The Delivery Processes
Delivery processes are the mechanisms through which care and support is commissioned and delivered. These processes form a chain from the point at which a person establishes the requirement for a care and support service through to the choice of service, the procurement of the service, delivery and ongoing review, and finally the termination of the service.
Historically these processes were prescriptive and directed by others. A medical model was adopted whereby people were seen as a list of conditions and diagnoses. This model and the practice it engenders perpetuates in many corners of Social Care.
Our challenge is to change this so that delivery processes are wholly person centred and person-led.
Current Issues & Problems
Processes are divided into two categories – those which relate to a person’s individual experience of accessing the care system and those which enable the system to operate. We term these ‘Individual episode processes’ and ‘Market operational processes.’
Individual experience processes
- Ownership. People rarely lead or own their assessment. Indeed, the term hints at a process in which something is being done by someone to someone else.
- Medical model. Assessments tend to focus on the medical model, to the detriment of people’s higher-order social, developmental and psychological aspirations.
- Duplication. People are often subject to repeated assessment by different entities, which can be de-humanising and confusing.
- Conflict of interest. Local Authorities are accountable for undertaking assessments, but they are also responsible for funding care and support.
- Choice. People often have little choice about where they are placed.
- Information. If you are a lay-person looking for a care service, where do you start? There is no national register of care providers.
- Guidance. How can people know what ‘good’ looks like?
- Local authority role. The Care Act 2014 indicates that people should be given options, but often they are not.
3. Care and support planning
- Ownership. Care planning is often a process done to someone, so the subject takes no ownership. Many people will not even know they have a Care and Support Plan.
- Accountability. The Care Act 2014 gives accountability for care planning to Local Authorities, but they rarely know the person well, so tend to be cursory and impersonal.
4. Service delivery
- Delivery models. The economic realities of our sector have shaped model design in a way which is not always beneficial for the people they support.
- Provider-led. Delivery of support is often shaped by the provider, not led by the person.
- Poor quality provision. The 2020 CQC State of Care Report notes that 275 (1%) registered providers are rated as ‘Inadequate’, with a further 3,429 (15%) rated as ‘Requires Improvement.’ This is too many.
- Building quality. It is difficult for many providers to maintain and build the quality of their services when funding is constrained and recruitment is so challenging.
- Right? Review processes often trample on people’s rights and dignity. What right does one person really have to critique the progress or failings of another?
- Ownership. The Care Act 2014 gives accountability for the review process to the Local Authority. Unnecessarily paternalistic, we would say.
- Attendees. The subject of the review seldom gets to choose who attends. It must feel like your life is being paraded in front of a bunch of random strangers.
- Focus. The agenda is seldom set by the subject. Local Authorities take the lead, and often focus on package cost rather than outcomes achieved.
- Negativity. Reviews can spend a lot of time on what has not worked well, rather than celebrating what has. A good opportunity to play the blame game…
- Medical model. In common with the assessment process, reviews tend to focus on basic needs, such as health and nutrition, rather than wider aspects of wellbeing.
Market operational processes
1. Policy setting
- Evidence. The broken state of the Social Care sector is unequivocal evidence of the failure of policy-setting and implementation at national level.
- No place on the agenda. The NHS is always at the top of the agenda, but Social Care is frequently overlooked.
- Local inconsistency. At local level, policies change with the wind. Every new Councillor and Director comes in with their ideas, shapes policy in their image, sets up a programme and then leaves before anything is implemented.
- Short-termist. Local Authorities are woefully underfunded, so their whole attention is focused on how to survive for another year. But policy needs to be long-term.
- Ineffective. Commissioning functions are sometimes just not good at doing what they are supposed to do. Providers can cite countless examples of poor practice.
- Financial constraints. Commissioning processes are hamstrung by the financial constraints placed upon them through top-down, financially-driven structures.
- Lack of creativity. Commissioning functions typically lack creativity. There have been many innovative proposals in this area, but they are seldom implemented.
- Commissioning behaviour. The behaviour of Commissioning functions is sometimes parent-child in its nature, a power imbalance which is sometimes exploited.
- Low bar. There are some poor services out there, led by people who are not fit, operating profit as their primary motive. They should not have been registered.
- Registering the wrong thing. Accommodation is important, but of nothing next to the ethos and values of the person who owns and operates the service.
- Registering supported living, shared lives and live-in care. The registration of supported living services is not fit for purpose, whilst shared lives and live-in care goes largely unregistered.
- Approach. CQC has historically been closed to consultation about the development of new services, loathe to comment prior to development.
