Home Care and Commissioning
Maggie arrives with a hello and gets Alastair a cup of tea. He drinks it, and they chat about how he’s feeling, they chat about his family, the weather, what he has been watching on television, the work he used to do when he was younger, and how he only likes to wear red socks. It doesn’t really matter what they talk about, he feels valued, and so does she. She is the only person he sees most days. Maggie has been a paid carer for Alastair for 18 months. She supports him to get ready for bed and makes sure he is comfortable before leaving. She feels satisfied.
Maggie arrives with a hello and reaches for the telephone. She clocks in. She used to get Alastair a cup of tea but now she knows that, as she has to clock out in 15 minutes, she had better get on and get him ready for bed first. As she changes him, she avoids asking about how he is feeling or his family because she worries that she may not have the time to sensitively finish the conversation. They chat about the weather, what he has been watching on television. It matters what they talk about, but in reality, they don’t talk, at least, not about what matters. She is the only person he sees most days. She helps him into bed, clocks out and leaves. She feels unsatisfied, the value is lost.
- Analyse – what already exists, what needs to exist, what could exist? All too often I am hearing of ‘just-in-time’ purchasing of a service, similar in behaviour to the way you might nip out to buy a pint of milk when you realise you have none left for your cuppa. Now I really like my coffee, but in no way can I compare that to how I value a human being. To do so is wholly undermining and lacks dignity and respect. Good commissioning needs to be done with the individual, with the purpose of achieving outcomes, and accounting for both the local and national context, considering e.g. market availability (what services are out there and are they the right ones, what can the community offer) and workforce (are there enough staff, and can they do/are they supported to do what they are needed to do). The interdependencies of these cannot be appreciated with ‘just-in-time’ purchases. Decisions need to be made around how we make sure the right services are available and paid for. Long-term commissioning will give services and those who use them greater security which will reflect in their success and sustainability. Long-term contracts (so long as they have flexibility for review), reduce the number of tenders which is more efficient for both provider and commissioner.
- Plan – so much of everything is in the planning. Take all that you discovered in the Analysis stage, and develop a way to implement it.
- Do – time to put the planning into action. If parts 1 and 2 are right, this should be the easy part.
- Review – what works, and what needs to change to make it work? Are there examples of innovation that could be shared and learned from? I often hear that this part of the cycle is delayed or even overlooked, because the system is so busy having to respond to the ‘just-in-time’ position described earlier. But this part is important - this is where we find out if there was enough flexibility and choice in the commissioning plan, and if it is actually making the right impact. Is the person receiving care being supported to achieve outcomes – ask them, their carers and the staff who support them, review their care plan. Is the system working - look for barriers, ask how does the plan fit in to the national and local context? What impact is it having? Every integrated authority has a commissioning plan, it is time to analyse their impact as is appropriate – just the same as should be done with local and spot commissioning. I agree that some of the questions raised may be difficult to find answers to, but they are necessary and must be addressed.
To proceed, go right back to 1. Analyse
You see, commissioning is a process, it links everything together, from individual to community, from local to national, operational to strategic, and the innovative to the static. Fundamental to the process is involvement – providers and people who use services need to be present and their contributions accounted for throughout the cycle. Call in the experts, they live it, they know where the gaps are, what is the most important, and what can be done realistically. The best commissioning I did had a Board consisting of 50% professionals and 50% service users. It is time to remember the importance of that process and the significance of each part of the cycle as it is key to supporting a human rights based approach to care, and is particularly crucial amidst the current context of 'more for less'. It is time to stop responding with procurement, and start properly commissioning. For Alistair and Maggie and all of our futures.
It is time to care about care.