Around the country many people are currently grappling to come to terms with the concept of commissioning, how to understand this and in some cases how to operationalise a commissioning approach. As I’ve written about before, one of the challenges with the commissioning literature is that it mostly comes from a different national setting – in this case England. This doesn’t mean that there aren’t important lessons to be learned from this evidence but we need to be careful when trying to learn across jurisdictions.
There is a challenge in learning from England if you are not familiar with the systems, processes and cultures of public services then it can be difficult to ‘land’ some of the concepts. If you aren’t familiar with the language and the various different actors then it can make it difficult to extract useful ideas to help drive commissioning in a rather different context.
There is a further problem for learning from other national settings too. Where we look at evidence from a system we are familiar with it is pretty easy to spot where things are truly helpful examples and solid lessons and where things don’t quite add up. There has been a lot written about commissioning over the past decade or so and there is a significant industry in the UK and this is growing in other countries. This industry purports to variously support, develop, diagnose and facilitate high performing commissioning. Yet, there isn’t a very strong or consistent evidence base relating to this topic and it is difficult to say with certainty which approaches do definitively support effective commissioning. If you aren’t familiar with the system and the different issues at play then if can be a challenge to decide which sources to trust.
I have been collecting various resources and case studies that I think are helpful in informing those seeking to better understand or develop a commissioning approach. Over the next few weeks I will post these into the commissioning resources section of this blog. Wherever possible I have drawn on free and publicly available sources so that these are easy to source without having to be subscribed to academic journals.
If there is anything I have missed or you would like to see added to these pages then drop me a line.
Over the last few weeks I’ve been involved in a bunch of different events and workshops on the theme of medical engagement. Last week we had our second Australian Health Network event which had a focus on this theme. I have also been involved in running events in Melbourne and Sydney focusing on how to measure medical engagement with my colleague Paul Long who heads the Centre for Health Leadership (which is so new it doesn’t quite yet have a website!).
So it was pretty timely for me to see a new special issue focusing on the issue of medical leadership. Edited by Graham Dickson and Karen Owen this is a collection based on papers presented at the World Federation of Medical Managers Conference from May 2015. There are range of different papers in this special issue covering national and international trends on medical leadership and how this can be developed and supported.
Erwin Loh attended this conference and presented a paper on behalf of a team that I was involved in and which investigated medical leadership in an Australian context last year – if you missed this see previous blog posts on this topic. Our paper explores the idea of the ‘dark side‘ of medical engagement, where those moving into these types of roles are seen as having gone over to the ‘enemy’. We talk about the various ways in which this theme manifests, the implications of this and what we might do about this.
The special issue is worth a look for anyone seeking to keep up to date with the medical leadership literature.
At the end of last year I was pretty hard at work revising a book series that I was first involved in back in 2008. At this time I was a series editor and autho
r or co-author on a number of books all broadly related to collaborative working. These were published by Policy Press and aimed to be short, academically robust, but accessible books for health and social care professionals and students with an interest in partnership working.
Not only was there a learning curve because these were the first books I had ever written, but it also turns out that writing five books at the same time with different co-authors within the space of about 8 months and doing a full time job and a PhD is pretty tricky. Who would have thought? Had you told me then that 7 years on I’d go through the same process I would have been pretty surprised (although at least now I have finished my Phd so have less of a workload!). And yet that is precisely what has happened and mostly because of the reaction of health and social care professionals to the collection.
Writing academic books is often a fairly solitary experience and publishing doesn’t always feel like the ‘big bang’ change that some people often assume that it will be. I don’t think it is unfair to say that often books can largely go unnoticed by all but a small and specialist community (well until a family member stumbles across you on Amazon and gets a surprise).
What was interesting about this series is that when meeting health and social care professionals in various parts of the UK people would know the books and often had one or more of the set and actually used it in the course of their work. When going to people’s offices it wasn’t unusual for someone to fish a dog-eared copy out of a desk draw as they spoke about how they had drawn on the various frameworks and tools within. The books seemed to be genuinely useful to people grappling with the complexities of making collaboration work on a day-to-day basis. I don’t think this could be a greater compliment given what we set out to achieve.
