Making the Market Work for People
There has, quite rightly, been a lot of negative press and comment about the marketisation of the NHS and social care services, the failure of Hinchinbrooke Hospital being a particularly dismal recent example.
Things reached a zenith with the news that some local authorities are (allegedly) operating an Ebay style of commissioning for individual older people – placing their details on-line and then inviting bids from providers to deliver care and support, with price being the main determinant. If true, this reaches a new low in the way that disabled and older people are treated as commercial products rather than human beings with rights and feelings. However, the concept of a market in social care should not be rejected. People are clear about what they want out of services and supports. They want choice over what is available, their voice to be heard, and their rights and dignity respected. This needs more than one or two support options to choose from and having choice, voice and rights could mean people get services and support that are delivered in ways that meet their needs and aspirations.
What we need is a market designed for the people it serves, where they can metaphorically shop around, see familiar and new things from interesting producers, compare quality and price and make their own choice, where they can chat to local producers who are interested in providing what they want. In other words a farmers market, not a supermarket.
The reason why the marketisation of health and social care has gone wrong is that there are at least five ways in which the characteristics of a functional market have been lost:
- Often there is little or no choice.
- Price rather than quality has become the major determining factor.
- There is little information available on quality or outcomes.
- The absence or weakening of the ‘shopper’s’ voice in the market means others are taking decisions about supply.
- Bureaucratic procurement processes can block access to the social care market for all apart from large, well resourced providers.
Local authorities and the NHS have a responsibility for market development, and should be addressing these flaws. However, the approach generally being taken falls short of what will work.
At NDTi, we are encouraging authorities to take a four-stage approach to market development:
1. The Individual. Support people who use services to understand what is possible with some creative planning. Without this, many people will think what they have previously had is the only way of being supported. From that, use real person centred planning as the prime source of information for the market changes that are needed.
2. Understanding Now. Map current provision and service usage but crucially, factor in informal and community supports. Analyse the gap between what is available, what people are using now and what people want.
3. Planning. Use this to develop a market position statement and commissioning strategy to fill the gaps – including through use of individualised and outcomes based commissioning.
4. Development. Commissioners need to be hands on – helping existing providers to develop and change, and seeking out new providers, including small local options – rather than using simplistic open tender processes that are most often met by the slick, ‘big boys’
The problem is that most national advice and local practice starts with number 2 rather than the individual (number 1) and then marginalises community provision and small, innovative practice.
The most widely promoted market development advice comes from ‘Developing Care Markets for Quality and Choice’ – a partnership between the Department of Health, ADASS and Care Provider Alliance (i.e. current providers – no vested interest there then). It contains no visible input from those who use services. Whilst containing elements of good advice, their materials start from my Stage 2 and place great emphasis on population predictions, label-based analysis and customer satisfaction of existing services. There is an implicit assumption that the future will be like the past but with greater demand – and that what is needed is more providers who hopefully do similar things a bit better. Where is the ambition that starts with opening people’s eyes to a different, brighter future - where the role of services is to help people live a full life as part of their communities?
Markets have to be stimulated with creative ‘offers’ nurtured and promoted. If they are not, then the positive characteristics of the farmers market are lost as the supermarkets come in and take over. That is already what is happening in the health and social care system. Unless the voice of people and outcomes from person centred planning become the starting point for market development, Hinchinbrooke Hospitals and care auctions on Ebay will become the norm.