National Care Service consultation: discussion events summaries

14 September 2021

• Theme of discussion: National Care Service - commissioning
• Time: 10:00-12:00
• Discussions leader(s): Anna Kynaston

Introduction

This is a summary of the key points raised by attendees at this session.  None of the points have been attributed to individuals as the purpose was to encourage broad and open discussion.  The summaries for all the national events will be provided to the independent contractor undertaking the consultation analysis.

Points raised at event

• How can Scotland aim for high-value, outcome-based commissioning.
• We can’t separate commissioning from other streams – including Fair Work.  Need to commit to an absolute cessation of hourly-based non-committal.  Need parity of esteem.  Independent contractors exists in NHS – dentists and GPS – are there lessons to be learned there regarding the message.  We need an absolute fundamental change – lets be bold and creative.
• Procurement and State Aid rules remain.  Please don’t think that there’s a free hand here.
• Ethical and creative is already there – Light Touch regime – most don’t use it.  Commissioning and procurement people need to be well trained.
• Identifying individual needs is essential but we know it isn’t working and is far-removed from persons’ needs.  Issue is eligibility criteria – Feely said they should be removed but you’re only reforming them.  Removing them would allow a four point model that starts with the individual.  Iterative and continuous.  Similar to the NHS.
• Shaping the specification should involve the providers.
• Self-directed support.  It would be a good idea to consider how much everything costs, people have to collaborate – the communication system has broken-down.  Nobody likes each-other and nobody talks too each-other.  Standardisation is only helpful if we all talk to each other.
• CCPS.  Providers of Social Care Services.  Exploring other methods – direct award, self-directed support, alliancing etc.  But the key thing is collaboration between recipients, providers and commissioners.   Three year tender cycle might be too short.
• Scotland Excel – Issues with Scot Excel frameworks and frameworks in general – they are generic and so force bidding against unknowns.  Fixed costs over years also means pricing-in risk.  When you focus too much on price you lose sight of the individual.  Standardisation must be balanced and considered as it can mean losing sight of the individual. Our experience of SXL framework for children’s residential services is that price is always the determining factor, although the split between quality/cost is 70/30, there is no correlation between the 2, as LA’s are given the ‘overall’ score + costs. In discussions with LA commissioning & procurement officers cost is the dominant topic & quality often feels like an after thought
• Made a good point about us not understanding one-another.  We know that good complex care is difficult in Scotland – people often have to go down south.  People with the most complex needs are being cared for by some of the lowest-paid people. 
• Panels that procure in some LAs don’t include people with lived experience. Services must be person-centred. 
• Contracts should not be handed back if and when they’re deemed not to be cost-effective. 
• Glad to see this getting tackled at a national level.  While it’s going to be really complex, glad to see it getting tackled seriously.  Workforce conditions must be addressed.  Respect for the workforce is an issue.  Need to recognise that other departments and organisations have a role to play.  Competition only works where you can have real choice.  Unless we do the ground work to produce the capacity, completion will never work. 
• I think the fundamental issues are about why a National Care Service should be outsourcing services when a National Care Service doesn't and why we should not be making all care not for profit.  If we did that we could stop procurement and re-focus commissioning onto how to design effective services with the public and voluntary sector and local communities.
• Closure of day care and respite services a step backwards in terms of preventative and proactive approaches. Short term thinking at partnerships. Current system is reactionary rather than precautionary and care implemented as a last resort when at critical need!
• Person-centred, fair work and moving-away from price-based all good.  Overhaul of the national care home contract is required.  When might we see something here?  This cannot wait three years. 
• Recruitment and retention crisis is real.  In rural areas very local  recruitment doesn’t work.  Some things shouldn’t be national but rather community-based.  Not for profit – we need to be careful here – as an employee-owned company our profit is for a purpose – improving the conditions for our workers. Profit appears in the GP model – it’s not as simple as profit = bad.  Commissioning for case-load work well in community nursing.  Weighted capitation works well at a local level – let’s do that.
• Difficult to commission for a group service but some things have to be done that way - advice lines etc only work if they’re funded as a resource for the whole community.  Current model supports crisis but not low-level needs that are not crisis and that are not necessarily very visible.  Outcomes-focussed commissioning sounds good but it’s difficult to put a pound sign on that.  Aberdeenshire council – some good work there.
