Specialist and generalist needs require different commissioning/procurement approaches and methodology
Response to CMA re interim report
Specialist and generalist needs require different commissioning/procurement approaches and methodology.
High level complex needs are not the same as generalist. They significantly differ by intensity and frequency.
Often children in care are discussed as having uniform needs requiring generic services and settings provided according to a set schedule or specification for which a unit cost is applied. This leads from the idea of ‘sufficiency’.
Sufficiency is generalist. Sufficiency is not specialist. Approaching specialist need with a sufficiency perspective is insufficient.
It is not the case that provision for specialist needs can be scaled up from generalist. There are numerous examples of this being attempted that have resulted in failure, placing children and staff in danger by not approaching the matter clinically.
Specialist and generalist start from a different place. Specialisms are not more of the same generalism, as we see with the increased use of 2:1, 3:1, 4:1 and the opting out of regulated provision. The increase in the use of highly staffed unregulated provision shows the failure of generalist settings to meet specialist need.
Specialism is not an enhanced generalism. Specialist needs are a different category of need.
A set schedule or specification for which a unit cost is applied squeezes specialist provision into an inappropriate system.
Residential child care options can be found in 2 and 3 in the following evidenced overview. These are different cohorts. A different methodology of commissioning/procurement is needed for both.
- Children with relatively simple or straightforward needs who require either short-term or relatively ‘ordinary’ substitute care
There is a local placement potential for this group
- Children or families with deep rooted, complex, or chronic needs with a long history of difficulty and disruption, including abuse or neglect requiring more than simply a substitute family
There may be a localised placement (not necessarily local) potential for this group
- Children with extensive, complex, and enduring needs compounded by very difficult behaviour who require more specialised and intensive resources such as a therapeutic community, an adolescent mental health unit, a small ‘intensive care’ residential setting or a secure unit.
There is only a regional or national potential for this group
High level complex needs are not commonplace and so will be small in number. There will be diversity within that number, either by single need or combination. Such specialism is overwhelmingly provided by small providers. It is not possible due a factors, such as models of care, for these to be brought together into one organisation, even as a consortium or federation. It is necessary to approach each specific cohort uniquely. This provision is likely to needs-led and require each placement to be costed uniquely. Often these small specialists have all their finances invested and none to spare for growth. The surplus of a placement above costs may be necessary to sustain the provision whilst waiting to be able to match a child with specialist needs to this specialist provision. To address profit of this specialist provision at a point in time may miss the point and result in difficulties.
The needs are often specific and the numbers so small as to be a unique cohort. It is unlikely that any one local authority can meet all of its high level needs within its own boundaries. Either the procurement is for a small aggregated market across a region or nationally, or in some cases, individual and bespoke.
A current commissioning/procurement project sets out to procure viable blocks of service from provider(s) for services for older hard to place children. To engage market interest the project has insufficiently granularity of needs. For high level complex needs the method is insufficient as it starts from the wrong place. Long term investment in provision may be possible if there is sufficient granularity of needs. These will likely need to be commissioned rather than procured using a soft block approach for 7 plus years. The provision will need to be jointly managed not contract managed (see Cross regional for example).
Additional factors – workforce
The workforce with the knowledge, experience and expertise of high level complex needs is very small. It is necessary to consider the workforce as part of the commissioning/procurement.
- Multi-professional workforce
Recent experience is that the knowledgeable and experienced multi-professional workforce necessary does not exist in the numbers required. It is also apparent that there is not a market solution to this workforce development.
With a personal care and welfare lens, matching of need to provision is required by social care legislation. With a procurement lens matching brings the most effective outcomes and thereby efficiency of spend.
A generalist approach of procurement of lesser needs uses a different will not be able to match the needs to the provision
- Commissioning/Procurement workforce
The matching aspects of commissioning/procurement requires to be undertaken by people with the knowledge and experience of the needs. This is possessed by very few of the commissioning/procurement workforce. Currently to bring it to the commissioning/procurement would require that the personnel are brought out of direct provision/practice.