The PSTA Commissioning Compass reading sources Reading edition from the original teaching documents, prepared 6 November 2026. June 2025 teaching text and June 2023 adult social care approaches pre-reading. Teachable lesson bodies, media, and downloads have not been compared. 0. Eight aspects of commissioning.pptx Selected teaching text from slides 4–87 and 99. Internal template instructions, blank slides, contact slide, speaker notes, and draft appendices are excluded. The complete PowerPoint is not offered for download. Slide 4 What do we mean by commissioning? Slide 5 Foundations of good practice Commissioning development offered through the PSTA draws from the good practice model of the eight aspects of commissioning.  Developed for the LGA and Partners in Care and Health​ Slide 6 What is the commissioning compass? The compass is: A system assessment tool for change A framework to hold in mind – not a maturity model Helps you see where change is possible Reveals what holds your system back Helps identify your best leverage points for change What do we mean by system? When you are commissioning for outcomes, you are connected to a large network of stakeholders, including citizens, communities, organisations, partners and providers.  All of this interconnecting network is your system. It makes up the complex whole.  Slide 7 What is the commissioning compass? We help you to assess your system and give you a sense of direction about how you can plan to improve.  The goal - helping you navigate complexity and impact on outcomes for people and place We have learned from practice in real places. We engaged 60 practitioners in collaboration with the Local Government Association.​ We have formally tested in three councils – whole council, adult social care, children's services. ​ We have developed the PSTA's Commissioning Academies (insert link) around the framework of the aspects of the Compass. Slide 8 What is the commissioning compass? The commissioning compass enables you to take a strategic view of commissioning.  It lifts you out of just considering the commissioning process (although we cover that too), encouraging you to ask yourself deep, reflective questions, and exploring your context. It helps you see and understand where the pushes and pulls are and identify strengths and areas for improvement.  You can use the compass just for yourself.  Or as a tool for development with your team, across your department or organisation.  It works best with partners as part of a development process, enabling you to really stretch up into whole system working for wellbeing.  At the heart of this assessment is how you, as a strategic commissioner, work with complexity. Slide 9 What is the commissioning compass? To use the system assessment, first, you assess your system using our 'eight aspects' of commissioning model. These aspects help you to: Appreciate how commissioning works now​ Identify where you can focus to unlock change​ See the full picture – not a single model​ or perspective Begin (or continue) a developmental journey Once you understand your system, use your current position, constraints, and enablers to create an action plan and to select the correct 'commissioning approach'. Only go into as much detail as you have time for, and as is useful! Slide 10 The Public Service Transformation Academy The Public Service Transformation Academy is a not-for-profit social enterprise, with RedQuadrant as the lead partner. We were founded in 2016 to take over the Cabinet Office's 'Commissioning Academy' programme. Today, we deliver training, consultancy and transformation. Our mission is to drive better outcomes for people and communities by developing the local, civil, social and health sectors’ capabilities to collaborate, innovate and lead. The founders of this academy share some core beliefs: That most of the problems the public sector and society is dealing with have a significant underlying level of complexity. This complexity differs – it can arise from having to deal with multiple stakeholders, from complex citizen needs, from a need for cultural or behavioural change, or from a complex system of organisations that need to work together. Often, all these sources contribute to the complexity at the same time. You can catch up on our latest activity, join our courses, and join our newsletter by following this link: https://link.redquadrant.com/m/PSTAOffers Commissioning Academy Set up as a flagship development programme by the Cabinet Office, this unique programme is focused on developing your skills and experience as a commissioner.​It brings together commissioners from across the system – often police, local government, adult social care, children's services, national bodies and many more. ​ We don't focus on rote learning or memorisation – you learn through doing in our action learning approach. Apply your learning to real challenges from your system in a hundred day plan to drive real change.​ Slide 11 Instructions for using the Commissioning Compass system assessment Remember, only use as much of the assessment as makes sense for you in your situation. The tool is intentionally wide-ranging to encompass strategic whole system working and commissioning tactics and processes. But it also takes you through a change process in each 'aspect’ of commissioning. The temptation is to start at the top, 'whole system working' this aspect is rightly aspirational. You may want to start at the foundational 'aspects'. These then assess your system readiness for the stretch to the more aspirational 'aspects' As an example. You may have good relationships in your system, but this is undermined by your capacity and capability. You may have good information and insight, but this is undermined by making room to make a difference. It is important to strengthen your system from the bottom up. There are six steps to carrying out the full exercise: Slide 12 Introducing the Commissioning Compass - eight aspects The system assessment is structured around the eight 'aspects' of commissioning - An aspect is a part or feature of the total complexity of strategic commissioning. Each aspect looks through a different lens. Capturing therefore a wider perspective than traditionally captured in commissioning cycles or definitions. Four of the aspects are more systems and outcome-based:​ Aspect 1 Whole system design: Work as one place to support and enable wellbeing, sustainability and mutual support. Key question: Are we making a place that helps everyone live life well?​ Aspect 2 Relationships and organisation across the system: Everyone focused on achieving shared goals with aligned incentives and funding  Key question: Is everyone working together coherently across our place?​ Aspect 3 Capacity, capability, and confidence: Shape markets, provision, and delivery of all those (place, assets, VCFSE, employees, families, friends, carers, neighbours, community, etc) who enable people can live their lives well Key question: Are we building the ability to meet or prevent needs, across all sectors?​ Aspect 4 Citizen, place, and outcome centred: Citizens in charge of their own outcomes, with success measured by people’s views on whether and to what extent they can live their lives well  Key question: Is the work led by the people or place who need it, and measured according to the outcomes they get?​ The other four are foundational pillars: ​ Aspect 5 Information, insight, and innovation: Commissioning approach that focusses on innovation and creativity and based on robust information / insight Key question: Is the work led by the people or place who need it, and measured according to the outcomes they get?​ Aspect 6 Making room to make a difference: Meeting, interpreting, and actively shaping the policy and legal requirements that we have to work within Key question: Do we understand and shape the law and policy we are working with? ​ Aspect 7 Commissioning process: Technically excellent, clear, and robust arrangements Key question: Do we have a strong, effective process?​ Aspect 8 Models and tactics: Design of delivery and intervention models that are fit for purpose, effective, and innovative, based on real attention to how intervention and infrastructure is structured and delivered Key question - Do we understand what makes a difference on the ground? Slide 13 Instructions for using the Commissioning Compass system assessment There are six steps to carrying out the full exercise: We have said in several places you can go into as much or as little detail as you wish with this assessment. If you want to have a strategic overview you can just complete steps one and two. For a more analytical view also do step three. For the assessment to inform an action or development plan you will need to additionally complete step four and five. And for the super advanced level step six is for you!  Step One -Getting started Spend a bit of time familiarising yourself with the 'eight aspects of commissioning. Understand how the top four are outcomes focused, and systems based and the bottom four are the foundational pillars. You need to have solid scores on the foundational pillar 'aspects' to be able to effectively move to be aspirational in the top four 'aspects' Give your place an instinctive score on how you are doing in terms of each of the 'eight aspects'. Do this quickly. It is just your first pass, your gut reaction. We will encourage you to revisit this after working through the questions for the aspects. Scores are categorised as below. Note that scores of 70 and above have been rare in system-assessments so far. ​ 0 – 24 Poor (significant risk)​ 25 – 49 Fair (lesser/lower risk, improvement required) ​ 50 – 74 Good (opportunities identified/issues need to be addressed) ​ 75 – 100 Excellent (no action required)​ Slide 14 Instructions for using the Commissioning Compass system assessment Step Two - self-assessment questions You will have already recorded a score for each of the eight aspects, based on your initial gut feeling. ​ Next, work through the assessment questions. These are encouraging you to take a deeper look at your system and develop more curiosity. Score your 'system' on each question. If you are doing this as a team and each person scored individually, do not simply average your results – look at the overall pattern of highs and lows, open up the conversation about what people are seeing in the system to give that score.​ In a workshop, this can be a great way to use appreciative or action enquiry. It will help you to be curious about how stakeholders experience each aspect and what the knock-on impact of that is. This will help too with the next step. At the end, we’ll compare your initial gut reactions to your actual score.​ Again, we ask you to be curious about where there are differences or alignment. What is that telling you? If you want to have a more analytical view now move onto step three. Slide 15 Instructions for using the Commissioning Compass system assessment Step Three - Factors that constrain and enable For each aspect, we will explore the factors that constrain or enable you Which hold you/ the system back ? Which most supports you to achieve change and outcomes? ​ Be curious about the depth of your awareness or understanding of each of the factors. You may wish to explore the factors further before you score them, but this is not essential at this stage. You can pick that up in your action plan later.   