6 Steps to Improving Health and Social Care Outcomes at Lower Costs

By Allan Watton on

Improving Health and Social Care OutcomesThe following post focuses on one of the key issues explored in our white paper on improving Health and Social Care Services and significantly reducing costs. Download your free copy here.

Improving health and social care outcomes, while significantly reducing costs, is a key focus of ours. Population growth and increased life expectancy, alongside a challenging financial environment, have necessitated the move by many councils to improve service delivery while, at the same time, also attempting to reduce costs.

We have found that councils have become frustrated with the fact that their attempts to deliver innovation alongside increased value are not being applauded as they should be. Often, this is because the ideas in the innovation process have been easier to think up than to implement in practice, which has typically resulted in challenges in respect of achieving the right outcome.

Two approaches councils may take

The reshaping required can be handled in-house or through integration with a local NHS Trust.

  • In-house is certainly a simpler and often more direct solution. A council may choose to review and supplement its internal capability while changing its operating model to reduce costs, though it is vital to consider the operational impact on service quality involved in any material change. Supplemental services can also be bought in, although care needs to be taken to resist the temptation to go for the ‘lowest-cost’ supplier as this often proves to be a false economy.
  • Subject to the services involved, integration with a local NHS trust can offer both collaborative working and an integrated healthcare environment, thus often providing sustainable and effective new ways of working. However, foresight and commitment in quantifying your business case, requirements, section 75/commissioning agreements and formal operating processes are essential if this approach is to work.

We strongly believe that the careful commissioning of services is the only viable solution to this.

“Careful” is the key word here, because we see far too many local authorities making the assumption that detailed service design can be avoided, as if simply ‘gluing’ services together can provide some kind of panacea by default. While intelligent and mature commissioning can result in improved service delivery and reduced costs, this is only the case when it is implemented in the correct fashion.

6 Steps to Improving Health and Social Care Outcomes

In this article, I want to explore six important steps that, in our experience, will genuinely accelerate your success so that the commissioning of Adult Social Care services results in improved health and social care outcomes

1. Prepare a Solid Business Case

Your business case will serve as the foundation for your commissioning agreement. Its strength underpins everything else you do, so you must make absolutely sure that a solid case is put together.

To avoid accusations of self-interest and/or being partisan, it makes sense for the Business Case to be prepared by an independent organisation, and its focus should be on the costs and benefits of the proposed integration and/or third-party commissioning arrangements. The key considerations of this business case are as follows:

  • improving health outcomes and reducing long-term costs, while understanding that upfront investment will likely be necessary;
  • identifying measurable outcomes, underpinned by performance and contract-management frameworks;
  • supporting the realisation of operational and financial benefits, by ensuring ownership and measurement of actual benefits achieved;
  • flexibility in permitting controlled experimentation, innovation and ongoing continuous improvement; and
  • clear delineation of service elements that will remain in-house or be commissioned to private suppliers.

Once a partnership is up and running, your business case will become a tool for benchmarking the supplier’s performance against your long-term service improvement and cost-reduction targets. It is therefore important not only that this business case is as clear and complete as possible, but also that it is communicated to your supplier in a way that assures understanding. Once this has been done, discuss with your strategic partner to clarify this understanding as, even with the best intentions and attention to detail, ambiguities and tough-to-translate jargon can creep in and misunderstandings can then occur. Catch them early and you could avoid a protracted realignment process.

2. Understand “Expert” Responsibilities

If you plan to commission “expert” private sector suppliers, you should understand their inherent responsibilities. Court rulings have clarified a number of specific duties that “expert” providers must perform, even if these are not documented in your written contract. Most notably, a “duty to warn” you if any of your expectations or requirements cannot be fulfilled within your specification, resourcing or financial constraints.

You can find out more about the specific duties here, but the key is in implementing what you learn into any commissioning agreement that you enter into. Your strategic partner must validate:

  1. the outcomes it can achieve;
  2. the outcomes it can’t achieve; and
  3. for the outcomes it can’t achieve, the consequential impact on the services.

With the above information clarified, you will have a better understanding of your supplier’s abilities and limitations, which will subsequently define suitable compromises and workarounds.

