Better Commissioning for Better Lives 2023 to 2028

A commercially-minded approach for Dorset Council

This strategy has evolved in parallel with the council’s newly defined approach to commissioning and commercial activity. Over the course of the first year we will work with these values and refine and develop our commissioning practice to become an exemplar across the council. In particular, we will work with other commissioners, both across the council and within the NHS, to refine our strategy to exemplify the “One Council” commissioning approach.

A new strategic relationship with the provider market: from transactional to transformative

Commissioning is not contracting, although that is an important part of the commissioning cycle. We recognise that our relationship with many providers of social care – even where they represent a very large part of our annual spend – is dominated by the contracts we hold with them. With a system facing such challenges, and needing creativity in how we continue to improve services for our residents, we want to shift this, and foster a culture of strategic partnership with providers, of all sizes and service types. This is represented in our plans. 

Working with our new care company

On 8 November 2021, Cabinet agreed to establish a new LATCo, Care Dorset, wholly owned by Dorset Council, and to transfer services for its residents to the new company. In October 2022, the services previously run for Dorset by Tricuro, totalling some £24m per annum, moved over to Care Dorset.

These decisions present a significant opportunity for us to work with the new company to establish a single programme of reform for a significant portion of our commissioned service spend (around 19% of the council’s adult social care spend). Establishing a clearly-boundaried commercial relationship, balancing our role of commissioner with our role as the shareholder of the company, is one of the most important commissioning tasks in the coming year.

The timing of the decision sits well with our statement – through these strategy documents – of our intentions for the coming years. Indeed, the forming of many threads of future ambition into these single strategy documents was a significant catalyst for the decision with regard to the new company. Residential care, reablement and day opportunities are major themes in the care-specific strategies that form part of this set of strategies, and the intentions that we set out here will set the direction for our partnership with Care Dorset.

To make this new venture a success, it is essential that there is a structured approach to developing and maintaining the relationships between Care Dorset, commissioners, and the council’s adult social care operations. Defining, at a high level, a key set of roles and responsibilities within council teams for leading the conversations with the new company will be important. New governance mechanisms for reporting on contract performance and for reviewing progress against the business plan will need to be established. The coproduction ambition, which is central to anything that happens to develop or change the portfolio of services in the new Care Dorset company, place further emphasis on the need for good joint working between the company and parts of the council.

In the Commissioning Strategy for Better Ageing, where there is discussion of ambitions around more therapy-led reablement, greater clarity about the role of reablement vs. the provider of last resort, and an emphasis on reablement as being community-based as well as supporting hospital discharge.

Again in the same strategy, where there is discussion of the demand for residential care, the need for care at higher acuity and for more flexible options, the need for homes with more modern facilities, and the favourable economics of larger homes.

In the overall Commissioning for a Better Life for Adults strategy, as well as the Better Ageing strategy, where the future landscape of day opportunities is set out, shifting away  from the emphasis on building-based provision towards a more flexible, community-embedded offer of day opportunities.

We recognise that markets are dynamic, particularly as they respond to changing and variable customer demand such as in the social care sector. The recent years have been particularly challenging as a business environment, with underlying workforce instability being made so much worse by the pandemic. We are keen to support the market as much as possible in the development of social care businesses, aligned to the emerging need of our population. For this purpose we are developing a new Market Position Statement (MPS), which will present to the market statements about the types, quantities and quality of services needed to support our population as it grows.

Responding to the dynamic nature of the social care market, we are intending to take a web-based approach to the presentation of the MPS. This will allow us to keep it live, and regularly updated. We will work with local social care organisations in the initial development, and intend to use our market engagement and provider forums to guide its development. Initially, we intend the Market Position Statement to:

• be aligned to the themes of this suite of strategies, principally grouping its messaging around people of working age, older people and carers
• include a strong emphasis on preventive service needs, as well as the need for service to meet established need, and strongly emphasise the need for social care businesses to be able to work with and respond to those with direct payments who are managing their own care
• include a blend of county-wide headlines for some service types, alongside a more locality-focused set of messages that will support us to develop more local service provision and work with partners and the market to commission “for place”

We intend to have the first iteration of this Market Position Statement online for the summer of 2023, as we develop our work on the Market Sustainability Plan in partnership with the provider sector.