Once you have discussed each of the factors that constrain and enable, select the three most important enablers and the three most important constraints for each of the eight aspects. If undertaking this assessment with stakeholders, it is likely that there will be very different perspectives in the system. In your workshops, think about how you can explore these perspectives to give you a deeper understanding of your system relationships. There are not right and wrong answers here. This is to provide you with insight and intelligence to identify where to intervene for the most effective change. If you want to develop this assessment into an action plan or commissioning development plan we recommend you complete steps four and five. Using your assessment to determine the possible commissioning approaches. The action plan needs to include all of the insights and actions you have captured along the way in your exploration, curiosity and conversations. Slide 16 Using your constraints and enablers in an action plan Step Four - Control and influence. Urgent and important  Once you have evaluated the most enabling and constraining factors for each aspect, you can move to determine what is in your control and what do you need to influence.   Whether the factor is:   in your control   influenceable  out of your control  whether, in the opinion of the group, the factor is:   to be boosted   not to be boosted  would benefit from innovation or experimentation  You can arrive at this by exploring the following questions.  How will we boost the enabling factors in our control? How can we influence partners and stakeholders for enabling factors out of your control? For constraining factors within our control, what actions can we take to overcome them?  How will we use our influence where we can, to reduce constraining factors and build on enabling factors?  How will we take account of and work around constraining factors that are not in our control?  What experiments can we run to look at constraining factors that require innovation?  Which of these are the most urgent?  Which of these are the most important?  Which of these would require the most work?  Are there any “quick wins”?  We suggest you use an action plan to capture your actions here. If desired, this action-planning can be developed into a Commissioning Development Plan.  Action-planning on the factors that constrain or enable can help you to expand your ‘elbow room’ - your space and power to make an impact on effective commissioning.  Doing this activity across all eight of the aspects at once is quite a big task.  We suggest you take the bottom four aspects first giving you twenty-four constraints and enablers to work from.  Develop an overall plan for these.  When looking at the top four you may need a separate plan for each.   Slide 17 Introducing the commissioning compass - eight 'approaches' to commissioning Step Five  - Exploring approaches to commissioning As you can see from the assessment, we are opening up all of the different ways to assess your strategic commissioning system.  The aspects help you see 'what' the system contains and here we introduce the 'approaches’ to commissioning, which help you assess 'how' to intervene.  You can approach commissioning in different ways, with different methods, different principles, and different means. We have classified this through our eight 'approaches' to commissioning.  Here is a summary of those approaches.  Place-based wellbeing: Design and creation of a place-based wellbeing system. Leadership of place for whole system change: Creating a system that works. Unlocking potential: A place where everyone can thrive.  Citizen-centred commissioning: empowering citizens within the system. Values-based/disruptive commissioning: Changing the status quo Strategic procurement of services against needs: Services that meet demand  Market management: Creating conditions for best value and outcomes within financial constraints. Delivery model design: Effective delivery models enabling effective practice. You can find more detail for each of the 'approaches' within the chapters on 'aspects' of commissioning.  This will allow you to explore in more detail all the options available to you and your system.   Slide 18 Familiarise yourselves with the selected strategic commissioning approach and start to implement it For each strategic commissioning approach, this includes: Introducing the approach How to move towards this approach What to do, and what not to do, when pursuing this approach Specific risks to watch out for, including when your room for manoeuvre is limited, and other hints and tips The commissioning skills and structure that might be needed for this approach Slide 19 Step Six – Not for the faint hearted! Now if you are the person at school who always wanted the stretch questions, the advanced level....here is one for you in this assessment. Once you understand your score on the eight aspects of commissioning, you can use this to select your most appropriate approach to commissioning.  Return now to your scoring for the eight aspects that you did at the beginning.  Add those scores into the table here.  Then read down the table from the top to the bottom The first score over 50, reading down the table, identifies the recommended strategic commissioning approach.  But critically it must not have a lower score beneath it in the table. For example - In this example, the system has been given a mix of scores and you could interpret it several ways. You might be tempted to focus on approach 2, 'Leadership of the place for whole system change', because it is high up on the table and you have a high score. We would suggest that you don't, because some of the lower down aspects – the ones that are foundational – have weaker scores of below 50. This example is particularly weak in aspect 4 ('citizen, place, and outcome centred' and also has weaknesses in aspects 3 and 6 ('Capacity, capability, and confidence' and 'Making room to make a difference'). In the example, we would suggest that you focus on fixing the foundations which involves focusing on some of the lower down aspects. If you want to pick a single commissioning approach then in this example you would benefit from 'Market management'. If you instead opt for a blend of approaches then consider researching 'market management' and 'Delivery model design' which are both within your grasp and 'strategic procurement of services against needs', and 'values-based/disruptive commissioning' which are both a bit more advanced than your current practice. In this example the temptation is to go with the 'approach' 2. leadership of place for whole system change.  However, this is undermined by the score on 3.Capacity, capability and confidence and 4. Citizen, place and outcome centred.  The next highest is 5. Information and Insight.  But undermined by 6. Making room to make a difference.  The assessment of your system will help you understand why you have these undermining features and are there quick wins to resolve them, allowing you to move up the approaches for more impact.  Note scores of over 70 are very unusual.  If you do not score over 50 in any aspect then you will need to begin with the foundational aspect of 8. Models and Tactics.  In summary-   An approach higher in the table, is only sustainable if the commissioning aspects lower down the table can support it. They are the foundations.  If the lower aspects are not achieving a high score the risks are higher. It is not impossible to apply a higher approach.  But you need to do it with the awareness that your basics and foundational practice needs boosting, scaffolding or nurturing in the process.  Considering the approaches in this way allows you to critically appraise, or to opt for a blend of approaches, sense-checking your understanding of your challenges, bringing in your insights on your constraints and enablers and any associated action-planning you have developed. A blend of approaches may be useful at different times and in different commissioning situations.   Aspect Score (/100) Approach Focus 1 Whole system design   20 Place-based wellbeing  2 Relationships and organisation across the system   60 Leadership of place for whole system change   Aspirational focus area with substantial risk. Substantial action to reinforce below otherwise system vulnerable to shock if key partners leave. 3 Capacity, capability and confidence   30 Unlocking potential  4 Citizen, place, and outcome centred  20 Citizen-centred commissioning  5 Information, insight and innovation   60 Values-based/disruptive commissioning  Aspirational focus area with risk reinforce below 6 Making room to make a difference 40 Strategic procurement of services against needs  Strengthen 7 Commissioning process  60 Market management  Primary focus area 8 Models and tactics   55 Delivery model design  Maintain and improve Slide 20 Introducing the commissioning compass - eight 'approaches' to commissioning Place-based wellbeing: Design and creation of a place-based wellbeing system. Leadership of place for whole system change: Creating a system that works. Unlocking potential: A place where everyone can thrive.  Citizen-centred commissioning: empowering citizens within the system. Values-based/disruptive commissioning: Changing the status quo Strategic procurement of services against needs: Services that meet demand  Market management: Creating conditions for best value and outcomes within financial constraints. Delivery model design: Effective delivery models enabling effective practice. Once you understand your score on the eight aspects of commissioning, you can use this to select your most appropriate approach to commissioning. Slide 21 Introducing the eight aspects of commissioning More systems and outcome-based:​ Whole system design - Work as one place to support and enable wellbeing, sustainability and mutual support. Key question: Are we making a place that helps everyone live life well?​ Relationships and organisation across the system Everyone focused on achieving shared goals with aligned incentives and funding. Key question: Is everyone working together coherently across our place?​ Capacity, capability, and confidence - Shape markets, provision, and delivery of all those (place, assets, VCFSE, employees, families, friends, carers, neighbours, community, etc) who enable people can live their lives well. Key question: Are we building the ability to meet or prevent needs, across all sectors?​ Citizen, place, and outcome centred Citizens in charge of their own outcomes, with success measured by people’s views on whether and to what extent they can live their lives well. Key question: Is the work led by the people or place who need it, and measured according to the outcomes they get?​ And the foundational pillars: ​ Information, insight, and innovation Commissioning approach that focusses on innovation and creativity and based on robust information / insight. Key question: Is the work led by the people or place who need it, and measured according to the outcomes they get?​ Making room to make a difference Meeting, interpreting, and actively shaping the policy and legal requirements that we have to work within. Key question: Do we understand and shape the law and policy we are working with? ​ Commissioning process Technically excellent, clear, and robust arrangements. Key question: Do we have a strong, effective process?