Argyll and Bute joint commissioning in care at home

Context

There are currently 15 providers of care at home delivering support across Argyll and Bute. Currently, 79% of all care at home is provided by the independent sector. Some are smaller local businesses but there are also national providers. As the demographic profile of Argyll and Bute changes, with more older people living in the area and a decrease in working population, the area faces challenges in supporting older people to stay in the community for as long as possible.

Both the planning and delivery of care at home support was seen as inefficient because of how rural the area is. Examples referred to included:

• Support being delivered in isolated rural areas for two to three people, using a variety of providers rather than thinking geographically
• Issues with overall recruitment and retention of staff, including staff moving from one provider to another, despite no meaningful differences in terms and conditions
• A lack of natural partnership between providers, meaning they rarely shared resources such as training or staff.

There was also growing concern about:

• Future ability to deliver consistent services
• Building capacity to support people to stay in the community for as long as possible
• The independent sector’s ability to grow and sustain a business
• Quality and consistency of care for older people in Argyll and Bute

The proposed long term outcomes from this work were:

• Better service provision in remote areas
• More efficient uses of resources (to be reinvested in care)
• Consistent quality
• Joint working
• Opening engagement around the Joint Commissioning Strategy

What did we do?

Rhiann McLean (Iriss) and Susan Spicer/Anne Austin from Scottish Care facilitated two initial meetings and one big event across three localities to build relationships and to explore the issues providers were facing.

Meeting 1: The issues

In our first meeting, we focused solely on the problems that the partnership had in planning and delivering care at home services. We looked at a whole system approach to understand issues in capacity and hospital discharge, but also at individual problems such as seasonal staff loss. At this stage, we did not allow for any ‘solutions thinking’ because we needed to understand the nature of the problem. Different people had different perspectives on the topic and suddenly, core issues such as recruitment came to be understood as multifaceted problems. Where some members of the group assumed that recruitment and retention of staff was an issue because of poor pay and conditions, other members began to discuss their own barriers which included: a lack of career progression, negative public perception of caring, lack of applicants who drive and seasonal competition from the hospitality industry.

At the first session, we introduced the ‘elephant in the room’, a poster we used to acknowledge that there were historical power relations underpinning the partnership. When people wanted to acknowledge these issues, we took the time to post them on the elephant, to give them attention but also to try to remove them from any future work. Issues on the elephant included ‘a race to the bottom on price’, ‘statutory services as money holders and decision makers’. These sessions also helped the partners understand problems as ‘our problems’ and begin to communicate based on shared frustrations.

Meeting 2: The future

Our second meeting was spent identifying future trends and looking at them in terms of risk and opportunity. The view was that rather than designing solutions that make sense here and now, the group should try to future-proof their ideas. Themes that emerged included: Integration, Self Directed Support, and SSSC staff registration. For some providers, this was the first chance they had had to openly explore these issues with their peers. In this meeting we also looked at two different authorities’ approaches to commissioning: Highland and Wiltshire council. Highland’s approach showcased the use of additional funding to retain staff, and Wiltshire’s case study was about looking at a more radical approach to commissioning for outcomes. The groups discussed these elements in the context of Argyll and Bute. At the end of the session, we asked providers to use ‘idea maps’ to think out any ideas they wanted to present at the Unconference.

Big event: The Unconference

We needed to bring together the local meetings with an Argyll and Bute wide event. But we were aware that the work needed to focus on partnership and joint ownership of ideas. We chose to host an unconference. An unconference is an event that is driven by participants, who think about their content in advance.

There was a balanced attendance, with representation from senior management across health and social care. We had lots of ideas to choose from. The groups debated their ideas, formed initial action plans and voted on which ideas they were most invested in. From here, they began to take joint ownership of making change happen in commissioning.

What worked?

• Strategic management was clear on their commitment to change, and as they had commissioned this work, it was seen as a priority for them
• The problems that the local authority had identified on a strategic level were the same issues that the independent sector were struggling with on an operational level. They were ‘everyone’s problems’ and this led to some really helpful common ground
• Although facilitators had some background, we deliberately went into the local sessions with open minds and curiosity, with no agenda of our own
• A focus on fully understanding the problems and where they came from before ‘solutions’ could be discussed
• The ‘elephant in the room’ worked as a way to acknowledge some of the underlying issues such as money and power which were underpinning the sessions

What were the challenges?

We identified three key areas in the course of this project: representation, action, and relationship building.

Representation

Generally, the biggest issue we had was with representation from all sides of the partnership. In some meetings, there was a marked absence of representation from health and social work. However, providers also felt disappointed in their peers who did not make an appearance. We had a particular session in Dunoon where only one provider was in attendance. When staff from health and social care did arrive, they had often ‘been selected’ or were representing their colleagues - which sometimes meant they weren’t engaged with commissioning on a strategic level. This may have been because the project had a very short lead-in period, and we didn’t have a lot of time to get the buy-in of health and social work.

