Commissioning and provider services: safeguarding people experiencing homelessness, 13 January 2021

Presentations for this event are available here.


Webinar

Webinar transcript

Moderator: Good morning everyone, hopefully people can hear me okay. My name's Adi Cooper, I'm the care and health improvement advisor on the Care and Health Improvement Programme, and I lead on safeguarding, and I'm here this morning to chair this session. Really, welcome everyone here this morning, really good that you've made the time to come and join us, really pleased we have the speakers with us today. The session today is on commissioning and provider services, safeguarding people who experience homelessness. We have over 100 registered delegates to attend today, there's still about 80 people registered. So, I'm assuming some people may join us as we carry on. I'm asking colleagues who are dialled into this seminar, if you can put your questions in the Q and A function that you should have on your screen, and then Michael Preston-Shoot and I will manage the, sort of, Q and A sessions after each speaker. The slides will be available on the LGA website after the session, so please be confident that you can access the slides later. By way of introduction, I'm just going to give a bit of background to this series of webinars. So, this is the second of a series of virtual seminars, and it builds on work that we undertook previously in 2019, 2020, on adult safeguarding and homelessness. During that period, we held four national workshops through the Care and Health Improvement Programme, which were really successful. They brought together people across the country and across organisations and different sectors to listen to speakers, to share their experience and discuss a whole range of issues regarding safeguarding people who experience homelessness, and particularly those who are at risk of abuse or neglect. The outcome of those four workshops was a briefing on positive practice in adult safeguarding and homelessness, which Michael Preston-Shoot authored, and that's published on the LGA website and was produced by the LGA and ADASS, the Association of Directors of Adult Social Services, and that's the background to these seminars.

 

Originally, before the COVID pandemic, we'd planned to have a series again of regional workshops disseminating the briefing, and use that to support further discussion and debate about what we could do better in terms of sector-led improvement around adult safeguarding and homelessness. But obviously, we weren't able to do that because of the pandemic, and so what we did in discussion with a group of people who we call our advisory group, which are a group of people who have been supporting us develop this programme from the start, is discuss what would be most useful at this time. And from their suggestions, we've developed and planned this series of eight workshops-, well, eight seminars, based on different themes, and brought together people to talk about those themes, and then with some Q and A slots within that. So, the objectives of today, which are similar to-, the same for all these seminars are to share some information, particularly regarding positive practice in the different areas of work around adult safeguarding and homelessness, to provide an opportunity to understand how safeguarding people who've experienced homelessness has changed, and particularly over the period since the COVID pandemic starts, and the response to everybody in-, and that continues to change. I mean, one of the things that's very-, I'm very mindful of speaking here at the beginning of January is, it's changing again. And so, we are really hoping that we can keep track of some of those changes, and the learning that has emerged and continues to emerge in this field during these changes. And so, what we're hoping to do is, as a result of these seminars, is to pull together another briefing or update which we can publish later this year that brings us more up to date in this area of, of work and practice.

 

So, that's why we're here, what we're trying to do, and hopefully will be helpful to all of you who have joined us this morning. I'll just reiterate, please use the Q and A function to put questions, Michael will try then and, and cluster them and, and help me manage the, the-, that part of the sessions. Do remember the slides will be available on the LGA website after the event. And I think without any further ado, I will pass over to Gill Taylor, who I'm really pleased has joined us this morning. Gill is the strategic lead on single homelessness and vulnerable adults in the London Borough of Haringey, and she's going to talk to us this morning around-, about commissioning services for this client group. So, Gill, over to you, and thank you so much for presenting this morning.

 

F: Thank you very much, Adi, I'm just gonna share my screen now, so I hope that this works. So, I hope you can see that. So, my name's Gill Taylor, I'm responsible for commissioning homelessness services in Haringey, as well as delivering a number of homelessness services in the borough as well. I want to start by giving an overview of commissioning, and hopefully I'm not preaching to the converted here in that some of you may well be commissioners yourselves, and I imagine that many people here are involved in commissioning in some way. Commissioning should be understood as a, kind of, continual process. I think a lot of people think that commissioning is the act of procuring or buying services, but it's actually a much broader spectrum of different activities that involves planning and procuring, and then managing and monitoring services. And it was argued that, when commissioning was first brought into public service, that that competition for resources would create greater efficiency, responsiveness and innovation from providers. Now, I think that that's also very widely contested, and certainly in the environment that we currently work in, where financial resources in particular are so limited, there's a lot of argument that actually, that efficiency has actually gone perhaps further now than creates the responsiveness and innovation that people want. And I think what that means for both commissioners and providers is that we have to use innovation to work around some of the issues of not having the resources that we need. But that's certainly why commissioning was brought in in the first place.

 

Commissioning for homelessness services and what was called housing related support started in 2003 with what was called the Supporting People Programme. And for any of you that have been around homelessness for as long as I have, you probably remember that, and it had many, many faults, the Supporting People Programme. But what it did do was identified housing related support and homelessness services as a really key mechanism for enabling vulnerable people to live fulfilling lives. And at the very centre of the Supporting People Programme were ideas around prevention, empowerment and independence, which are things that you will see paralleled in work around adult safeguarding as well. And at its heart was also a commitment to quality services, continuous improvement and the accountability of organisations in the work that they delivered. Supporting People was disbanded in 2009 and the funding programme was aligned with other local authority funding programmes, what's called the ring-fence of that funding was taken off. But in an assessment of the Supporting People programme, it was understood really, really clearly, a strong case was made by CapGemini, as they were called at the time, that homelessness services provided huge financial and social benefits for the whole country around things like preventing criminal justice involvement, preventing hospital admissions, et cetera. So, we should understand commissioning services within this broader context of the social environment that we live in, and I think at the moment in particular, everything is changing in society, as is commissioning as well, in order to respond to the pandemic.

 

So, there's the, kind of, case for commissioning, if you like, and it's set out here in three areas. So, we have national legislation, and I could have written a number of different bits of legislation in this box, but I wanted to pick out a few in particular that are related to homelessness and safeguarding. Many of you will know the Homelessness Reduction Act, it came in a couple of years ago, and it really represented a step change in homelessness policy and legislation. And what its focus was, was around prevention and intervening rapidly in homelessness, and again that's mirrored in safeguarding principles and in reactions under the Care Act. The Care Act also when it came in had a heavy focus around commissioning, and around good commissioning in particular, and particularly the practices of quality and improvement, and continuous development. And then the Equality Act, so thinking about injustice and how the local authorities have a responsibility in commissioning and delivering services to look at equality, and bringing different communities and different people with protected characteristics together in ways that improve the social environment in the community. Beyond legislation is the national policy that underpins it, so I again could've mentioned all kinds of different national policies here, and often in national policy, what is set out are the principles and the aims that the legislation is seeking to achieve. So, for example, thinking about the Rough Sleeping Strategy, which was most recently published in 2018, there's a really clear link between adult safeguarding and homelessness practice, and commissioning work. So, thinking about how commissioned services, local authorities and other stakeholders work together not only to end rough sleeping, but to reduce the harms that are affecting people who are rough sleeping. And the other strategies and policies that you can see there are seeking to do many of the same things, and particularly around addressing inequalities of access to services that people often experience, and how commissioning practice and provider strategies can work to do that. And then at a local level, for every individual commissioner, we're guided by our local strategies and strategic priorities, which would include things like our safeguarding adult support strategic priorities, homelessness and rough sleeping strategies, community safety, and health and wellbeing. And often what those local strategies are doing is telling commissioners exactly how and why they will be commissioning the, the services that they are in their local areas. And it should give a really clear steer from legislation all the way through to that local strategy what are the underpinning features and factors, and particularly at a local level, where are the identified needs that that commissioning practice will seek to meet.

 

So, for people that are familiar with commissioning, you might have seen a diagram that looks similar to this before. This breaks down the idea of the commissioning cycle into four areas. So, plan, do, review and analyse. And when I think about this, I always start with analyse, but in theory, you could start anywhere in this-, in this cycle, and participate in the commissioning process. And what I'm gonna do in this presentation is just go through each of those four areas in turn and talk about how some of the practices of commissioning relate to adult safeguarding, particularly around homelessness. So, in the first one, as I said, I start with analyse. So really, this area is about data and understanding, and you'll see in each of the slides that comes forward that co-production is at the start of all of the activities. And the reason for that is because it's an underpinning activity in all of commissioning practice, or at least it should be. For people who are not familiar with co-production, what it means is working with people with lived experience of either the services or the particular area that you're commissioning services for, working with them throughout that process so that what they want and their needs are at the centre of that work. And co-production can in and of itself be a form of analysis, looking at what it is that people experience in services, the common themes that run through that, and the particular barriers and challenges that they might face, and where those particular crunch points are in any local system. Then, other forms of analysis exist, so needs analysis, thinking about what you know about the people who access your services. So, when this comes to safeguarding, it might be speaking with social care colleagues, asking them for example about data, about safeguarding alerts raised about homeless people, and making an analysis of what that might tell you about how a commissioned service could respond to that need. During the pandemic, a lot of this needs analysis has been focussed around health for example, and how health inequalities can often result in safeguarding issues, around the pandemic how health inequalities and inequalities of access to services often mean that people have been placed at greater risk of being affected by the harms of COVID.