This is a vital phase in the creation of a true partnership as it will provide you with insights, powered by your supplier’s industry expertise and experience, with which to formulate a plan of action.

3. Set Clear Service Expectations at the Outset

You are only likely to achieve desired outcomes if they are clearly quantified at the very beginning. The first step in doing so is to be as clear as possible about the scope of the service – i.e., what is included and what isn’t. This scope can then be turned into an outcome-based specification, which sets out:

  • your objectives for each element of each service;
  • the specific outcomes you want to deliver for service users; and
  • the performance indicators that measure the achievement of these outcomes.

Although the Department of Health has published a set of desired outcomes at the national level, these still need to be translated into local specifications, which are often unique to the regional population. Such specifications can then be communicated to the supplier, so that they can provide feedback based upon their expertise.

Once specifications are agreed, they should be documented so that you and your supplier can agree them formally. These will form a guide, steering all parties towards commonly agreed goals to keep the relationship on track.

4. Use the Right Contract Negotiation Tools

If you are thinking of integrating Adult Social Care provision with another Council or an NHS Trust, you will likely be using a Section 75 agreement. The starting point for creating the Section 75 agreement, or any commissioning agreement with a private-sector partner, should be a set of specification and contractual process maps. These will help you and your supplier to understand the operational methods that need to be used to deliver and manage the agreement.

The purpose of these maps (which will need to be aligned to suit the specific services you will commission/integrate) is to facilitate effective dialogue between operational and legal teams. This is done by creating a diagram of the contract which both groups can understand. Once the diagram’s content has been agreed, changes can be made to a template Section 75 or private-sector commissioning agreement. Templates usually contain the majority of the contract terms, so your legal team avoids extensive drafting.

This process of providing a universally understood format for agreeing terms is far more efficient than traditional methods. It also ensures that your desired outcomes are clearly defined in the Section 75/commissioning agreement itself. Due to this method’s clear simplicity, you can expect to cut negotiation times drastically and to build a strong relationship foundation aligned to the successful achievement of re-shaping Adult Social Care.

5. Put a Performance Management Framework in Place

A commissioning agreement is only as good as its performance management framework. This framework should feature a number of key areas, three of which are:

  1. Measurable Key Performance Indicators (KPIs). A partner’s performance should only be judged by measurable KPIs that align with your desired outcomes, which should be backed by a consistent and clearly defined measuring and reporting mechanism.
  2. A mechanism to deal with non-performance.This should be intended to help any third-party or NHS supplier to improve its performance, without undermining key aspects of your contractual relationship or agreement. If your supplier struggles to improve, you need an appropriate escalation process which helps to resolve issues efficiently and amicably, while taking financial ramifications into account.
  3. An exit management process. Should the worst happen, you must have a process by which an agreement can be wound down in an orderly fashion. Continuity of service and a smooth transition to a new supplier are key requirements.

6. Manage and Document Changes to the Services

A successful supplier partnership is typically marked by adaptation and innovation. As the needs of service users evolve or new technology becomes available, you may need to amend or stop an existing service, or introduce a new one. You therefore need a way to manage this change process.

An effective reshaping process ensures that changes to specifications, operating procedures or contract management processes are documented, so the contract terms and schedule remain aligned with what is happening on the ground. It is vital to do this, because changes in your behaviour or your partner’s behaviour will affect how the contract is interpreted, even if the written contract is not updated.

The contract should be reviewed on a six-monthly cycle, to sweep up all the major, minor and incremental service delivery changes that happen on a day-to-day basis.

A key benefit of the effective management of changes to the services is that it ensures that you and your supplier are always thinking about the service delivery process. This encourages experimentation, and the piloting and reshaping of services for lower costs and better outcomes.


The balancing act of increasing the provision of health and social case services while seeking to reduce the cost of supplying those services is a delicate one.

How you choose to approach this will depend on numerous factors, but in our experience commissioning, when implemented correctly, can often deliver far better results than attempting to make the required changes through in-house means.

However, it is important to remember that commissioning is not a cure-all. Care must be taken to follow each of the stages listed above with a focus on clarity and collaboration to truly tackle the challenges in your Adult Social Care services, while also achieving the significant cost savings you are looking to make.

To view our white paper on Improving Health and Social Care Services and Reducing Costs. Click here.