Outcomes-based commissioning and consumers

A new report has just been published by the Sax Institute based on a piece of work that myself, Katie Moon and Karen Gardner. The NSW Department of Family and Community Services (FACS) commissioned this review to explore which approaches to outcomes-based commissioning have been effective in improving client outcomes in the human services sector. Stage One of this review found that very few studies actually explored the impact of commissioning on consumer outcomes. Stage 2 examined literature about when and how consumers have been involved in the various stages of the commissioning cycle, then searched for evidence within that literature about improvements to client outcomes.

Although many sources described the theoretical benefits of consumer engagement, little empirical data exists to demonstrate these outcomes in practice. Perceived benefits of consumer engagement fell into two categories: benefits for consumers participating in commissioning processes and improvements in services, including to environments (e.g. decor, food) and access. The review revealed no evidence of the effectiveness of outcomes-based commissioning in improving client outcomes. The most universal element of the reviewed literature was the description of the challenges of consumer engagement in commissioning and recommendations about how to undertake it effectively.

We conclude that, as both commissioning and consumer engagement are relatively new fields, there is an opportunity to grow the evidence base in coming years, especially if we can achieve consistency about how engagement and commissioning processes are described and measured.

You can download the full report you can find it here.


Commissioning and the community sector

Last year I had the pleasure of being part of a panel discussion on commissioning and the community sector that was hosted by the New South Wales Council of Social Service.  The panel was convened to try and support those working within the community sector to gain a better understanding of the concept of commissioning and the evidence base behind this.  Given the focus on commissioning and contestability developed by the NSW government, there are a number within the sector who are keen to better understand what the implications of these reforms are for their operation.

Where commissioning reforms have taken place in other jurisdictions we have seen some significant challenges posed for those in the community sector.  A report from the UK House of Commons Public Administration Select Committee found that there was a lack of clarity over working definitions of the concept of commissioning and this posed challenges for community organisations, particularly those who work across multiple government agencies.  The report set out a number of areas where improvements might be made in these processes.  The Third Sector Research Centre at the University of Birmingham also developed a number of case studies exploring the challenges that community organisations have encountered in commissioning relationships with governments and where some of the gaps in the evidence base lie.

NCOSS have continued to do work on this topic to develop resources for community organisations and have developed a series of information sheets.  There are three resources in total that explore commissioning, the government and community sector role in these processes and the potential impact within the context of government funded community services sector in NSW.   These are short and very accessible documents that provide a really helpful and accessible introduction to the concept and its role in the policy context.  The three documents are:

If you are a new-comer to the topic of commissioning, whether you work in the community sector or not, these are a really great introduction to the area and the evidence base.




New South Wales Commissioning and Contestability Resources

In 2016, the New South Wales Treasury established a Commissioning and Contestability Unit (CCU) to assist with the improvement of public services by exploring delivery models including a mix of government, NGO and private sector providers.  Last year’s state budget allocated $2.9 million to create this team, with the expectation that this investment should release efficiency savings.  A key role for the CCU is to help the government decide which areas of service delivery to outsource or externalize through commissioning approaches. 

Late last year the CCU released papers outlining the policy and a supporting practice guide, developed to assist practitioners in applying commissioning and contestability.  I was one of the individuals approached asking to feedback on these documents as they were being developed and was interested to see their publication and what will be developed in this space in the coming months and years. These are pretty helpful resources for anyone working in a commissioning role at present.  

The policy aims to create a platform to support NSW agencies to explore ways to create better services outcomes.  This policy suggests that this will be done through the use of commissioning and contestability to apply rigour to the design and funding of services.  What is welcome in this policy is that this does not suggest that services should be outsourced or externalized, but that consideration should be given to where best particular services sit.  This may involve moving some services out of government, but could also involve moving some back to government from third parties if the intended impacts are not being generated. 

The policy goes on to set out a set of principles that should shape service delivery reform across NSW Government, namely:

·         commissioning of services should focus on improving outcomes and delivering quality services, regardless of organisational boundaries and constraints

·         Government must act in the interest of customers and the community by putting them at the centre, with greater attention to the integration of services and an improved end-user experience

·         productivity, quality and efficiency benefits should be shared with the customer through service improvements as well as being reinvested in Government priorities

·         effective commissioning will clearly define and prudently manage delivery and financial risk

·         commissioning will encourage innovation and an openness to more diverse service delivery models in the public, private and not-for-profit sectors. These models should be flexible, reflect the needs of the customer and recognise the limitations of certain markets

·         contestability allows Government to challenge existing providers to deliver service outcomes within agreed resources

·         agencies should consider their role as policy-maker, commissioner, regulator and provider and whether a separation of roles would be of benefit within the service design. 

Ultimately this policy aims to support agencies to achieve consistency and practice across the entire government.  Definitions of commissioning and contestability are set out in the policy document in a clear and accessible way and there is a clear sense of what these roles mean in terms of the changing role of government.  In doing this the CCU does a good job of getting to grips with some fairly complex ideas and presenting a level of nuance to debates around commissioning that have at times been absent in recent years.  