We also struggled with having representation present from the Care Inspectorate. We hoped that we could work closely with them on the final event to have some buy-in with the ideas, but senior management felt it appropriate for the local inspector to attend, and he withdrew at the last moment. Also, some of the support providers who aren’t for ‘older people’ were not involved in the general engagement strategy. If we were to run the sessions again, we would include all groups who delivered services in the area to get a wider understanding of the issues. This process was made easier as the Scottish Care Development Officers had an existing relationship with the local authority and could make a personal push for managers to be present at the sessions.

As this project was about partnership and joint working, the absence of certain partners was very strongly noted. It was felt (on all sides) to signal disengagement.

Action

There was a perception of change being impossible/improbable. This was a historical perception that had come from the locality meetings being known as a ‘talking shop’. People involved wanted assurances that there would be action. As facilitators, we weren’t always able to offer this in a concrete way.

There was also a resistance to joint working amongst providers because of a protectiveness of business autonomy. In particular, the larger national companies felt they were less in a position ‘to just try it and see’ because they had to adhere to larger policies across the organisation.

We struggled at the big event to find a course forward because of the quantity and diversity of ideas. We wanted to tie up ideas with a single strategy (ie. present your idea at locality level for a small test of change); however, some ideas (such as reablement) already had working groups and workstreams that needed to be utilised. The end of the day was messy because we weren’t able to give people a straightforward set of actions. Instead, facilitators appointed leaders for each group who were made responsible for developing a 90 day action plan and looking at how this would link with existing work.

Building relationships

Historically, providers had been pitted against each other in competition for contracts. Some providers found it hard to imagine closer joint working (such as sharing staff) without seeing it as a threat to their own business identity. We learned in the sessions that relationships are about more than contracts and commissioning, and more time needs to be spent working together on more than the mechanisms of commissioning (the tick boxes and contracts) and focusing on relationships that focus around sharing responsibility and action together.

We noticed at the final Unconference, that while most ‘idea groups’ had a mix of independent sector providers, statutory partners and NHS input, some groups were cliques of colleagues. In the local meetings, we had created a situation where different partners had no other option than to work with a diverse group. This showed us that work needed to be done in order to make partnership working the default position, not something that has to be actively facilitated.

What was the impact?

• Local sessions were well evaluated, but the people involved did all note the issues in representation. The final event was seen as a good starting point:

Very worthwhile – good opportunity to come together and share ideas

Great discussions generated – positive and exhilarating

Very informative of ideas to take forward. Good joint working and identify some issues across A + B

• Partners reported improved communications and relationships between providers, local authority and NHS
• The events fostered a more positive attitude towards new approaches to commissioning; one provider described the events as ‘positive and exhilarating’
• Allowing people to lift their heads from day-to-day operations to look to the future
• Five formal ideas which have joint leadership from the independent sector and a 90 day action plan
• Building the capacity for stronger independent sector leadership

Three Lessons Learned

• When partnerships are unstable, representation is really key to showing a commitment to working together. When key partners don’t make themselves available, it can be seen as a statement about working together not being a key priority.
• It is important to take the time to understand the problems in full from different perspectives; this is vital to beginning the process of change and innovation.
• This programme had an impact because it had a focus on action, tapping into existing workstreams and future direction to make sure it isn’t just a ‘talking shop’.

The Future

This was the first step in a very long journey, which we hope will be driven forward by all key partners and supported by the Scottish Care Development Officers. All ideas taken forward have a team with representatives from the full partnership taking responsibility for making them a reality. We hope that this will continue to fortify relationships and make partnership working the status quo.

Postscript

It had been agreed initially it was important that idea group leaders were from the independent sector to provide a positive message about shared ownership of the issues and that managers in the sector were equally keen to find solutions for the future regarding commissioning.

However, at the follow-up in December 2014 when delegates met again it was clear that initial energy and enthusiasm has been dampened by slow progress for many groups. The challenges exposed in the intervening three months included; difficulties in freeing up time to meet and progress discussions, continuing perceived differences in culture between sectors, eg. public sector versus independent business, but also genuine time constraints of managing their business on a day-to-day basis to deliver service.

In recognition that more support is required from the public sector for this new way of working, it has been agreed with senior management in the council to look at the groups again in a more cohesive way. Each month, the leaders will meet with the strategic managers of social work, the commissioning team and the NHS to try and bring the strands together more strategically and work through what is a complex task.There may also be opportunities to fund the implementation of these projects through the integration fund and early discussions will take place to look at what resources might be needed to provide extra support to the sector to enable them to work as genuine partners in co-designing the solutions.

References

Argyll and Bute Council (2014) Argyll and Bute Social Care Survey

Argyll and Bute Council (2014) Population: Demographic Profiles of the Council's Administrative Areas. Available: www.argyll-bute.gov.uk/info/population-demographic-profiles-councils-administrative-areas