Commissioning: if you always do what you've always done...
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10 February 2020
By Kate Sibthorp
Andy Brogan’s presentation was thought-provoking to say the least and, I sensed, quite challenging for some people in the room.
He argued that commissioning for outcomes in social care is a bad idea. What?! Let’s be clear here; he’s not saying we don’t want to achieve outcomes, but that the process of commissioning for outcomes leads us to measure the wrong things, things that don’t make a positive difference to people’s lives.
I’ve come across this personally, when I secured funding for one of my daughter’s PAs to go to college to get a Certificate in Care. She decided to abandon it after just two weeks. She was being told that she had to record in writing, every day, exactly what they’d done – how many drinks, how many visits to the loo etc. She told the course tutor that I didn’t want to know these things. I wanted to know if my daughter had had a good day – was she happy, had people been friendly, would she enjoy going back to wherever they’d been or seeing a film again. The tutor said that the PA should still write everything down to ‘cover herself’ in case of a problem situation. It was all process, not relationships or happiness. The only way anyone could measure what matters for my daughter would be to count smiles and laughter. The relationship between me, my daughter and her PAs is built on trust. Sometimes the PA might do something I wouldn’t have done, but if it’s coming from the right place, the heart, that’s fine. And anyway, who’s to say the PA’s ‘wrong’ and I’m ‘right’? I’m happy for them to try things and see whether my daughter likes them or not.
As Andy Brogan explains...
Populations don't experience outcomes. People do.
In this context, Andy Brogan’s approach makes good sense to me. He says that great results in social care are achieved through relationships between people. If we accept this, then commissioning needs to evolve into a process that secures the right underpinning values, attitudes and relationships that will deliver good, meaningful lives. I hear people talking a lot about moving away from the time and task approach. The question is, how do we commission the underlying conditions that will enable human relationships to flourish and enable great outcomes to emerge?
It seems to me that Andy’s view of commissioning is far more dynamic than what currently tends to happen. It recognises that we don’t always know exactly what outcomes we want (human lives are messy) and people who access services are endlessly diverse. So commissioners need to work with people, communities and providers in a way that figures out what to do as we go along, running with what works and abandoning what doesn’t. It means that commissioning would have to become a more continuous learning process, more open and flexible, more iterative - not a straightforward specify/deliver/measure approach. There would have to be continuing conversations between commissioners, people who access services and providers to share how things are going and think about what’s working, what’s not working and what else to try. It couldn’t be anything other than place-based and co-produced.
There are lots of challenges associated with this. Not least, and something I’m interested in exploring, is how we enable people in communities, including people who access services, to evolve from being passive customers or recipients to authentic co-production. There are some excellent examples of co-production, the relationship between Think Local Act Personal and the National Co-Production Advisory Group being one. But most people I know don’t get it; in my experience, there isn’t a latent majority of people who access services ready and willing to co-produce. We need to nurture co-production.
This approach takes guts, leadership, collaboration and heaps of trust. It feels like a real opportunity and I’m hoping that the Social Care Innovation Network will generate some interest in giving it a go!