 

Gaps analysis, similar thing, it's looking at where are the gaps in our local system. What are the things that we don't have that we might want to commission already, or what are the things that we have commissioned that are not working in the way that we want? What are the gaps that that's leaving behind? Obviously for commissioners, a lot of our work is about resources, so it's also understanding what is the money that we have available to commission these services, but what are the other resources as well. What are the local forums, meeting groups, multi-agency stakeholder sessions, that might be available in this commissioning process that can help us to commission the services, that can also work with those commissioned services moving forward? And the reason that that's important is in the subsequent phases of the commissioning cycle, those resources will be drawn into the different activities that you're doing, to bolster and strengthen the services that you commission. Again, stakeholder feedback, so in a similar way to co-production, working with the people delivering services, or working alongside them already to understand what’s going on in those services, what's effective and what isn't. I've mentioned legislation already, so in analysing legislation in this regard would help us understand what our legal responsibilities are as commissioners, but also for the services that are being provided. So, for example, how is it that legislation around safeguarding needs to be woven into commissioning practice in order that not only the council or the local authority, but the provider is meeting those statutory requirements, and where possible is going beyond what is expected. And then again, looking at the local strategic aims, what analysis can we make about the services we would commission in our local area based on our local strategic priorities. So, in rural areas, in urban areas, they might look different. In areas with particular communities and particular community profiles, they might look different. Those local strategic aims really give a framework for what it is that we'll be commissioning. And as you can see there at the bottom of this slide is the outcomes that those activities will achieve. So, understanding what people want and need, what the legal requirements are, our local priorities, and pathways and partnerships. And importantly, mapping what and who is and isn't part of that local system so that commissioning practice can fill some of those gaps.

 

Plan. So again, co-production should be in the heart of planning. So, thinking about how are we going to do this commissioning exercise, who are we going to involve, in what ways do people with lived experience of homelessness participate in the planning of services, the way that they will work, and in particular thinking about their experiences of those services, and what that tells us about some of the things we want to write into the design process. Often in the planning process there will be a commissioning strategy. Certainly in Haringey we're currently developing a new housing related support strategy, which will look at our plans over the next few years to improve services through the practice of commissioning. And for us, one of the things that that's specifically going to look at in the next few years is how do we embed more adult social care integration and partnership as part of the homelessness system. And in different areas, that particular need is-, has been developed stronger, and in other areas it's, it's weaker. So, I think there's something around what in your local planning do you want to implement into your service designs and specification. Many of you who are either commissioners or providers will have seen service specification documents before, they're often very lengthy and very wordy, and not always necessarily the greatest reflection of the service that is gone on to be provided, but the intention is that that service specification will describe what it is that the commissioner is looking for that service to deliver. And it will include things such as the principles it hopes that the service will work on, the particular activities that might be involved in service delivery, some of the performance monitoring measures and key performance indicators, and also some of the partnership expectations around that. And ways that we might embed safeguarding practice into that service specification and design is thinking about describing the relationship, for example, between the homelessness service and local safeguarding teams, or adult social care first response services. It might also include incident reporting practices, so how do you want, as a commissioner, your providers to respond to incidents. In particular thinking about safeguarding, in what ways do you want safeguarding to be woven into all of the aspects of the way that service is delivered. And as a commissioner, it's our responsibility to articulate that in the service specification.

 

For us in planning, there's also mapping of the system. So, thinking about the ways in which this particular service you might commission is connected with other local services. What gaps does that leave? And particularly around adult safeguarding, we know that transitions between services can often become cliff edges. It's often the point at which a person who might be at risk, or might be vulnerable to abuse and neglect, might fall through the net, so to speak, or might find themselves without a service at all because services aren't operating in alignment. So, as commissioners, we have a responsibility and an opportunity to map that system and think about what those cliff edges might be, work with people with lived experience to understand what's happening in the local system, and design services in such a way as to be flexible and to try to create more porous boundaries between services. And that's really challenging as a commissioner because writing that into a document is a very challenging thing to do, never mind the actual delivery of that. But that's certainly something I think as commissioners we should be thinking about. How do we create more porous boundaries so that risks are not heightened at the point where somebody moves between services? And that, kind of, moves us into things like referral pathways, exit strategies, move-on planning, how do we make sure that somebody's journey through services is seamless and is-, works in the way that they need, and responds to their needs. And you can see there, the outcomes are about understanding what's available, working in more integrated and aligned ways, and working efficiently with the resources that are available, and planning how those resources will be used over the course of a particular contract. And then, increasing the investment of partners and stakeholders at that very early planning stage. So, working with other stakeholders, so for example the NHS, around how a homelessness service might support them in delivering what their-, what they need for their patients. And what that often does is creates a level of investment with partners really early on, so that the service is more likely to achieve its aims at the point where it's being delivered.

 

The do is where a lot of the activity that we might understand as commissioning often happens. So again, co-production, so how are we working with people with lived experience in our tendering processes. How are people with lived experience helping us as commissioners to select the right organisations to provide the services we're looking for? How does the tendering process itself, so the bidding process, how does that look at safeguarding? So for example, as commissioners we could be thinking about including questions in bids around what the safeguarding practice of that organisation looks like. We can ask for case studies to give examples of people that they've worked with. We can also ask for their involvement or understanding of their involvement in national or regional safeguarding forums, or safeguarding adults boards. So, I think the tendering process is a really important opportunity to understand as commissioners what providers' relationship is to their safeguarding responsibilities, and not just at the point that it becomes a Care Act eligible safeguarding enquiry or an alert, but actually how are they thinking about safeguarding as a part of all of what they do. And as commissioners, how are we seeing that as well, so what is our role in the, the tendering process around embedding and building in that safeguarding practice. And then the service delivery itself also sits within the do area. So, once the provider has been selected, they've implemented their service and they're delivering it. And so, essentially, that is the whole period of the contract that exists. And during that service delivery time, that's when you get to see as a commissioner, if your service specification and your analysis were correct. Is the service that you've commissioned delivering what it was that you hoped for? And what's really key in this area is that co-production should be taking place in the services themselves.

 

And I know that Rebecca is going to speak more about the relationship to commissioning as a provider in a moment, so I won't talk too much about that. But I think it's really important that we think about as commissioners, how is-, when the services are being delivered, what is taking place, what are the activities, how are the people with the lived experience involved, how are safeguarding issues responded to as part of the service delivery. And that might be again around things like incident reporting, it might be around thinks like reviewing fatalities when people pass away in a service, it might also be in the day-to-day support planning work that's taking place. How are we working with people to understand their risks, their vulnerabilities? And as commissioners, how are we supporting our providers to do that, and how are we making sure that we are as commissioners, enablers of effective service delivery, and not only monitoring delivery that takes place? And then in review, so looking at the contracts that we have, working with our providers to understand their performance. So for example, one of the things that we do in Haringey is we monitor the incidents that take place in our services. And we work with providers to look at what takes place in an incident, at what does that tell us about our practice, what does it tell us about the local organisations and systems that are involved in supporting people, and how do we learn from incidents that happen to reduce and prevent risks in future. And I think this is a really key area for us in terms of learning and thinking about a lot of our responsibilities around safeguarding as practitioners, being around learning, and continuously learning through all of the work that we do. And really, this review stage is about all of that, so how do we implement things such as communities of practice, for example, and how as commissioners do we support them to take place in our local areas so that front-line practitioners and their managers are able to come together and talk about things that have happened, in order that we can learn and move forward. And often out of communities of practice, other sorts of forums and reflective practice sessions, you really get a lot of insight as a commissioner into how your commissioning practice may or may not have delivered what you were hoping for. And in particular, what opportunities there are to improve the local system, using your influence as a commissioner to work with other parts of the local system, for example adult social care, local hospitals, local mental health trusts, et cetera, to make services more aligned and integrated for service users.

 

And really it's about understanding, kind of, the blockages I think at this point. Reviewing what's going well, in a way, is quite easy. We spend a lot of our time thinking about great outcomes, but it's also really important to think about what's not working, what are the barriers that practitioners face, what are the ways that they're navigating around the system rather than being able to work with it. And often what we find is that really, really good front-line practitioners have learnt really well how to navigate a system which doesn't work very well, or often doesn't work in the way that we hope. Rather than the supporting people, often what we find as commissioners is that aspects of the system that we in fact have often created can work against front-line practitioners. So, this review stage is really important in thinking about what it is that we can do to change the environment that we're working in so that provider organisations and the service users that they're supporting can work more effectively together. And it's particularly important around safeguarding because safeguarding encompasses so many different aspects of a person's life, and it's a feature in so many different parts of service delivery. And if we're not, kind of, continuously looking at and reviewing that practice and the particular experiences and issues people are facing, we might miss opportunities to change and improve what's happening in our local areas, even beyond the services that we're directly commissioning. And what it also helps us to do is plan for the future. So again, thinking about commissioning as a cycle, at the review stage, it's not the end. The review stage then moves on to the next phase of analysis, so action planning for the future and thinking about perhaps some long term projects that we might want to implement comes in this review stage. And examples of that might be thinking about areas of funding that you might seek to bring into your local area, new initiatives that you might want to be embedding into the local system, new strategies or strategic aims that you might want to build in to future local strategic planning.