​ Models and tactics Design of delivery and intervention models that are fit for purpose, effective, and innovative, based on real attention to how intervention and infrastructure is structured and delivered Key question - Do we understand what makes a difference on the ground? And an overarching aspect: are we convening change in a way that works? Slide 22 More systems and outcomes focused More enabling and foundational Eight aspects of commissioning Citizen, place, and outcome-centred Capacity, capability, and confidence Relationships and organisation across the system Whole system design Models and tactics Commissioning process Making room to make a difference Information, insight, and innovation Convening change Slide 23 Introducing the eight approaches to commissioning Place-based wellbeing: Design and creation of a place-based wellbeing system. Leadership of place for whole system change: Creating a system that works. Unlocking potential: A place where everyone can thrive.  Citizen-centred commissioning: empowering citizens within the system. Values-based/disruptive commissioning: Changing the status quo Strategic procurement of services against needs: Services that meet demand  Contestability and Market management: Creating conditions for best value and outcomes within financial constraints. Delivery model design: Effective delivery models enabling effective practice. Slide 24 Eight aspects of commissioning Citizen-centred commissiioning Unlocking Potential Leadership of place for whole system change Place-based wellbeing Delivery model design Contestability and market management Strategic procurement of services against needs Values-based/ disruptive commissioning Slide 25 Aspects of commissioning Approaches to commissioning Whole system design - Work as one place to support and enable wellbeing, sustainability and mutual support. Place-based wellbeing - Design and creation of a place-based wellbeing system. Relationships and organisation across the system - Everyone focused on achieving shared goals with aligned incentives and funding  Leadership of place for whole system change - Creating a system that works. Capacity, capability, and confidence -Shape markets, provision, and delivery of all those (place, assets, VCFSE, employees, families, friends, carers, neighbours, community, etc) who enable people can live their lives well Unlocking potential - A place where everyone can thrive. User and outcome centred - Citizens in charge of their own outcomes, with success measured by people’s views on whether and to what extent they can live their lives well  Citizen-centred commissioning – Empowering citizens within the system Information, insight, and innovation - Commissioning approach that focusses on innovation and creativity and based on robust information / insight Values-based/disruptive commissioning - Changing the status quo Making room to make a difference - Meeting, interpreting, and actively shaping the policy and legal requirements that we have to work within Strategic procurement of services against needs - Services that meet demand. Commissioning process - Technically excellent, clear, and robust arrangements Contestability and market management - Creating conditions for best value and outcomes within financial constraints. Models and tactics - Design of delivery and intervention models that are fit for purpose, effective, and innovative, based on real attention to how intervention and infrastructure is structured and delivered Delivery model design - Effective delivery models enabling effective practice. Slide 26 Self-assessment exercise - purpose This exercise is not about benchmarking or comparison, but about improving: Our immediate commissioning practice; and Our ‘room to manoeuvre’ with commissioning –capability, capacity, freedom, power. To that end, we are evaluating ourselves across services and aspects, then creating a development plan. Only go into as much detail as you have time for, and is useful! Slide 27 Self-assessment exercise - Scoring Give your place an instinctive score on how you are doing in terms of each of the eight aspects, then revisit this after working through the questions and aspects and scoring them out of 100. Keep these categories in mind, and note that scores of 70 and above have been rare in self-assessments so far: 0 – 24 Poor (significant risk) 25 – 49 Fair (lesser/lower risk, improvement required) 50 – 74 Good (opportunities identified/issues need to be addressed) 75 – 100 Excellent (no action required) Slide 28 Simple questions for each of the eight aspects More systems and outcome-based: Whole system design - Are we making a place that helps everyone live life well? Relationships and organisation across the system – Is everyone working together coherently across our place? Capacity, capability, and confidence - Are we building the ability to meet or prevent needs, across all sectors? Citizen, place, and outcome centred - Is the work led by the people or place who need it, and measured according to the outcomes they get? And the foundational pillars: Information, insight, and innovation - Do we really understand all the needs in our place, including the unmet need? Making room to make a difference- Do we understand and shape the law and policy we are working with? Commissioning process - Do we have a strong, effective process? Models and tactics - Do we understand what makes a difference on the ground? Give yourself an initial instinctive sore out of 100 on how you do on each of these aspects of commissioning Slide 29 The Commissioning Self-Assessment Slide 30 Instructions for the self-assessment You should have already recorded a score for each of the eight aspects, based on your initial gut feeling. Now, we are going to work through a longer set of questions. Score your place on each question, but do not simply average your results – look at the overall pattern. At the end, we’ll compare your initial gut reactions to your actual score. For each aspect, you will also be presented with a number of factors in place that constrain or enable you as part of the self-assessment. Which of these factors most holds back your ability to work in this space? Which most supports you? Think about both your level of understanding of the factors and also the factors themselves. The aspects that hold you back or enable you to work on this aspect of commissioning will be picked up in your commissioning development plan. Slide 31 Aspect 1 Whole system design Work as one place to support and enable wellbeing, sustainability and mutual support. Slide 32 Whole system design Give each question a score and once completed document some observations and examples for each aspect 0 – 24 Poor (significant risk), 25 – 49 Fair (lesser/lower risk, improvement required) ,50 – 74 Good (shortfalls identified/need to be addressed) 75 – 100 Excellent (no action required)​ ​ Are we making a place that helps everyone live life well? How are we working as a whole, place-based system? Do we understand need and capacity as a whole? Is the whole system coherent? Do we have a plan as a whole system? Are we putting social and environmental justice at the heart of the system? Can we shift the dial to building on strengths? Developing an enabling, technology-supported self-help system, achieving prevention and early intervention? Are we learning as a whole system? Can we work systematically at a strategic, place, , community and individual level? Slide 33 Whole system design – Factors in place that constrain or enable (1/2) Population needs assessment, including levels of health, well-being and age distribution of the population Wage rates and employment market, relative and absolute poverty Levels of community safety and crime. Other geo-demographics of your place – characteristics, location, and density of population Understanding the underlying need and what is actually shaping behaviour or demand. What matters to people and communities – local views about wellbeing and care. Geographical marginality and isolation. Transport ease and accessibility. Which of these factors most holds back your ability to work in this space? Which most supports you? (Remember to look at the next slide as well) . Slide 34 Whole system design – Factors in place that constrain or enable (2/2) Levels of deprivation. Population changes Amount, quality, and accessibility of green spaces Urban design Funding and structures of the council and partners (and how they link together, or don’t) Degree of health and care integration, and at what spatial level Land value and planning issues Workforce and workforce planning Pressure to provide standardised services (discussion of ‘postcode lotteries’, etc.) National funding and payment funnelled through individual organisations or providers, not place. Which of these factors most holds back your ability to work in this space? Which most supports you? (Remember to look at the previous slide as well) . Slide 35 Approach 1 Place-based wellbeing Design and creation of a place-based wellbeing system. Slide 36 Approach 1: Place-based Wellbeing Introduction: Focuses on upstream investment in wellbeing and community resilience to reduce demand on care services. How to move toward: Start by mapping strengths and needs, and build a shared long-term vision with partners. What to do: Promote co-produced prevention strategies and enable community-led responses. What not to do: Don’t neglect statutory duties or assume full system redesign is required before progress. Risks and issues: Vulnerable to short-termism, leadership changes, and funding volatility. Commissioning skills and structure: Requires communicators who can influence widely, build alliances, and hold the strategic view. Slide 37 Aspect 2 Relationships and organisation across the system Everyone focused on achieving shared goals with aligned incentives and funding Slide 38 Relationships and organisation across the system Is everyone working together coherently across our place? Do we have effective governance? Are we learning from the past? Can we look at the knock-on effects of our setup and our decisions? Do we have effective collaboration, partnership, and challenge across all key groups: commissioners, providers, politicians, communities, etc? Are all stakeholders engaged with open communication? Are we learning about and working on our relationships? Are we optimising our results by responding appropriately to the maturity level of our relationships? Give each question a score and once completed document some observations and examples for each aspect 0 – 24 Poor (significant risk), 25 – 49 Fair (lesser/lower risk, improvement required) ,50 – 74 Good (shortfalls identified/need to be addressed) 75 – 100 Excellent (no action required)​ ​ Slide 39 Relationships and organisation across the system – Factors in place that constrain or enable Politician / partner politics Governance Formal partnerships Existing and historic relationships Different values that organisations and places put on commissioning Ethics and values of the organisation itself and people in it – culture Level of trust and involvement (not just engagement) of citizens / community Culture / behaviour development Incentives driven by funding streams Trust / relationships / culture – open and honest vs judgemental and punitive or avoidant Which of these factors most