A wider reform programme

The reform of the financial basis of adult social care was one significant part of a package of reforms set out by Government in the “People at the Heart of Care” whitepaper. This 10-year vision was based on 3 objectives:

1. People have choice, control, and support to live independent lives.
2. People can access outstanding quality and tailored care and support.
3. People find adult social care fair and accessible.

The ambitions set out to achieve those objectives included innovation and investment in models of care, support for the care workforce, a new assurance and inspection framework for councils’ adult social care, and a series of funding reforms.

Whilst all of our activities within these strategies are supportive of the reform agenda, it should be noted that the Government delayed the introduction of funding reforms for individuals as part of its Autumn 2021 Autumn Statement. However, we will continue to prioritise the work to strengthen the basis for our delivery of a modern, responsive, personalised and digitally-enabled social care system.

Raising the emphasis on market sustainability

Since the introduction of the Care Act 2014, councils have been under a duty to promote the efficient and sustainable operation of their local care markets. The duty is spelled out in the accompanying statutory guidance, requiring local authorities to “have regard to guidance on minimum fee levels necessary…” to ensure providers can operate within the local market to deliver a reasonable level of quality, pay reasonable wages, and make a return that makes their business sustainable for the long term.

In practice, as has been widely acknowledged, councils have leveraged their buying power to pay less than the cost of delivering care, the balance for providers being made up by private payers. This operates differently across sectors of the care market, with cross subsidy most heavily embedded where there is most private resource into the system: older people’s care, both residential and in the home.

The Government’s Market Sustainability and Fair Cost of Care funding regime was intended to address these issues and stabilise the market. In December 2021 it was replaced with grant funding that had a broader set of requirements attached, but the emphasis on market sustainability planning still remained as a policy driver.

Dorset’s approach to establishing the Fair Cost of Care

In Autumn of 2021, prior to Government announcements, Dorset Council commissioned two independent consultancies to undertake a Fair Cost of Care [FCoC] exercise. This set Dorset up well for the introduction of the Market Sustainability & Fair Cost of Care funding from Government, which required such an exercise. The intention is to determine the sustainable rates for care, and how Dorset Council benchmarked against other local authorities, as well as establishing a robust evidence base on provider operational costs. This was designed to leave a toolset for commissioners to manage future years’ uplifts, and to improve the transparency with which the market was engaged. It required providers to supply information to the consultancies, with various activities to improve uptake.

The market sustainability plan

The Market Sustainability Plans resulting from the ‘fair cost’ work, are integrated into our Better Ageing Strategy. This recognises the volumes of purchasing involved in these markets, but nonetheless it should be noted that the plans have wider impact than just older people’s services.

What we mean by commissioning “for place”

Place-based commissioning is a key principle of the drive towards Integrated Care Systems, where commissioners take a joint and more complete view of the needs of a population and pool their commissioning power to target the issues that most need intervention. However, we can also apply it at levels below the overall council or partnership area.

In a county like Dorset, with a blend of rural and urban areas, there can be significant differences in how people live and what matters to them. NHS England acknowledges that:

With the majority of social care services being delivered in people’s own homes, and their health services being delivered through local GPs, pharmacies and health centres, getting the join-up right and the balance of provision to meet local needs is critical. Moreover, the networks of support that people turn to first – their friends, family members, neighbours and community infrastructure – is intensely local, and if we are to harness people’s strengths then this needs to be part of our commissioning thinking.

The role of partnerships in commissioning for place

If we commission for place, it pushes us to start with the priorities, issues strengths and assets of the people in our localities, towns, communities and neighbourhoods. That means we are pulled away from our organisational silos, and partnerships and collaboration become even more important to us pooling our strengths and delivering what people need and want locally, and building on what they already have.

This is why the integrated care system is an important development in the health and social care system locally. At the highest level, leaders of the system need to be enabling the people in their organisations to think creatively and across boundaries about how we collectively meet the needs of people in their local communities. Without that enabling culture, the act of commissioning the right services to meet the needs of local places will be a constant tension with the dominating needs of large organisations.

