Involving older people in service commissioning: more power to their elbow?

Key points

• Public policy has made increasing reference to voice and choice for service users. Yet there are few examples where users have a real say in commissioning and more strategic approaches to service planning.
• Commissioning is not merely a technical process of analysis, procurement and review. Values and principles shape who gets what, how, when and where. There has been a shift in the focus of commissioning, from services to outcomes for end users.
• Mechanisms for involving older people in commissioning in Salford and Dorset included consultation on local strategy, forums for older people and devolved neighbourhood management.
• Older people and agencies in Salford and Dorset felt that their local involvement processes were worthwhile and associated with identifiable results. National focus groups were more sceptical about whether outcomes justified the time and resources involved.
• There were concerns about the mix of older people able and willing to participate in standard meetings-based engagement. Both sites had developed initiatives to overcome barriers to participation and attract a fuller range of voices.
• Stakeholders in Dorset and Salford identified a number of unresolved issues. These can be framed in terms of whether older people are viewed as citizens or consumers.
• Involving older people in commissioning can lead to service change and improvement, but within relatively narrow limits and dependent on wider democratic processes and power relations.

Background

Policy for older people has been influenced by a wider public service reform agenda which aims to put the individual rather than the service at the centre of commissioning and service delivery. However, initiatives to develop the capacity of individuals to engage with and shape the services they receive have not always been integrated with commissioning. This research explores examples where the involvement of older people in commissioning processes is more fully developed.

Commissioning for older people

Commissioning for older people has traditionally been in relation to social care and health services, but this focus is increasingly considered too limited. A broader understanding of commissioning encompasses the role of prevention, community inclusion and universal services. There has also been a shift in focus from services to outcomes for end users.

Commissioning is often represented as a chain or cycle of activities, which can be split into four main stages: analysis, planning, implementation and review. Commissioning also takes place at three levels:

• the authority or strategic level;
• the community or neighbourhood; and
• the individual.

The effective engagement of older people in commissioning enables them to influence decisions about care and support where they live and priorities for resource allocation. It can also provide older people with opportunities to exercise choice and control over their own lives. Commissioning is not merely a technical process; commissioning activities are located within a set of more or less explicit values, principles and outcomes that shape who gets what, how, when and where.

Involving older people in Salford and Dorset

Salford and Dorset were selected for their reputations as sites which were relatively advanced in promoting the involvement of older people. While socially and geographically very different, both have dedicated structures and processes for involving older people at different levels of commissioning.

Older people in Salford were engaged in extensive, long-established networks which influence commissioning decisions. These have two distinct origins:

• A city-wide strategy for an ageing population, 'Growing Older in Salford', which sought to place the voices and needs of older people at the centre of strategic commissioning.
• Devolved neighbourhood management, in which community committees produce action plans, decide on the use of devolved budgets and scrutinise local services.

• A network of 18 over 50s forums across the county, brought together through the Association of Dorset Forums.
• Involvement of older people in district and county level Local Strategic Partnership mechanisms.
• Representation on the South West Senior's Forum and other external and national links.
• A successful Partnerships for Older People Projects (POPPs) bid, providing funding for low level support and capacity building activities.

Salford was also selected as a LinkAge Plus pilot, aiming to bring together Salford people, commissioners and providers, to encourage partnership working and support the development of scrutiny by and on behalf of older people.

Dorset was also providing a range of opportunities for older people to be engaged in commissioning, including:

There was little to report about individuals commissioning their own care. In both sites at the time of fieldwork, take-up of direct payments was low and early work was underway to introduce individual budgets.

What difference have older people made?

Focus groups in Dorset and Salford identified a range of ways that older people had influenced commissioning priorities, particularly the quality of service planning and delivery.

At both sites, older people had exerted influence at a strategic level. The 'Growing Older in Salford' strategy was based on priorities identified by older people. In Dorset, older people's forums had been influential in the planning and development of more extra care housing as an alternative to more residential care places.

