Balancing the human with the business of commissioning
I remember being struck by what seemed like a bit of an error made by a senior commissioner. They were in the process of scoping out a new prevention service. The aim was to identify older people who’d be needing some sort of care in the fairly near future and targeting them for low-cost interventions which might prolong their independence. It was one of many such ideas to try and reduce the increasingly unmanageable costs of health and social care for older people, and seemed like one which had a good chance of having a positive impact. Sheffield has some pretty stark socio-economic inequalities between areas (see the 83 bus route study for a good example of this) and the initial plan for this project was to target the less well-off parts of the city where people would presumably have access to less support. That plan changed though, and the thing that swung it made me feel really uneasy.
The commissioner had a personal link with some older people in a (broadly speaking) more affluent part of the city and in thinking through their needs, decided that the programme should be broadened to similar areas. I was secretly appalled. The small budget for this work would now be stretched even further, and not because of any objective assessment of the impact on health and social care budgets (the whole purpose of the initiative), but because of someone’s feelings and personal ties. At the time I couldn’t understand why this decision had been made in this way.
In my current role, one of the tag lines for our project is “connecting human stories to strategy”. We work with commissioners of health and social care to try and help them to do exactly what this commissioner had done (albeit arguably somewhat narrowly in this case) and to listen to the people who’ll use a service. We actually go further and want commissioners to involve people throughout the planning, implementation, evaluation and running of a service. And it’s pretty easy to forget that they spend a huge portion of their time and energy doing everything they can to operate like a business.
And business means numbers, facts, objectivity and often doing everything you can to block out the emotions which might be tugging at you when you’re making a decision. And it means being accountable to your seniors for your decisions. And for commissioners, accountable to the whole city for whether or not each person’s needs get met, which is essentially all about the bottom line. When you remember all this, it’s not so difficult to see why they’re not all dashing out into the community with a smartphone to capture videos of what older people want from the new extra care scheme they’re planning.
Our argument for co-production (and I think it’s a pretty compelling one) is that if you do it right, you not only wind up with better services, you save money. Quality increases and costs go down. It’s certainly not easy, especially if you’ve not got a history of doing it, but the benefits are well-established, well-evidenced and very business-friendly. But if we want to help commissioners change and adopt these new ways of working, we need to remember the enormous weight of established practice and the tremendous pressure they are under to get things right. Just as important as listening to the public and understanding their needs, is seeing the tightrope that health and social care commissioners are having to negotiate every day, and how long the drop must feel from up there if they put a foot wrong. I’ve realised now that it’s very possible the commissioner making that decision was simply doing the best they could to look at things from the perspective of people who needed the service, but without the time, resources or support to do it properly.
Chris Hewitt - Co:Create Programme Co-ordinator