We believe this is the perspective that local government is so good at bringing into the integrated care system, articulating the needs of local areas, and identifying organisations, local activity and inspiring energy that can add an enormous amount to the work of the statutory sector and our impact on what matters to people.

The most significant issues that affect places differently

Through this suite of strategies you will see a range of areas where locality-based and place-based working are key to our approach.  Some key elements include:

• our early ideas for a new model of day opportunities for those with disability, mental ill-health or dementia would be based around a Hub and Spoke approach, and would develop a locality-based network of community organisations and care businesses providing ‘spokes’, with the specialist ‘hub’ at its heart
• in time this can link to other community activity and widen out to be a more radical place-based offer of community, preventative support and service delivery
• for care and support in the home for older people, we are creating a more defined set of operating ‘zones’ so that the travel management is more feasible – but also facilitating more connections between these services and local community organisations and assets
• other ideas we would like to explore include, for example, care homes operating as community or provider hubs within localities, connecting to local community assets and enriching life in the care home, allow other to tap into care homes’ expertise, and offering spare accommodation capacity to support and strengthen local provider networks

In 2018 Dorset became one of the first Integrated Care Systems in England. Now all areas across England will follow this way of working and become an ICS. The ICS covers the Dorset Council area together with Bournemouth, Christchurch & Poole – over 800,000 people. Integrated care is about removing traditional barriers between services so people can access the support and care that they need when they need it. The commitments of the ICS are:

• to be collectively responsible for managing things like budgets and staffing and delivering the best care for people in Dorset
• to give consistent advice and proactive support so people can stay well, particularly those who are vulnerable or at higher risk of developing serious or long-term health conditions;
• to join up care and treatment when needed
• to improve access to services so everyone is given the right care in the right place at the right time; and
• to work at a local level with communities on how services are delivered

The final point is critical for Dorset Council, to ensure that the granular local needs of our populations, both urban and rural, are met. The Dorset Health and Care Partnership provides a forum for NHS leaders and local authorities to come together, as equal partners, with important stakeholders from across the system and communities. It includes NHS trusts and commissioners, together with council representatives, the Police, Fire and Ambulance services, and community, voluntary and public representation. It supports integrated working and works together with the Health & Wellbeing Boards in the two council areas.

NHS Dorset is the public name of NHS Dorset Integrated Care Board (ICB), which came into being on 1 July 2022. NHS Dorset undertakes the statutory responsibilities of the former Clinical Commissioning Group (CCG) and will also be responsible for planning to meet the healthcare needs of people and communities in Dorset.

The ICS views ‘place-based working’ primarily in terms of two partnerships, one in the Dorset Council area and the other in Bournemouth, Christchurch and Poole. Whilst this forms a useful co-ordinating point for our joint work (and aligns with the Health and Wellbeing Boards), it is at the more granular level of towns and natural neighbourhoods that our impact will be felt, as working more closely with such local communities creates opportunities for health and care organisations to improve the services they provide. The  aim of the place-based partnership is to:

• work together to tackle common challenges
• talk to and work directly with communities, voluntary sector and neighbourhoods

The Better Care Fund

The Better Care Fund (BCF) is the current national policy approach for integrating health and adult social care. It has been running since 2014/15. The BCF spans both the NHS and local government and seeks to join-up health and care services, so that people can manage their own health and wellbeing and live independently in their communities for as long as possible. The policy brings together resources from the NHS and local government and requires local plans to be produced and overseen by each Health & Wellbeing Board across England.

The BCF and iBCF (“improved” BCF) provides Dorset with a total pooled budget of £136,827,560. Working collaboratively Dorset Council and Dorset NHS alongside input from the local NHS providers, including Acute Trusts, the provider market and voluntary community sector have continued to invest BCF into the following schemes:

• maintaining independence
• high impact change – hospital discharge
• integrated health and social care teams
• strong and sustainable care markets
• carers
• moving on from Hospital Living

These schemes ensure that Dorset Council meets the requirements of the BCF as set out in guidance, forming a basis for many of the strands of activity in our strategies.