The series sold fairly well and Policy Press had positive feedback and commissioned us to revise the first book in the series in 2014. We did this and again it was met with a strong response and a request for the others to revisited and updated. So in early 2015 I found myself agreeing to revise the remaining four books in the series and deliver them in a space of about 7 months.
On coming back to the books we realised how much the evidence base and the policy context had moved on – even though many of the same questions remain unanswered fully. There were also a number of things we were keen to improve on and change – such as a desire to inject a more international flavour into the books. Given issues over availability of some co-authors and work I’ve done with others of late there have also been some author line-up changes in some places.
The revision of the books actually became less of an update and more of a re-write and most are substantially different as a result. This made the whole process even more of a challenge again but I think we are pretty happy with the end result and hope that this continues to make the books as relevant today as they proved to be when the first editions were published.
The revised series is available now as a set of books or as individual publications. The series starts with an introductory book written with Jon Glasby called Partnership Working in Health and Social Care, which provides an introduction to the topic area, an overview of the (mostly) UK policy context and evidence about what makes collaboration work. Having set out the background the remainder of the books in the series focus on different themes in relation to health and social care collaboration.
All in all these were a great team to work with as were Policy Press. I am looking forward to seeing the final books in print (once they finally make it through the Australian postal system) and hope that they prove as useful as the first editions. Although if we are to be luck enough to be asked for a third edition I hope someone reminds me of this blog post…
If you have seen me present on commissioning in the last few months then chances are you will have heard me talk about some of the current debates about this remind me of Hans Christian Andersen’s story the Emperor’s new clothes.
Now this might not seem like the most robust academic analogy but I think it is a helpful one because it is probably something that most people are familiar with or can get to grips with pretty quickly. It’s a familiar tale and allows us to populate it with the various characters and use it to make sense of difficult and complex situations. This tale in particular is often still invoked as an idiom or a cautionary story.
Before I start to relate this to the concept of commissioning I will do a brief re-cap of the story as I realise not everyone had the pleasure of reading these tales as a child (or continue do so as an adult like I do). For those of you who want to skip my patchy description there are some cracking clips on YouTube that do far more justice than I will – like this.
The plot in this story revolves around a vain Emperor who loves wearing the best clothes. Two weavers come to town and promise him the finest suit of clothes from a fabric invisible to anyone who is unfit for his position, or who is, in the words of the time pre-political correctness, ‘hopelessly stupid’. The Emperor’s ministers can’t see the clothes but pretend to as they don’t want to fear being unfit for their roles and the Emperor does the same. The story culminates in the Emperor marching through the town in his new suit and the townsfolk playing along with the pretence, not wanting to appear unfit or stupid.
A child in the crowd who is too young to understand the need to keep up the pretence shouts out ‘he’s naked’ and the other townsfolk join in at this point having been freed from this social bond. The story finishes with the Emperor suspecting that he is naked but not wanting to admit it still.
The beauty of this short children’s tale is the wide array of different allegories that it contains. I don’t invoke this tale as a perceived attack on the pride or vanity of policy makers (heaven forbid) or event to suggest that they surround themselves with individuals of an obsequious nature. It is not, either, an argument for children to run public services as the only group able to spot untruths or nonsense. One need only watch a small amount of the Wiggles to know this not to be the case. Neither is this to suggest that the commissioning agenda – like the Emperor’s new clothes – is little more than a collective belief in nothing.
Why I use this metaphor is to guard against the unquestioning acceptance of ideas or the uncritical appraisal of solutions. In a context where many are desperately seeking for solutions that will help to transform public service systems, the temptation can be to jump to embrace the next idea that promises to help us overcome the myriad of challenges that we face. As this story tells us, what sounds like a perfect answer rarely is in practice if we simply accept it in an uncritical way.
Commissioning as a term developed initially in the UK as a response to attempt to create more effective stewardship of what had increasingly become very complex service delivery environments and where government agencies lacked traditional means of control over the various organisations within this context. Commissioning in a dictionary definition sense covers a range of different stewardship functions including those relating to funding, ownership, purchasing, provision and regulation. The breadth of this definition is important because commissioning is more than simply outsourcing more functions or a way of externalizing aspects of provision. It is about systematically steering complex public service systems (and I’ve written more about the background to commissioning in previous posts). The key point is that commissioning is a complex set of functions than involve technical and value-based decisions, such as concerns over ethics, equity and values.