The practice guide that accompanies the policy provides a foundation for consistency in understanding what commissioning and contestability are and the key steps to consider when commissioning and contesting services.  There is a clear outline of when commissioning should be used, what the process entails and importantly the key questions that agencies may wish to ask at the different stages of the commissioning process.  This last aspect is key.  Not all commissioning processes will look the same or involve all of the same activities and considerations.  One size does not fit all. These questions are a helpful guide to those driving commissioning processes, supporting individuals and teams to take ownership of these processes.  There is also the unpacking of consumer choice, potential funding models and contracting approaches, understanding of markets and how these operate and issues of contract management.  One of the key sections for me relates to capability for commissioning and contestability, in terms of what agencies will need to operate such an approach. 

The practice guide won’t transform the way that NSW agencies work over night; this is a big task after all.  However, this is one of the more useful guides that I have come across recently for those who are seeking to make a reality of a commissioning approach.  If you are in this field I would certainly suggest that you take a look at it.  Further resources will need to be developed to sit alongside this to enable agencies to engage with this activities and my understanding is that this is on the agenda of the CCU.  All in all it seems like NSW is doing some pretty exciting work around this space and I will be interested to see just what happens next.


Explaining Primary Health Networks and commissioning

As Primary Health Networks approach their first anniversary a number of people have asked what kind of progress they have made to date and what’s to come over the next 12 months or so as they roll out their first commissioning strategies.

The Health Services Research Association of Australia and New Zealand recently hosted a webinar ably chaired by Associate Professor Suzanne Robinson (Curtin University, WA) and comprising a panel of me, Learne Durrington (Chief Executive, WA Primary Health Alliance) and Jason Trethowan (Chief Executive Officer, Western Victoria Primary Health Network Ltd.) to review the progress of PHNs to date.

The background to the webinar can be found below and if you want to view the discussion then you can find this here (due to some odd technical issue I am missing for the first 10 minutes or so!).

Health systems are challenged by pressures of increased demand and rising costs. The rise in complex chronic conditions means that the current system design that stems from an era when communicable disease was more prevalent than chronic is struggling to meet the changing health needs of the population. As governments look to ways to reform health systems we have seen an interest in the role of commissioning as a mechanism through which to reform many different aspects of public services. Primary Health Networks (PHNs) have been charged with commissioning primary care services in Australia. The essence of commissioning is to take a stewardship role with a focus on providing vision and direction for the health system, collecting and using intelligence, and exerting influence – through regulation and other means.

As PHNs reach their first birthday it’s timely to take stock of how commissioning is developing both nationally and internationally. The webinar incorporated research, policy and practice perspectives on the development and implementation of commissioning in Australia.

The panel session focused on broad areas relating to the following:

  • The current understanding of commissioning, and what it should achieve in PHN  localities;
  • The challenges and opportunities of the commissioning process in Australia;
  • Concepts and elements of successful commissioning;
  • How are PHN commissioners working with wider stakeholder groups?

Commissioning: Background and evidence reviews

There are an increasing number of reviews that describe what commissioning is and review the evidence pertaining to this concept.  Some of these are written from particular vantage points (e.g. community sector, health or commercial sector view) or focus on particular types of commissioning approaches (e.g. integrated, strategic, intelligent).  Here I have summarised some of those which I think are most helpful in providing a good background and sense of the evidence around commissioning in a general sense.

I’ve done a few of these reviews myself in recent years.  The most recent of these was published by the Melbourne School of Government and this sought to extract lessons from the evidence base that are of relevance to the Australian context.  This review examines what commissioning is and what is important in developing a commissioning approach.  This built on previous work I had been involved in, such as this review of different commissioning models that was done for the National Audit Office in the UK in 2012.  The report focused particularly about the role that the third sector plays in these models (and was published by the Third Sector Research Centre).

The UK Cabinet Office hosts a commissioning academy and this sets out a short and very straightforward introduction to this concept.  It was published a few years back but provides a helpful overview before starting to delve into the detail.  For those with an interest in children’s services, this document can be a helpful companion, containing some case studies to exemplify these ideas in practice.  The Office for Public Management sets out a literature review of multi-level commissioning which provides definitions of this concept.

In 2015, the Irish Government undertook a ‘rapid review‘ into the evidence relating to commissioning in human, social and community services.  This is a pretty helpful introduction to commissioning in Ireland, what commissioning is, the different approaches and models and the benefits, risks, impact and cost of commissioning.  The report finishes with a series of key messages such as the need for a coherent policy rationale, the need for a clear definition of commissioning and that the outcomes of commissioning are hard to measure.

Back in Australia again, the Sax Institute published a rapid review of the evidence for the New South Wales Ministry of Health in 2015.  Again this report cycles through issues such as what is commissioning, what impact it has and the requirements for effective commissioning.  This is focused on the evidence with particular relevance to an Australian primary care context and a focus on supporting chronic disease management.  It finishes with  a series of tables that set out features of the Australian primary care context and the potential impacts and implications for commissioning, which are helpful in thinking through the future operation of this agenda.

There are a range of other reviews around but many of these don’t go beyond the sort of evidence and lessons set out here.  Next time around I’ll put some documents and examples up that deal with commissioning for outcomes.

Commissioning resources

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.