holds back your ability to work in this space? Which most supports you? Slide 40 Approach 2 Leadership of place for whole system change Creating a system that works. Slide 41 Approach 2: Leadership of Place for Whole System Change Introduction: Positions the council as a key partner in a shared system, not the central controller, focusing on whole-system impact. How to move toward: Use shared evidence and cross-organisational learning to build coherent joint working. What to do: Build trusted relationships, promote co-commissioning, and align vision across partners. What not to do: Don’t rely on shared plans alone—ensure changes affect frontline practice. Risks and issues: Can be undermined by weak governance, relationship breakdowns, or overfocus on strategy. Commissioning skills and structure: Needs senior-level influencing skills, governance literacy, and blended commissioning capabilities. Slide 42 Aspect 3 Capacity, capability, and confidence Shape markets, provision, and delivery of all those (place, assets, VCFSE, employees, families, friends, carers, neighbours, community, etc) who enable people can live their lives well Slide 43 Capacity, capability, and confidence (1/2) Are we building the ability to meet or prevent needs, across all sectors? How effective are we at building the capability of people to support themselves or their place? How effective are we at supporting people to help support each other ? Such as families, neighbours, communities, neighbourhood, place. How effective are we at building capacity and capability in providers from all sectors and sources (voluntary, community, faith-based, social enterprise, private, and public)? How consistently are we taking an enabling, strengths-based, approach? Do we engage with internal and external providers, suppliers as partners and collaborate with them? Effective balance of collaboration and contestability Give each question a score and once completed document some observations and examples for each aspect 0 – 24 Poor (significant risk), 25 – 49 Fair (lesser/lower risk, improvement required) ,50 – 74 Good (shortfalls identified/need to be addressed) 75 – 100 Excellent (no action required)​ ​ Slide 44 Capacity, capability, and confidence (2/2) Are we taking an asset-based commissioning approach? Do we have strong insight into our system of interventions and delivery, including our current and potential markets? Do we have good capability to develop all provision and supply, including where needed, market making and market management capability? Do we have a good understanding of all current delivery models and quality? Are we providing funding and support that takes a long-term view and looks at impacts, including environmental and social justice? Are we taking into account the local economic impact of our spending? Are we actively supporting workforce development? Give each question a score and once completed document some observations and examples for each aspect 0 – 24 Poor (significant risk), 25 – 49 Fair (lesser/lower risk, improvement required) ,50 – 74 Good (shortfalls identified/need to be addressed) 75 – 100 Excellent (no action required)​ ​ Slide 45 Capacity, capability, and confidence – factors in place that constrain or enable Asset and provision mapping Potential for funding models to better support capacity and capability Major costs and pressures Local provision strengths/weaknesses Cost and quality of provision, interventions and delivery. State and current role of the community and voluntary sector State of supply, from all providers and the wider market Levels of citizen satisfaction Understanding the current configuration of interventions Workforce development Which of these factors most holds back your ability to work in this space? Which most supports you? Slide 46 Approach 3 Unlocking potential A place where everyone can thrive Slide 47 Approach 3: Unlocking potential Introduction: Aims to build long-term capacity, confidence, and capability in communities to prevent need. How to move toward: Map formal/informal support, use social value tools, and engage local assets. What to do: Support micro-providers, community initiatives, and co-production at local level. What not to do: Don’t expect short-term savings or shift burden onto communities without investment. Risks and issues: Depends on leadership consistency and maturity of the local voluntary/community sector. Commissioning skills and structure: Requires strengths in market engagement, community development, and economic analysis. Slide 48 Aspect 4 Citizen, place, and outcome centred Citizens in charge of their own outcomes, with success measured by people’s views on whether and to what extent they can live their lives well Slide 49 Citizen, place, and outcome centred (1/2) Is the work led by the people or place who need it, and measured according to the outcomes they get? Are we commissioning and working together in a way that drives real change on the ground, as measured by real impact and reported by citizens and communities? Are we taking outcomes-led approaches, learning from real change on the ground, tracking and learning from impact, and reports from citizens and communities? Do we have real engagement with and understanding of actual needs, demand as different from need, including active identification of unmet needs or unmet demand? For economy, infrastructure, citizens and community, seeking to identify real needs rather than our belief about what is needed? Give each question a score and once completed document some observations and examples for each aspect 0 – 24 Poor (significant risk), 25 – 49 Fair (lesser/lower risk, improvement required) ,50 – 74 Good (shortfalls identified/need to be addressed) 75 – 100 Excellent (no action required)​ ​ Slide 50 Citizen, place, and outcome centred (2/2) Are equity and sustainability at the heart of our commissioning approach? Do we have co-production, co-design, or engagement at all stages of the commissioning cycle? Do we know when to use each type? Do we have a commitment to co-producing analysis, design, decision-making, delivery, and governance with all citizens, stakeholders, promoting inclusion and equality, especially from underrepresented groups? Do we look at the whole experience of from the citizen community side, as opposed to a narrow organisational, structural, service, or process silo? Are we making access to interventions, support and infrastructure clear and accessible to all? Including those who wish to pay? Are we influencing the approach of the whole organisation and partners in a way consistent with citizen, community, and outcome-centred working? Give each question a score and once completed document some observations and examples for each aspect 0 – 24 Poor (significant risk), 25 – 49 Fair (lesser/lower risk, improvement required) ,50 – 74 Good (shortfalls identified/need to be addressed) 75 – 100 Excellent (no action required)​ ​ Slide 51 Citizen, place, and outcome centred – Factors in place that constrain and enable (1/2) How success is defined in your place – supporting citizens, ticking the right boxes, keeping costs down etc Leadership and bravery of local system leaders The aspirations of your local leaders, including political leaders at a local, sub-regional or National level. Political ideology or vision (and interaction between local, regional, national or wider scale ideologies) How goals and targets are set for interventions, developments or improvements. Outcome-focused vs time-and-task approaches Use of technology to support delivery of outcomes Which of these factors most holds back your ability to work in this space? Which most supports you? Slide 52 Citizen, place, and outcome centred – Factors in place that constrain and enable Levels of coproduction – feasible and aspirational Level of education of community about areas to change, such as inclusion, sustainability, environmental, population, and health improvement. Focus on supporting wider enabling outcomes, e.g. creating environmental and population health through urban design to improve fitness and healthy weight How funding is connected to outcomes Which of these factors most holds back your ability to work in this space? Which most supports you? Slide 53 Approach 4 Citizen-centred commissioning Empowering citizens within the system Slide 54 Approach 4: Citizen-Centred Commissioning Introduction: Puts the individual in charge of their care and prioritises personal outcomes as success measures. How to move toward: Develop a compelling shared vision and embed feedback like “Did you get what you needed?” What to do: Enable co-design, empower personal choice, and align services around lived experience. What not to do: Avoid tokenistic engagement or overwhelming citizens with too many disconnected choices. Risks and issues: Risks losing system oversight or statutory compliance if not well-integrated. Commissioning skills and structure: Requires change agents with high credibility, openness to learning, and system navigation skills. Slide 55 Aspect 5 Information, insight, and innovation Commissioning approach that focusses on innovation and creativity and based on robust information / insight Slide 56 Information, insight, and innovation (1/2) Do we really understand all the needs in our place, including the unmet need? Do we have an ambitious and clear adaptive route map for change? Do we practice active learning and insight development? Do we have a culture of innovation, experimentation and learning from failure (and success)? Do we commission from a values-driven position, taking responsibility for outcomes while avoiding the ‘heroic’ mode of ‘fixing everything’ in favour of an enabling approach where people feel involved and part of designing and implementing things that matter to them? And we involve the workforce in design. Are we using approaches that harness complexity and an appreciation of whole systems? Give each question a score and once completed document some observations and examples for each aspect 0 – 24 Poor (significant risk), 25 – 49 Fair (lesser/lower risk, improvement required) ,50 – 74 Good (shortfalls identified/need to be addressed) 75 – 100 Excellent (no action required)​ ​ Slide 57 Information, insight, and innovation (2/2) Do we work across different paradigms as appropriate, based on multiple perspectives? Do we have an understanding of and great leadership of transformational change? Are we able to connect small-scale tests of change with larger strategic bets? Are quality, social value, and value for money evaluated proportionately and evidence-based? Do we have and share data from across the whole system, including identifying gaps and unmet needs that will result in demand? Do we seek external challenge, peer review, coaching, development, and reflective practice? Are we powerfully advocating for commissioning and leading by example? Give each question a score and once completed document some observations and examples for each aspect 0 – 24 Poor (significant risk), 25 – 49 Fair (lesser/lower risk, improvement required) ,50 – 74 Good (shortfalls identified/need to be addressed) 75 – 100 Excellent (no action required)​ ​ Slide 58 Information, insight, and innovation – factors in place that constrain and enable (1/2) Skills bases, experience and confidence of commissioners and key stakeholders/decision-makers Ability to innovate Quality of data analytics