The magnitude of the challenge of commissioning is illustrated in relation to the range of drivers that underpin this agenda. Commissioning is about efficiencies – both technical (in terms of provider performance) and allocative (across the whole budget), but is also about response to consumers, making priority decisions more explicit, challenging a range of traditional approaches to resource allocation and the dominance of some sectional interests and a counterweight to professional dominance in processes of service specification.
Yet, when we turn to the evidence concerning commissioning and impact, overall we find that there is a lack of evidence to demonstrate that across-the-board commissioning approaches positively impact efficiency, quality of services or outcomes of services. Although there is some evidence of impact in terms of efficiency, services responsiveness and quality, on the whole these tend to be rather isolated incidences. In some cases the introduction of commissioning approaches has led to other inefficiencies in terms of managerialism, datamania and other disruptions.
It is important to note that commissioning is difficult to measure and to talk about with any certainty. One experience familiar to those who have attempted to explore the outcomes of commissioning is that where a positive impact is identified there can be protracted debate between commissioners and providers about who it was that had the greatest impact on these outcomes!
Despite the lack of evidence, the call for commissioning continues. We have seen this recently in Australia in terms of the central role that this plays in Primary Health Networks and the creation of Commissioning and Contestability units in some State Government departments. It looks like this agenda still has some way to run. Yet, the gap between evidence and action has led some to question whether this latest wave of reform will deliver real change or just involve lots of talk about something new and different but nothing new in reality?
Juliet Woodin and Judith Smith make an important observation relating to the notion of expectations. They point out that commissioning was introduced in the UK against a background of high expectations (as we have seen in the range of drivers that it is supposed to achieve) and at a time of significant social and economic challenge – not to mention the fact that the commissioning architecture has undergone significant and sustained reform over the years. Furthermore, there have not been significant investments in evaluating the impact of commissioning approaches. This means we cannot say for certainty whether or not commissioning has significant impacts particularly over the long term.
Why these are observations are helpful is they remind us that the function of commissioning is a complex one being realised against a backdrop of significant turbulence and disruption. We therefore need to realistic about what we might expect to see in terms of impact and over what kind of timescales. It is unrealistic to expect that commissioning can deliver against all the outcomes that have been promised of it overnight and it will need the courage to stick with an agenda but also the astuteness to identify when things are going awry if it is to be successful.
At the moment I seem to spend a lot of time talking with public servants up and down the country about commissioning and it is safe to say that many are sceptical about this agenda and whether it is underpinned by any significant substance. It is true that we could look at this agenda in a rather sceptical way and it see it as just the next big political whim with unclear parameters and a shaky evidence base. Indeed if we do see it like this then there is a strong chance that the Emperor will stay unclothed. But, to stretch the analogy to breaking point, I think there is more we could with this concept to ensure that the Emperor is dressed. In my next blog post I’ll set out what some of these steps are.
The Australian Labor Party announced yesterday that it will lift the Medicare rebate freeze if elected to office in the July federal election. We know health issues feature strongly in election debates, but what does this proposal actually mean for most of us?
How Medicare works
Medicare is our public health insurance system and funds a range of services such GP visits, blood tests, x-rays and consultations with other medical specialists.
The Medicare Benefits Schedule (MBS) lists the services the Australian government will provide a Medicare rebate for. Medicare rebates do not cover the full cost of medical services and are typically paid as a percentage of the Medicare schedule fee.
GPs who bulk bill agree to charge the Medicare schedule fee and are directly reimbursed by government.
Those who don’t bulk bill are free to set their own prices for services. Patients pay for their treatment and receive a rebate from Medicare. There is often a gap between what patients pay for services and the amount that Medicare reimburses (A$37 for a GP consultation, for example). This gap is known as an out-of-pocket expense, as the patient is required to make up the difference out of his or her own pocket.
Under an indexing process, the Medicare Benefits Schedule fees are raised according to the Department of Finance’s Wage Cost Index, a combination of indices relating to wage levels and the Consumer Price Index.