A digital council in a digital place

The council’s digital vision is well-aligned to the ambitions of these commissioning strategies. Digital developments can be a powerful enabler of social care outcomes, whether simply giving people more choice and control over the care services that they arrange for themselves, or bringing about a step-change in independence through the use of technology-enabled care.

We recognise that adult social care can be a leading contributor to the council’s vision to provide “digital leadership across Dorset” and to set community aspirations. We also recognise that we have a way to go to ensure that the digital mindset, in support of the delivery of the better services that people want and need, is embedded throughout our commissioning and operational services.

In ‘A Better Life’ we set out the ways in which the directorate is working to deliver effective and efficient services, which where possible, are ‘digital by design’:

• meet growing demand for adult social care by targeting digital resources where they are most needed
• technology will compliment, not replace, personal care with the potential to transform peoples' lives, maintain independence for longer and achieve better value for money
• ensure services are working as efficiently and effectively as possible with the tools required to enable this
• look to reduce, or eliminate where possible, unnecessary effort with a range of appropriate and accessible on-line tools for use by colleagues, residents,  carers, and external agencies
• enable residents to engage with the council in a way which suits them, support residents to access the right information at the right time to make informed choices about what to do next
• contact with Adults and Housing will add value to the individual's situation and not be the last resort because they do not know where else to go
• digital will help us to monitor the choices that self funders are taking which in turn will inform our commissioning decisions

Digital is not only about the experience of our residents and those who use our services, it is also about improving the experience of our workforce so they are in turn better supported to deliver for residents. It can be a crucial intervention in stabilising the workforce, and is therefore an important area for our partnership with the provider sector.

We have set out that we are committed to coproduction, partnership, and to a flexible and responsive approach to developing our services. This strategy has been shaped by many conversations, relationships and pieces of data analysis over the past months and years. We believe that, certainly in its early ambitions, it represents a shared view of how services need to develop to better serve the people of Dorset who need care and support. However, particularly over the longer timeframe of the strategy, there is still a lot that we need to work on with all those who use, or work within and alongside, the social care system.

Under each strategy area we have set out our planned actions for the coming year, and a broader set of aspirations that represent how we see social care evolving in the years that follow. To turn those broader aspirations into action, we have also set out some ‘conversations’ that we think are important to ensuring that we bring as many partners and people as possible with us.

In February 2021, we published a set of broad “commissioning intentions” for discussion/comment. Those activities have been incorporated into this commissioning strategy. The strategy also reflects the considerable work that has been done through the integrated care partnership arrangements with the local NHS. At the same time, we hope that by setting out our ambitions for social care more fully in this document, we can give new impetus to those partnership discussions and a clearer basis for our joint working.

Finally, over the summer of 2021, we ran an engagement exercise – the “Summer of Co-production” – which provided us with rich insight into what people want from social care services, particularly day opportunities. Again, this strategy builds on what we heard from people during those discussions.

The council values the contribution residents with lived experience can bring to the development of Adult and Housing Services in Dorset. Our aim is to move away from delivering services ‘for’ residents, to a model where the council collaborates ‘with’ residents and stakeholders. We will share power and commit to working in partnership with communities.

Short term (1 to 2 years) 

Dorset Council will have achieved some ‘Quick Win’ co-production projects that demonstrate our commitment to working in partnership with our stakeholders.

Long term (3 to 5 years) 

Dorset Council will evidence that the people we support have been actively involved in the design and co-production of the majority of our services.

Beyond (5+ years)

Dorset Council is recognised as a leading Local Authority for public engagement and co-production.

