On commissioning and the Emperor’s new clothes

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.

 

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