Communications, advocacy and influencing Capacity and resources in the spaces above Reputation of commissioners and commissioning Position of commissioners in formal and informal hierarchies Clarity about what ‘commissioning’ means to us Opportunity or not to design commissioning loops from information gathering through decision making, to commissioning and learning from outcomes Level of understanding of markets, providers, supply and delivery Which of these factors most holds back your ability to work in this space? Which most supports you? (Remember to look at the next slide as well) . Slide 59 Information, insight, and innovation – factors in place that constrain and enable (2/2) Understanding of place Understanding of unmet requirements and need compared to gaps in the system Understanding of provision and outcomes History of the market/supplier or delivery – levels of change and engagement Longer-term view of changes in the environment, citizen, provider, supplier markets or delivery Understanding of different funding streams, spending conditions and incentives Which of these factors most holds back your ability to work in this space? Which most supports you? (Remember to look at the previous slide as well) . Slide 60 Approach 5 Values-based/disruptive commissioning Changing the status quo Slide 61 Approach 5: Values-Based / Disruptive Commissioning Introduction: Uses values or innovation to challenge outdated models and promote new solutions. How to move toward: Start with options appraisal, build commissioner freedom, and learn from outside systems. What to do: Encourage experimentation, data-led insight, and open collaboration for reform. What not to do: Don’t pursue perfection or impose innovation without testing in real practice. Risks and issues: Too much disruption without buy-in risks failure; too little leads to stagnation. Commissioning skills and structure: Needs creative, data-savvy commissioners with coalition-building and risk-balancing ability. Slide 62 Aspect 6 Making room to make a difference Meeting, interpreting, and actively shaping the policy and legal requirements that we have to work within Slide 63 Making room to make a difference (1/2) Do we understand and shape the law and policy we are working with? Are we understanding and complying with the core constraints and enablers of commissioning through active engagement with existing and current legislative, regulatory, and quality assurance requirements? Do we have strong analysis and performance management, business intelligence, presented honestly and effectively, informing decision making? Do we understand how to manage compliance and get permission to extend capabilities – explain why we might get better outcomes if we do things differently, jointly focus on why things should be done, not ticking boxes, etc.? Give each question a score and once completed document some observations and examples for each aspect 0 – 24 Poor (significant risk), 25 – 49 Fair (lesser/lower risk, improvement required) ,50 – 74 Good (shortfalls identified/need to be addressed) 75 – 100 Excellent (no action required)​ ​ Slide 64 Making room to make a difference (2/2) Do we have a proactive and dynamic risk appetite approach? Are we creating effective, good practice policy and guidance? Are we playing an active role in shaping organisation, place, and national policy? Give each question a score and once completed document some observations and examples for each aspect 0 – 24 Poor (significant risk), 25 – 49 Fair (lesser/lower risk, improvement required) ,50 – 74 Good (shortfalls identified/need to be addressed) 75 – 100 Excellent (no action required)​ ​ Slide 65 Making room to make a difference – factors that constrain or enable (1/2) Interpretation of key legislation and up and coming policy changes and other statutory requirements Understanding of funding levels and drivers of cost Implications of Medium-term Financial Planning / long-term financial situation Approach to market sustainability? Clear equalities policy for commissioning and use of Equality Impact Assessments Strong understanding and strong use of the Social Value Act and Sustainability Act Which of these factors most holds back your ability to work in this space? Which most supports you? (Remember to look at the next slide as well) Slide 66 Making room to make a difference – factors that constrain or enable (2/2) Implications of regulatory/ inspection or quality assurance regime Understanding of other relevant legislation Clear local commissioning strategy and policy Shared approach across the organisation Shared approach across place Which of these factors most holds back your ability to work in this space? Which most supports you? (Remember to look at the previous slide as well) Slide 67 Approach 6 Strategic procurement of services against needs Services that meet demand Slide 68 Approach 6: Strategic Procurement of Services Against Needs Introduction: Focuses on structured procurement to meet defined needs efficiently and compliantly. How to move toward: Strengthen procurement-process alignment, market intelligence, and performance monitoring. What to do: Develop clear specifications based on engagement and evidence, and manage contracts robustly. What not to do: Avoid focusing only on limitations—procurement should support broader strategic goals. Risks and issues: Risk of becoming rigid or over-prescriptive; must avoid analysis paralysis. Commissioning skills and structure: Requires technical procurement, contract management, and analytical capability with service insight. Slide 69 Aspect 7 Commissioning process Technically excellent, clear, and robust arrangements Slide 70 Commissioning process (1/2) Do we have a strong, effective process? Are you balancing meeting urgent financial and other priority requirements with thinking about long-term impacts? Does your commissioning process support good collaboration, market development and co-operation, competition for improvement, value for money and commercials, and clarity of types of contracting improvement? How do you relate your timeliness of engagement in your strategic commissioning process? Do you balance time on co-production, design, market/ provider co-design, specification development, contract management, learning, etc? Do you have a positive approach to types and design of procurement and commissioning that focuses on proportionality and matches the design and the outcomes sought? Give each question a score and once completed document some observations and examples for each aspect 0 – 24 Poor (significant risk), 25 – 49 Fair (lesser/lower risk, improvement required) ,50 – 74 Good (shortfalls identified/need to be addressed) 75 – 100 Excellent (no action required)​ ​ Slide 71 Commissioning process (2/2) Are you using a broad range of evidence to inform decision making and commissioning, and contributing your own insight through reflection and evaluation? Does your process have a strong focus on Nolan Principles, social value, sustainability, equity, ethics, and openness? Are you able to maintain a strong commissioning process even in joint and shared commissioning and shared arrangements? Give each question a score and once completed document some observations and examples for each aspect 0 – 24 Poor (significant risk), 25 – 49 Fair (lesser/lower risk, improvement required) ,50 – 74 Good (shortfalls identified/need to be addressed) 75 – 100 Excellent (no action required)​ ​ Slide 72 Commissioning process – Factors that constrain or enable Risk appetite Flexibility or alignment in terms of different commissioning teams in the same ‘place’ following the same approach Flexibility of procurement and commissioning approach – enabler, or fixed constraint? Ability to de-commission to free up resources for innovation or alternative delivery ‘Permission’ to be innovative/use different approaches Which of these factors most holds back your ability to work in this space? Which most supports you? Slide 73 Approach 7 Contestability and Market management Creating conditions for best value and outcomes within financial constraints. Slide 74 Approach 7: Market Management Introduction: Uses commissioning tools to balance cost, resilience, and provider diversity for best value. How to move toward: Map needs and supply, align procurement strategies, and ensure ongoing engagement. What to do: Collaborate with providers, manage performance data, and foster innovation. What not to do: Don’t let commissioning become narrow, repetitive, or overly process-driven. Risks and issues: Can marginalise co-design or context if dominated by procurement logic. Commissioning skills and structure: Requires technical strength combined with flexibility, systems thinking, and bridge-building. Slide 75 Aspect 8 Models and tactics Design of delivery and intervention models that are fit for purpose, effective, and innovative, based on real attention to how intervention and infrastructure is structured and delivered Slide 76 Models and tactics (1/2) Do we understand what makes a difference on the ground? Are we investigating innovative delivery and funding and financing models that deliver demand reduction, reduced costs and increased impact, used appropriately? Are we engaging effectively with disruptive technology? Are we taking and encouraging a partnership approach to workforce challenges? Are we undertaking measurable supply chain optimisation? Do we have a strong focus on Social Value? Give each question a score and once completed document some observations and examples for each aspect 0 – 24 Poor (significant risk), 25 – 49 Fair (lesser/lower risk, improvement required) ,50 – 74 Good (shortfalls identified/need to be addressed) 75 – 100 Excellent (no action required)​ ​ Slide 77 Models and tactics (2/2) Do we have a proactive approach to cost, with genuinely proportionate costs. Including reducing demand for high-cost low low-volume delivery? Do we have supplier/ provider/ direct delivery relationships not focused on costs but on quality, improvement, and outcomes? Is there appropriate aggregation and joining up between models? Are we reducing waste and customer journey failures? Give each question a score and once completed document some observations and examples for each aspect 0 – 24 Poor (significant risk), 25 – 49 Fair (lesser/lower risk, improvement required) ,50 – 74 Good (shortfalls identified/need to be addressed) 75 – 100 Excellent (no action required)​ ​ Slide 78 Models and tactics – factors in place that constrain or enable Current funding and financing models Workforce issues Supply chain management Waste in delivery models Joining up between delivery models Potential for (dis)aggregation Digital and technical capability Opportunity to bring in different funding streams Which of these factors most holds back your ability to work in this space? Which most supports you? Slide 79 Approach 8 Delivery model design Effective delivery models enabling effective practice Slide 80 Approach 8: Delivery Model Design Introduction: Focuses on how services are structured and delivered to improve quality and citizen experience. How to move toward: Engage users, map processes, and learn from service design innovations elsewhere. What to do: Link design with real practice, co-develop models, and ensure practical implementation. What not to do: Avoid rolling out untested models or becoming fixated on structure over