Initial priorities

We have identified an initial group of issues that we think need to be further explored in the first year of these strategy with those who draw on support, our partners, providers of social care, informal carers and others. They include:

Direct Payments/Individual Service Funds:

• continuing to explore how we improve the system

Day opportunities:

• involving people in the design of a new model

Dementia:

• opening up the conversation about how we improve dementia support

Autism:

• opening up the conversation about how we/ improve support for Autism

Social care reforms/digital:

• new financial arrangements for social care, self-assessment, access to care records

Birth to settled adulthood:

• continuing the conversation with people who draw on support through transition about improving the service offer

Some priority conversations for the longer term

For technology-enabled care:

• working on pilots with individuals across Dorset, trialling new equipment and devices checking that the person is capable to using the equipment and the infrastructure is there i.e. mobile technology, for example working with the 5G team and Vodafone to develop a pilot of the Internet of Things (IOT) where there is little or no mobile signal.
• working with health colleagues to see where a combined system could develop benefits across the services for both organisations

For older people:

• continuing the conversations about what it means to age well in Dorset, including specifically in local communities

For residential care (for older people):

• we are keen to have discussions with self-funders who are new to residential care, and their families, about the choices that they made and what alternatives could have been made available for them to remain living independently for longer.
• there are also opportunities for community organisations to be part of enhancing the richness of life in our care homes and we must develop the conversation further with the market as we continue to share information about the future of provision. This will include discussions about the property and environmental challenges and opportunities in the sector, and how the physical estate can be improved. It will also include conversations on developing and supporting a stable workforce.

For direct payments/individual service funds:

• we need more insight into the self-funder market, as well as the placement activities and trends of our healthcare partners. This will all be part of building greater insight into the functioning of the market, including within specific geographies within the county.

For community resilience and participation:

• rather than focusing on work on specific issues, we will work to develop a regular forum for exchange of information. This will support continued work with VCSE infrastructure partners as well as the wider sector and local communities

For carers:

• we will work to further develop the Dorset Carers Reference Group, which can shape with us our co-production activities. There are a number of areas identified where we will be developing new service offers, and we need to involve carers from the earliest stages. This will include around improving carer breaks provision.

Our aim is to build more systematic and insightful use of data to support decision making, particularly decision-making in partnership, in co-production settings, and in the bridge between commissioning and operations. However, we also recognise that data should never replace professional judgment, particularly in a social work practice context. Good data analysis can, though, support professional judgment, by providing insight into how systems are functioning, and the decisions people make within them. Data can also alert to possible developing problems, with predictive analytics pointing us to where people may benefit from preventive interventions.

Identifying those who may benefit from preventative support

We need to work smarter with the available data and evidence base to identify and target those individuals who may benefit from particular types of preventative support. There are a number of interactions and access points that could bring a person into contact with the council or a partner organisation and act as a trigger point for the council to consider a preventative service. For example:

• initial contact through the council – via the Central Access Team (CAT) and the Adult Access Team (AAT), whether by the person concerned or someone acting on their behalf
• contact with other professionals such as GPs, community nurses, housing officers, which leads to a referral to the council
• an assessment of needs or a carer’s assessment

Pilot work is underway to redirect referrals form the Adult Access Team into a ‘case holding’ community connector service for people who will benefit from an early support intervention. 

There are key points in a many people’s lives where an intervention may be particularly appropriate. We need to understand these flags and consider how to identify and respond to potential opportunities. Examples will include:

• bereavement
• hospital admission and/or discharge
• people who have been recently admitted to or released from prison
• application for benefits such as Attendance Allowance, or Carer’s Allowance
• contact with/use of local support groups
• contact with/use of private care and support
• changes in housing

By using datasets in the Dorset Intelligence & Insight Service we know we can identify people with particular vulnerabilities, such as being at risk of falling, who could then be targeted with a preventative offer. Evidence suggests that targeting people with two or more co-occurring health issues can make a considerable impact on their need for further care as well as health interventions. Many people with low level care and support needs will approach the voluntary sector for advice in the first instance. We are already working proactively with the sector to develop a public facing ‘Community Front Door’ which aims to support the sector locally to step up and respond.

For adults of working age with support needs

The service reviews referenced in the actions for year 1 will require considerable data analysis to ensure that they are evidence based.

For birth to settled adulthood

The strategic review of the current service offer will require such insight in order to inform the development of the service.

For technology-enabled care

Further work is required with our provider and the Digital team to capture data that measures benefits for people with certain conditions being supported to live independently, and avoiding hospital and long-term care admission. A temporary OT post will support data capture from pilots but we will need to look at how we capture reports from AI systems and better co-ordinate a response.

