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Editor's blog 12th February 2009: Discussing commissioning

Good afternoon. I hope this finds you well.

This morning, I went to the discussion event on strategic commissioning held by and at the Social Market Foundation (www.smf.co.uk). Thery are due to produce a report later in the year on this subject. The purpose of this event was to focus the topic and to share learning and experiences.

Dr. Simon Griffiths of the SMF outlined the policy context framing the question of how to improve strategic commissioning in the light of:
1. devolution of central control
2. personalisation
3. solid performance management
4. equity

He suggested four additional areas for discussion:
1. what are the appropriate levels at which to commission – national, local or individual?
2. skills and capacities of commissioners
3. market management and commissioning
4. how best to measure outcomes

Commissioning: not procurement
It was observed that in trying to discuss commissioning, there is a significant risk of talking about procurement instead. Another overall difficulty was to achieve a valid definition of ‘strategic’ (though one participant gamely offered the idea that ‘strategic’ is “stuff that lasts for ten years”).

One classic dilemma in commissioning is the decision regarding whether to ‘make or buy’ a service. An equally crucial decision is that of who makes that decision, and with what democratic and political legitimacy.

Discussion also noted the potential for more effective commissioners to provide more or better services than less effective commissioners. This will inevitably create high-profile and media-risky political issues in the vein of ‘postcode prescribing’ in health, and may be an inevitable dynamic of the tensions between equity and locality that arise from devolution.

In this sense, it was felt that there is an echo of a broader lesson around trying to generalise about commissioning (strategic or otherwise): one size will not fit all.

Some comments suggested that the introduction of commissioning is at least as much a cultural shift as a technical change and set of skills. Some participants argued strongly that effective commissioning requires functioning markets and competition as preconditions. Others warned that it is important to consider the ‘ecology of markets’, and to design in appropriate social ecology around assessing the commissioned service to capture the complexity of outcomes that services may produce.

It was also pointed out that commissioners have the ability to require the market to be sensitive in ecological or other terms.

The professionalisation of procurement
While it was generally agreed that procurement is indeed not commissioning, it is an important consequence of commissioning. It was observed that professional procurement is a necessary but not sufficient condition to commission well.

Various participants observed that in some sectors, the procurement process has become effectively professionalised. One added that a city council may have a directorate of 12 people with job titles including ‘procurement’ and who are trained to high standards. However, around 300 other employees have procurement responsibility in their jobs – and it is, the speaker suggested, neither effective nor efficient to attempt to train all of them up to a professional level. However, ensuring they have the basics of commissioning skills was, he argued, important.

Another participant observed that in the commissioning process, it is necessary to decide the absolute basics:
what service to deliver;
who should pay for the service;
who should decide who delivers it;
and who should deliver it (and whether the choice can be left to the market or must be more defined).

These decisions on commissioning and procurement are also, it was noted, intrinsically political.

Wanted: 20-20 scoping
Various participants experienced in being commissioned to provide services by the public sector described problems around scoping and horizon-scanning for new services. There was a strong sense among this group that ‘starting with a blank piece of paper’ rarely happened, and that for whatever reason (possibly fear of crossing legal boundaries), those responsible for commissioning would rarely involve the provision market (extant or aspiring) at an early stage of the process.

Although scarcely news to any present, significant problems were also reported about the increasing burden of bidding for work, creating rising costs for providers.

One participant from a major commercial provider of services recounted having already spent £10 million bidding on a £2 billion 10-year PFI contract. The ‘passporting’ of providers with successful projects under way or completed elsewhere was also felt to be on the decline. The need to forge a balance between proper accounting for public money and unnecessary multiple-handling and duplication appeared evident.

Informing commissioning
It was clear that commissioning needs to be seen as a cyclical process, based on the best available data and evidence (while also recognising that the often-political choice of aspirations from the commissioned service may include certain outcomes which may be difficult or impossible to attribute directly and purely.

An example given was of services for young people in the community, which may have impacts on education, health and social services  - but ones that are difficult or impossible to measure. However, it should also be noted that the First Law of Social Work may come into effect – that the amount of social work to be done expands in direct relation to the resources available to do it.

Market management
Another philosophical, political and technical question arises around market management. In one example of market prevention in health, it was noted that some NHS Foundation Trusts had legally blocked (or attempted to block) their consultants from discussion the provision of new community-based services in partnership with providers and GP practice-based commissioners.

It will be interesting to see what shape this report takes.