 

Psychologically informed environments are something that people understand a lot about in the homelessness system at the moment. For commissioners, I think we often think about this as something which is taking place in services, so actually creating psychologically informed environments as commissioners is not only about writing that into service specifications. It's also about as a commissioner, working in a psychologically informed way with the provider organisations you're supporting, but also creating that within your teams. So, within the commissioning offices that I'm responsible for managing, for example, thinking about how we embed this in all of what we do. And actually, at the very heart of psychologically informed environments is the idea that actually, it must run all the way from the top to the bottom, and all around of every organisation that commits to it, otherwise it's not a truly psychologically informed environment. And I would say that for most of us, psychologically informed environments, PIE to most people, is an aspiration and not something that we've achieved. It's something that everybody is continuously working towards and will always be changing, because it should be responsive to the people that are working in or living in the, the environment that you've created. And there's, kind of, five underpinning pillars of psychologically informed environments, and I'm not going to go through all of the different practices underneath here.

 

I think one of the things that really strikes me about this is actually how a lot of this maps against the commissioning cycle. There's lots of talk about evidence, analysis, creating an understanding of the environment and the people that are being supported by a service or in a particular local area. And there's also a lot around activities of the particular policies, procedures, practices that might be implemented in a service, and how these keep people safe, how they keep people in a situation where they feel that they are able and willing to access what's available to them. And also, thinking about being creative, and I think for me, one of the reasons that I enjoy commissioning is 'cause it's an opportunity for creativity, particularly when you don't always have all of the money or all of the resources you might need, we often have to be creative. And I think psychologically informed environment principles really, kind of, tell us about why creativity and alternative responses to what we might traditionally think of are really important. And thinking specifically around safeguarding, the psychological frameworks that underpin our practice, so thinking about trauma informed care, gender informed ways of working, alternatives to evictions and exclusions, alternative responses to managing distress and conflict between service users, between service users and staff.

 

These are things that, as commissioners, we can really build into that service classification and design process. And also, build into the way that we as commissioners work with our providers. And an example of that, for, might be around evictions, for example. Often commissioners monitor how many people are being evicted from a hostel or a supported housing service. But often, what is not being monitored is why those decisions are being reached. Could they have been prevented and avoided? What happened that led up to that? And actually, in doing some of that analysis alongside providers and alongside service users, we can start to understand what's happening in the local system, in that particular service. How can we work together as commissioners to improve that service in a way which perhaps reduces evictions, but also makes sure that those decisions are made in a way which is appropriate and makes sense and is safe? And I think often because of the pressures that we're all under, there can be conflict between the things that are being monitored by commissioners and the reality of delivering those things on the ground.

 

And often where we see the effects of that, is in what happens to people accessing services. So, often being evicted might be a response to something that the provider organisation feels that they must do because the commissioner has asked for it. And that, kind of, chain of actions and reactions can, in relation to safeguarding in particular, can increase or reduce risk accordingly. So, I think it's really important that we understand as commissioners that what's happening in services, we have a direct relationship to, all the way through the commissioning practice and starting with the strategic priorities that we set in our local areas. So, you can see here there's a range of ways that psychologically-informed environments relate to commission, and often what we see is that actually, commissioners are always learning from provider organisations that we work with. Frontline practice and working with people with lived experience is where ideas, new innovations are generated. And as commissioners, what we're tasked with doing is taking those ideas and those practices, and building them into the system that we're responsible for commissioning. And, you know, we all have different levels of success with that and, to some degree, that's guided as well by the resources we have available and the local, the local systems we have and the funding.

 

My final slide. Oh, I've gone backwards. My final slide is about integration. I'm the housing-related support commissioner. I work really closely alongside commissioners in the NHS, in adult social care and children's services, and I think that one of the things that the Care Act really explicitly draws out is the need for integration between all elements of the system. And that runs, should run through commissioning practice as well. So, what you can see here is a model that I've been developing with colleagues across North Central London. It was developed by the Healthy London Partnership initially, and it's called the Our House Model. I've, sort of, shaped it slightly for the purpose of this presentation, but essentially it's looking at, what are the different elements of a system that supports a whole person to recover from homelessness and prevent the involvement of criminal justice organisations, reducing health crises, etcetera? And we've got, kind of, five pillars in the one that we look at. So, evidently, housing is crucial. What does housing commissioning contribute to that system? Health, and that, as you can see, includes a wide, wide range of different health services. I just wanted to draw out here that often when we think about health related to homelessness, we ignore or certainly de-prioritise certain aspects of health, one of which being things around sexual health, for example. Often, it's understood only at a point of somebody being at risk of harm, rather than being about relationships. So, there's something as well about the way in which health services, public health, should be thought about in relation to homelessness, which in practice isn't always seen as a priority.

 

Social care evidently, safeguarding practice, the assess, Care Act assessments, residential care facilities, hospital discharge pathways. All really, really important, and all of these services are often commissioned in some way either internally or externally by local authorities. And so, there's a key link there to be made between different commissioning practice taking place. Really crucially, I think, and something that's come out really strongly through the last year is the importance of, kind of, emotional and individual wellbeing, and relationships in community. Again, often seen as less important, perhaps, than say mental health or substance use support, but what we've really seen over the course of the last year, all of us have, is the importance of relationships and social connection. So, whilst this might not necessarily be activities that are commissioned, as a commissioner, these are things we can be thinking about utilising in our practice, and making sure is built into the kinds of support that we hope will be provided by the services we commission.

 

Harm and safety, so thinking about involvement with Police. Prisons and probation services. Thinking about the use of public space, and how that homelessness commissioning and homelessness strategy can think about public spaces. We know that a lot of homeless people, the safeguarding incidents that they experience don't take place in their homes necessarily. They often take place outside. They often take place in parks, on the streets. So, how does our commissioning practice think about the environments that we work in, and work with community safety colleagues, etcetera, and embed some of those mechanisms in the first place.

 

Underpinning all of that is opportunities for joint commissioning. So, how do we pull our funding together? So, how might I fund a service alongside an NHS colleague, which looks at a health outcome as well as a homelessness outcome together? How do our referral processes, assessment processes, reduce the risks that people experience? So, for example, how do we effectively share data about risk? And how do we do that in a way which also doesn't define somebody solely by things that have happened to them fifteen years ago? And, as commissioners, how do we think about how we commission services in a way which enables provider organisations to do that and work with people in a person-centred way? And you can see a number of other things there. I think, importantly, it's having that shared vision and principles across the organisations, and particularly a shared commitment to safety, and to risk assessment and management, and supporting people to plan for their own safety. And then, as I've had all the way through my presentation, is the underpinning co-production, and this is really drawn out in, in safeguarding practice around things like making safeguarding personal. And other aspects around choice and empowerment. How do people make their own decisions, and how as commissioners do we create enough space in the services that we commission to allow for that?

 

Often, you might see a service classification, for example, 50 pages long, describing every single activity that is and isn't acceptable under that service. So, that doesn't leave any room for personalisation or for choice. It doesn't allow any room for creativity or innovation either. And it's often born out of an idea of the, of a deficit. A commissioner needs to describe everything that will be done otherwise a provider won't do it. So, there's something about that trust that is developed between commissioners and provider organisations, which is really key. And I think, again, that thread running through. How do we then share that trust with our service users? Work with them around their safety, around the risks and vulnerabilities they experience, in a particular way in, within a service that's been commissioned, so that everybody involved is, kind of, linked together. And again, the providers and frontline practitioners are not having to navigate around their commissioners in order to achieve things, but are able to work together. And, I guess, I'm finishing on this slide, but what I want to, kind of, leave as a take-away is that I think commissioning is often understood, and relationships with commissioners are often understood as something which can be quite challenging or that can certainly be about, again, that navigation. How do, what do we tell our commissioners? What do we tell our providers? What is our relationship? What's a secret? What's not a secret?

 

And, I guess, for me as a commissioner, the practice that I'm trying to develop is around being accountable, being transparent, and equally about being equally responsible for the outcomes that people achieve. Because, as a commissioner, I have described what those are, and I think that's something that is really important around safeguarding. It's that sense that we all have a shared responsibility in keeping people safe and supporting them to keep themselves safe. And through the pandemic, we've really seen that coming to the fore, particularly in the ways that peer support has been bedded into commissioning and service delivery, and the ways that people have kept themselves safe by working together. So, thank you very much. That's all from me.

