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Guest editorial Thursday 18 April 2012: Three unlikely commissioning support inspirations

About the author: Cassander Grey works for a PCT cluster somewhere in England. He is interested in health policy, the analysis and presentation of data, and reducing health inequalities. Outside of work he enjoys foreign travel, music and photography. His satirical dictionary, the NHS Lexicon, has appeared in the Health Service Journal.

He can be found on Twitter as @PCTCassander.

Cassander Grey is a pseudonym.


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If nothing else, NHS managers always get plenty to read: an Operating Framework every Christmas; a flock of Quality Accounts each spring; the tantalising prospect of an Information Strategy always just around the corner.

The private sector, deprived of this bounty, fills the void with management books; a high-energy blend of common sense, pop psychology and non-standard semantics by a range of authors from Sun Tzu to Winnie the Pooh.

With the bright new dawn of commissioning support services (CSS) being less than a year away, there's never been a better time for current PCT staff to embrace all things business-sounding.

I've only ever been able to finish one management book: the excellent Bluffer's Guide to Consultancy. On the other hand, I once met a prolific business author, the late David Freemantle, at a hotel. We held a conversation lasting several minutes.

It seems the key to success in this field is not so much the content – much of which is relatively straightforward – but the manner in which the content is presented. With enough modish analogies, people are likely to forget that the Rotatulator® is merely a reinvention of the wheel.

It is in this spirit that I offer the following three unlikely commissioning support inspirations – colourful characters from the worlds of vice, music and chasing caribou – each of whom can tell us something about how to survive the transition from calling the shots to pleasing the new stethoscope-toting paymasters.

The Vice King
Unlikely inspiration #1 is Jason Itzler, erstwhile provider of negotiable affection to the wealthy via his NY Confidential escort agency. Given that NHS commissioning support is one of the world's newest professions, it may initially seem somewhat unfair to compare it to the world's oldest.

Rather, it is Itzler's methods of differentiating his operation in a crowded marketplace which are worthy of note.

Escort agencies notoriously make use of the ’bait and switch’ technique; Itzler made a point of avoiding such ruses. A CSS may have several CCG clients competing for its time, and financial realities mean that headcount must stay low. However, it is important to avoid the temptation to promise each CCG client a certain number of hours from an experienced member of staff, with the intention of giving much of the promised work to less senior, cheaper employees.

Commissioning support is similar to affection-by-the-hour in that both exhibit the Veblen effect, where increasing cost increases demand, rather than decreasing it as would normally be expected.

Whilst a CSS must be competitive in a marketplace of CCGs with fixed per-capita management cost allowances, there's nothing wrong with a marketing strategy that suggests the best is worth paying for – this isn't just commissioning support, it's Anyshire CSS commissioning support.

Itzler's career is also an object lesson in the kind of “don't you know who I am?” hubris which CSS staff would do well to avoid. For Itzler, it took the form of loudly declaring himself “king of all pimps” after too much to drink in upmarket restaurants; for CSS staff, it could easily be something like a Facebook group called 'We still run the NHS'.

The Dub Maverick
Unlikely inspiration #2 is dub reggae auteur Lee 'Scratch' Perry – an idiosyncratic, brilliant example of how the tools available can matter so much less than the person who wields them.

Already an established music producer and vocalist, in 1973 Perry built himself a recording studio in his back garden in Kingston, Jamaica. Known as the Black Ark, the studio was fitted with equipment which was dated even by early-70s Jamaican standards; rival Kingston producers worked on 16-track mixers, Perry's desk only had 4. Yet out of the Black Ark came a series of outstanding, innovative tracks, all the more remarkable for their low-tech origins.

Whilst it would perhaps be unwise to copy some of Perry's eccentricities, particularly those of a sartorial nature, the basic message to take away is good people + cheap technology > all the gear + no idea.

In my time in the NHS, I've seen proprietary (read expensive) pieces of software being bought and implemented which provide an end result no different to that which could have been achieved with the already-paid-for but unglamorous MS Office suite.

Much of the analytical work for commissioning support will require the evolution of actionable intelligence from the primordial soup of already-collected NHS data. The right people will be able to do this whether they're looking at the data via the utilitarian ugliness of a PivotTable or overlaid onto a photorealistic 3D model of the local area, complete with real-time weather effects.

Starting with the right people is vital – this step cannot be skipped over and compensated for by purchasing a fancy reporting front-end. Lee Perry in the Black Ark is preferable to Pete Waterman in Castlefield Chapel, every time.

The Apex Predator
Unlikely inspiration #3 comes in the four-legged shape of Canis lupus, the common wolf. The most obviously transferable wolf trait – teamwork – is discussed at lengthelsewhere.

For me, two more esoteric lupine qualities are more interesting (and more spinechilling): observational learning and efficiency.

Wolf attacks on humans are rare, and tend to be preceded by a series of intermediate steps, starting with nocturnal visits to the edges of habitation and culminating in daylight sorties which quickly progress from clumsy to lethal. Throughout the progression, the wolves will spend a great deal of time observing humans, first from a distance and then moving gradually closer, building up a picture of how this unfamiliar animal behaves – and how best to bring one down.

The eventual attacks on humans are initially tentative: the wolf may nip at limbs or tear at clothing. The wolf is putting its observational knowledge into action, and figuring out exactly how much strength is needed to kill a man. Victims of wolf attacks often receive wounds caused by a force considerably less than the maximum power of a wolf's jaws.

Like the wolf, a CSS will be operating in a harsh environment full of unfamiliar challenges. A cautious approach, characterised by close observation and culminating in the expenditure of the minimum resources necessary for success, is ideal for a CSS.

A good CSS will have staff with the ability to take observations and apply them in practice, without the need for extensive trial-and-error experimentation. Being first out of the authorisation starting blocks is an advantage, but in reality a CSS will not have many chances to get their service right before the clients become skittish. Taking the time to get things right on the first go is a wise investment.

A CSS will operate under tighter financial constraints than PCTs do currently. Time, enthusiasm and expertise are all finite resources; working out the optimum resource commitment needed to make a project successful (and ensuring that this is not exceeded) will be essential to meet the demands of several client CCGs at once.

Like a wolf, a CSS should bite only as hard as it needs to.