We have set out some principles that guide how we approach the task of commissioning social care provision. Commissioning is simply a business process, through which needs are assessed, responses planned, and the required services are contracted or arranged, and later evaluated.
With such significant demand for social care services in Dorset, it’s important that we get this planning process right. We will face our financial challenges by being ambitious and creative in the way we shape future services. The social care system doesn’t work in isolation. We will develop strong partnerships to ensure that we commission the right joined-up support.
We will:
We will commission services that are flexible, adaptive and responsive to local community needs, recognising that needs change over time. We will involve people – foremost, the people who need our support, and their carers – in the development of support, using a coproduction approach.
We will strive to share power, working together, ensuring everyone is involved; We will understand co-production as widely as possible: fundamentally about involving those who benefit from our services, but also wider communities, community organisations, independent providers and statutory partners. We will deliver great outcomes through strengths-based commissioning, building a support system that makes the best use of the strengths and assets of our communities and people.
For this we will develop a detailed understanding of the actual strengths and needs of adults within the local place at both an individual and population level, alongside risks and opportunities, and work with people and organisations to design and invest in different forms of services and support. We set out these principles in our Commissioning Intentions, published and shared for comment in February 2021.
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.
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.
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:
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.
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:
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.
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.
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 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.
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.
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.
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:
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:
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:
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:
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.
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’:
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.
Dorset Council will have achieved some ‘Quick Win’ co-production projects that demonstrate our commitment to working in partnership with our stakeholders.
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.
Dorset Council is recognised as a leading Local Authority for public engagement and co-production.
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:
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.
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:
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:
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.
The service reviews referenced in the actions for year 1 will require considerable data analysis to ensure that they are evidence based.
The strategic review of the current service offer will require such insight in order to inform the development of the service.
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.
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.
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.
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.
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.
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.
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.
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:
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:
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.