 

Moderator: Thanks, Jill, that's really, really helpful. I'm going to take chair's prerogative and ask you a question before anyone else gets in there and Michael pulls some more questions through. That last comment you made about what's happened during this last, almost a year now with COVID. I suppose I'm interested in, in all those areas, to what extent COVID's had an impact on commissioning practice, and whether you could just say a bit about how, in particularly vis-à-vis safeguarding, the particular challenges since February last year and how commissioners have responded to that? Would you mind-,

 

F: Yeah. I think one of the, kind of, key things about the last year has been how rapid and reactive commissioning has had to be. Normally commission, a commissioning cycle may take five years from the first idea to when the contract ends, or even longer. So, I think we've had to work really, really quickly, and I think in some ways what that's done is reduce the bureaucracy. We haven't had the time to do and think about all of the many, many documents that we would have been expected to do before. And, what that's enabled us to do is respond much more quickly to what's going on on the ground. It has meant that we've had to think about some of the regulations differently. So, procurement practice has changed. In relation to safeguarding, I think one of the challenges I've had as a commissioner is during the pandemic in particular, thinking about the hotels and commissioning support into the hotels, they're often buildings that are not in the borough that you're commissioning services in. Equally, those people are then placed in a borough that they're not normally living in, and the way that safeguarding works means obviously they're then, the safeguarding alert would be made to a different council who doesn't know them. And, actually, as local authorities communicating that as commissioners and talking about what's happening to clients in services, etcetera, is really hard, and because people have moved around so quickly it's, it's made that quite a challenge. So, I would say that, kind of, cross-borough, cross-boundary working has been the biggest challenge as a commissioner during this period. That said, it has also created opportunities for better working relationships. I've certainly learnt about some quite interesting safeguarding practice in other London boroughs during this time, that I wouldn't have known about had I not had this way of working.

 

F: Thanks, thanks, Jill. I'm going to privilege the one question that's come in on the Q&A before I follow up with one or two thoughts of my own. But, Paul has asked whether you think immigration status should be included somewhere in your house. I really like the house, incidentally. I think it's a lovely metaphor.

 

F: I like it.

 

F: But, whether immigration status should be included under social care or perhaps under, under, under all of the boundaries of the house.

 

F: Yes. I mean, I think in, this year, in particular, has shown us just how vast the gap is between the experiences of people who are British citizens and those who have no recourse to public funds or who don't have EU settled status. One of the things that I've felt really fortunate this year to be able to do, is for the first time, to commission some dedicated immigration advice for homeless people in my borough. And, that has only been possible because of the pandemic. And, what that has enabled us to do really, really quickly is understand people's access to services, whether or not they're getting their entitlements under the law, etcetera. And often, as we know, for people who don't have British citizenship, accessing accommodation is quite frequently through social care provisions. So, through safeguarding and social care need. And so, for me, immigration status has to run through all of what we do. Unfortunately, as commissioners, we're often very limited in what we can commission for people who don't have recourse to public funds, and that often means being quite creative about where we do have responsibilities and duties, but also thinking about, how do other bits of the system that are not commissioned respond?

 

So, one thing that I've felt very, very privileged to be able to do this year is work really closely with non-commissioned night shelters, organisations like Crisis, who are doing work which is, works with people regardless of their immigration status, and that I might not be able to commission directly but what I can do is make sure that my services are working more in alignment with those organisations. And so, yes, absolutely. Immigration status has to be everywhere.

 

F: Yeah, and, and what we know from safeguarding adult reviews in recent times, including the national analysis, that Adie (ph 43.27) commissioned myself and search in practice to, to do, is that services are paying insufficient regard to people's race, culture, religion, language, heritage, in short. And, and, that all of that should be underpinning commissioning and indeed service provision just as you have rightly emphasised, gender and trauma. It's, it's, it's, it's, it's another overarching concern that should inform what we do.

 

F: Definitely. We've looked at this year again, because of what happened and has happened in the US and the impact it's had nationally, one of the things that we've just started doing, which I think will really influence our commissioning practice, is understanding the racial inequalities around things such as evictions, warnings, positive and not-positive move-on, and we can see very, very clearly that in particular black men are vastly over-represented in all of the poorer, most negative outcomes. And, that tells us something about what the gaps are, so, yeah.

 

F: Okay. And then, another question that's come in, this time from Ed. Asking, with increasing deaths of homeless individuals on the streets, how can we ensure that deaths are scrutinised as part of adult safeguarding reviews, and could someone please explain the difference between a learning review and a SAR? Well, I'm quite happy to answer the second part of that, the difference between a learning review and a SAR, and I'll do that in a moment, Jill. But, I know that you've led in Harringay on fatality reviews and the interface between fatality reviews, and the adult safeguarding board and its section 44 SAR mandate.

 

F: Absolutely.

 

F: And, I know that that's been picked up by a number of other local authorities and SABs. So, perhaps you might answer the first part of Ed's question with your thoughts on learning from tragic deaths.

 

F: Absolutely. So, thanks, Ed, for your question. I think perhaps the root of this question is that often the deaths of homeless people, until fairly recently, were not understood as safeguarding adult concerns, and so many safeguarding adult review opportunities were missed for homeless people. That's significantly changed thanks to the work that Adie and Michael have been doing in particular over the last couple of years. One of the things that we've done in Harringay is, in recognising that, we've then developed and implemented what we call homelessness fatality review procedures. Under the Care Act, safeguarding adults boards have the power to implement any review process that they want, to look into either a death or a serious incident. So, in Harringay, we've developed the homelessness fatality review process to make sure that every single death on the streets and in our hostels is reviewed. We borrowed from what is called Leader, so that's the review process that looks at learning-disabled adults' deaths and children's deaths. And, the reason that we looked at that particular review process was because one of the key things that we wanted to capture in our reviews, was the person.

 

Often homeless people, and particularly when talking about bad incidents, negative situations, are talked about in relation to their needs, their risk, what they didn't do, what was deficit in their lives, what they failed to engage with. And, one of the things that the Leader process really wants to draw out is the human-being. What they did, what they were good at, what they wanted in their lives. Who cared about them and in what ways was that care evident in their lives? And so, for us, developing this review process has enabled us to not only learn but also to hold ourselves and others to account, and our review process is directly connected to safeguarding adults reviews. So, for example, we might conduct a homelessness fatality review and, in doing that, identify that a safeguarding adults review would be beneficial. And then, our review becomes evidence to that, to the safeguarding adults review. And, and in other, in other cases, we might conduct our review and identify that the person didn't have any care and support needs, and so the review itself becomes a learning opportunity for the people involved.

 

I can see someone's got a question that says, am I able to share the review process? Absolutely. I did a workshop for the LGA on the review process that we have last year, so I can share the slides, perhaps again, with everybody who's come today, if that will be useful. So, yes, that's what we've done, and what we've learned from that is similar things to what the safeguarding adults review processes have shown. And, that's been really encouraging in that we're learning similar things, and it's telling us that the system needs to change. But, what we've also learnt is actually how important that relation, that connection between safeguarding adults reviews and homelessness practice really is. So, yes, thanks.

 

F: Okay, thanks, Jill. And, I'll just answer the second part of Ed's question. Ed, I, as a first, the first issue that needs to be resolved by a safeguarding adult board is whether the board is commissioning a review under Section 44, subsections 1, 2 and 3, which is a mandatory review where 3 criteria are met, and therefore an independent chair like Adie or myself has no discretion. A review must be commissioned. Or, whether the board is exercising its powers under Section 44, subsection 4 of the Care Act, to commission a discretionary review. In other words, all of the criteria for a mandatory review are not met, but the board nonetheless believes that there is learning to be had from, from reviewing a particular case or a number of cases. And, the board exercises its discretion. So, that's the first question the board must answer. Is it a mandatory or a discretionary review? The next question the board must then answer is, how are we going to do the review? Are we going to do a review that is thematic, that looks at a number of cases, and looks at the commonalities and the differences between cases? Or, are we just going to focus on one review? One case. Are we going to use a learning review-type methodology, or are we going to use some other kind of methodology? So, the short answer to your question is that there is no difference between a SAR and a learning review. The key questions are, is it mandatory or discretionary? And then, what is the methodology that we are going, that we're going to use?

 

There are examples of reviews, thematic reviews. Adie and I did one that's been published by Oxfordshire. That's a thematic review. There are also examples of single-case reviews, which are mentioned in the learning briefing that is on the LGA website, that I wrote and that Adie mentioned at the beginning. And, a session, I think it's session five in this sequence of webinars, will have an update from me on reviews. So, I hope that helps, Ed. There's nothing else in the chat-box at the moment but we've still got a few more minutes. So, Jill, if, if, if I can take the liberty now of, of asking a question. You talked about integrated commissioning and you talked about that in the context of health, housing, social care, in a sense pooling all of their perspectives together. I wondered whether you've got any thoughts about integrated commissioning in, in the context of local authorities working with each other? So, if we were to take London, for example, as an example, how Harringay, to use your context, might work with neighbouring boroughs to share the responsibility for commissioning market-shaping and, and, and so forth. Whether you've got any thoughts on that.