Older people in Salford had become involved in the scrutiny of domiciliary services commissioned by the council. They had also worked with commissioners and providers of older people's mental health services to redesign hospital and community services.

At a neighbourhood level, work in Salford helped tackle social isolation amongst older people by providing a visiting service and social activities. In Dorset, participants highlighted involvement in local topics such as bus services, libraries, community centres and rapid response services.

The POPPs programme in Dorset provided leadership and service delivery roles for older people, a structure for effective partnership working and the development of lower level services and community resources, including budgets for older people to initiate such activities. Commissioners commented that this engagement of older people had helped meet local needs. Both Salford and Dorset were making significant progress in developing ways of co-working. The older people and agencies concerned had no doubt their local involvement structures and processes were worthwhile; they were associated with identifiable results which, they felt, justified the inputs of time and other resources.

The major exception to this positive, overall assessment was the view in Dorset that constructive dialogue had not extended to financial priorities.

National focus groups were generally sceptical about whether the outcomes of involvement processes justified the time and effort expended. Engagement in commissioning was described in terms of increasing activity but little tangible outcome.

Ingredients for success

The local focus groups emphasised that progress had not come easily, but required high levels of commitment from statutory agencies and older people. Structures and processes had matured over time, taking advantage of local and national opportunities as they arose. Participants identified some important ingredients for success:

• Senior managers were crucial in developing a culture that promoted the importance of the views of older people, making resources available and enabling front line staff to work more closely with older people.
• Political leadership was important in promoting a culture of engagement, combating inherent ageism and recognising older people as valuable resources in their community.
• Joint commissioning structures were seen as offering older people the opportunity to engage more effectively with the health sector, which was generally viewed as having less well developed structures for engaging older people.
• Transparency in the engagement process meant older people felt more able and willing to contribute; they felt their views were valued, information was shared openly with them and links were made between consultation, engagement and outcomes.

Barriers to engagement

A number of factors affect older people' ability or willingness to attend meetings, from practical considerations to personal inhibition, language problems and health. A recurring theme in the literature is powerlessness and a sense of tokenism, with service users complaining that they are not valued by the professionals and that they are patronised. Researchers have also commented on the tendency for there to be a small group of active individuals who become 'insiders' in participation exercises.

Participants in Salford and Dorset believed that engagement should be as inclusive as possible, but recognised the difficulties involved. The most common structures for involvement were forums for older people or local communities, or inviting older people to other formal decision-making groups. These forms of engagement were recognised to have limitations, in that only a minority of older people are interested or skilled in formal meetings. Whatever their potential weaknesses, however, formal structures and processes promoted continuous dialogue rather than one-off consultation.

Both sites had designed initiatives to attract a fuller range of voices and combine involvement with other activities such as coffee mornings and tea dances. In Dorset, some of the POPPs funding had been used to distribute newsletters to people in care homes and purchase a projector for presentations to be given in residential homes and sheltered housing.

Unresolved issues

Stakeholders in Dorset and Salford were still seeking to understand and manage a number of tensions and choices. At one level, these unresolved issues can be seen as a 'to-do' list for continuing organisational development. At another, they can be seen as different approaches to involving older people in commissioning, reflecting more fundamental power relations and debate over the respective roles of the state and the market (see table one in PDF).

Conclusion

While findings from Salford and Dorset are not typical of wider experience, they point to the possibility of constructive and productive partnerships between older people and formal services. In principle, older people's involvement can help define outcomes and strengthen the focus of commissioning processes. Whether it can make a significant contribution to shifting underlying power relations is more doubtful.

Recent reports have re-emphasised shortcomings in care for older people and commissioning is widely seen to have had limited impact on outcomes in the past 20 years. In this context, engagement processes are unlikely to compensate for underlying weaknesses. Ultimately the influence of older people on public services depends upon the effectiveness of their contribution to wider democratic processes rather than to service improvement agendas alone.