- Accountability. It is not clear to Providers who the CQC is accountable to.
- Independence. It is a pre-requisite that the regulator has to be independent, but with provider covering more of the funding there is a growing conflict of interest.
- Poor processes. The poor quality of some of the current CQC processes has to be experienced to be believed. Every provider has a tale of woe.
4. Procurement and contracting
- Focus on cost, not quality. Never mind outcomes, drive down that unit cost.
- Limiting choice. You can have any service you like, as long as it’s the cheapest.
- Procurement behaviour and culture. The unequal Procurement/Provider relationship can drive hard-nosed commercial practices and directive behaviour.
- Poor quality, biased contracts. Imposed contracts do not fairly balance the rights and obligations of each party – a symptom of the imbalance in the relationship.
- Contract wheel reinvention. Every Local Authority wastefully produces its own contracts. There is no standardisation, and quality is patchy.
- Mismatch. Inspections still focus heavily on medical approaches, but progressive Social Care is about supporting people to live enriched lives of real purpose.
- Inconsistency. There are significant variations between the approaches, behaviour and judgements of inspectors.
- Providers are not part of the process. Providers are generally not interviewed as part of the inspection process, a significant omission given their role in shaping the culture and quality of their organisation.
- Inspections are granular, even when low risk. Inspections take place at unit or activity level, but this is inefficient. There are better ways to inspect providers who have proven themselves over many years.
- Approach to giving advice. CQC’s Statement of Purpose states that they seek to encourage services to improve, but inspectors sometimes fail to engage positively or give advice.
Personal experience processes
1. Aspiring (replacing Assessment)
- Aspiring. A new name for a refocused assessment process which not only considers a person’s clinical needs, but higher-order social, developmental and psychological aspirations too.
- Ownership. People should lead the production of a Statement of Aspiration and own its content.
- Support to produce. The person should be supported to produce their Statement of Aspiration by an approved person, who might be a provider who knows them well.
- Structure. The Statement of Aspiration should be undertaken in accordance with a National Aspiration Framework to ensure completeness and consistency.
- Form. The written word isn’t the most accessible form of communication, so let’s be creative and use videos, storyboards and other forms of accessible media.
2. Choosing (replacing Placement)
- Choosing. A new name for a refocused placement process which places the emphasis on individual choice.
- Person-led. The choosing process must have the person at its heart. The person’s involvement should be maximised, with family and advocacy support if necessary.
- Guidance. There is a need for national best-practice guidance so that people are enabled to exercise their choice expediently and wisely.
- Market insight. We would like to see a National Register of Providers, with an easy search facility, to enable people to analyse and understand the market, and help them make an informed choice.
3. Care and support planning
- Ownership. People should participate fully in the production of their Care and Support Plan and own its content.
- Support to produce. The Care Act gives accountability for care planning to Local Authorities, but the provider is often best placed to support a person to produce his/her Care and Support Plan. More flexibility please!
- Structure and content. Whilst Care and Support Plans should not be prescriptive, it would be helpful to define what ‘good’ looks like in a new national Care Planning Framework. This framework would drive Care and Support Plans to become broader, focusing on aspirations and quality of life as well as health.
4. Service delivery
- High quality, ethical providers. If services are delivered by high quality, ethical providers then people will have good options from which to choose and be sure of receiving great care and support (addressed more fully in the ‘Markets’ domain).
- Person-led. People should shape the way their care and support is delivered.
- Effective managers. The best services have the best managers. We would like to see a greater focus on Manager training, qualifications and career opportunities.
- Outstanding staff. Service delivery happens in the moment of interaction between a support worker and the person being supported. Each moment should be as good as it can be (addressed more fully in the ‘Workforce’ domain).
- Delivery processes. Operational practices and procedures should be fit for purpose, with a clear focus on the outcome being targeted.
- Enabling technology. Technology can enhance a range of functions, from supporting people to live more independently to enabling organisations to delivery support more efficiently and effectively (addressed more fully in the ‘Technology’ domain).
5. Reflection (replacing Review)
- Reflection. A new name for a refocused review process which is driven by the person, not by Social Services.
- Should it happen at all? Only if the person receiving the care and support wants it to…
- Approach. Time to move away from a mechanistic, tick-box approach. We want to see greater innovation in the way reviews are held, driven by individual choice.
- Person-led. The reflection must be owned by the person who is the subject of it. It should be a time for the person to take stock of how things are progressing, in the nature of self-assessment.
- Form and content. The person should define the form and content, with help and support as appropriate.
- Positivity. The reflection should be celebration of what has gone well and focus on progress towards achieving aspirations, determining the changes needed to ensure that big life goals are achieved.