 

F: Yes, definitely. So, in London, and I know this is also the case in a number of other cities and in unitary and secondary authorities, there is a lot of joint commissioning across borough boundaries. It's not without complexity in that we all have different amounts of money, and different priorities and principles, but it does happen. So, to give the, kind of, London example. There's a number of homelessness pan-London commissioned services. So, thinking about our outreach team, for example. There's a pan-London street outreach team called the Rapid Response Team. The reason why that's commissioned for London is because obviously, people move around. Also, people might sleep, might live in one borough but rough-sleep in another borough, and there's lots of reasons why people do that. So, having a pan-London approach to street outreach helps to make sure that resources are used effectively, etcetera. What it also does is gives London boroughs one place to go to for that, kind of, conversation, and things like Street Link, which is a mechanism that most people will be aware of, underpins that pan-London commissioning to enable people to access this one place.

 

Also in London, we commission with neighbouring local authorities. So, I'm part of the North London Housing Partnership, and we commission together a number of different things, including night shelters, immigration advice at the moment. Particularly a lot of support for EA nationals we commission on a North London level. And also, one of the things that we do that is beneficial to that joint commissioning is, when the need is quite small in one individual area, when we work together we're able to commission something. So, for example, we're looking into youth homelessness at the moment on a pan-London level, and recognising that young people who rough-sleep make up quite a small proportion, but of course, they have a really specific need and they often are coming from quite particular backgrounds and experiences. But, individual boroughs might not want to commission a service for five young people, for example, so working in partnership, we're able to commission services together.

 

What's also really great about that is that people don't always want to stay in the borough that they're from, for various reasons including safety. Being able to offer somebody something in another borough is a really crucial part of maintaining people's safety. So, yes, it does happen. It often is quite complex, but it's also often, for me, really enjoyable because you learn a lot about the different commissioning practices in different boroughs, and the different things that they have available to them. So, it's something I think which we should all be doing more of if we can.

 

F: Okay. Thanks, thanks for that, Jill. There's still nothing else in the chat-box, but I would encourage the 106 or so people that are currently listening to this to, to continue to use the chat, sorry, not the chat function, the Q&A function as we go through the rest of the morning. We've got five minutes left.

 

Moderator: No, we're, no we're breaking now, Michael, actually-,

 

F: Oh, are we? Okay.

 

Moderator: Yeah.

 

F: Alright.

 

Moderator: Sorry to interrupt.

 

F: That saves Jill from another question-,

 

Moderator: So, according to my timetable. Thank you so much, Jill, really, really thorough and comprehensive presentation. Really insightful in terms of the Q&As as well. So, thank you so much and hopefully you'll stay with us for the morning if people have further questions after Bex's presentation. So, just to tell everyone that we've got a ten-minute break. If we can rejoin at 11:05 that would be really helpful. But, go and make yourself a cup of coffee, come back in ten minutes, and then I'll hand over to Bex to talk about providing services in the second half of this morning's seminar. Thank you so much, everyone, for your contributions and for people who put up the questions, and see you in ten minutes. Just don't log off, just go away for, for ten minutes. Well, hopefully, welcome back, everyone. Can I just remind people to use the Q&A function to ask questions of speakers? And I'm really pleased, this morning, to welcome Becks, Rebecca Pritchard from Crisis, to talk us-, to us about commissioning safeguarding-, commissioning services for people who are homeless, experiencing homelessness, from a provider's perspective. So, really complimenting Jill's presentation, looking at this whole area from a, a commissioner's perspective. So, over to you, Rebecca. If you could share your screen and I'll go on mute.

 

F: Thanks very much, Adi. And thank you to everybody who is still with us. Yeah, I'm, I'm probably not going to be quite as articulate as Jill was, but this is very much a provider's perspective on commissioning. A bit of a disclaimer, I'm predominantly a provider. I have had roles within commissioning, I helped set up the Supporting People programme for Surrey, and was Interim Manager for Cornwall some years ago, which certainly dates me, I think. I'm currently working for Crisis. Most of our funding comes through voluntary fundraising, and, and different trusts, and grants, and corporates. So, we aren't actually a commissioned provider in the majority of locations where we operate. So, I want to make that as a disclaimer. But hopefully-, I've also got experience as a trustee for existing organisations who are commissions, and have been with them for the last five or six years, so hopefully the provider perspective feels legitimate. Just trying to see if this will-, right. A bit about Crisis, for those who don't know. We are a national homelessness charity, and our work is all about ending homelessness. The bits of the organisation I have responsibility for works with around 8 or 9,000 people each year in England, Wales and Scotland, which from a safeguarding perspective is a joy, as there's three different sets of legislation to get your head round. But a big part of our work is around research and evaluation around what works to end homelessness, and influencing and campaigning to build public commitment to the fact that, you know, homelessness is not inevitable. It can be ended, it should be ended, it will be ended. So, I think some of my presentation will repeat some of what Jill covered, but hopefully that's a repetition for emphasis kind of repetition, and I won't dwell too long on the areas where there is-, there is overlap. Commissioning, as, as-, as Jill very clearly talked about, is a process, or a series of processes, very much around analysis planning, securing services, and reviewing them, which I think fits exactly with her, her structure. So, it's great that we are both on the same page for that. I think good commissioning-, and I think what Jill was describing was primarily-, was pretty much really good commissioning, all the way through. It's described by ADAS and LGA, in this, kind of, document, or, or-, or slide, here. And it has these-, it has four key areas, and I added in 'Integration' to it.

 

And there's nothing really here that I think people would disagree with. You know, it's very much about good commissioning being person-centred and outcome-focused, and promoting health and wellbeing for all. It should be co-produced with local people, their carers. For that, I would also add in, 'And providers, and the communities'. It should promote equality of outcome, as well as really positive experiences. Commissioning needs to be well-led, and it really needs a whole system approach, and I think particularly for homelessness, where people are often presenting with complex needs, which don't necessarily fit easily into predetermined structures and thresholds for, for service eligibility. A whole system approach is really key, and it needs to be evidence-based. So, you really-, we really need to be clear about what is working, what isn't working. And I think sometimes commissioning can work against that, that learning process. It's great to see Jill's very much focused on, on that approach, but I think from a provider perspective, particularly in a competitive tendering-based environment, it's quite hard to be open to learning. You know, when you're competing against others, that can engender defensiveness. So, I think it is really exciting to see somebody like Jill talking about a psychologically-informed approach, and a whole system approach, as well, that, that will really support that approach. And also, commissioning needs to, obviously, deliver value for money, but it also needs to have a sustainable and diverse market, and I think some of the things that we've experienced as both commissioners and providers over the last, sort of, decade or so means that-, and I think Jill picked up on it and-, in one of her comments around, you know, that efficiency drive maybe has gone beyond where it's actually effective, and people are less sustainable, there's less diversity, and value for money isn't just about a focus on price. You know, it really just needs to be reviewed, I think, and revisited. And it's also about developing workforce. And as a provider, sometimes the first thing to go in your discretionary spend, and it shouldn't be discretionary, is that investment in the skills and training of your staff.

 

And when we obviously go through the presentation, we'll really look at the, the-, the challenges that people are facing and having to work through, and the skills that you need your providers to have, and the confidence, the expertise to safeguard people who are homeless means that actually if, if the contract prices have got to a point where, you know, it's hard for providers to invest in that training, then I think commissioning can step in and, and, sort of, help fill that gap, on a-, on a level playing field. And it absolutely needs to be integrated, particularly, as I said, for people who often end up falling between the gaps. Quality, I think, won't go into that too much, but it is about effectiveness. It is about sustainability, it's about positive experience, and as Jill talked about, it's about innovating and responding to people's needs, and being innovative on an ongoing basis, not just when a-, you know, the Covid-led crisis has forced us into that. But also recognising that, that there is a cost to safety and continual improvement, and again, I think that some of the things that have been challenging for all of us, and this isn't just a, you know, a provider's, you know, perspective, it's, it's recognising the impact on all of us, and it has been a real difficulty, so, to really fund and, and-, and, you know, recognise the cost of quality in our contracting.

 

So, what gets in the way of good commissioning? Basically, I don't have an extra slide on funding and austerity, because I think most of us have experienced it. Jill talked about it, I, I-, I've mentioned it, already. There has been, over the last decade, and actually ever since-, almost since the Supporting People programme started after-, as a provider and commissioning sector in the run up to, to Supporting People. I think, you know, the original estimation from central government was that, you know, we were spending about .6 of a billion, £600 million a year on supported housing and housing-related support services. And that had gone up to 1.6 billion at the beginning of the programme, and, you know, by March 2002. And the treasury has been rather unimpressed with that, and, and-, that actually drove an awful lot of-, you know, a focus on what was eligible for Supporting People funding, and that really, I think, has influenced the, the issues around focusing on activities, rather than outcomes, that Jill did allude to. Some of the other issues, I think that have, have-, have been driven by austerity is the rise in non-commissioned services, and that's why I wanted to put the disclaimer in. I don't count myself amongst the, the challenging organisations, there. We have our own internal commissioning, and we are our own-, you know, our-, we do constantly try and, and challenge, and we're also fortunate that we can invest in, in the skills that our teams need. There's issues around power imbalances, and then there is, despite the importance of integration, there is still a real challenge and a barrier to good commissioning because of that lack of integration. So, I'm not going to say any more about austerity, but I am going to talk about non-commissioned services briefly. We have seen a-, quite a significant increase in what's known as 'support exempt' providers across the country, as margins have got tighter and services have been closed. Support exempt accommodation is, is accommodation that's provided by non-metropolitan county-, that should be 'county' councils, housing associations, registered charities or voluntary organisations, where there, there is a link between the provision of accommodation and the provision of care, support or supervision. The majority of those services are probably fine, but there's very little governance of them.

