Adopting a different approach: on not eating the elephant

Karen Hedge reflects on the need for bold changes in social care commissioning.

Don’t eat the elephant… yet

The African proverb ”there is only one way to eat an elephant: a bite at a time” could be applied to the creation of a National Care Service, but I warn that if we go down that route alone, we will fail.

Sure, the elephant metaphor is great for goal setting – breaking things down into to small measurable tasks sounds sensible, and I have used it many times to great success, from planning and executing a house move to making it round IKEA with small children (and getting everything on the shopping list, without buying any more tea lights, injury, or destruction…).

But the issue with the NCS, unlike the poor elephant, is that social care is very much alive and must remain so, or there will be catastrophic failure to the people and the wider systems it supports – think NHS. It doesn’t matter which bit of the elephant you start on or how you progress – it’s not going to affect any other part. Social care is entirely different and the failure to embrace its dynamism, difference, inter-connectedness, and hyper-localism is what has prevented lasting systemic change to date.

Social care is comprised of a rich myriad of organisations who aim to deliver services which the people who rely on them for independence want. Despite this laudable aim, they sometimes fail at the point of delivery because competition driven systems and processes prevent them from doing so. A prime example of this is thinking about care delivery in 15-minute increments rather than intent, and the difference it is making. Oftentimes public sector procurement activity is confused with commissioning, which is much wider and of which procurement is only a small part – from the Independent Review of Adult Social Care (IRASC):

“In Scotland, we used the term strategic commissioning to mean medium to long term planning that determines the choice of services and supports to meet individuals’ needs, rights and preferences to live independently or as independently as possible.” IRASC (this link will take you away from our website)

The great contradiction being that it is working together which maximises resource and potential. As such, the IRASC calls for collaborative and ethical commissioning in the NCS. Now this should not be surprising news – commissioning and procurement have  required overhaul for many, many years now. It has been going on so long some have suggested it is a wicked problem, but quite to the contrary, there are many papers explaining how we should commission and there are plenty of documented small-scale successes. So, instead of thinking that this legacy will be hard to overcome we need to take advantage of all that evidence and ask the question, “How do we make it work this time?”.

Well, and here is the crux, people think the next question is “How do we create an NCS which has collaborative and ethical commissioning?” Instead, the question we should really be asking is “How do we use collaborative and ethical commissioning to create the NCS?”.

Turns out in one mighty metaphor combo, that all this time we have been looking through the wrong lens whilst eating our elephants.

Ethical and collaborative commissioning must be embedded in the approach from the onset. And to overcome the implementation gap, we must embrace and adopt some fundamental principles towards this new commissioning approach as those outlined in Scottish Care’s “Time for Change”, a Framework towards the NCS (this link will take you away from our website). Everything in this framework supports a commissioning approach which considers the uniqueness and diversity of social care as an advantage, understands the need for local solutions for local interests, and takes seriously the need to work collaboratively with all stakeholders in the system having equal status, including those with lived experience and those deliver care and support. It also recommends that we “put the foot down”. This one needs no explanation; simply put, time is short.

Laying the groundwork for the NCS will not be easy. While we have design methodologies that will take us towards a flourishing NCS, it is the initial steps taken which will be the marker of things to come. To fully embrace ethical commissioning, an approach based upon collaboration and grounded in human rights, there needs to be a shared ethos and framework underpinning that design process, with a mutual regard for expertise and desire to effect positive change.

While the NCS will offer national structures of governance and accountability, it must be also be fluid and agile, creating the conditions for diversity and localism, led by and for people not systems. We need to recognise and value our social care ecosystem and its potential as outlined in Scottish Care’s paper “What if and Why Not? (this link will take you away from our website):

“When we look to the future of social care and the role of social care in this integrated partnership, we need to understand the layers of complexity, contextual nuances and the relationships that exist within its own individual ecosystem. By starting at the point of people and communities, we can begin to understand the needs and aspirations for health, social care and wellbeing, and work together with people, communities and partners to identify the preferable and most appropriate ways to support these. We must shift beyond the mindset of existing systems and services to embrace individual and community capacities, and collaborative opportunities to enable innovative support mechanisms. If we wish to achieve a transformational vision for health and social care in Scotland, we need to reimagine the whole system and go through a careful process of understanding the contributions, capacities, and potential of every element. Further, this needs to happen at a societal level involving individuals, communities, partners at every step of the journey.”

This time it’s not about reinventing the wheel. It’s about adopting a different approach.

Oh, and recognising that eating the elephant is the very last part of the process.

Karen Hedge, Deputy CEO Scottish Care

No elephants were harmed in the making of this blog

This opinion is part of the ALLIANCE’s Future of Social Care series. You can find other entries in the series here.

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