Organisations such as the Australian Medical Association (AMA) have long argued this process is insufficient and Medicare schedule fees have not kept up with “real” increases in costs to medical practitioners of delivering services. The rebate freeze compounds this financial challenge by continuing to keep prices at what the AMA and others argue are “unsustainable levels”.
Where did the freeze come from?
Although the Coalition is largely associated with this issue, Labor first introduced the Medicare rebate freeze in 2013 as a “temporary” measure, as part of a A$664 million budget savings plan. The AMA, the Coalition and others loudly criticised the then government for the freeze.
On being elected to office, the Coalition put forward a number of proposals to reform the payment of health services and deal with rapidly rising health costs. Health expenditure had grown 74% over the past decade and was considered unsustainable in the long term. Primary care and medical services costs (including Medicare) had grown by more than 60%, representing an A$11 billion increase.
The Coalition government proposed a number of ill-fated reforms including:
a A$7 co-payment for GP, pathology and imaging services that would offset a A$5 reduction in Medicare rebates
a ten-minute minimum for standard GP consultations
a A$5 reduction in the Medicare rebate for “common GP consultations”.
What did manage to stick was a continuation of the indexation freeze, initially for four years starting in July 2014 and further extended in the recent federal budget to 2020. It has been estimated this will save A$2.8 billion from the health bill over the six years.
Impact of the freeze
The extended freeze means GPs and other medical specialists will be reimbursed the same amount for delivering health services in 2020 as they were in 2014. Doctors will pay more for their practices, staff, medical products, utilities and just about anything else that goes into running a medical practice. But the amount paid for medical services will remain static.
At the time the Coalition extended the freeze in 2014, research showed this move would have a greater impact on GP income over the initial four-year freeze than the proposed $A5 reduction in the GP rebate would have produced. In other words, failing to lift the reimbursement amount would ultimately prove more detrimental to GP funding than actually reducing the rebate amount.
Opponents to these changes argue this leaves medical services underfunded and may ultimately mean that additional payments will be passed on to patients. AMA president Brian Owler estimates the extended freeze will lead to each GP visit costing A$20 more for patients. Some commentators referred to this as the introduction of the co-payment by the “back door”.
Some argued it could reduce the number of bulk-billing practices. Yet levels have risen steadily since 2013 to an all-time high of 84.3%.
What about costs passed on to patients? The AMA estimates suggest that at present the Medicare rebate (A$37) covers only about 50% of the recommended consulting fee. This means that either medical practitioners cover the remainder of the costs themselves or pass this on to patients.
The impact of the extended freeze goes beyond simply reducing the gross income of GPs, or patients having to pay more for their health services. There are profound implications for equity. The effects of these types of policies are typically regressive in that the impact is often greatest on the most disadvantaged within our community.
Australia already has a large gap between the quality and timeliness of the public and private health systems. Changes such as this could potentially exacerbate this gap, by reducing the number of bulk-billing practices. This has the potential to create a two-tier system, where those who can pay receive the best care and those who can’t pay delay or avoid treatment, which ultimately exacerbates their condition.
The Coalition expects GPs and medical professionals to pass on costs to the patient, thereby sending “price signals” about health services, with the aim of reducing the numbers of “unnecessary” consultations. However, the international evidence shows that increased co-payments for patients may save a little money in the short term, but can ultimately increase the number of people accessing hospitals and other acute services, which are more expensive to run.
Labor’s bid to end the freeze
Labor’s announcement that it will end the freeze and restore indexation from January 1, 2017, has been costed at A$2.4 billion by 2019-20 and A$12.2 billion over a decade.
The AMA and other medical professional groups that have argued against these measures have welcomed this announcement. And Labor will no doubt be pleased to have such powerful interest groups on side (for now at least). But critics will ask where this money will be found in the budget and what will need to give in return.
Ultimately, just unfreezing the Medicare rebate will not make Australian health services more sustainable in the long term. There is an urgent need to reconsider how we incentivise and reimburse medical practitioners for the services they deliver and how we invest in preventive measures to avoid people becoming sick in the first place.
