Effective join-up of commissioning arrangements and service offers is something of a holy grail in the public sector – much-praised and continuously sought, but difficult to describe and even harder to find. As local authorities look for ever more creative ways to balance the books, this kind of partnership working can offer one solution, but its key challenge lies in taking a step back from operational thinking – to provide the right service for the right child at the right time – to look at wider, more strategic and longer-term arrangements.
Chasing one’s tail (spend)
In my area, a recent analysis of “tailspend” – one-off or repeated purchases of under £10,000 – identified a range of individual therapeutic packages being commissioned; including counselling and psychotherapy, support services for young people with special educational needs and disabilities (SEND), and therapies for adopted children and their families funded by the Adoption Support Fund (ASF).
Most authorities have in place strong resource panels to allocate funding for individualised support, which are critical to joint commissioning but not always well linked to effective contractual arrangements to deliver or monitor these services, leading to spending decisions that do not comply with regulations. Lack of detailed management information from providers and complex processes for recording panel decisions can result in poor understanding of demand and needs, compromising commissioners’ ability to forecast accurately and plan strategically.
This creates a cyclical effect of uptake in specialist panel requests – since block or framework contracts are often unable to meet the true levels of need – which in turn generates more tailspend. A search of the government’s Contracts Finder database identifies some examples of how local authorities and partnerships who have awarded therapeutic contracts within the last two years are managing this issue, which are set out below.
Adopting good practice
A number of regional adoption agencies (RAAs) are closing the therapeutic provision gap with simple but effective framework contracts. The ASF enables commissioning of post-adoption support for children and families, including counselling and other interventions – although as a central government grant it is out of scope for council savings programmes.
ASF service users have a high level of choice of provision. This means that traditional framework “call-off” mechanisms, where a supplier is selected according to a ranked list, or those of dynamic purchasing systems, where providers “bid down” in a mini-competition in order to offer the best rate for individual packages, cannot be the sole method of selection within these contracts.
Since these services often fall below financial thresholds set by regulations, commissioners may utilise flexibility under Schedule 3 of the Procurement Regulations (the “light-touch regime”) to allow greater freedom in both the calling-off of services and the operation of framework contracts, for example, more flexible timescales and re-opening dates to enable new providers to get on-board.
Such contracts operate differently in each RAA: Adoption Central England operates separate contract “lots” for each different type of provision, affording social workers and service users a menu of approved providers structured by intervention type. One Adoption has implemented an “approved provider list” with lots for each geographical area. And Buckinghamshire County Council used the light-touch flexibility to seek three quotes rather than go to open tender, to award their birth-relative support to a single provider.
SENDing reinforcements
A large proportion of spending on therapeutic provision is concentrated in SEND support services including speech and language, occupational therapy and occasional specialist interventions such as music or sensory integration therapies.
Requests for these services relate to supporting a young person’s educational needs and tend to be channelled through multi-agency panels. Funded by the “high needs block” of the government’s Dedicated Schools Grant (DSG), they are rarely considered for efficiency savings and there is disagreement over the extent to which commissioning them is subject to procurement regulations. However, a more streamlined commissioning approach in partnership with clinical commissioning groups (CCG) can potentially release much-needed DSG funding from these areas to be used for other provision.
Sufficient capacity for these services should be built into mainstream community health contracts, which are competitively tendered by CCGs and represent better value than spot-purchased services. The use of Section 75 Agreements to “passport” funds directly between local authorities and CCGs is one method of expanding capacity, but ensuring when services are first commissioned that there is scope for contract variation to adapt and scale-up provision to meet emerging needs is also crucial. This was our thinking when the Pan-Bedfordshire community health contract was tendered through a Competitive Dialogue Process – subsequent variations enabled Bedford Council to reduce individual spend on SEND therapies significantly between 2019/20 and 2020/21.
Location, location, location
Panel referrals for counselling and psychotherapy are also often driven by lack of capacity within community mental health services, especially at Tier 2 in the CAMHS (child and adolescent mental health services) system. Therapy for a child or whole family may be required to inform court decisions or as part of a time-limited plan, and over-stretched CAMHS can be ill-equipped to handle short turnarounds, leading to local authorities relying heavily on both the voluntary and private sector.
