Sophia Christie on world class organisations

Or they would be, if they had time between Darzi review meetings and injunctions to come up with imaginative interpretations of what an accident and emergency wait is.

Where we do have space for reflection, we might wonder whether world class commissioning can happen outside of world class organisations.

Teams of academics and others are slaving away to define what "world class" means, but I think we can safely assume a working definition of "considerably better than we are now". It is interesting we have focused on this element of the name, at the expense of reflecting on the very broad definition of commissioning implied by the competency framework.

Usually - generally when we are trying to avoid making substantive progress across the health and social care divide - we are happy to spend a frivolous hour or two debating the finer points of the relationships between commissioning, planning, procurement and so on.

However, the world class commissioning competencies make it explicit that commissioning in their terms encompasses everything we do and how we go about it. And, probably most significantly, how we are perceived by main stakeholders including local government, clinicians and the public.

In this respect, world class commissioning is less about the investment or contracting process in itself and more about what kind of organisation we are and aspire to be.

So let's assume this is a policy initiative to design world class organisations. There is a considerable literature on designing for performance, but here I will summarise the essential aspects as clarity of vision, articulation of strategy and operational delivery. It should concern us all that in the assurance process pilots these were the three elements found wanting.

Vision and mission work has a tendency to be associated with 1980s toe-curlingly embarrassing workshops which all produced the same patently untrue statement about having the best services. Despite this it remains the case that successful organisations are those that have a clear purpose.

Truly great organisations, according to Collins and Porras (2000), also have genuinely "audacious" ambitions for the quality and resilience of their services or product. The purpose is a simple statement of what the organisation is there to do; goals are aspirational and drive a culture of improvement. This may sound obvious, but is your organisation there to "commission health services on behalf of local people" or to "improve the health of local people"? They are quite different activities and require very different strategies and processes.

If you aspire to truly "customer-centred" services, Galbraith's (2005) work would suggest you have to radically redesign the typical NHS organisation. Similarly, we have to stop confusing strategy with national policy. The Department of Health is a politically accountable organisation responsible for developing policy: a course of action which may or may not be associated with expedience, sagacity or shrewdness.

As local NHS organisations we are responsible for interpreting, tailoring and acting on those policies. But to be effective we need to filter them and ensure they are aligned with our own strategies, which should have emerged from our own clear purpose and aspirational goals.

Local strategies should determine our direction and approach in areas central to our success. Without explicit strategy, we cannot design effective structures or processes to deliver and will not know what sorts of people and skills we need to deliver. We will potentially be subject to systems of remuneration and measurement which divert us rather than incentivise progress.

Much of the assurance process will focus on execution and excellence in knowledge. But there is a risk of focusing on the transactional skills required to deliver specific elements of the competency framework, at the expense of consistent delivery of excellence through process management. Process management itself will only deliver within an organisational framework in which it is aligned with strategy.

This is the bit of strategy true bureaucrats love, as it represents the translation of strategy into plans. There is nothing a good civil servant loves more than a fat plan. This love seems to be spiralling into fetish as we are increasingly expected to duplicate material along similar themes at the expense of action. If the DH wants us to move from strategy to execution, it should establish we have a plan, grounded in our purpose and strategy, defining a clear set of actions which are reflected in our investment and procurement activity.

So back to delivery. The world class commissioning vital signs will be the real test of our ability to translate our core purpose into visible difference. The systems of reward and definitions of failure will play a major part. Last year, some of the highest performing teams in the NHS did not receive their annual inflation rise because despite delivering huge savings and improvements in services, they missed ersatz control targets.

If vital signs definitions are set as absolutes, it will be career suicide to work in a disadvantaged area.

The DH has bravely set in train a policy which begins to facilitate a real focus on investment rather than expenditure, outcome rather than input and public value rather than professional comfort. This shift has the potential to deliver world class performance, but it will not be an easy transition. It will require world class organisations to lead it.

See the world class commissioning debate