At a time when we see significant increases in levels of chronic and complex diseases, we need a health system that is designed to serve these issues and not simply episodic periods of illness. Without a broader mandate for change within the health system it is unlikely that this promise alone will lead to better health services for all of our community.
As a child there were two things I really enjoyed – football (or, soccer in Australian) and astronomy. These days my mum teaches physics at a high school, but when I was younger she was studying for her degree and then teacher training while bringing my brother and I up. We were often guinea pigs for potential teaching exercises and she was enthusiastic about physics, maths and astronomy and we, in turn, were too (nobody knows where the football bit came from).
I studied physics and maths to A-level and my performance in these was always better than that of geography, which I eventually went on to study at university (I have always been a little contrary). I have remained interested in developments around physics and other so called “harder” sciences which is interesting to some people as a contrast to the academic work that I do which is often more interpretive in nature.
Personally I have never really seen this as a contradiction and more a sign that I am interested in a whole range of “stuff”. I have never really viewed the “harder” sciences as being any more “objective” than social sciences and think that both are built on constructed belief systems and are therefore subject to similar forms of fallibility (not always a popular perspective).
Over the past month or so I have been indulging in a bunch of different books that focus on physics and in particular on the implications and applications of quantum theory. I had seen this mostly as taking a break from the political science and public management-type books that tend to inevitably dominate my reading when I’m not reading marvellous music memoirs that is (most enjoyable ones of the last 6 months Carrie Brownstein’s Hunger makes me a modern girl, Viv Albertine’sClothes, Clothes, Clothes, Music, Music, Music, Boys, Boys Boysand a re-read of Patti Smith’s Just Kids). Anyway, a recent article suggests that this reading might be more than simply an indulgence on my part and could actually be an indication of my research ‘orientation’ and have implications for the quality of research and its potential impact. More of that later.
On my “to read” list for some time has been Richard Feynman’s Surely you’re joking, Mr. Feynmanwhich is essentially a series of anecdotes about the life and thinking of the Nobel Prize-winning physicist. It is an entertaining and engaging book full of funny stories and incidents and certainly lived up to what I would expect from a thinker as great as Feynman. But the really fascinating stuff was getting an insight into how he thought. Feynman wasn’t interested in knowledge for the sake of it and was only really interested in things that had a real world application. This meant that Feynman often went beyond the confines of conventional approaches.
In his book Feynman describes difficulties he had in helping a friend with a particular piece of maths. The reason for this problem was not because Feynman didn’t understand the maths but that he had essentially taught himself and had developed his own process of notation (for sin, cos, tan etc) that didn’t match the standard approach. Although he felt his own approach to notation was superior, he realised at this point the limitations of personal notation and the importance of a common approach if one is to be able to successfully communicate about this.
Feynman was a curious individual who learned by being interested in things and wanting to understand them and wouldn’t give up on something once it had got his attention. In some senses there are similarities here with Alan Turing, who is the subject that begins John Gribbin’s Computing with quantum cats. There is a now-famous story about Turing and a bike chain that kept slipping. He realised that this happened after a certain number of pushes on his bike peddles and so counted these resetting his position so to avoid this happening and even installing a counter on the bike so he would not miss this. He eventually realised that this was related to the number of revolutions of the wheels and finally discovered that this was due to a bent spoke in one of the wheels. A bicycle repair person would have been able to diagnose and fix this in a matter of minutes, but Turing went through a long and meticulous process to identify this himself. This is an interesting example in the sense that it indicates the way sin which his mind worked and the processes that underpinned his thinking around issues.
One of the joys of Gribbin’s book is that it isn’t just simply a description of quantum computing or the potentials of this application. It tells the story of computers and their development from Turing and the need to decode ciphers in World War Two up to recent attempts to apply insights from quantum theory to computing. I am completely fascinated by, and in awe of the potential of this sort of technology, and what the implications of quantum theory are for how we think about our everyday world. I don’t understand all of it and it has been a test to revisit the quantum mechanics that was on my A-level physics syllabus and have a bunch of other books on my bedside table waiting to be read in the hope that this will help me better grasp some of these concepts.