• Most of the conversation seems to be around ‘statutory’ provision. Lots of people are supported through social care, particularly in third sector, who don’t meet the threshold for a care package and in order to prevent crisis. How do we ensure these voices are not lost?
• Remote and island means national vs local is very difficult – must have equal services regardless of location.  Local must be part of it.  Digital and physical connectivity must be considered.  Pulling on community support is part of it – local flexibility and local innovation.  Equality of access to services.
• Commissioning decisions can result in a worsening of behaviours.  Training commissioners will be essential.  Some people are placed in the wrong kind of care – need to consider capable environments and right places for individuals.  Short-term placements that are wrong can lead to trauma for individuals and families. 
• Good discussion had, return to budget then politician’s for more funding. Panels that procure don’t have anyone on them with lived experience, collaborative working. Wheelchair services, we can strip parts of wheelchairs and reuse them. If people with lived experience are on these panels they can contribute to using gloves NHS v buying Amazon.
• Consistent approach in relation to standardisation and what we can do locally is across Scotland. Work in partnership with provider and care at home provider, consistency, rates are in keeping with Fair Work practices. Utilise Scot Excel contract if it’s a complex need and experts in the field. Services are person centred and recognise the person and where they come from Highlands. How they commission that and how they commission it locally.
• How heartening this area been spoken about, greatest area of frustration for her. Hugh differences in East of Scotland, staff conditions and competition could produce something simply not capable off. Fully aware of complex and difficulty of journey. Wider issues of commissioning, some really important points made and person centre. Wider environment in East of Scotland and economic problems, workforce and availability, respect for workforce and relationship between social care workforce and other health professions. How do we get other health professionals to support social care workforce. Prevention can’t happen in social care arena and out of social care services, not funded by health and social care. Ended up without providers who can deliver, ground work to do capacity before commissioning.
• Key thing is getting balance right for local and national commissioning. National commission freeing up people, knowing what to do national and how much and leave locally. Separate discussion from social care commissioning from other parts of social care. Relation to market oversight and analysis and difficult to unpick from market oversight rules but not possible to split out. Set out key roles and responsibilities and sharing information. It would be potential wasted opportunities and explore the opportunities and build on the work from Scot Excel. Worth confirming they work in different areas and some contracts have 100% uptake and other contracts don’t have.
• Training the staff in the first place and can be a major thing. SDS, not all social workers are fully aware of this and don’t under the legislation. People actually know about it and have an agency coming into people’s homes. If we see difficulty of social workers not understanding SDS, will we have a difficulty in understating NCS directives.
• Hear very little on national care home contract and is fully price based. Is too low. While it says NC home contract should be overhauled but no alternatives. When will we see something more fully and can comment on this. Cannot wait for years and see sooner rather than later.
• My concern is that this appears to move to "organising" (commissioning) before a full benchmark recording of current situations (which vary greatly across Scotland , but even within local authorities)
• Totally agree there is much more potential than is being realised to be flexible and ethical (and lawful) in our approach to procurement and commissioning than is being currently realised
• No credible plan to reform eligibility criteria – we need to remove it and not reform it. This will allow for social workers to co-produce. Need to rethink decision to remove eligibility criteria
• In terms of light touch regime – this is under used and any new framework should replicate the frame works already used. There are financial enveloped for services already used. Needs to be greater emphasis on quality. Need to move away from price based tendering. They want to see greater collaboration between LAs and SG
• Collaborating is key – social services don’t talk to one another. Communicating is key
• Collaborative commission model – move away from procurement – procurement practices happening every three years – is this really what is best for the customer?
• Strategic commissioning:  identification of individual need, not driven by eligibility, consultation reforms not removes – not credible –funding not enough.
• Longer term contracts – minimum 5 years.
• National Care Standard needed.  All LAs are doing their own thing.
• Too much profit being made by private providers – need to tackle this leak of funds.