This article examines the new commissioning framework recently published by the Department of Health and Communities and Local Government. The analysis points to three key issues within the framework – the structure, culture and capacity of the commissioning role. The authors argue that the effectiveness of modern commissioning will depend on the extent to which these challenges are dealt with.
The Department of Health commissioning framework for health and well-being was published last month and delivers on some of the expectations, and fears, of those in the health and social care community.(1)
The framework represents a fundamental re-shaping of how services are delivered although, in practice, it is a tentative step to breaking down the barriers between health, social services and other parts of local government.
Presented as a “consultative” document, there are many suggestions as to “what” the shape of local service delivery might look like in future, but rather less concrete direction on the “how”. Three key areas will require further unravelling and development – the structure, culture, and capacity of the commissioning role.
The framework defines commissioning as “the means to secure best value for local citizens”. Such a broad definition encapsulates all undertakings that define, secure, and evaluate service delivery under the auspices of commissioning. This formally places purchaser-provider relationships, at whatever stage of development they may be, within one set of activities, for which the commissioner will be held fully responsible. In this context, it is the structure of commissioner relationships that will be critical.
First, the framework indicates that the critical lever in commissioning will be the joint strategic needs assessment, designed to ensure that health, social services, and other local government stakeholders work together to define the needs of a local area.
The government may establish a duty on primary care trusts and councils to produce this joint assessment, but there is uncertainty as to whether legislative compulsion will be the most effective means to achieve it.
A standardised approach backed by law will ensure that some form of strategic assessment is going in the local area, in all parts of the country. But this may prevent innovative grassroots responses, and stifle the sense of ownership that will encourage areas to develop their own services.
Second, the discussion about the “culture” of commissioning reflects a recognition that important adjustments to the formal, structural relationships between commissioners will not result in improved outcomes without fundamental changes to the attitudes, beliefs and behaviours of those involved in implementing the framework.
Indeed, the culture change required to drive a truly joined-up service delivery approach is possibly the biggest challenge that one reads between the lines of the framework document.
The change in perspective the DH appears to seek has specific indicators that include:
● Engaging with broad coalitions and working with everyone who can contribute to promoting physical and mental well-being, particularly with local businesses and job centres.
● The call for more direct information-sharing within and between organisations.
● The possible involvement of GPs in commissioning “non-health” interventions.
All of these will challenge traditional ways of working and thinking, as will any genuine attempt to put individuals at the heart of commissioning. Good decisions by an individual (and “for” an individual) will not always be in the interest of the local population in the wider sense, and vice versa. This is not a new contradiction but becomes more serious in the face of genuine “user-centred” commissioning.
There are many places in which PCTs have worked with social services and other parts of local government to create unique and effective arrangements for individuals, many of which are described in the framework.
To make joined-up working ubiquitous, commissioners must feel both protected and free enough to pursue the changes suggested and be innovative in their own right. The suggested accountabilities and governance frameworks, while outlining what partnerships are needed, present a myriad of new relationships that may confuse commissioners.
Skills and training
Third, the entire framework rests on the assumption that there is sufficient capacity in the system to undertake all the activity required, and that commissioners (and GPs and PCTs) have the skills, knowledge, and strategic capability to work effectively with the required stakeholders, either now or in the near future.
Training has been available for contract managers and commissioners across the UK for some time and a host of tools for improved commissioning are in the framework. But the framework asks for a type of commissioner with new types of capabilities including the ability to think and work strategically across the health, social services and wider local government environment.
The framework requires that commissioners complete both the joint strategic needs assessment and business plans and work in concert with both local strategic partnerships underpinning local area agreements and contribute effectively to sustainable community strategies.
Training programmes are emerging already in response to the new requirements. For example, the University of Birmingham school of public policy has an accredited masters degree in public services commissioning beginning in September 2007 that will address the strategic nature of the commissioner role. It also provides both in-house and bespoke training for commissioners and contract managers.
With other programmes, this will go some distance to addressing the capacity issues that the new framework presents.
Finally, one could look at the new framework from a “glass half-empty” or “glass half-full” perspective. In one sense, the framework is overly ambitious commissioning across sectors is complex and difficult.
From another perspective, the framework is a positive first step in making commissioning a highly professional, sought-after role that is at the heart of the evolution of service delivery in the UK.Barbara Allen and Elizabeth Wade are programme directors of Birmingham’s new MSc in Public Service Commissioning.
Training and learning
The author has provided questions about this article to guide discussion in teams. These can be viewed at www.communitycare.co.uk/prtl and individuals’ learning from the discussion can be registered on a free, password-protected training log held on the site. This is a service from Community Care for all GSCC-registered professionals.
For further information on the course contact the authors or visit www.publicpolicy.bham.ac.uk
This article appeared in the 12 April issue under the headline “A measure of promise?”