impact. Risks and issues: May challenge entrenched interests and stretch delivery capacity if not managed well. Commissioning skills and structure: Needs design thinkers with operational understanding and credibility across services. Slide 81 Summing up your score Slide 82 Have you completed your self-assessment? The self-assessment is a flexible tool and we suggest that you only use the parts that make sense in your context. If you do the whole thing then by the end of the workshops you should have done the following: You have produced an initial ‘gut score’ on how your system performs against all eight aspects. You have worked your way through each of the eight aspects and worked on the questions. You should have a score out of 100 for each question. You have worked your way through the ‘factors that constrain and enable’ for each of the eight aspects. For each of the eight aspects, you should have a list of the three most important constraints for your system and the three most important enablers. If you have completed all of this then your scoring is complete and you can proceed with the next section. Slide 83 Your scores For each aspect of your commissioning, look back at the long list of questions and the scores that you gave yourself per question. Weigh up how your system has performed and give yourself an overall score for each aspect out of 100. Record it in a table similar to the one below, with the aspects presented in this order: Aspect Score (/100) Approach Whole system design  Place-based wellbeing  Relationships and organisation across the system  Leadership of place for whole system change   Capacity, capability and confidence  Unlocking potential  Citizen, place, and outcome centred Citizen-centred commissioning  Information, insight and innovation  Values-based/disruptive commissioning  Making room to make a difference Strategic procurement of services against needs  Commissioning process  Market management  Models and tactics  Delivery model design  Slide 84 Your scores Use your scoring table to identify which strategic commissioning approach will provide a best fit for the place, building on local strengths, without letting them to be undermined by weaker aspects. This will not simply be the approach that aligns with the highest scoring aspect.  The first score over 50, reading down the table, which also does not have a lower score beneath it, identifies the recommended strategic commissioning approach. This reflects the fact that an approach higher in the table, whilst being more strengths, system, and outcomes-focused, is only sustainable if the commissioning aspects lower down the table can support it.  Before making the decision whether to select the recommended strategic commissioning approach, or to opt for a blend of approaches, it will be useful to sense-check the suggested strategic commissioning approach with an understanding of specific commissioning challenges, considering key constraints and enablers and any associated action-planning to support the development of local commissioning, and the description of what to consider for this approach. A blend of approaches may be useful at different times and in different commissioning situations.   Aspect Score (/100) Approach Whole system design  Place-based wellbeing  Relationships and organisation across the system  Leadership of place for whole system change   Capacity, capability and confidence  Unlocking potential  Citizen, place, and outcome centred Citizen-centred commissioning  Information, insight and innovation  Values-based/disruptive commissioning  Making room to make a difference Strategic procurement of services against needs  Commissioning process  Market management  Models and tactics  Delivery model design  Slide 85 Using your constraints and enablers in an action plan For each aspect of commissioning, you should have a list of three key enablers and three key constraints, giving a total of 24 important constraints and 24 important enablers. Work through these factors and answer identify and record:  Whether the factor is:   in your control   influenceable  out of your control  whether, in the opinion of the group, the factor is:   to be boosted   not to be boosted  would benefit from innovation or experimentation  This will enable you (either with or without partners and other stakeholders) to consider action-planning to support the development of the commissioning function for the place.  Action-planning on the factors that constrain or enable effective commissioning can help you to expand your ‘elbow room’ – yourr space and power to make an impact.  Making space to develop your effectiveness in commissioning will pay dividends in supporting the implementation of the selected strategic commissioning approach and enabling the delivery of strategic commissioning plans.  Slide 86 Familiarise yourselves with the selected strategic commissioning approach and start to implement it Read or re-visit the pre-reading – Introducing and Implementing Strategic Commissioning Approaches 1-8 to familiarise yourself with the selected strategic commissioning approach(es), to explore and understand the selected approach, to learn what may be required, understand and plan for the associated strategic risks and start to put it into practice (Step 6). For each strategic commissioning approach, this includes: Introducing the approach How to move towards this approach What to do, and what not to do, when pursuing this approach Specific risks to watch out for, including when your room for manoeuvre is limited, and other hints and tips The commissioning skills and structure that might be needed for this approach The Council may wish to develop a Strategic Commissioning Plan. The council may wish to articulate the selected strategic commissioning approach in a strategic commissioning plan, which may set medium or long-terms goals for meeting the adult social care needs in the place and how it intends to meet those needs and may also include the intended plans for commissioning development (see Step 5 above) in the place. Slide 87 Using your constraints and enablers in an action plan No set format is provided for the action-planning, but we suggest that you could work through some of the following questions to support the development of actions in response to each factor.   How will we boost enabling factors?  For constraining factors within our control, how will we ensure we overcome them?  How will we use our influence where we can, to reduce constraining factors and build on enabling factors?  How will we take account of and work around constraining factors that are not in our control?  What experiments can we run to look at constraining factors that require innovation?  Which of these are the most urgent?  Which of these are the most important?  Which of these would require the most work?  Are there any “quick wins”?  If desired, this action-planning can be developed into a Commissioning Development Plan.  Slide 99 Acknowledgements This project was designed and developed by the Public Service Transformation Academy for Care and Health Improvement Programme (CHIP), now referred to as Partners in Care and Health (PCH), which is jointly run by the Local Government Association and Association of Directors of Adult Social Services (ADASS). It was produced by RedQuadrant and the Public Service Transformation Academy initially between 2021 and 2023 for a social care audience. Since then it has been rewritten to meet the needs of multi-sector commissioners by Fiona Fleming of the PSTA. 2023-06-05 Pre-reading - Introducing and Implementing Strategic Commissioning Approaches 1 - 8.docx The eight approach sections from the original pre-reading, including its practice examples and references. This is the 2023 adult social care source; it has not been compared with the later Teachable lesson bodies. Strategic Commissioning Approach 1. Place-based wellbeing Design and creation of a place-based wellbeing system. Introduction to this approach This commissioning approach fits most closely with the ‘whole system design’ commissioning aspect. It represents the shift from thinking about care needs first, to thinking about wellbeing first, and begins with a view that the best way to deliver outcomes for the community is to start early and ‘upstream’ to the individual, families, neighbours, the community and other support wherever and as much as possible. Ideally, this is well before what is called ‘prevention and early intervention’ and is about creating the conditions for people to be healthy, resilient, and connected in their communities. It is more than just keeping people out of care; it is about establishing the environment, so people are able to have healthy lives. It has to be recognised that a large part of this is a demand management approach which needs to be monitored and evaluated for impact on cost and outcomes, otherwise the risk is of wider service provision while the most vulnerable continue to miss out, and services continue to struggle. Here, the council's role is to plan and commission interventions and services that are resolutely focused on building community well-being and individual health through carefully planned public health and joined up strategies with key agencies and providers. Commissioning is therefore focused on understanding need – the needs of the whole place, not only individual services – and on ensuring that suitable approaches are set up or enabled to reduce the demand arising from that need. Indeed, it would be even better to focus first on strengths and capabilities in the place, and how they could be enabled and strengthened such that the needs do not arise. This approach means that this work is necessarily co-produced – it is about creating the conditions for people to be in charge of or co-produce their own care and wellbeing – and is more complex and emergent because the council cannot dictate terms or set out and then implement a programme. Such an approach works best where there is a robust professional practice and commitment to prevention, political leadership is resolutely focused on the long term. Levels of deprivation and need are significant but need long-term action, and all parties from providers to community bodies work well together and are willing and able to invest for long-term benefits. How to move towards this approach This is a long-term approach which needs consistency of purpose, leadership, capacity, and capability. A good first step is to keep a focus on overall strengths and needs in the local place (even if they cannot be worked with immediately). Share this with partners and public as a ‘convening call’, be clear about where the potential lies to begin to ‘get upstream’ to reduce needs for care and support wherever possible, demonstrate some of this through judicious experimentation, try to create more flexibility for providers, community groups and partners to experiment and work hard on building mutually supportive relationships across the system. If local commissioning is reasonably strong in the other aspects, your commissioning development plan could consider how to focus all parties on a vision of a place that helps people to maximise their wellbeing and minimise their care needs and where needs are dealt with in a way that focuses on supporting and increasing self-efficacy. What to do, and what not to do, when you are pursuing this approach The