Recently I seem to have spent quite a bit of time speaking with people about commissioning, particularly in health care where I think it is fair to say that there is still some lack of certainty over what commissioning is – or at least what this means to an Australian context. I have come across a number of myths about commissioning in these conversations. In this post I speak about some of these and draw on the evidence base to demonstrate the degree to which these statements do and don’t hold up.
- Commissioning is a coherent model. It isn’t unusual within everyday speak to hear someone refer to a ‘commissioning approach’ or ‘the commissioning model’, but commissioning is anything but a singular or coherent model. Commissioning is a broad term and frankly the terminology isn’t terribly helpful as the word doesn’t mean much to many of us (and even less to those outside the system). There are many different definitions of this concept and often they are fairly broad in nature such as ‘the process of finding out about public needs, then designing and putting in place services that address those needs’. As this definition suggests, commissioning approaches vary according to the contexts they operate in and need to be tailored to the aims of the process and the environment this takes place in.
- There is one way to do commissioning. Following on from the previous point, it probably comes as no surprise that there is one right way to ‘do’ commissioning. Indeed, just a cursory glance at the literature reveals a whole range of different forms of commissioning: joint commissioning, strategic commissioning, outcomes-based commissioning and even “intelligent” commissioning (important for those of you out there planning unintelligent commissioning!) amongst just a few. Commissioning can take place at a number of different levels, aim to achieve different things and draw on a variety of tools to support this process. Commissioning happens in lots of different ways and one size does not fit all.
- Commissioning is just a different word for procurement. This myth has emerged because although the definition of commissioning is broad, in practice much of the attention has been around one particular aspect of this approach. Despite the fact that most commissioning cycles incorporate needs analysis, planning, stakeholder engagement, service design, performance measurement and a range of other different sorts of functions, a remarkable amount of the literature and the debate among policy makers and professionals involved in commissioning processes seems to focus on the procurement or purchasing of services. The emphasis has been on the processes of identifying suppliers and buying these under some sort of contracted arrangement. Australia is not alone in this situation, in a study of mental health commissioning in the UK, Miller and Rees observed that although organisations have moved towards a commissioning approach, many typically focused simply on a few components (typically purchasing and contracting) and not enacting a broader notion. But the important point about this is that where this has happened, commissioning approaches have not been successful and commissioning has been seen as simply another word for procurement and not a broader process of reform.
- Commissioning is just about outsourcing. Given that much of the policy literature tends to focus on processes of procurement, then it is not surprising that there is significant concern with the relationships with third party providers of public services. It is true that in the UK discussions about commissioning emerged around the same time that a number of different policy areas have increasingly shifted from being predominantly delivered by government agencies towards an expansion of involvement from private and community organisations. It is sometimes assumed that a commissioning approach should involve a process of outsourcing as services are externalised from the public sector. The Institute of Public Care argue that the existence of a market of some sort is necessary for commissioning (and I’ll post a more detailed analysis of this case soon). However, markets do not need to be dominated by, or even necessarily involve, private or community organisations. Indeed, much of the early experience of commissioning in the English NHS took place in a quasi-market where purchaser and provider functions had been separated and the majority of providers in the secondary care market remained within the public realm. The key message here is that outsourcing is not an inevitable part of the commissioning process and a decision needs to be taken about the most appropriate provider for the purpose of the services.
- Commissioning is a technical exercise. One of the problems with commissioning approaches that I often hear described is a lack of data or an ability to pull together information systems to facilitate commissioning processes. Data is a crucial part of commissioning, of course, but is not the only crucial element and just analysing more data and better will not help overcome these challenges. For example, needs assessment exercises in health care often become debates over epidemiological and demographic data and what receives less attention is debate over what we do value in terms of services and health outcomes, where we should invest and where not. If at its most basic commissioning is about improving services for a particular population, then it involves difficult decisions about what to focus on (and by implication what not to). This is not a technical exercise and is highly normative. To believe all this can be achieved through just a closer analysis of data is unrealistic.
- Commissioning is a new thing. If the discussion of the last few myths demonstrate anything, it is that commissioning is broad and crosses a number of reform-related themes and issues that public services have been grappling with for some time. Yet, many of the present discussions around commissioning tend to work from the starting point that this is a new idea and agenda. As the UK Health Committee recognised: ‘Although the term ‘commissioning’ has only been in use since the 1990s, the functions it refers to have been present, in one form or another, since the inception of the NHS. It has always been necessary to determine the health needs of the population and to design services accordingly, with due regard to the available level of resources. The NHS has always aspired to ensure that its services meet high quality standards’. It may therefore be that there is nothing entirely new or specific about the commissioning agenda. Having said this, organisations have not, on the whole, attempted to bring together this full range of themes and activities within the context of one strategic reform programme as is associated with a commissioning approach. The processes and activities associated with commissioning should therefore be seen as an extension of a reform journey, rather than an entirely new path. A further implication of this is that even if a specific focus on commissioning retreats from policy, these themes are not going to disappear overnight.
- Someone else will be more expert in your commissioning approach than you. If the UK experience demonstrates one thing, it is that commissioning agendas are able to spawn entire support industries. There are a number of different organisations presently position themselves so that they can garner business from the current commissioning push. But the reality is that no one else can do all of your commissioning approach for you. Nor are they more expert in your organisational context and history than you are.
If there are other myths or dilemmas around commissioning that you have come across and want me to examine the evidence base around then please get in touch.