Commissioning and ??????? Council

1. Introduction

1.1 In addressing the complex and multi dimensional subject of Commissioning this report comments upon historical developments and applications of Commissioning. It further attempts to identify universal core principles to provide a discussion platform which avoids biased ontological perspectives of a subject interpreted and adopted by many before.

1.2 Commissioning has been the subject of countless papers adopting it’s principles as business solution methodologies, all of which can be compared with the facets of modern strategic management. The commonly adopted Analyse, Plan, Do and Review (APDR) cycle is not dissimilar to the approaches of Strategic Analysis, Planning and Implementation; therefore commissioning has a relationship with modern strategic management.

1.3 The unstructured applications of principles have offered widespread possibilities and created many and varied commissioning models. There is little evidence that any of these models can be directly attributed to any distinct concept of applied commissioning, only bound by some common principles. It can be argued that commissioning models are likely derivations of principles associated with strategic management theory. Therefore the challenging discussion for Wiltshire will be to debate proposed universal principles and place these into strategic context, considerate of other means and methods of local government service delivery.

2. Objective

The objective is to identify and propose universal principles of Commissioning to promote discussion as to the potential beneficial applications of Commissioning for ???????.

3. Commissioning Evolution

3.1 Commissioning is generally thought to have evolved from analysis of the payer/provider relationships within the USA Health Care system. Significant further developments from McKinsey and KPMG helped evolve the principles of World Class Commissioning (WCC) where suggested core competences emerged.

3.2 Commissioning as a distinct term within the UK public sector arguably has its origins within the NHS as part of the purchaser provider split with Primary Care Trusts (PCT) controlling a majority of NHS funds through a process of commissioning services across acute trusts, GPs and other organisations. Commissioning as a concept has further spread to cover the flow of money at a strategic level within local strategic partnerships, in addition to operational contracting within social care in local authorities. This map has added complexity by the development of Clinical Commissioning Groups (CCGs) to be formed in April 2013 which challenge joint commissioning relationships in relation to payer and provider roles.

4. Commissioning Applications and Perceptions

4.1 The term commissioning is used in varied context such as:

Health and Well Being Building & FM Procurement Strategic Commissioning Micro Commissioning Macro Commissioning Operational Commissioning

Commissioning authority Joint Commissioning Area Commissioning Total Place

4.2 The many contexts and varied applications of the commissioning term reinforce its amorphous nature and the need for local definition if it is to be considered for its strategic delivery capability and contribution.

4.3 The commissioning links between high level government agendas promoting devolved and local decision making can be tenuous and subjective. In responding to criticism of the principles of the Big Society, Government policies and subsequent legislations supporting Localism and political devolution can be construed as supporting a commissioning model which focuses on needs analysis.

4.4 The Health and Wellbeing agendas consider multi level commissioning approaches which consider JSNA (Joint Strategic needs Assessment) data and deliver an internally defined business model usually considerate of the APDR cycle; these are professionally and functionally defined models as are other newly evolving areas such as Building and Area Commissioning models.

4.5 This work could quote from many sources all defining commissioning from organisational or professional biases; this is arguably pointless apart from highlighting diverse understandings and multiple applications. Therefore to promote and develop shared understanding, universal principles need to be identified and communicated across professional boundaries. Promoting and marketing a commissioning position allows for shared understanding and enables external organisations to view the Council approach beyond silos.

5. Commissioning Value

5.1 The benefits of effective commissioning appear to be that it sets out a framework for deciding how best to deploy resources strategically and tactically in order to achieve objectives and/or outcomes. However this is more a universally applied business objective than a clear benefits case for commissioning, which appears dependent on agreed principles and specific application.

5.2 As a model approach to deliver objectives, commissioning is generally promoted as a whole systems approach to delivering outcomes; the same description could be applied to other strategic and non strategic business models; therefore more mature models may provide greater value due to having established principles and sharper definitions.

5.3 The value of different commissioning models appears wholly reliant on the business cases built to support their development. This may be financial, citizen outcome, strategic alignment or project delivery based and dependent on objective and added value. Therefore it is recommended that any commissioning proposal is considered with other models and approaches to delivery, focussing on the effectiveness of delivery; this may not be as simplistic as just ‘outcome’. Therefore to enable commissioning to become useful and universally applied it requires definition at the principle level to facilitate common and shared understanding, which provides form with which to consider applications.