goal here is to make health, wellbeing, and minimal care needs the default, easy option, so it is important not to neglect statutory requirements and crisis intervention services, and to find a way to progress incrementally, building on and reinforcing (and, if necessary, defending) moves in the right direction. You will need to build a strong understanding of your place and its possibilities, and widely embed the concept that it is better to create the conditions where people can have their needs met by the community, meet their own needs, or not fall into need in the first place, than to provide services. Remember that it is not necessary to have control over and redesign the whole system to make a difference, if you have a good overview and can identify the most effective things you can do to support a system of wellbeing. Specific risks and issues The challenges with this approach, apart from its scale and optimism, are clear. Apart from all the many demands on commissioners’ time and attention, large-scale issues around funding, crises, policy changes, changes of leadership and of structure will all impact success in this space. Sustainability of even small steps will be in question given current funding challenges and the push to unit-based provision. Few councils are able to consistently work using this approach. It is also noteworthy that some examples are not easy to scale up or sustain, and do not fit into the paradigm of ‘services’ or comfortably into adult social care commissioning. In other strategic commissioning approaches, you will also see examples that seek to move towards place-based wellbeing, which may in some ways be more practical – to really move fully to place-based wellbeing, a lot of rethinking may be required. Considerations for commissioning skills and structure The need referred to above to communicate and enthuse people about the possibility of working very differently suggests that commissioners in this approach will need to be skilful communicators, and also to demonstrate examples at a small scale. It will also be important to have a grip on service delivery and costs while building a large-scale systemic picture of your whole place, influencing senior leaders, strategies, and plans, and building joined-up governance. Rather than attempting to recruit super-heroes, it is important to consider how social care commissioning can build alliances and appeal to the motivations of relevant people and organisations – acting as a catalyst and shaper, rather than taking on all the responsibility. Examples of this approach in practice As part of Leicester City Council’s Supported Living and Extra Care Housing Strategy, the council aims to provide up to 396 new units over ten years, including provision for supported living and other housing to delay entry into statutory care, replacement of sub-standard existing statutory care provision, and provision for care leavers aged 18-25. Two new developments contain a mix of working-age adults with care and support needs and older adults, and are connected. Tenants report that the mix has a positive impact, supports diversity, and that “some younger residents help the older ones with shopping etc, and some of the older ones support the younger ones who may not have family. This makes for a nice community of people who can balance each other’s strengths and needs.” With over 2,000 people living with dementia in the borough, Dementia Inclusive Greenwich is an initiative to help businesses adapt their services to be more inclusive. It offers local organisations free training and practical support to make changes that can help people with Dementia – to both the built, physical environment and also the social environment. The scheme has been very successful and now requires funding and power to take it forward. The Small Supports Programme, delivered by NDTi, supports people with learning disabilities, mental health issues and autism and who are identified as having complex support needs because of their behaviour, forensic or offending history. The programme has a vision of people getting support that is right for them and having a choice about where they live and what they do. It supports organisations and ‘partners’ (including all the people who are helping the person), to plan and deliver support in a truly person-centred way. In a programme with the LGA and NHS England, they looked at how to spread this approach to more areas, identifying a number of strengths and opportunities, and a number of barriers, including a commissioning ‘myth’ that those who engage small providers might be sued by large providers, and a challenge that while this type of support is necessarily small, person-centred, and adaptive, this makes it hard to offer a concrete ‘thing’ for commissioners to grasp and understand. One thing to read Transforming care and Support, SCIE, https://www.scie.org.uk/transforming-care Strategic Commissioning Approach 2. Leadership of place for whole system change Creating a system that works. Introduction to this approach This approach is paired with the ‘relationships and organisation across the system’ commissioning aspect and is all about achieving that capability. It begins with a view that since communities are complex and their needs are constantly changing, often in unanticipated ways, the best way to deliver good results is to understand the whole system, intervene collaboratively and disrupt compassionately. It also requires an understanding that what is often referred to as a ‘system of care’ may not be – and often is not – a functioning, purposeful system at all. The council is not at the centre of the system but is one of the core, and most critical, building blocks. This approach sees the role of the council as working in partnership with all the other players in the place, and commissioning based on a shared understanding of what makes the difference to local social outcomes, particularly regarding joined-up pathways and effective referrals between different organisations. Commissioning is therefore focused upon identifying a rich mix of services, support and involvement in the local social economy to achieve pragmatic results. This approach is associated with the relationships aspect of commissioning because it depends heavily on formal and informal relationships at various levels to succeed. The approach is likely to be called for when community need is in a state of flux, and both provision and service need are diverse and challenging. It is important that political leadership is comfortable with uncertainty and ambiguity and that there is a focus on appreciating the whole while pursuing what works, and the ability to collaborate effectively and learn through experience. How to move towards this approach Like whole system design, this is also an approach which requires time and broad capability. A good way to begin is by providing concrete evidence of where costs can be lowered, and outcomes improved through making the system more coherent. If different organisations can learn to work together more effectively, the case for working as a single system becomes stronger. Beyond that, good relationships are needed to ensure the recognition that interventions paid for in one part of the system, which create savings elsewhere, are important for the whole system. There are huge opportunities to engage with frontline staff, carers, providers and service users to identify opportunities for improved coherence. Clearly, integrated commissioning and funding would also be a logical step forward in this regard. Work on shared culture, identity and vision will be valuable and necessary to progress this approach. It is also important to recognise and work with professional boundaries and the threat that a joined-up approach can pose to organisational leaders by destabilising their power bases. A strong, shared vision about how care should work in your place, with processes for learning, will, however, go a long way to support this. What to do, and what not to do, when you are pursuing this approach It’s important to understand that this requires working across boundaries and the ability to cut through to honest conversations, confront issues productively, and to find the mechanisms which will allow a shared view – often bringing people face-to-face with the citizen experience, or demonstrating the overall savings available through a joined-up approach (along with managing the discussion about how these savings are shared). In the long-term, the drive will be towards co-commissioning with single funding pots across wider scope and organisational boundaries. This is the espoused goal of Integrated Care Systems and so it is important to engage both constructively and critically with plans and governance – it may or may not be appropriate for councils to ‘put all their eggs in the one basket’ of ICB governance, as it is likely that much joining-up will still be achieved outside of the formal structures. All of this means there is a need to manage the balance between national politics and nationally driven change, and local change. All kinds of providers, the community, the voluntary sector, and other services outside the scope of the ICS will also be critical. It is important not simply to pay lip service to real joint working, ignoring the challenges of incompatible funding and performance drivers, and not to be drawn into the avoidance tactic of producing beautiful analytical shared plans which do not actually change practice on the ground. Specific risks and issues This approach can be derailed by poor governance, relationship challenges (between organisations and even individuals), being distracted into other urgent ‘whole system’ challenges, and a focus on strategy, planning and governance at the expense of practice. There is also a risk of distribution of time and focus, and losing sight of other vital elements of the commissioning role. The main motivating factor here is that if extended governance is right, and based on real understanding and learning, it will be possible to guide and steer the whole system to be better. It is important to pursue a strategy of incremental gains and pragmatism. There can be real challenges with a single large or dominant provider when you are on the outside seeking to influence it, or shape the market. There can be power imbalances between large and small providers, particularly if commissioners are driven by short-term funding streams. It can also be difficult to influence alliances as part of collective place governance, if the alliance is developed outside those governance structures. Considerations for commissioning skills and structure This approach requires strong internal relationships with politicians and senior leaders, and the ability and gravitas to influence at board level, as well as striking a balance between the procedural and the pragmatic – getting down to real change. There is likely to logical support for a long-term move to shared commissioning on a broad basis, so it is important that principles of, and approaches to, commissioning that reflect the statutory requirements and values of social care are embedded for the long-term. This approach, like others, requires the ability to draw on all of the skills of other approaches. It is unlikely to be the exclusive approach unless it is already well advanced and may be blended with another