What I did find gripping in Gribbin’s account are the dynamics of power and politics (with a small ‘p’) that have contributed to the development of quantum computing. In one such example, the darling of physics and quantum theory – Johnny von Neumann – published a book on quantum mechanics setting out an important proposition that was based on some unusually shaky mathematics. This was refuted almost straight away by Grete Hermann who pointed out to Heisenberg and colleagues that there were some inappropriate assumptions in the mathematics underpinning van Neumann’s work. But these concerns never appear to have been taken seriously and people continued to believe van Neumann’s perspective simply on the basis that he told them this was the case – rather than engaging with the work itself. He was so revered in this field that it was out of the question that he might not be right. There are any number of things going on here relating to charismatic leadership, belief, gender, subject specialism and other factors too that point to the importance of politics in the creation of knowledge (in addition to the constant big ‘p’ politics of the world wars that play out in the backdrop to the development of computing). These accounts clearly demonstrate the impact that a range of these factors have for the production and re-production of knowledge in even in “harder” sciences.
Richard Feynman tells in his book about how he took a range of different subjects while studying at university in many things besides physics, maths and the compulsory English subjects. He describes being involved in metallurgy, biology and other areas to expand his studies – which may seem unusual for an individual who was already starting to make significant contributions to the field of physics at a relatively early stage. However, perhaps Feynman was able to make such significant contributions to the advancement of physics precisely because he went beyond the confines of his own discipline.
A recent study found that having a “transdisciplinary orientation”, that is a predisposition to engage in cross-disciplinary work, can have implications for the quality of interdisciplinary research. Those more open to ideas outside of their own discipline were found to be more able to synthesise concepts, ideas or methods from different disciplines and to produce scientific outputs that have greater translational, policy and practical relevance. A transdiciplinary orientation was also seen to have a slight positive impact on ratings of creativity and intellectual quality of work. For someone who works in a interdisciplinary school and who has always drawn quite liberally on different areas of literature this is good news indeed. For those who aren’t naturally predisposed to this way of working, don’t worry – the research team believe that this isn’t a fixed trait and can be developed.
In the mean time I’ll continue on reading outside of my ‘home’ area and being open to all sorts of ideas. Next up is John Butterworth’s Smashing Physics , an account of how the Higgs particle was discovered at CERN.
I have recently been spending a lot of time talking with people about the topic of commissioning and there are lots of people looking for answers on this subject. During these conversations I often feel like I am disappointing people as I can’t (or possibly won’t) provide hard and fast answers on this topic. In fact pretty much any answer to a question about commissioning tends to be “it depends” (to quote my fantastic colleague Janine O’Flynn).
Commissioning (and other complex reform processes) can’t be done through cookie-cutter solutions where there is a series of standard or common steps that organisations go through to produce high performing commissioning practices. Rather than seeing this as a negative thing I think it is a positive and creates some potentially exciting spaces for commissioners to work within. In this blog I say a little about why the lack of cookie-cutter solutions is a good opportunity rather than a bad thing.
As an example of the sorts of things I am working on in this space, I am part of team (with the King’s Fund and PwC) who are doing a project for the Federal Department of Health creating evidence and guidance for Primary Health Networks (PHNs). PHNs are relatively new organisations in the Australian primary health space and differ from their predecessors – Medicare Locals – in the sense that they do not provide services and are commissioning-only organisations. This is a big change in the health sector where organisations have traditionally been built on the provision of services and this is important not only in terms of what sorts of things those organisations do, but also in terms of their identity and attendant claims to legitimacy. This example also illustrates some of the kinds of changes that are also taking place in other parts of the public service.
The Australian changes mirror to some extent the developments that took place in the English primary care context about a decade ago with the introduction of Primary Care Groups that have subsequently evolved into Primary Care Trusts and then Clinical Commissioning Groups. Since this time commissioning has become somewhat of an industry in England, as it has expanded into a range of different public service spaces. There are a large number of organisations that promise to support commissioning processes for those engaged in these activities and to support them to become “high performing commissioners”.
