Improving commissioning in a time of change
With reforms to health and social care on the way, policymakers have a unique opportunity to embed and strengthen what we know works.
By Felicity Simpkin, Associate Director of New Business & Contract Retention
Commissioning health services is a complex task. How it is done, who is responsible for it, and how success is measured has changed many times in recent years. Navigating these changes in an era of long-term disinvestment and local variation in budget and service quality has been a big challenge for those who commission services.
Commissioning is also grappling with the impact of procurement processes that can undermine the success of the very services being delivered. Tendering can be resource intensive and lengthy, distracting from the day-to-day running and development of existing services. At its worst, this disruption can result in inflexibility, stifle innovation and be costly. While many areas have lengthened contract terms, and are working to align contracts across a system, services for people with multiple and complex needs are also too often siloed, commissioned separately and to separate time-frames.
A new round of national reforms are now underway and the processes used to commission services are under the microscope of policymakers. The Government has published new plans to reform public procurement, there’s a new White Paper outlining the biggest NHS reorganisation since 2012, and Public Health England is about to be abolished and functions folded into the Department of Health and Social Care (health improvement) and a new UK Health Security Agency (health protection). The sector is also awaiting the publication of the Dame Carol Black Review of Drugs and a new Government Addiction Strategy. All these processes will have something to say about how services are commissioned and delivered.
In light of this, we need to ask ourselves what aspects of commissioning do we want policymakers to hold on to? And what needs to change?
Commissioning works best when it’s kept local.
In our experience, a strong place-based strategy and culture of collaboration in commissioning and between different types of providers is the best model to support treatment and recovery, and provide the greatest benefit to the wider community. Where decisions are made locally, by people who understand or are part of communities, the local health system is able to meet diverse needs and reflect the priorities for local solutions and treatment systems in their design.
Local authorities play a pivotal role in listening and design — providing flexibility, brokering partnerships and supporting integrated commissioning models, such as supporting joint working between VCSE and the NHS. The principle of place-based commissioning should be at the heart of any new commissioning structures.
At With You, we have seen the impact of having local collaboration at the heart of a commissioned service. In Wigan, the local authority has committed to a model of partnership with the local community — the ‘Wigan Deal’. They encourage providers to work together and collaborate towards shared outcomes. We provide drug and alcohol treatment services, but work in close partnership with housing, domestic violence, mental health and NHS services to make sure that people are able to get the support they need in a joined-up way. This means services work around, and for people, and provide for a wide range of positive outcomes.
Commissioning needs to support diversity and flexibility
Despite the challenges of the last year, we’ve seen many benefits of a more mixed approach to offering support during the pandemic. The way the entire system responded together to support people without accommodation during the pandemic (through the ambition to get ‘Everyone In’) showed the importance of being flexible and changing the way services are provided. There are lots of opportunities for system-wide commissioning models that if continued allow for flexibility and choice. We have a role as providers to ensure we hold on to these positive changes.
We’ve been able to adapt the methods used to deliver services on a scale and timeframe that would never have been possible without the restrictions we’ve been living under. What we’ve learned in delivery must continue, including a mix of remote services such as an information and advice website, phone appointments, video groups and the option to talk to a trained advisor online alongside more traditional in-person services. Holding on to this mixed approach of offering support is essential for people to engage with services in a way they prefer, on their own terms, and at an earlier stage of their journey.
We must also keep hold of what we’ve learned about innovation and testing different approaches. Commissioning for innovation, or building in development to models must continue to allow services the flexibility to reach people where they are at, so they can communicate with service users in a way that is most convenient for them and their needs.
Retendering isn’t the only solution
The frequent re-procurement of services and pilots can waste vital resources, create disruption to services, and can result in poorer recovery outcomes. Commissioning longer contracts can have a big impact on the recovery outcomes of the people we work with. It allows local relationships to be developed over a long time-frame and results in improved partnership working with communities, commissioners and other local providers. Having a break clause in longer contracts can also ensure services can be redesigned if needed.
While pilots can be helpful to test new models and develop evidence bases, they also run the risk of providing a short-term sticking plaster that leaves gaps if not continued, or because funding can only be committed for a set period.
We have a wealth of evidence about what works; we should commit to delivering and developing that rather than redesigning it to seem novel.
We have to put the person front and centre
Some people we meet with simply aren’t ready for treatment straight away. Integrated services that support a person with all areas of their life can be vital in helping them get to a point where they may be ready to make changes or get support. Being visible in communities, listening, understanding and building this trust takes time. Early intervention, prevention and active engagement have to be seen as an important part of a treatment journey and invested in.
Key to the National Lottery Community Fund programme Fulfilling Lives that we delivered in Blackpool was partnership with a range of statutory and voluntary agencies, and a model of lived experience and navigators. Navigators (staff whose role was to connect service users to different services) with small caseloads offered intensive, person-centred support helping people get to the stage where they are ready to engage in drug treatment. This model of having integrated services for people with multiple and complex needs has been proven to be effective in supporting recovery, as well as being cost effective. A recent evaluation found for each person engaged in this programme there was an annual cost saving of around £10,000 from the reduced use of other services like A&E and the police — yet the Navigator model doesn’t deliver ‘treatment’.
Language around performance and impact is important in commissioning
Commissioning models that are based on the outcomes most important to the people using them, need to become the norm in drug and alcohol commissioning. Reflecting the lived experiences and changes that communities want to see for themselves will encourage innovation and is more likely to bring real impact than measuring input, activity and process. This doesn’t mean ignoring the evidence base, or rewriting all baseline metrics, but adding layers of measures that are designed by the community and are strengths based. While system outputs of our Breaking the Cycle model looked at changes to child protection status, our evaluation measured how families spent time together (eg sharing meals) pre and post intervention; something that the families we supported saw as a real measure of change.
There is an opportunity to look beyond performance and use commissioning as a vehicle to drive the impact we want to see on people accessing the service and wider society.
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The ongoing reforms to health and social care, alongside the reviews into drug treatment and commissioning processes will result in some big changes to how our services are delivered.
Though there are risks with any re-organisation, there is also an opportunity for policymakers to embed and strengthen what we know works. Alongside policymakers, commissioners and providers also have a central role to play in ensuring new commissioning models are designed and implemented correctly, and contribute to improving service provision for people needing support and treatment.