 

Some of them will be registered through the Social Housing Regulator, or the Charity Commission, but actually, on the ground, a lot of the time it's the housing benefit teams who are the closest to what's going on. Those services have developed outside commissioned pathways, and whilst most of them are very well intentioned, there have been examples of financial and institutional abuse, and a real lack of safety among those non-commissioned services. So, it's something that is a challenge for providers, and, and commissioners, because I think you do need to, to consider them, as-, even though you're not actually funding them. But, there's some really good work that's come out recently in Birmingham, and it's highlighted in recent government guidance, MHCLG guidance, around how to ensure even non-commissioned services are safe. But, you know, as a provider working with people across the, the country, we've ended up having to make safeguarding referrals, both in the North East, West Midlands and South London, for people who have come to us who are being financially and institutionally abused in those services. So, that's a-, I think that adds a different level of complexity.

 

There are real power imbalances. I think Jill's approach was really positive, but as I said, you know, it's very difficult to learn and actually be as honest as you'd want to be with your commissioner in a situation where you know that your-, you know, your contract is only for the next year or two, and you're going to be competing. I think, also, key performance indicators, if they're not co-produced with the providers and, and-, and the clients, you can end up with unintended consequences. In a trustee role that I have, I, as the safeguarding lead on the trustee board, you know, I've had a look with, with some of the, the-, the senior staff, at quite a detailed coroner's report from an incident that happened nearly six years ago, which led to a very tragic death. A lot of that, I think-, the coroner took it right back to the point of referral into the system, which originally the team weren't that happy with, because they thought it should have been about a later point at which information around somebody's discharge back into that particular accommodation hadn't been shared with the organisation. But I think, you know, their-, the KPIs are about service utilisation, the speed of taking referrals, and actually pushing back and having the power to say, 'Hold on a sec, we're not sure about this client'. When you're being judged against quite specific KPIs-, can actually become a real challenge. And I think there's lots of situations where, you know, we often feel, as providers, that we're not seen as equal partners. You know, even where we are making really quite well-informed judgements and, you know, the information either isn't shared with us, or we are not invited to key situations. People don't accept our insights into clients' views and experiences as equally professionally informed. There's a sense that, you know, risks can be normalised. We still hear that people are choosing to sleep rough, and sometimes I like the-, you know, I absolutely agree that there should be lots and lots of expectations on us as providers, in terms of making safeguarding referrals, working in certain ways. But there's very often not an awful lot in those specifications that will reassure us that when we make those safeguarding referrals, we will have a, a timely reciprocated response, and that we'll be kept informed about what's happening. Sometimes it can feel very one way.

 

So, there's a lot of expectations set out for us, but the rest of the system, you know, doesn't actually-, there's no expectation on them to respond to us equally. And sometimes we can struggle to convene. Sometimes we are the best people to bring others together, and that's not always recognised. There's a couple of case studies that I'm not going to go into, but they basically exemplify those, those experiences. Fragmentation, I think there was a real loss, particularly around governance, when we lost the ringfence to Supporting People. You know, maybe I should be moving on after twelve years, but, you know, but the commissioning bodies really did bring really key people together, and there was much more of a focus on homelessness, compared with some of the health and wellbeing boards that are up and running at the moment. Housing is often recognised as a core component of health and wellbeing, but often there's a, there's a focus upon the quality and suitability of the accommodation, you know. There's the Housing LIN, which is a fantastic organisation, or, or-, or group of-, community of practice, but often that aspect dominates in health and wellbeing discussions, rather than homelessness and the lack of having it. And there are also, as you all know, boundary issues and, and legal and budget, sort of, issues. And there are still challenges with pools and joint commissioning.

 

I think also for, for clients who are homeless, you know, it's quite difficult to get the right data for people. And I do think, you know, unless you've got very specific commissioning strategies around homelessness, out of sight can be out of mind. We often talk about rough sleeping, people in hostels and supported housing, but people who are sofa-surfing and are, you know, more hidden are often not included and not recognised. And it's great to talk about people commissioning across boundaries, because people do move, and if you’re homeless, you're more likely to be moving round than others. And often, you know, people are seen as only having a tenuous local connection, and can often be excluded from commissioning decisions. What enables good commissioning? It's almost the converse of the things I've just been having a bit of a whinge about. I think absolutely respect and reciprocity, you know, as providers, we can be your equal partners. We can-, we don't want to hand off, we want to share responsibility for the safeguarding of our clients. We-, but we do need that, kind of, respect and, and people coming back to us and including us, and keeping us in the loop. I think it's, it's really good for JSNAs to have homelessness themes, and also for health and wellbeing boards to make sure that they have homelessness, and not just housing, represented on, on those boards. As I've said, you know, commissioners have a real key role in investing in the skills, and, and developing their workforce to level up, and maybe challenge some of the, kind of, downward pressure on contract prices and the implications that has for quality and investment longer term. Really do believe in, in setting really good, outcome-focused KPIs, alongside the people with lived experience and the providers, and moving away from activity-based contract monitoring to experience and outcome-based. It really can help reduce the risk of unintended consequences. I've worked in drug and alcohol treatment services in the past, and picked up a number of contracts some years ago that were part of the PBR pilot, the Payment By Result pilot. And the commissioner in that particular area was very keen on public health, and so huge amounts of payments in that contract were linked to people having dry blood tests, and, you know, blood-borne virus, hepatitis vaccinations, and it was very difficult to create really positive relationships with new clients when, really, what you wanted to do was jab them in-, you know, jab them and, and inject them, and that often got in the way of really good conversations, and actually, drove the wrong behaviours. So, having that dialogue with-, setting those outcomes will help reduce the risk of that. I think also using competitive dialogues, bringing providers together to set service specifications, and, you know, not-, if you can, having very short contract cycles will support investment and development, and some good work that, that's happened in York over the years that, that actually took on that approach.

 

I think to be person-centred, you've got to be systemic, and at a systems level in your service commissioning, because again, people have complexities and they might not meet specific thresholds. So, you've got to be systemic if you're going to be person-centred when you're designing services, and commissioning around people and around their needs. And I think there's a real power that the Safeguarding Adult Boards have to convene and to help drive that dialogue, bring people together, cross boundaries, because they are the ones that are ultimately seeing what can happen if commissioning and the delivery of the-, of services isn't, isn't right. This comes from a, a-, a publication around-, from the King's Fund, which is really looking at particularly healthcare, as opposed to safeguarding, but it is about going above and beyond, or at least going above and beyond our normal practice in order to get people the right outcomes. And that really talks about, you know, really taking steps to find and engage people, and I would say not just sleeping rough, but who are homeless and hidden. Again, it talks about building and enforce-, you know, supporting the workforce, being very relationship-focused and recognising that sometimes, the voluntary sector has the opportunity to create relationships with people that are much more relational, and it comes back to power, you know, much more-, we-, there is still a power imbalance there, but sometimes, you know, it, it can be much more focused around that individual's priorities, rather than what the commissioner thought the right priorities should be, and what the provider is trying to achieve. It needs to be tailored to local context, but it absolutely recognises the importance and power of commissioning to bring people together and really engage, and I think a lot of the work that-, the description that, that Jill gave earlier would really help achieve that.

 

And finally, from my provider's perspective, we are your trusted partners. Do involve us, we can help design services, and we want to design them around the outcomes and the impacts, rather than processes and activities, because that gives us the power to be person-centred, to flex, to change. When I was a commissioner, one of my favourite providers would come to me and say, 'You know what, it's not working. We think this would work better', you know, and actually, it might not have been in the spec, and I might not have followed perfect procurement practice every time, but we got much better outcomes by working collaboratively in that, in that approach. Absolutely, I think you-, we, we need to invest to save, if we provide training, and actually if we facilitate reflective practice for providers, rather than telling them that it's something they should do. It's actually quite complex, it's quite challenging, it's quite difficult. It needs to have the whole management team, it takes time to have reflective practice, but it will get better outcomes, and I think it's something that potentially, commissioners have got the power to commission at a much better price than organisations who maybe have to outsource that because they don't have the skills in-house. Do recognise that we will have different perspectives on, on individuals. Our relationships are different with them compared with statutory services, and we're often seeing things that others might not in different situations. So, it's important that we are heard. We would like you to have high expectations of us, but also have them of your statutory colleagues. Do get back to us in the time scales and please don't make us have to be tenacious and persistent and a pain in the, the proverbial in order to get responses for our clients. And I think absolutely, as Jill was talking about, you know, we're all in it together, it's a challenging environment out there and I think it's really important that we convene together to innovate and be creative, and that includes people with lived experience, and providers, and I think we will get better outcomes for the clients who need us to get outcomes with them and for them together, in that, kind of, much more collaborative approach.

