Developing Relational Commissioning #3 – Relationships, Relationships, Relationships

Thinking differently about commissioning Kings Fund (2022)

TBAC summary (print).pdf (kingsfund.org.uk)

• Strategic planning is increasingly a collective activity in which system partners come together to understand available resources, explore local population needs, agree priorities and make resource allocation decisions looking across health services (and in some cases, across health, social care and wider public services).
• Procurement processes are being simplified wherever possible. Areas are using competitive procurement as a tool of last resort (or spot purchase) . At the same time, financial arrangements between commissioners and acute providers are being simplified – through block or aligned incentive contracts – to tackle incentives that create tension within the system.
• Performance monitoring increasingly focuses on the performance of the local system rather than individual providers. For example, system-wide financial reporting with a focus on cost effectiveness as outcomes as the key indicator of system performance. Monitoring and evaluation are the least developed parts of these new models of commissioning. (hence BERRI or similar)

Strong relationships among key stakeholders are central with mutual understanding between commissioner and provider leaders in local system with shared views and understanding among senior leaders that go alongside operational staff with a focus on supporting them to work more effectively with colleagues in other local organisations. Collaborative service planning – senior leaders together to discuss operational challenges, is central to how local organisations work together without being a formal decision-making meeting.

• Agreeing a set of shared values can be a useful resource when challenges arise. Tensions between stakeholders within collaborative planning arrangements are inevitable, but our case study sites found a defined set of values helpful as a way of anchoring conversations at times of difficulty.
• New collaborative commissioning approaches mean commissioning staff may need to work differently. After nearly 30 years of a quasi-market framework, collaborative commissioning requires different behaviours and involves navigating uncertainty. For some staff this can be challenging. It will require investing in organisational development.

Emerging collaborative planning approaches are yet to coalesce into a single body of thought; rather, there are a number of approaches co-existing that share some common elements.

Different terms are being used to refer to approaches in this area, including collaborative commissioning, asset-based commissioning and community commissioning (for examples, see Lent et al 2019; Burbidge 2017; Davidson-Knight et al 2017).

Some key ideas feature prominently, as follows.

• In place of measuring the technical efficiency of individual services, there is a focus on collaboration between different services to meet the full range of people’s needs.
• The attitude towards frontline staff – and how they are supported – is central to these approaches. Rather than mandating staff to follow operational rules and guidelines, emphasis is placed on empowering them as autonomous professionals to use their judgement in meeting service users’ needs.
• Rather than arm’s-length relationships between commissioners and providers, whereby commissioners are agnostic about how services are delivered (sometimes known as black-box commissioning), these approaches envisage close, ongoing dialogue between providers and commissioners so that both partners are fully aware of operational demands.
• Instead of funding mechanisms that allocate risk to providers, commissioning approaches informed by these ideas generally develop long-term, predictable financial arrangements that make it possible for commissioners and providers to maintain an honest dialogue about delivery.
• The value of experimentation is emphasised: operational ideas are tested, amended, rolled out or abandoned (and failure is embraced as a learning opportunity) on an ongoing basis. This is in contrast with long-term contracts that can serve to lock in particular operating models.
• At the centre of these approaches is a behaviour change process for staff who are asked to work together differently (both within commissioning organisations and with provider organisations). It involves overcoming traditional organisational or territorial demarcations and focusing on shared endeavour and mutual support.

A new commissioning ethos brings a new role as commissioner as ‘the glue’, ‘a facilitator’, ‘an enabler’ and ‘a connector’, providing ‘a population-eye view’ of issues, and using collaboration and collective leadership to make more effective choices about how to improve care for children. population health. This is a significant change from enforcing contracts and creating competition to enabling system-wide discussions and promoting collaboration with a mix of formal and informal.