It has become clear that a new kind of commissioning will be needed to meet the many challenges ahead, say David Colin-Thomé and Georgina Craig.
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Whatever emerges from the parliamentary passage of the Health and Social Care Bill, one thing seems clear. We will need to take a fresh approach to commissioning.
Commissioning is in its infancy as a discipline compared with literally hundreds of years of healthcare provision. Up until now, the process has taken a narrow, linear approach and consequently it has failed to drive large scale, transformational change. We need to redefine and extend the concept and its purpose – and most importantly, change how commissioners behave.
There are three healthcare domains:
- being the “people’s organisation”;
- building new relationships and partnerships with the health ecosystem and specifically with providers;
- providing system leadership that creates a focus on population health and quality – safety, effectiveness and patient experience – and facilitates innovation, productivity and integration.
Because success in this new paradigm is about building trust and creating sustainable partnerships to drive change, underpinning all three domains are highly developed “soft” management skills; skills that have been undervalued in NHS management circles until now.
A public first
The first and foremost relationship is with the public. In the new paradigm, successful commissioners understand that their most important asset is their trusted relationship with local people and the community; and that nothing less than transparency is acceptable.
Previous commissioning guidance included such a requirement and undoubtedly new guidance will follow. Successful commissioners won’t need it. They will understand that being transparent is the key to trust and building involvement.
To achieve transformational change, we need a commissioning approach that harnesses people’s motivation and unleashes their creativity to improve this highly complex, adaptive NHS system.
Successful commissioners will have complete clarity of purpose. They will understand that in order to engage and motivate those they rely on to deliver change, they need to hand over power and give people autonomy to do the right thing. They will set clear expectations and engage the system in developing a bold vision of improved care. They will create a shared sense of purpose and let people get on with it. Coupled with engaged local people, this will prove a powerful way of holding providers and the system to account.
Ultimately, we are commissioning services for people and their carers – not contracting for quantities, activities or isolated processes. This holistic approach means we need a deep understanding of what matters to people.
Successful commissioners will walk in the shoes of those they are commissioning for – or even better – co-design commissioning strategy with them. Looking at the world through the eyes of the person will ensure commissioners can describe a great experience of high quality, coordinated care. This insight will also help commissioners set meaningful patient reported outcome and experience measures that reflect the things that matter most to people. The most successful commissioners will value experience measures as highly as they value clinical outcomes.
Healthworks Clinical Commissioning Group
The clinical commissioning work undertaken by Healthworks in Birmingham and The Black Country has applied these principles in practice. In 2011, Healthworks used the Experience Led Commissioning approach to engage the local community and front line staff in co creating a strategy for end of life care.
At six co design events, more than 100 individuals and organisations worked with Healthworks commissioning leads to do this great work.
Over the course of the events, Healthworks received over 40 pledges of support from a range of organisations to deliver change. The strategy identified: three short term improvement priorities; a three year path to improvement that will see 90 per cent of people dying where they choose; and a drastic reduction in unplanned deaths in hospital. Everyone involved now feels a sense of ownership and is highly motivated to move forward.
Moving to implementation through five improvement work streams, headed up in the main by passionate leaders from the provider community, the newly formed South West Birmingham Clinical Commissioning Group cluster is now adapting and adopting the Healthworks strategy to cover a total of five CCGs.
The whole system – including community leaders - is now united and focused on delivering a great end of life experience. Healthworks is investing in a personal coaching programme for 15 change champions – including the clinical lead, improvement work leads and the lay project manager (who is also the regional dementia champion).
They are also providing coaching for a team of volunteers who want to drive improvement and champion the strategy out into the community. This investment will support the growing tribe of champions for change to become a cohesive team and ensure they are highly motivated and effective in delivering great end of life care.
Dr Niti Pall, GP clinical champion for the strategy and vice chair of Healthworks feels that she has found the way forward for commissioning, “Health has not really worked in this way before. Up until now, the commissioning process has been designed for commissioners and clinicians alone. We are very excited about ELC - we see it as our future modus operandi.”
This Experience Led Commissioning for an end of life care project was evaluated independently by the University of Westminster. Click here for more information on the results.
Successful commissioners will also understand that they are only as good as people’s worst experience of care. They will work collaboratively with providers and co-design rather than prescribe the metrics of improvement.
This shift will see commissioners letting go and providers becoming explicitly responsible and accountable for care quality and population focus. Clinically led commissioning will drive clinically led provision so that, over time, providers take on many of the functions that we associate with commissioning today.
Leading from the front line
Autonomy is a fundamental driver for engagement and motivation. Without it, great work simply does not happen. While management research proves this, NHS system leaders persist in writing top-down prescriptions and centrally determining form and function.
Why do we keep expecting this will inspire and motivate the front line? It’s counter-intuitive. We all know it will fail in the long run. Faced with unprecedented challenge, we need to look at the evidence of what works. The centre needs to let go now; and trust people to do the right thing for patients.
We want our new clinical commissioning organisations to be “in the zone” – that powerful place where you have autonomy to take on a challenge that you feel you can achieve when you push yourself and channel all of your creativity towards a purpose that delivers for the greater good.
Knowing that relationships are key to this change, we must let people work with whom they want and come together as and when it feels right to do so.
This is going to be a pivotal year for the NHS. The work that is done in 2012 by clinical commissioning groups needs to be great work. Are we ready to make the shift now?