 

Moderator: Thank you so much, Bex, that was really really helpful in terms of complimenting but also giving an alternative perspective on commissioning from your perspective, from your position. I'm going to again use my chair prerogative to ask you actually the same question that I asked Jill which is from a provider side in terms of commissioning, in terms of safeguarding, what's the, sort of, impact, what are the new challenges since last February, because of the Covid pandemic, how have you seen those changes play out, and then I'll pass over to Michael.

 

F: I think with my Trustee hat on, we've had some really great support from commissioners, some of them have put reprocurement timetables to one side and extended contracts because, you know, what we don’t need is any more instability and insecurity. And that has been much appreciated. They’ve actually provided additional funding to help us re-, you know, respond appropriately, so we’ve had things like parking passes, you know, for car parks or, you know, parking restrictions so that we can go and visit clients face-to-face in the community, socially distanced, but actually do it without using public transport, which reduces not just the risk to the staff, but also reduces the risk to the clients that they're visiting. So there's been some really good stuff there. I think in terms of safeguarding, one of the real challenges is that we have ended up working more remotely, I think that means that, it took us a while to, you know, as a provider in terms of safeguarding, and I think probably from a safeguarding team's perspective as well, are-, the alerts that I saw, that I see across our piece, they dipped very slightly in the first few months, or first couple of months. Because we were trying-, we were missing things, you know, and I think there has been risk there. I'm quite happy now the number of alerts are back to normal. There's been impacts, just practical impacts on people's availability of health staff, and actually, you know, sort of, being able to go and visit and really engage with people.

 

Sort of, you know, to, to really check out what's going on for people, so I think there are risks associated with that. But, you know, one of the things we've been able to do, through our fundraising and various other things is make sure that everybody that needs one has a smart phone, and we've been providing data so that we can have interactions over Zoom and things like that with people, or FaceTime, so we actually get to see people, and we've kept staff going and visiting people, even if it's, sort of, like, talking at the door, rather than going in, but there are those sorts of challenges, actually getting in and, and seeing what's going on, so some real practical things there. But I think also the other thing that we've seen is a huge-, and actually I see it, because I read every single incident and actually on a quarterly basis I review all of the incidents that have come in in that quarter, which is what I was doing between Christmas and New Year, which is a fun thing to do, the amount of anxiety and risk, real risk, you know, real overdoses, real serious self-harms, there's been a lot of suicide risks, I know that's often seen as mental health, but actually a lot of people are self-neglecting. And one of the things that we've learnt as well is when our staff are supporting people who are in a lot of distress, it's hard enough if you like, to do it at work. When you're doing it in your bedroom, or at the kitchen table with your 12-year-olds home-schooling, you know, it becomes really stressful. So it becomes much more intensive to support people, to do the right work, so I think those are some of the real practical challenges that we have experienced and that we're learning our way through.

 

Moderator: Thank you, Bex, I think those issues that you've raised are concerns and challenges across the whole system. I think it, it's particularly exacerbated in terms of people experiencing homelessness because of the change in their lives and the challenges in their lives, and as you’ve described the shift in, in working and that drop in concerns in the beginning of the pandemic is something that has been reflected in the national data so I'm not surprised to hear that. But then accompanied with a surge upwards as those, those concerns didn't go away, it wasn't that those risks went away, they come through differently, and there is a huge concern around the ongoing impact of isolation, social isolation and self-neglect, the cross-over or the interface with suicide risk as you describe, and mental health issues around this. And I think across the whole system but particularly for, for people experiencing homelessness, it has to be an ongoing challenge for us, particularly now as we're in this third wave. So thank you for providing that insight, Michael I'm going to hand over to you to deal with the questions that have come through the Q and A, thanks.

 

M: Okay, thank you, Adi, I think that both Bex and indeed Jill, they have answers to the three issues that have come into the chat function, so maybe I'll go through the three issues in turn, and maybe ask Bex to respond first and then, and then Jill to add. So the first of the three issues was about the advantages and disadvantages of mixed funding streams, so if you are a, a s I understand the question, if you're a provider and your funding is coming from not just the local authority, but from other sources for a service, what might be the advantages and disadvantages of that, and then maybe Jill can, going back to her theme of integration, talk about the advantages and disadvantages of commissioners having to put together different funding streams in order to provide a service.

 

F: Okay, go on, I mean one of the joys of my current role is that we have a whole fundraising team who do all of the, all of the, where we've got restricted funding, all the returns and things like that, but yeah, it takes me back to my days at Centrepoint and Thames Reach and other places. Yeah, I think the pros and cons, the pros are that you can actually add value, with different income streams, you know, actually have restricted, or unrestricted, I mean restricted funding is, is, is useful because that can add in additional posts, unrestricted funding is a joy because you can really follow the evidence and really innovate and, and do what, what really works. It can obviously give you a real advantage in terms of presenting added value, it gives you a way of, sort of, spreading your risk in terms of your funding, so it’s not all in one place. I think some of the challenges though if, I mean, you know, the, is that you do have to monitor really carefully, sometimes you have different KPIs and different outcomes that you’re having to report on for the same service, and it can be a real challenge when they are not-, you know, they're not the same duration for funds so, you know, you’re having to remember which bit is running out when and, you know, re-, you know, recycle that. And I think sometimes the cost of tendering isn't always under-, I mean I'm sure the commissioners do understand it, but sometimes I think, ya know, the amount of number of times you have to recycle your bids and things like that’s, it's, it's, it's a bit of, you know, it has a real cost, it takes a lot of time, and it's probably one of the reasons I’ve been at Crisis for longer than most other organisations, because I don’t have to do it at the moment, and it's really rather nice. But I think it does give you-, you know, it does spread risk, it can bring added value, it can bring different perspectives, but it's complicated and time-consuming.

 

M: Okay, thanks Bex. Jill, anything you want to add?

 

F: I think, well, from the point of view of a commissioner, I guess the, one of the advantages of mixed funding is about bringing investment from other commissioners, so particularly in homelessness, and we’ve seen it really really strongly this year, joint commissioning between homelessness and health organisations has really improved what's available for homeless people around their health. And I think as a commissioner it also means that you get a bit of an insight into what other commissioners priorities are, and start to be able to bring those together. It is really really challenging, because our funding all has specific outcomes and requirements, and so bringing them together can take quite a long time. And actually from the point of view of, and Bex mentioned this, the cost of tendering exists on both sides, and it’s a hugely laborious process for everybody involved. One thing I would say is a disadvantage when dealing with local authorities, and I don’t think this is exactly the question, what the question meant, but I think it’s useful, big organisations for example such as Crisis who've got fundraising teams are able to leverage huge amounts of added value and additional funding. Small local organisations that don’t have fundraising teams can't do the same thing, and so when you come to commissioning and tendering, the added value that some organisations can offer is irresistible to commissioners, even as we know that actually we might be commissioning with an organisation that doesn't have the same local knowledge or specific specialist expertise. And so I think often big organisations, and Bex mentioned this as well, in terms of what commissioning can do around competition, it, it can flatten competition, so I think there are advantages and disadvantages to having it and not having it, but there's definitely something for commissioners in terms of not advantaging too much those organisations that can bring in that added value, and also valuing that local knowledge and expertise, even where it's not additional funding.

 

M: Okay, thanks, Jill. The second and the third questions are perhaps inhabiting similar areas, but I'll, I'll deal with them separately. So the second question to come in was about private landlords and letting agencies, and the experience of the questioner, the private landlords and letting agencies are, are perhaps abusing the legal entitlements of tenants, and the question was about how can we improve the legal protections for tenants who may be being exploited and their legal rights abused by private landlords and letting agencies. So I don’t know, Bex, whether you've got anything you want to start on, on that before I pass to Jill?

 

F: Yeah, well I would say, you know, I suppose a bit of a, a plug is we have a best practice team, we have a campaigning team, we have an influencing team, so if you’ve got examples of that, you know, or particular concerns, then, you know, we understand where you're coming from and it would be great to, sort of, share intelligence on that. You know, I suppose it's-, yes, I mean, I think sometimes because I’ve been around for so long in this sector, I, I still get shocked at the quality of the private rental sector accommodation that is available, particularly in London, and in, in markets that are much tighter and, and much more competitive. You know, and, and whether or not homelessness can be sustainably ended in, in, in some of that provision particularly where people, you know, are subject to the shared accommodation rates, you know, it's, it's, it's just not what it used to be, even, sort of, 20 years ago. I think there are really good examples in Wales and Scotland, where people, tenants have got better private rights. I would also say that actually this is where commissioning potentially can come in, into the mix alongside partners within the local authority, and actually look at, you know, sort of, registering landlords, you know, again austerity has really had an impact on, on the power of the, you know, the, sort of, rent officers and the environmental health teams to go and, sort of, like, police regulate the private sector. But there is, you know, I think, there is still capacity in the system for the worst of those abusers. It's also about making sure, I mean, one of the, one of the things that we've done is we have procurement teams now, rather than having our housing coaches all scrambling around and all trying to do a little bit of something, we've actually got a couple of specialists in our London services who go and actively seek out good landlords and work on a, kind of, reciprocal basis. We also check who we are placing with, and, and there is some really good practice resources still around, I think it is just about reporting to the relevant people in the local authorities if you think people are actually breaking the law, in terms of health and safety, and also I guess the eviction ban at the moment, you know, it is still in place, I think it’s been extended now till the end of March, or was it June, I think it might even have gone to June, anyway. You know, we know that there are still people being put under pressure so-

 

M: Sorry Bex, and, but I would add to that based on my knowledge of some safeguarding adult reviews that I’ve been reading recently, not least the national analysis, referring in adult safeguarding concerns, if you become aware that somebody with care and support needs is, is living in wholly unsuitable accommodation, rather than simply coming disattuned to the risks that arise from living in damp, unhygienic, without heating and running water-type accommodation, so referring in adult safeguarding concerns is, is an important part of this equation. Jill, anything you want to add before I move onto the third question?