5.4 A report published by the Department of Health chaired by Kevin Barron (March 2010) said: "It is a sorry story if, after 20 years of attempting to operate commissioning, we remain in the dark about what good it has actually done. The Government must make a bold decision: if improvements fail to materialise, it could be time to blow the final whistle." It is questionable if the application of commissioning delivers more benefit than other models. Mid Staffordshire Hospital Foundation Trust was forced to close some facilities (2012) when it applied a model with a bias on financial savings which was ostensibly to the detriment of

patients; running debts of c £46M (http://www.bbc.co.uk/news/uk-england-stoke-staffordshire-19602537). Recent NHS television news coverage (Sept 2012) has highlighted that the NHS is still far from delivering the citizen and financial benefits commissioning has been promising.

5.5 Another example of contentious added value may be the local government response to the Putting People First White Paper (Department for Health, 2007); where differing interpretation of the principles spent £300m+ of public money in what can (subjectively) be described as an experiment promoting changes with links to the concept of the Big Society. Some local authorities delivered citizen outcomes and financial benefits according to local strategy and values. Certainly more citizen choice was considered and delivered but outcomes were restricted by the commissioning models designed locally; an example of the subjective nature of commissioning applications. Therefore it can be argued that commissioning is a set of principles without firm methodology.

5.6 Agreed principles of commissioning may provide insights to the capability to deliver organisational aims from commissioning methods; without developed knowledge of agreed principles and applications it may be difficult to establish aims. Therefore from a set of agreed principles, the aims and applications of commissioning activity can be considered.

6. Suggesting Universal Principles

6.1 As commissioning expertise emanates from as many areas as commissioning addresses, this report sought to collate principles from a wide catchment of sources selected across the evolution of the concept, these include:

Title Principles Universal Non-UniversalRoyal College of General Practitioners (RCGP) – Centre for Commissioning

http://www.rcgp.org.uk/centre_for_commissioning.aspx

Working with the full range of partners to develop effective, sustainable and integrated healthcare systems

Engaging local people and communities throughout the commissioning cycle and prioritising the needs of patients and the public

Meeting the healthcare needs of the whole population, including the disadvantaged and the vulnerable to improve health outcomes

Putting clinicians at the heart of designing and delivering innovative, evidence-based and high quality healthcare services

Collaborative Community Focused Comprehensive

Clinically Led

Improvement and Development Agency (I&DEA)

http://www.communities.idea.gov.uk/welcome.do

This is a community platform supporting collaborative networks for those involved in local delivery: central departments, local authorities, other public bodies, frontline staff, health staff, people working in charities and the private sector who are in some way delivering for the public.

Understand the need Provider consultation Outcomes for users Provider analysis Provider capacity

development Transparent and fair

procurements Risk sharing Seeking efficiency User feedback

The Kings Fund

http://www.kingsfund.org.uk/NHS-Commissioning

Active support at centre of process

Improving the management of users

Efficiency

Primary prevention

Secondary prevention

Lancashire County Council

Citizen empowerment Equality

Use as a primary vehicle to

http://www.lancashire.gov.uk

Partnership Choice

manage care quality

Build on citizen capacity

Commissioning Support Programmehttp://www.commissioningsupport.org.uk

Evidence based decision making

Adherence to changing policy and government guidance

Openness and transparency

Lean processes and continuous improvements

Accountability

Providing early intervention services

Provide challenge for all practitioner activity

Sustaining relationships between key practitioners and vulnerable families

Tower Hamlets Council Trust Openness Clarity Honesty Flexibility Effective Equalities Commitment to the local

community Standardisation Knowledge transfer

7. Developing Commissioning Principles

As well as developing agreed universal principles the commissioner/provider relationship and expectations needs to be considered. From the sources above the common and non- biased principles are as follows:-

8. Conclusions

Commissioning is no longer the sole preserve of Health and Social Services and is providing many business models.

The analysis of commissioning success is as subjective as the variants of applied commissioning models.

There is likely to be benefit in comparing Commissioning models with the outcomes expected from more defined change delivery approaches and methods.

If organisational application of commissioning stays at the principle level, question the value of these principles.

Commissioning principles may not exist outside of the scope of modern strategic management.

It is advantageous to have a high level and corporate common understanding of commissioning derived from principles to promote effective communication across specialisms.

Therefore a discussion pathway may consider:-

What are commissioning principles The value of any identifiable commissioning principles What are the applicable benefits of principles Behavioural links What is the cost of commissioning confusion of a concept with unclear principles and therefore situational and opportunistic application Are any identified valid principles (if any) to be applied:-

Selectively Universally across an organisation Not at all

What are the existing and potential relationships with other promoted & available models of working and delivering strategy

Any alternative delivery vehicles or approaches to management.

Suggested Discussion Pathway

Discuss Universal Principles

Discuss & agree Aims

Discuss suitable Applications