A natural question to ask is “What’s that?”, and it’s a very good question.
Before answering that, though, I think there are questions we should ask before, such as:
- “What do we mean by ‘integrated’, ‘personal’ and ‘commissioning’?”
- “What difference do each make?”
This is the third of three posts looking at each topic individually (see the introduction to this short series and the posts on ‘integrated’ and ‘personal’). It’s a very quick way into the issue of commissioning, sharing information that I’ve found useful in my own learning. It’s not intended in any way to be comprehensive! Thus, if there are things you think should be added feel free to do so in the comments or on Twitter. I’ll update the posts accordingly.
What do we mean by ‘commissioning’?
Put bluntly, the core role of commissioners has been to buy services for their populations, although it has always been more than this.
This is from Health Select Committee’s report on Commissioning in the NHS (pdf) – a report which notes (rightly) that the vast majority of the public don’t know what commissioning is despite its central importance to the running of health and social care.
There are endless reports, chapters and even books on the topic of commissioning. Below, therefore, is a very brief summary of some of the key developments in commissioning relevant to health and social care.
Commissioning in the NHS began in earnest with the ‘purchaser-provider’ split of 1991 and has
been maintained since then (though in various guises – see Box 1 to the right). The “more” than buying services for populations that commissioning is has best been captured by the commissioning cycle. There are hundreds of versions of the commissioning cycle, but each is essentially a variation of the following:
As with integration, commissioning can happen at a variety of different levels. This is most obvious in health:
Commissioning in social care also emerged at the same time as the purchaser-provider split in the NHS. It took a slightly different form, however, with more emphasis put on the role of care management – where social workers were central to assessing need, arranging packages of care and managing and negotiating resources. This new approach was reflected in the Caring for People White Paper (1989).
Commissioning has come a long way since then, at least in the number of commissioners. The Barker Commission highlighted particular the problem of increasing fragmentation of commissioning responsibilities between different organisations within the NHS and local government – estimating there to be over 400 organisations with responsibility for commissioning. The main response to this has been “joint” or “integrated” commissioning across health and social care.
The development of personalisation in adult social care was a focus of attention in commissioning, especially focusing on the role of market shaping, market facilitation and market development. This was a new role for local government, best captured in the work of the National Market Development Forum (pdf).
Finally, an alternative to top-down commissioning is bottom-up commissioning, or more nicely what we might call people- or community-led commissioning. At the individual level this is essentially what Direct Payments are (and what we are seeing in the extension to Personal Health Budgets; see the post on Personal for more information on what this is and its effects). At a collective level it is best represented by the idea of co-production in commissioning or people-powered health.
(It’s worth noting that relatively little attention has been paid to decommissioning. Two honourable exceptions are this paper from IPC (pdf) and this decommissioning toolkit from the National Audit Office.)
Here is a selection of what I’ve found to be the most useful documents on commissioning:
- A history of commissioning in the NHS (pdf) (pp.8-18), Health Select Committee
- A wonderful timeline on the history of commissioning in both health and social care. The section specifically on the advent and realisation of the purchaser-provider split between 1989-1995 is especially relevant
- 10 years of joint commissioning across health and social care
- Options for integrated commissioning – a very useful document that looks at what existing joint/integrated arrangements currently exist (Section 75 arrangements etc.) and what options we have for the future (King’s Fund)
- Outcomes-based commissioning – the newest game in town. The Institute for Public Care has published an excellent discussion paper on this looking specifically at outcomes-based commissioning in social care
- The implications of personalisation for commissioning
- People-led commissioning – both through co-production in commissioning and people-powered commissioning (Note: we don’t here include information approaches to building community capacity or community empowerment, although these are arguably varieties of commissioning.)
- In case that isn’t enough and you are this way inclined, here’s an overview of commissioning and how it relates to different areas of public policy (pdf) (including health, social care, working with the third sector, children’s services, welfare etc.)
What difference does commissioning make?
[It is] clear that there are few examples of robust evaluations of commissioning in the academic literature. Moreover, the grey and practitioner literature tends to focus on commissioning in single government departments, local initiatives or single services/client groups. It has been noted that the efficiency, effectiveness and efficacy of commissioning and strategic commissioning is typically taken for granted rather than demonstrated… The evidence base on the outcomes of commissioning remains under-developed and such evidence as exists is equivocal – Williams et al. (pdf)
Asking whether commissioning makes a difference is a very interesting question. One of the issues with it is knowing exactly whether what is happening in practice is actually good commissioning. Mark Britnell, who led the development of World Class Commissioning within the NHS, commented:
It might strike you as slightly odd—it did me coming into the department—that no-one had defined what good commissioning was in 20 or 30 years. (para 137) (pdf)
Having thus defined what good commissioning looked like, an assurance framework to quantify how good commissioners were showed that most commissioning wasn’t very good: in only one of ten competencies did people achieve better than half marks in their ranking:
If knowing what was happening in practice was actually commissioning was one problem, the other major issue was in understanding the difference commissioning makes is. The main issue here was the lack of a counterfactual: if commissioning is the only option, there’s nothing to compare it against.
Against this backdrop, we therefore shouldn’t be surprised to read that nearly all flavours of commissioning attempted in the NHS have not had much impact against a variety of themes, including efficiency, equity, changing patterns of service delivery, quality and partnership working.
The best of what we do have is therefore as follows:
- Significant early findings about the impact of commissioning are here (pdf)
- A considerably detailed review of joint commissioning is here
- On integrated commissioning, there is even less information. As concluded here:
Overall the research suggests that examples of fully integrated commissioning are limited, and that this approach is typically confined to a small number of service areas. It follows that research into the nature and, in particular, the effectiveness of joint commissioning is also relatively limited… The evidence that is available suggests that the nature and success of integrated commissioning arrangements varies significantly between local areas and between services.
- A summary of all findings on integrated commissioning is here; a more comprehensive (though accessible) treatment is here (pdf), summarised in the Table below:
In social care there is a similar issue. Only recently has the University of Birmingham attempted to create a comprehensive framework of what good commissioning in social care is. Even then, there is no requirement to use this framework or measure commissioner performance against it. Much of what we know about the effectiveness of commissioning in social care comes from the literature mentioned above.
People-led commissioning is an emerging area; as such, the literature is nowhere as well developed. There are some bits of evidence, however, most notably the findings of the People-Powered Health initiative (pdf). Other evidence is available from particular sites, such as work in the Isle of Wight done by the Health Foundation.