 

F: Only that I think, commissioners often have a role much more broad than commissioning, so for example relationships with private landlords, relationships to legal responsibilities that the council has, are all often a part of a commissioners role, so for me, we for example work with a number of private landlords, we have some landlord forums that the council has, and so my role there is to very much ensure that things like this don’t happen. Unfortunately they do all the time, and I think that, as, as Rebecca pointed out, it's really important that commissioners, provided, local authorities, use the powers that we have available to us to bring those things to attention of the right people as quickly as possible. And I think sometimes working with landlords as well to think about, well what do they need to be able to appropriately support people? There are landlords who want to do a good job in providing housing for people, and so identifying them and working with them, I think, is something that a lot of commissioners do do, kind of, aside from the tendering process of commissioning.

 

M: Thanks, Jill, and, and, one of the people in the, in the audience, as it were, today, has added, 'Making links with law centres and, and encouraging referrals to law centres as, as part and parcel.' Anna who, who kicked off this particular question has asked Bex whether she could have your email address and give you some examples from the area in which she's working? So perhaps Bex if you're prepared to share your email address in the Q and A box, if that’s possible, and then Anna can pick it up. The third question was about non-commissioned services and providers with competing agendas that may not about, that may not be about improving outcomes for citizens, but presumably lining pockets, and, and, and so forth. So again, whether Bex and Jill, you have any thoughts on what more could be done, in terms of challenging providers of non-commissioned services? So any thoughts in that area, I'm sure Ellie, who asked the question, whom I know, so good morning Ellie, whether you've got any, any thoughts for Ellie.

 

F: I mean, certainly this, the MHCLG issued just towards the end of last year Supported Housing Good Practice Standards, which were really aimed at the non-commissioned sector, there's some really good examples and good practice in there, particularly around Birmingham which I'm aware of because we made a couple of safeguarding referrals for people who were in non-commissioned, sort of, provision, and our, one of our former members of staff wrote a big report, I think she was very exercised by it in her role. I think, yes, do make the ref-, I think there's two things, there's the, kind of, regulatory approach, you know, make the safeguarding alerts, also have somebody really helpful like Michael to help confirm to the people you're making the safeguarding alert, that just because somebody isn't in registered care doesn't mean they don’t have care and support needs, which was one of the pushbacks that we’ve experienced when we’ve made those referrals in the past, and we're, like, going, 'Is that right? That doesn't seem right?' So we've sorted that out. But I think also it's about, a lot of those organisations, they are quite well intentioned, so it's, it's what can we do, as providers and commissioners, to support them, which is why it is about, you know, it’s not just regulation, basically having a, you know, inspecting and saying, 'This isn't good enough and we will-, not going to make you have, you know, agreeing with your increased housing benefit payments.' But it's working alongside them, offering them training, you know, bringing them into the, the pathways and bringing them into the fold, and I think it is really a key role for, for both providers who can work alongside, but also commissioners who can actually, just cause you're not funding them, doesn't mean you can't develop and support.

 

M: Thanks Bex, Jill, anything to add?

 

F: I would echo everything that Rebecca said but probably also to say that things like homelessness prevention boards and some of the work that's been enacted as the result of the Homelessness Reduction Act is a really good way of bringing all of the, kind of, players, if you like, in the homelessness system together, and think-, similarly thinking about writing your rough sleeping strategies, bearing in mind that whole system of commissioned and non-commissioned services is one way to do that. And I think for me one of the things that I’ve found, often between non-commissioned services, providers and the local authority, there's a lot of mistrust, there's a lot of a sense of people working away from each other and not towards each other, when actually often are aims are broadly similar, and so one of the things that I see my role as commissioner being is, kind of, enabling organisations to work together, even as they might have some different approaches, and seeing where there are similarities rather than only looking at the differences, and I think that's been particularly acute around faith-based organisations, so organisations like Housing Justice that supporting a lot of night shelters and faith-based organisations, have been really really helpful in, kind of, working with us to work through some of those tensions, and working through where there's a lot that we have in common and where there's that alignment. So for me that's been a real area of learning.

 

M: Okay, thanks, thanks Jill, and, and it strikes me, and, and I don’t know whether-, how many independent chairs of safeguarding adult boards there might be in the, in, in, in the webinar this morning, but certainly Adi and I are, are chairs of safeguarding adult boards, and it, and it strikes me listening to both the presentations this morning that SABs have a question to answer, which is how well-sighted they are on, on commissioning, and, and, and providers, and, in this whole area. And I suspect that for some SABs at least, there is more that SABs need to be doing to be well-sighted on this, on this particular area. So a person called I Scott has, has put in, in relation to evictions, has said, 'The ban extends at the moment to the 21st February, bailiffs not allowed, case, cases are still going to court.' So that’s obviously an area that we need to watch and advocate about in relation to, to central government. Anna I’ve picked up your message that you’re not sure that you can see Rebecca's email address, so I have it and with Rebecca's permission I'll email it to Anna afterwards, so, so that that link is, is made. There's nothing else that's in the Q and A, Adi I’ve lost total sight again of, of when I should be wrapping up.

 

Moderator: Well now I think we can, we can-

 

M: Thinking that we're wrapping up now.

 

Moderator: We're wrapping up now, so if you could just put up the slides on the other workshops that colleagues who have joined us this morning might be interested in, so do you want to talk through the other work that we're doing, just share your screen and-, or I can do it.

 

M: No, here it is.

 

Moderator: Excellent.

 

M: So, hopefully everyone can see that. So as Adi, who leads the Care and Health Improvement Programme, highlighted, there are eight webinars or seminars in the series, the first was on the 17th of December and you can find the slides on the LGA website, the slides for this particular seminar will be on the LGA website just as soon as Jill and Rebecca can send them to Nicky, who will then do the necessary to, to put them up. You'll see that on the 18th of January, in fact at 3 o'clock in the afternoon on the 18th of January, there is a session on Psychologically-informed and Reflective Practice, which picks up something that in particular Jill mentioned in, in her presentation, so I'm looking forward to that session, 3 o'clock on the 18th of January, hope as many of you as can will join that session. Then a session on the 25th of January, some of the speakers are still being confirmed but I'm hopeful that we may have speakers from local authorities, and indeed from Crisis again, Bex, there you go, it's a large organisation, on the 25th of January. That’s in the morning at 10 o'clock. And then you can see that there are further sessions in, in February and, and in March, so that's what's on offer, you can find all of these details on the Local Government Association webpages. In addition to that, we have launched, and you can find on the LGA website detail, a report on the first national analysis of safeguarding adult reviews in, in, in England, and there are some links there to where you can find those materials. And again under the Care and Health Improvement Programme there are some webinars on making safeguarding personal, and indeed there are a lot of making safeguarding personal resources also on the, on the LGA website, so again I'd encourage as many of you as can to sign up for those webinars. There's also the Insight Project that Adi is leading on, collecting data about the impact on adult safeguarding of the Covid-19 pandemic, and also some useful resources in relation to Section 42 and the duty of enquiry, that is in the Care Act, trying to identify best practice around safeguarding concerns and safeguarding enquiries. And there's an email address if you’ve got any, any queries or observations about any of the resources that I’ve just flagged up. So that's it from, from me, so just to emphasise again, the slides will be available on the LGA website just as soon as we can manage that, so that answers another question that's in the chat function. So I'm going to pass back to Adi, but before I do that, thank you Jill, and thank you Bex from me, it's-, I've learnt a lot this morning, it's been really informative, so thank you both. I'll pass back to Adi now to, to close the session.

 

Moderator: Thank you, Michael, and thank you Bex and Jill and Michael, thank you to colleagues at the LGA who have helped set up the session and are supporting us in the series. Thank you everybody who's joined us this morning, I hope you found it useful, as Michael said the presentations will be available on the website soon. There will be a short survey that's sent to you, please respond, we welcome your feedback, we've changed the structure today in response to feedback from the first session, so we do listen to what people tell us, and thank you everyone for coming this morning, and please stay safe, goodbye.

Presentations

Commissioning to safeguard people who are homeless – a commissioner’s perspective

Commissioning to safeguard people who are homeless – a provider’s perspective
Rebecca Pritchard
, Director of Services, Crisis