Research and Evidence: User involvement in commissioning services

 The Joseph Rowntree report covered a range of service users, including older people

THE RESEARCH

KEY WORDS: Service user groups ❙ Age Concern ❙ personalisation ❙ commissioning

Authors: Silvia Schehrer, Stephanie Sexton, Samantha Mauger and Gordon Deuchars

Title: Involving users in commissioning local services

Published by: Joseph Rowntree Foundation (with Age Concern London), May 2010, 58 pages, www.jrf.org.uk

Aim: To explore service users’ experience and views of involvement in commissioning and the experiences and views of commissioners when involving users.

Methodology: Literature review (published separately) and summary of interviews with adult service users and commissioners in a small number of London-based case study sites.

Conclusion: The report does not end with recommendations, but instead reflects a series of key questions and challenges on user involvement in commissioning. This includes a diagrammatic representation of the key principles, pressures and components of systems for involving users in commissioning.

Increasing the effectiveness of public service commissioning is a key policy priority, but the issue of user involvement in commissioning has often been neglected. Although most official guidance emphasises that user involvement is important, it typically has less to say about how and when to do this, what it achieves and how it feels for users and commissioners.

Against this background, the Joseph Rowntree Foundation and Age Concern London have published a think piece, Involving Users in Commissioning Local Services. Based on a literature review (published separately) and research with service users and commissioners, the report is quick to point out that “it has not been written as a traditional research paper nor as a toolkitbut rather as a think piece” to encourage reflection of the pressures and factors at stake. Because of this, it doesn’t present research methods and findings in a traditional manner, but instead provides a brief summary of previous literature and policy and of the experience of users and commissioners – using the latter to identify the challenges, principles and issues to consider when trying to develop more effective user involvement in commissioning.

A key strength of the report seems to be its inclusion of a broad range of user groups (a parents’ group, people with learning disabilities, people with mental health problems, people with a dual diagnosis, people with HIV/Aids and physically disabled people).

Common topics for service users included their motivations for being involved (often a desire to see things change) and common barriers to involvement. These barriers could include involvement becoming a tick-box exercise, a clash of cultures, inaccessible language or when professionals aren’t skilled at facilitating involvement. Also significant were issues of funding and payment, with some participants feeling that their time and expertise should be paid for but with some concerns that payment might attract the “wrong” sort of person.

For the six commissioners interviewed, there was a sense that NHS trusts were lagging behind local authorities in terms of their commitment to user involvement, with a top-down world view. The commissioners also discussed the difficulty of finding ways to seek involvement from the “right” people who use services – there were concerns over how representative some people’s views were.

Also of concern to commissioners was the relationship between commissioning and the political process; there were several insights into ways of engaging local councillors to ensure that involvement and commissioning could be effective in practice.

Interestingly, most of the commissioners felt that user involvement could bring a different perspective to decision-making and highlight different priorities, but rated the impact of user involvement to date as only a four or five out of 10. When asked to identify a change in a commissioning decision due to user involvement, only a minority of commissioners could identify an actual change (a record described by one commissioner as “very sad”).

After this, the second section is headed “reflecting and thinking”, and includes a discussion of emerging evidence and the observations of the research team on its own processes and approach. Key themes here include the importance of personal relationships, the difficulties caused by a system that is output/activity rather than outcomes-driven, and the need to make underlying values explicit.

This section includes helpful recognition of the complexity of the issues at stake, meaning that a “quick fix” or a “one-size-fits-all” approach is unlikely to work. With this in mind, the final section avoids specific recommendations (as all service areas and approaches will differ from place to place) – but instead summarises a series of principles and elements that contribute to effective involvement in commissioning.

This includes consideration of a range of individual, local and external factors. Rather than specific recommendations, this takes the form of a “menu of ingredients” required for effective user involvement in commissioning. This includes the need to involve users at every step and agree roles and boundaries, within a framework for involvement, and reviewing and learning from the process.

In part because of its “think-piece” format, the report has an unusual feel in places. Many of the issues raised seem reasonable and true to life, but the absence of more formal research methods makes it difficult to know exactly what the authors did in order to produce the paper and how they produced their subsequent conclusions. Although this might not matter to some readers, it seems strange to draw on “primary research” with users and commissioners without setting out the detail of the approach adopted.

The report also refers to what is described as a “detailed” literature review, although publishing this separately and drawing only briefly on it again gives a slightly unusual flavour to subsequent discussions. Above all, the research that is (sort of) reported here was conducted in 2008, giving some of the policy debates a dated feel. None of this is to detract from the common sense of many of the issues raised and the conclusions drawn – but an unusual approach does make it difficult to categorise the subsequent report and to know exactly what and how it adds to existing knowledge.

Practice implications

● For all commissioners and public service leaders, users could and should be involved at every stage of the commissioning cycle.

● For public service commissioners and people supporting user involvement, it is important to discuss and agree the role and boundaries of authority of both users and commissioners at every stage.

● For all people working to promote user involvement, it is important to be clear about external pressures that affect different stages of the commissioning cycle. This involves being clear about the operating environment and any political, practical or financial constraints that will limit users’ influence.

● For everyone involved in the process, different situations, individuals and groups require different approaches, and taking time to build relationships, communicate effectively and review and reflect together is crucial.

Encouraging involvement

Examples of service user involvement might include people involved in selecting service providers, user involvement in joint strategic needs assessment (an assessment of the local population’s needs by health and social care commissioners) or drawing on service user experiences when monitoring service quality. However, much of this work has tended to take place at local level, with limited scope to share and learn from such examples.

Further reading

Arrol, B (2008) User involvement in commissioning health and social care – a literature review related to developing best practice (developed as part of this project)

Jon Glasby is professor of health and social care and director of the Health Services Management Centre, University of Birmingham

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This article is published in the 30 September 2010 edition of Community Care under the headline “User involvement in commissioning services”