Putting clothes on the Emperor: What do we know about high quality commissioning?

A few weeks back I wrote about how some of the conversations around commissioning in Australia tend to have a little bit of a sense of the Emperor’s new clothes about them.  But this scenario isn’t inevitable and here I add a few thoughts about how we might ensure that the Emperor isn’t naked as commissioning is rolled out across the country.

When talking about commissioning it is important to recognise is that there isn’t one model and the approach needs to be relevant to the context that it is being enacted within. This means empowering those who lead commissioning locally to really take on this agenda and understand what is important for that particular area.

The reality is that commissioning often has many different aims and drivers. It is therefore important that you are clear about what your priorities are and what it is that you aim to achieve  through your approach. Inevitably it will be difficult to achieve all of these aspirations at once. Research shows that having a clear sense of which you prioritise and formulating a clear plan in relation to realising these objectives, is far more effective than trying to achieve a whole plethora of aims simultaneously.

How you organise commissioning activities is important and there is no perfect size to operate your commissioning approach over. Again, the form needs to be appropriate to the function.  One important finding that is well illustrated in the recent experience of mental health commissioning in England, is that if you only focus on the procurement aspect of commissioning then you will miss the wider picture. Commissioning is about more than simply procurement practices when done well and yet this has been the main focus of individuals and organisations engaged in commissioning processes.  Just buying things in slightly different ways will not deliver the type of outcomes sought through commissioning approaches and it is important to pay attention to wider activities that support the procurement process.

Commissioning is a data hungry activity and requires a variety of different appropriate forms of data appropriate to the task. While it may seem like an obvious point, the skill set of commissioning staff is absolutely crucial. Yet this has often not been systematically planned for in practice. There are some obvious gaps often cited such as in terms of commercialisation abilities or particular forms of data analysis. There is no doubt that these are crucial, but it is often the case that there are also a broader set of skills and abilities that are necessary to high quality commissioning approaches.

One area that this lack of skill base is particularly apparent, is in respect to engagement. Although not all would agree with me on this, I would go as far as to suggest that engagement is possibly the most important activity in commissioning and one that has all too often been neglected.  Without engagement across a range of different stakeholder groups it can be difficult to identify just what the role and aims of commissioning are or should be, what appropriate data is required and what modes of working are most effective. Without engagement then commissioners can lack the legitimacy to act and this is of particular importance when it comes to making significant and sustained change.

In England, many commissioners found that having not undergone a careful process of community engagement they came across significant opposition when seeking to make changes to services. This was most apparent in terms of hospital services where attempts to move beds from hospitals or close down ineffective emergency or maternity services were met with large opposition from the broader community.  In many cases the public were unsure of who the commissioners were, although they had long standing links to institutions like hospitals. If commissioners are to be effective it is important that they find ways to explain to the general public who they are and why their function is important.

What is clear is that the evidence base for commissioning is not as clear-cut as we might expect given the enthusiasm for this concept. But are we surprised if one approach is unable to solve a series of complex and pernicious challenges that have long been central to public services?  How likely is it that one approach could ever resolve all of these issues in the short term? The likelihood is that we are setting up any approach for failure if we think that it will quickly and easily overcome these challenges.

One of the things that I often hear when speaking with public servants is the phrase – we know what we need to do, we don’t know how to do it’. What people mean by this is that the problems have been well defined and reiterated multiple times. The challenge is knowing how to deliver against these aims.  Commissioning can be, I would argue, one helpful way of starting to address these in the sense that it gives a framework and a vocabulary for reform in terms of the stewardship role of public services systems. This has arguably been lacking in many service systems around the world, which tend towards being provider-centred.

There is also the advantage at present that commissioning has a high degree of political salience, meaning there is at least central support for now. The irony here is that Australia’s commissioning enthusiasm is on the rise precisely at a time when the agenda is losing support in England.

However, if we are to enable commissioning to be more than a passing fad then we need to put some meat on the concept. As I have already argued, one of the key ways to do this is through engagement, having a clear sense of what consumers desire in terms of public services and what the important features of the specific contexts within the commissioning locale are. It also involves all of playing a role in critically analysing proposed changes and not simply going along with these for fear of looking stupid. Providers need to take a responsibility for these processes as much as commissioners and cannot simply note that they knew the Emperor’s clothes were missing all along but didn’t feel the need to point this out.




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