PHNs are keen to understand how to become high quality or excellent commissioners of health care services. As such one of the questions I am frequently asked of late is what are the 4 (or 5 or 6 or 7…) steps that we can follow to become great commissioners? I understand where this question comes from – PHNs are relatively small organisations and are under pressure to deliver a number of things very quickly to meet government milestones. At such a time it is pretty reasonable to ask what can we learn from other countries in terms of how we can make this happen. But if we are looking for steps or activities in a specific and generalisable way then I think we are asking the wrong question. There is no such set of steps available and nor do I think there should be.
I have written a number of pieces in recent years considering what Australia might learn from international experience (including this recent review). In general this evidence base seems to raise more questions than it answers. What we find is a rather complex picture where there is no singular definition or model of commissioning and an evidence base that is unable to demonstrate either the veracity of this concept or the sorts of processes and activities that deliver effective commissioning. It is important to note that this doesn’t mean that commissioning doesn’t or can’t work – more that there isn’t yet the evidence to clearly demonstrate this. This is in part because there has not yet been sufficient investment in generating this evidence (and good quality research evidence takes time) and also because the English commissioning infrastructures have been so frequently reorganised that it isn’t always clear what changes have produced what impacts.
From the evidence base I would argue that you can’t just outline 6 or 7 steps that organisations or teams can follow and promise that this will support them to develop high quality commissioning. What we do know is that commissioning is highly context-specific. The environment in which commissioning is operationalised is important in terms of what it is that commissioning should achieve for that locale. Further, in relation to the activities and processes of commissioning, there will be things that organisations already do well in addition to areas for improvement.
The reality is that commissioning is to some extent a new activity for public service agencies but this difference may be more in terms of name than in practice. If we think about PHNs for example, a number of the commissioning activities that they will undertake will have a new hue, but many of the practices of Medicare Locals (undertaking needs assessments, performance managing, managing contracts, engaging with stakeholders) are also central to commissioning processes. So this isn’t an entirely new way of working and this is where existing knowledge and expertise is crucial. In the rush to cookie-cutter solutions we risk losing some of this good practice and also denying the tacit knowledge of experienced practitioners.
As I have written about in other places, one of the perhaps negative and unforeseen implications of the evidence-based practice and scientific management movements has been a devaluing of the expertise and knowledge of public service professionals. The reality is that few decisions or agendas that public servants are faced with have simple or formulaic answers to them. Academics, consultants and a range of other “experts” who sit outside of the system are very adept at pointing out the failures of public services and implore public servants to work in a more agile, lean, collaborative, innovative, engaging, efficient (delete as appropriate) way. Like most things it easy to point out how others should do these often mutually incompatible things when many of us are not actually doing these things ourselves.
In asking the question about the 6 steps to effective commissioning then it seems to suggest that there is such a simple to solution to what is actually an incredibly difficult and challenging process of reform. So why would we think that someone could come up with these easy steps that will deliver the outcomes we desire and across multiple settings, transcending context?
For sure I think that we can offer principles to guide commissioning processes and I think there are definitely times when commissioning approaches should not be used (a topic for another blog post). There is best practice and examples that can be drawn on in the processes of realising commissioning or reform processes more broadly, but no singular person or organisation has all of the answers. Rather than thinking about how an external expert can guide us through a process in a series of steps we should be thinking of how we support the expert knowledge of practitioners to leverage this to best effect in commissioning processes. This means that we need to think about the practice of policy more carefully and how we support and develop public servants to engage in reform and not simply spend time designing “perfect” policies.
Not being able to offer a series of codified steps for creating a commissioning approach makes it potentially more difficult to work through and this is even more challenging for public service organisations that don’t have an awful lot of time to do critically reflective work. But if it were a simple process we wouldn’t have to worry about recruiting and training great people to be public servants. We could get anyone in and give them a checklist of steps to work through. So we need to stop fixating on the “answers” and start thinking about how we support individuals and teams to use their judgement and their tacit knowledge of the services and organisations they are expert in. This is both more sustainable in the long term and more exciting for all those involved.
So I will continue to disappoint people with my “it depends” response but for those interested I am starting to develop some action learning set approaches to support those working through difficult commissioning processes – rather than being an expert with all of the answers to difficult decisions around commissioning. If you are interested in this then get in touch to discuss further.