissioning for social care (April 2015), Professor Bolton says: “One of the bigger issues that emerged for councils approaching outcomes based commissioning is how to link the payment for the services delivered to the outcomes achieved in the simplest possible way. One approach that is being developed is to pay for outcomes for populations rather than for individuals. In this model, a council can commission a service with a clear expectation that the service will deliver a set of specified outcomes for a wider population.”In a separate paper commissioned by Mears, Professor Bolton explores how this approach might benefit domiciliary care. In it, he lays out the major issues for councils and providers – and his solutions. Here are the top ten…1. Councils may not want outcome-based commissioning as they want to ensure that every hour that is delivered can be accounted.Councils could still monitor the hours actually spent through electronic monitoring, providing care as part of contract monitoring in order to best understand the real costs of the care model – assisting future negotiations, particularly if providers found they could deliver this at a significantly lower cost.2. Councils may also be concerned that this approach encourages providers to cut corners and to leave older people to their own devices too early in the process.The main answer is for quality checks to be taking place with customers, as part of contract compliance, to ensure that their needs have been met.3. The approach does not fit easily with the Care Act requirement for people to have a personal budget.Wiltshire Council’s ‘Help to Live at Home’ scheme – which looks at each individual and assigns a sum of money to meet their care needs – overcomes this. Or there could be a sum of money linked to a person’s needs. There would need to be an ability to convert each individual package into a personal budget to be compliant with the Care Act.4. Providers may discover the approach is much more cost-effective and make big profits.The whole model is based on the balance of risk between the provider and the council. Providers are encouraged to be innovative and possibly take more risks for bigger rewards. Profit sharing can be introduced between both parties.5. Failure of a provider to supply enough care workers.The model should allow providers to recruit staff to a stable level and to offer firm terms and conditions which are more attractive than the current arrangements. A penalty clause can be put in place for failure to deliver a required service. An understanding of managing the care market has to be a main consideration in selecting providers.6. Moving to this approach would cost money.The known costs are fixed in advance and the model puts much of the risks onto the providers – they have to meet the needs and deliver improved outcomes to gain profit from the approach.The transaction costs for this approach are significantly less than any of the other models that have been used in the past.7. How do we best identify outcomes for customers?There are three main options:

  1. include as a key part of the assessment process within the council;
  2. or allow the provider to work with the customers to develop the best possible outcomes;
  3. or commission for populations or groups of people within a service area.

8. There could be increased costs for providers if outcomes are not delivered in the expected way.Providers will need to be mindful of both risks and opportunities – the larger the volume of customers, the more likely that the overall averages will even out. Smaller numbers of customers may lead to greater risks.9. What providers do varies so much from one council to another.Getting the care model right might deliver significant rewards both in financial and reputational terms. The best reablement schemes result in 66% of people not requiring further care.Many people who have low level packages of care may be able to get their needs met in a different (and lower cost) way. There is enormous scope for piloting new approaches and being innovative.10. There is a significantly variable level of NHS health care available in an area.Failure to manage the health care of older people is the biggest risk in the need to increase packages of care, and this can lead to admissions to residential care or increased costs of domiciliary care outside the control of the provider.Outside of the fully integrated model of care that operates in Torbay, Swindon or Northumberland – and the part integrated models in Greenwich, Islington and Richmond – there is limited opportunity for other places to set a single health and care system commission.The level of health care available in the community varies significantly between areas. This may have a major impact on meeting older people’s needs and is probably the biggest risk to the provider arising from the model.In conclusion, John says: “There will not be a single solution that will work everywhere. Each contract and the way it will run will need to be negotiated at a local level. However, there are tremendous opportunities if both parties are keen and willing to adopt this approach, and negotiations should be entered into with an open mind.“Always remember that the key issue is managing the balance of the risks being agreed between the provider and the commissioners. Councils and providers are urged to work more collaboratively to develop a model that is sustainable, affordable and, most of all, delivers improved outcomes for older people.”• Find the full report, Consideration of paying for outcomes from a set of the population for domiciliary care, on the Thought Leader LinkedIn page


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