The issue is further complicated by the types of therapies requested. National Institute for Health and Care Excellence (NICE) guidelines recommend the use of psychological therapies to treat mental health issues in five- to 18-year-olds, but in practice there is often little choice beyond cognitive behavioural therapy.
Most areas have robust voluntary sector and private counselling provision, and cash injections from the 2015 Future in Mind programme have resulted in joint-working initiatives between local authorities, CCGs and schools to strengthen local provision for open-access and early help mental health support, which can help divert the need for specialist individual services. These include traditional one-to-one counselling services as in contracts recently commissioned by Kirklees Council and Staffordshire County Council, “youth club”-style or groupwork sessions implemented by Leeds CCG and Swindon Council, whole-family therapies such as those in Kensington & Chelsea and Stockton, and digital services such as the online mental health platform recently implemented in Bedfordshire.
In the most common tendering models, a local CCG is the lead commissioner for these contracts, either as part of, or an offshoot to, a larger community mental health service contract, and local authorities contribute a proportion of the costs depending on local need. However, when new trends in these needs arise, “umbrella” contracts such as these may not be able to adapt swiftly enough to meet them – however, smaller, locality-based providers often can.
Procurement Policy Note 11/20 offers one solution, recently used by Stirling Council, which enables organisations tendering under certain financial thresholds to restrict procurements by supplier location, and/or specify that only small and medium enterprises and not-for-profit providers can bid, allowing spending to remain local and delivery to be more agile.
TOP TIPS
GOOD PRACTICE FOR COMMISSIONING THERAPEUTIC SUPPORT SERVICES
There is no “one-size-fits-all” for therapeutic support – either in terms of the type of intervention or commissioning models. Commissioning authorities need flexibility to adapt to the needs of service users, while also maintaining compliance to procurement regulations and their own contracting rules. The contracts discussed above represent some good practice themes which could be adapted across these support strands:
Adoption Support frameworks are an example of how disparate support types can be drawn together under a single contractual heading, allowing practitioners to call-off services depending on families’ needs, wishes and feelings. When a specialist request comes to resource panel, providers are already approved and due diligence already carried out. Their success, however, is dependent on availability within the provider market and capacity within internal teams to carry out effective contract management, particularly for larger consortia contracts. If frameworks operate geographically, consideration should also be given to how children placed out of area will receive these services.
For all specialist services, referral pathways should be incorporated into terms of reference for resource panels. Commissioners and procurement/finance leaders need to be active members of these panels, to provide effective challenge to requests for non-compliant services and to channel referrals into existing contracts. This enables reductions in off-contract purchasing and tailspend, decreased likelihood of challenge from the market arising from insufficient competition, and better insight into volumes of need and outcomes through contract performance data. If current contracts do not allow for urgent or specialist activity, it may be possible to make a variation to these contracts to include it, and consider building such activity into the specification in the next round of procurement.
For these models to work, effective needs analysis must take place so that commissioners understand how many children, young people and families require specialist services and how much is needed, which providers are being commissioned and what the impact of these services is. If contract data is too limited to build this picture and link individual with strategic commissioning, it is worth looking at deep-dive analysis of panel requests, spend analysis and information sharing through local peer networks, which can identify and join up micro-commissioning not currently linked to contract registers or procurement plans. Findings should be embedded within local joint strategic needs assessments, to allow providers to horizon-scan and plan provision accordingly.
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Toni Badnall is senior commissioning officer, children’s and public health, Bedford Borough Council
FURTHER READING
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Reserving Below Threshold Procurements: Action Note PPN 11/20, Cabinet Office (July 2021)
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Depression in children and young people: identification and management: NICE guideline [NG134] (June 2019)
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Guidance on the New Light Touch Regime for Health, Social, Education and Certain Other Service Contracts, Crown Commercial Services (Oct 2016)