For older people

Understanding care choices made by people as they age is important (either on their own or with the support of services). This will include a more in-depth modelling of housing demand for older people and the choices that people want about housing for older age.

For residential care (for older people)

Improving information management about care provision to better support commissioning decisions will allow us to bring more people into our decision making, including the care market and health partners.

We need more insight into the self-funder market, as well as the placement activities and trends of our healthcare partners. This will all be part of building greater insight into the functioning of the market, including within specific geographies within the county.

For direct payments/individual service funds

Building a good data picture about DPs/ISFs is important, especially greater qualitative insight.

Analysis of the base rates and the costs involved in purchasing/providing care through this method will also be important, to ensure that it remains a viable option for people.

For day opportunities

We have a reasonably clear picture on the kinds of services people want to access and how they want to spend their days. However, we also know that we have further data analysis to undertake to inform our continued discussions. This will be an early priority. In particular, we want to understand more about private day opportunities, and how moves to direct payments will further expand that market.

For community resilience and participation

A dedicated Performance Analyst role will develop evidence base for cost savings and cost avoidance on locality basis, where social work teams gain support from local community and voluntary sector.

There are a number of interactions and access points that could act as a trigger point for council/partners to consider a preventative service. Data helps us better understand currently missed opportunities, including high risk of hospital admission/health inequalities.

For care at home (for older people)

Locality-based analysis is important to inform all of the interventions in these strategies. This will need to be regularly refreshed.

These analyses will also show changes in flow through short-term services, and inform future decisions about reablement/rapid response.

Analysis of handed back cases will also allow for a model to identify providers at risk of failure, to minimise demand for ‘provider of last resort’ intervention.

For carers

Continued work to build the picture of support needs, including with Health and providers.

As part of that, understanding more clearly what data can tell us about the risk to caring arrangements breaking down will be invaluable.

The council is responsible for establishing and maintaining a multi-agency Safeguarding Adults Board. This is a strategic forum, responsible for coordinating and reviewing the full range of safeguarding activity across the local area. As such, the priorities established by the Board directly influence how the council approaches its responsibilities for commissioning effective care and support. From the 2021-24 Safeguarding Adults Board Strategic Plan The Board has set out a number of priorities that shape the work of the council’s commissioning and operational teams. For the coming year they remain:

• continued development with partners of preventative work in safeguarding
• work within the new Integrated Care System in the context of the safeguarding assurance framework – continuously developing how the board delivers assurance with the evolving governance frameworks within the NHS and social care
• transitional safeguarding – working closely with Safeguarding Children's Partnership to ensure that the complexities for children and young people who have transitioned from children's service intervention are recognised when safeguarding concerns are considered by adult services and that there is good information sharing, when necessary, between the services
• homelessness – ensuring there is good multi-agency working with a contextual safeguarding approach to preventative activities for people who are homeless
• involving people in the work we do – through reviewing how we communicate more widely to citizens and ensuring we listen to the voices of those who have experienced safeguarding interventions
• improving assurance on health and social care practice and provider care quality – by understanding the significant impacts on commissioning services by health and social care; by understanding how we work in partnership with citizens (through Healthwatch) and the regulator (CQC); through having oversight, through single and multi-agency audit which shows how risk is identified and responded to
• improving assurance on delivery of safe practice in private mental health hospitals – through understanding the extent of commissioned out of area placements and the quality assurance

Developing our quality oversight systems and practice

For our part in the SAB’s commitment to improve assurance on social care provider quality, we will be reviewing and continuing to strengthen the approaches we take to managing and overseeing provider quality. This will include:

• concluding a restructure of the commissioning team to strengthen the resources available to manage provider quality
• improving our data flows and management of insight into provider quality, so that we can be more confident in forming judgments as to the risks associated with different providers
• implementing the Provider Assessment & Market Management Solution (PAMMS) to automate reporting by providers on their business performance and service quality
• improving systems for people to report to us concerns about providers – we heard from people in our engagement work how concerned people are to report where they have provider concerns – we want to ensure that they can be reassured to report these to us for action

These and other actions will be developed further as the new team shapes its work programme over the early months of the strategy.

This strategy was last reviewed in 2023. 

The next expected review date is 2027.