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.