Market operational processes
1. Policy setting
- A place on the agenda. We implore the Government to keep Social Care high on the agenda, and to embrace the challenge of sorting it out.
- Clear accountabilities. Make it clear who is accountable for policy setting at national and local level, and hold them to account!
- Engagement. Policy-setting should be a team game, so all stakeholders should be closely involved – especially providers!
- Inspection. National and local policy-setting processes should be subject to external inspection and review. We really do need to make sure this is being done well.
- Standardised processes. There should be standardised best-practice processes for setting policy. These may exist, but they are opaque to us.
- Education. Policy-setters need to be really good at it! We need to ensure that they are appropriately trained and qualified to fulfil their policy accountabilities.
- Creativity. More than anything, we wish to see innovative commissioning which promotes the development of high-quality services which change peoples’ lives.
- Performance. Get the basics right! This means understanding the needs of the population and future demographics, then shaping the market to deliver services which meet those needs.
- Signposting. Providers should be in no doubt about type of services which are required in their locality so that they can tailor their development plans accordingly.
- Connectivity. Commissioning functions need to be well connected with all stakeholders in the Life Care systems.
- Long-term lifecycle planning. Commissioning must take a long-term view. For some people, lifecycle planning might indicate that up-front investment in the development of skills and capabilities might increase their independence and reduce long term support needs.
- Separation from Procurement. Commissioning is a strategic function, whereas Procurement is operational. They don’t need to be conjoined.
- Inspection. We would like to see Commissioning functions being inspected by CQC. This would increase transparency and accountability, and drive quality up.
- A high bar. Provider registration should be as failsafe as possible, so the bar must be set really high. We would wish to see three new requirements – training and qualifications, experience and professional references.
- Re-focused registration. The most important aspect of registration is not accommodation, or systems, or processes, but people. We need registered providers and managers with the utmost personal integrity and exemplary values.
- Continued professional development. Social Care evolves quickly, so Registered Providers should be subject to a requirement for CPD.
- Outcome-based Registration. Registration focuses on inputs, but we need to be registering people and services who can support people to achieve brilliant outcomes.
- Consider the business model. Care organisations are more likely to support people to achieve brilliant outcomes if led by a caring, passionate and talented owner-operator. Where this is not the case, additional safeguards are required.
- Registering new models. New and emerging models of care and support need to be registered, so our registering authority needs to be highly creative in establishing how. We suggest broadening the scope of regulated activities.
- Registering more than providers. Providers are registered, but that is all. We can see merit in considering the registration of other functions within the system, such as care management and commissioning. These services also need to be populated by sound organisations and people with exemplary values.
- Efficient and effective processes. There really is no excuse for the poor quality of many CQC processes. They just need fixing by someone who can design processes.
4. Procurement and contracting
- Refocus on quality. Procurement processes should emphasise quality, for example by giving quality of service and outcomes greater weight in tendering processes.
- Encouraging choice. Procurement processes should broaden people’s choice rather than narrowing to the cheapest.
- Fair procurement practices and positive behaviours. Procurement must ensure that practices and behaviours are fair and balanced, even when the pressure is on.
- Fit-for-purpose national contracts. There should be standard national contracts which fairly reflect the rights and obligations of both the Purchaser and the Provider.
- Standards. We would like to see the introduction of a Procurement Code of Conduct and a set of working standards.
- Inspection. Procurement functions should be inspected. This will ensure that conduct and standards are maintained, and promote good procurement practice.
- Independent arbitration. Where Providers come into conflict with Procurement functions there should be a fair and expedient arbitration process.
- Provider interviews. Gaining an understanding of proprietor’s ethos, values, objectives, involvement, attitude to quality and shaping of culture is an excellent measure of the quality of the service and an indicator of risk.
- Organisational inspections. Good providers run good services. A smart and efficient organisational-level inspection would be an assurance of quality. No need to inspect at unit or activity level.
- Inspecting in progressive models. CQC is still hamstrung by the medical model, but Social Care is progressing, with social and developmental models that focus on quality-of-life outcomes. Inspection models need to evolve.
- Support, help and advice. Within the context of a mature, professional and supportive relationship CQC should be able to give help and advice.
- Helping services with poor ratings and inspection on request. We would wish to see CQC supporting providers with poor ratings by helping them build a route map back to a good rating.
- Utilising technology. CQC needs to up its game so that it can inspect through the progressive IT systems being implemented by many providers.
Commentary on ‘People At The Heart Of Care’: The Adult Social Care Reform White Paper (published 01/12/21)
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