What is enough choice...and whose choice is it?

For choice and control to work well, there needs to be a good range of options available for people to choose between. The Care Act recognises this, placing a new duty on councils to shape local markets (Clause 5) to ensure their "sustainability," "quality" and "diversity" for the whole population, alongside putting personal budgets on a statutory footing for the first time. Naturally, what this means will be different from one area to the next given local needs and preferences, but the duty reflects the important role commissioners should play in shaping what is available in every area.

In reality, whether choice has increased as a consequence of people's individual purchasing decisions or diminished due to squeezed budgets is not an easy question to answer and both arguments might in fact be true for different parts of the country. The Act pushes in the direction of an increased role for micro-commissioning and personal budget pooling, with market shaping as a genuinely shared endeavour - all of which are positive developments. What is clear is that for the Act to be implemented well, commissioners, providers and people with care and support needs will need to better understand the dynamics that impact on choice and market diversity, so that well informed decisions can be made together about the shape of local services for the future. Policy and legislation are not the only drivers here:

• Contraction in public spending: As budget pressures have increased Local authorities' total spending on adult social care has fallen by 8 per cent in real terms between 2010-11 and 2012-13. One consequence is that the balance of care purchased by the public purse as opposed to by self-funders has changed so that fewer people are eligible for state funded support. This means that local authority commissioners have less direct influence than before on the choices available in the market overall. Whilst data on this is scarce, we know that older people who pay entirely for their own care occupy 45% of all residential care places, almost 48% of nursing home beds and buy at least 20% of all support delivered at home. The picture varies greatly from one part of the country to another, but the general trend is set to continue.
• Use of resources: In this context, councils have sought more innovative solutions and greater value for money, with many seeking to shift resources towards preventative interventions. While reported reductions in the numbers of people receiving formal support may to some extent reflect their success, there is currently no adequate data to support this. The available national data does however show there have been significant changes in patterns of service provision and expenditure, which have accelerated since 2010, including a rapid reduction in most forms of traditional community based services and a slight increase in levels of home care.
• Market forces: While the social care market is different to other markets (people enter it reluctantly, often with limited prior knowledge and at time of crisis), it remains subject to market forces. For example, increasing demand can cause costs to rise and supply to increase, while an excess of supply can bring prices down. Similarly, the prevailing economic and employment situation within an area will effect local market characteristics and costs. Like in other markets, providers compete on cost and quality which can grow, contract or fail (Southern Cross in most dramatic fashion). Taken overall, this can mean either market fragmentation, with numerous provider types and services coming into the market, or consolidation, with a smaller number of providers taking a larger market share.
• Commissioning practice: Increased personal budgets numbers and concerns to drive up quality have also led to changes in commissioning practice, including the more prevalent use of framework contracts, which can offer greater flexibility to commissioners and some assurances for providers in the context of people making their own purchasing decisions. In some instances this has meant a dramatic decrease in the numbers of providers contracted, often alongside geographical zoning, for home care for example. Whilst there is some evidence to suggest that choice of how support is provided and by who are often more important considerations than the identity of the provider, especially for older people, this sort of practice clearly impacts on choice and market diversity.

So, while policy and legislation are advocating choice and diversity, there are other powerful factors that could potentially pull in the other direction. The concept of market shaping is relatively new, but it will be vital for commissioners to have the skills and competencies necessary to fulfil the new duty in the Act. In particular, the skills needed to work in collaboration with local markets and in coproduction with people with care and support needs, carers and families to strike the right balance locally between choice and sustainability. TLAP will be producing a range of materials to support this through our market development programme over the coming months, so watch this space.