approach. Examples of this approach in practice A popular and successful radical approach in this space is some form of ‘alliance contracting’: establishing a partnership or alliance of relevant delivery bodies with shared governance, and sharing relevant budgets across all parties with a targeted scope of interventions or outcomes (or both). This allows for various legal forms of agreement which take competition out of the picture, or limit it, and allow collaboration across a wider system to work towards shared outcomes. The Plymouth Alliance for Complex Needs was formed by Plymouth City Council and part of Devon CCG with a budget of £638m gross, driven by strategies for wellbeing, community, children and young people, and enhanced and specialised care. The scope covers public health, leisure services, housing services, children’s services including direct schools grant, adult social care, primary care, community health services, and acute provision. The integrated commissioning team commissioned seven provider organisations under a single alliance contract, worth £7.7m and lasting up to ten years, to work together supporting adults with complex needs. The attempt is to work as one truly integrated system. The charitable company Community Safety Glasgow, which from 2006 to 2019 (when it merged back into the council) was a Company Limited by Guarantee, owned by Glasgow City Council and Police Scotland worked with single vulnerable people and community safety. By encapsulating responsibility – and the budget to address it – in a single entity, the model allowed a single-minded outcomes focus. A London borough brought together its community and voluntary sector funding into a single outcomes-based contract which it specified had to be delivered by a local alliance. The local umbrella body led a successful bid for the contract and the alliance as a whole – which needed significant support and put significant effort into developing its own governance, bid, and outcomes measurement capability – is now working in partnership with the council to deliver. One thing to read Place-Based systems of care: A way forward for the NHS in England. The Kings Fund (2015) https://www.kingsfund.org.uk/publications/place-based-systems-care Strategic Commissioning Approach 3. Unlocking potential A place where everyone can thrive. Introduction to this approach This approach is paired with the ‘capacity, capability, and confidence’ commissioning aspect and is about having the resources, capacity, and capability available – from various sources (business, charity, mutual aid, self-efficacy) – to meet need at the point of demand or to enable people to live their lives without falling into need. It begins from a view that the best way to deliver outcomes for the community is for the community to do this for itself, and to ensure that all spend and provision is targeted to creating capacity, capability and confidence (pushing ‘upstream’ as much as possible, to try to prevent needs rather than deal with demand). This approach is likely to be relatively disinterested in the delivery model but focused on the direct and indirect impacts of health and care. The council's role is to assist in the supporting of capability-building activity by deploying its assets (spend, buildings, legal advice, leadership, connections, media) to support the creation and sustaining of community groups (with varying levels of formality) and VCSE organisations, alongside other providers, to co-produce social outcomes. Commissioning is focused around understanding and influencing all the assets available to the community, and helping the community to become stronger and more capable of supporting its members; ‘care by the community not merely care in the community.’. Such an approach works well where: There are strong, connected communities Political leadership is brave, confident, and community-focused Levels of deprivation and need are significant but not overwhelming There are established public partnership bonds of trust It requires an ability to engage with providers as partners, to consider co-commissioning approaches, and manage an effective balance of collaboration and competition, while staying within procurement and other guidelines. How to move towards this approach This approach requires a view of funding and support that considers the long-term and wide-ranging impacts. Therefore, strong market insight, market making, and market management capabilities are needed – a good starting point is sound knowledge of current provision, both formal and informal, and analysis of the secondary impacts of the council’s actions. There is now a strong evidence base for this kind of approach, but active engagement with all parties who can support people is critical, so developing a combination of systems analysis and engagement skills is critical. Good first steps are to explore social value – through the provisions of the Social Value Act and mainstream contractual requirements – and to prototype one or more approaches, like alliance provision (awarding to an alliance of often voluntary sector providers). Commissioners will need to work proactively with all parts of the system to deliver change and to be able to bring in economic analysis to underline the secondary benefits as well as savings. Work to understand costs of care and market sustainability may provide an opportunity to make changes in this area. What to do, and what not to do, when you are pursuing this approach The main focus here is a community and place which support positive outcomes, with active and dynamic capability from an effective mixed market, all of which support self-efficacy. It is important to invest and measure returns in all parts of this, while still delivering responsive services and ensuring that they are effective and not increasing dependency. Councils need to ensure they connect to wider wellbeing agendas, including, for example, employment and physical activity. It is important to see ‘unlocking potential’ as a long-term benefit, not a short-term way to save, and to be creative and collaborative in how capacity, capability, and confidence are built, including making social value core, and integrating this thinking into your Market Sustainability work. It is also important not to pay lip service to ‘enablement’, but to follow validated approaches like Good Help. Specific risks and issues This is an approach which hugely benefits from top-down support and sponsorship and place-based agreed activity. Its success also depends on the latent capacity of your markets, community and voluntary sector etc, and the history of working with them. It is likely to require long-term consistency of purpose. A short-term savings focus in this area can lead you to unsustainably loading community, carers etc, and undermine long-term capability. You also need to ensure you are well set up to appropriately use a mix of funding mechanisms. Considerations for commissioning skills and structure Market engagement, community development, and a strong focus on self-efficacy are all needed – and the ability to balance a focus on unlocking potential with meeting needs in the here and now. Ideally, commissioning would be structured around pathways from need and dependency to self-efficacy, mirroring services, and be place-based or council-wide, or at least linking to an overall place-based plan. Examples of this approach in practice Commissioning Home Care to rural communities: A local authority in a large rural county had experienced difficulties in securing reliable providers to deliver home care services across the county. The area covers large sparsely populated areas, comprising small towns and villages as well as isolated hamlets and farming communities.  The existing providers were finding recruitment and retention increasingly difficult as other employment pays more, and travel costs had become a growing disincentive to home care staff. Many providers said that they could no longer cover rural areas and could only respond to requests to take on new work in the larger urban parts of the county. Hospital discharge delays were increasing partly due to the availability of home care services.  The council engaged with community groups, district and parish councils, voluntary organisations, carers groups, and NHS partners. They heard that in some parts of the county, there was the potential for greater community and neighbour support, particularly for vulnerable older people with care and support needs. However, this was unevenly spread and could not be relied upon to support newly identified needs including hospital discharge. Commissioners decided to earmark a proportion of the home care commissioning budget for a new approach. This involved establishing district home care support budgets which could be accessed by local teams – including GP surgeries – to directly ‘commission’ neighbours, friends and community groups to deliver care and support to vulnerable older people. At the same time the commissioning team promoted the development of micro-providers, working with the local Voluntary Service Council to offer organisational and financial support to get started.  Enabling community development and unlocking latent potential in staff: In dealing with a fast-growing crisis and setting up the Wigan Deal, the council supported capability development in two ways that are sometimes overlooked. By the end of 2018, they had put £10m into Community Investment (at the same time as delivering over £130m of net savings). Along with reducing demand on public services and capacity building, this fund leveraged £3.9m of external funding, £5.6m of social and economic benefit, and £1.26m of recurrent savings. The asset-based approach applied to staff, too, with a focus on their strengths, their ability to focus on the strengths and capabilities of citizens and put control with citizens, a clear and inspiring development plan, and permission to spend up to £50 to resolve a citizen issue without authorisation. Community-led support: Somerset faced a crisis in care, with the number of people over 75 years old projected to double by 2039, and sought to move from ‘assessment for service’ to ‘being part of joined-up community-based ‘system of support’, aimed at helping people to ‘get on with their lives’. Co-produced, joint working with the council played an enabler role. They began to work hyper-locally in West Somerset using a “test and learn”, open approach that became Community Connect, supported by Community Catalysts. The work created 575 active micro-providers and sixteen trusted trader networks, providing over 9,000 hours a week of flexible, local person-centred support to over 1,500 people, supporting community resilience, and delivering £500,000 annual savings to adult social care, and £2m total savings to the health and care system. Expanding the principles more widely across the council created a whole range of positive outcomes, reflected in customer contact metrics and better care outcomes. A contact centre aims to find community-based solutions and where possible avoid referral for a formal social work assessment. Community Connectors act as local or village-based agents with knowledge of local community assets and support a range of activities from community cafes to supporting hospital discharge, connecting people to community assets and informal services, whenever possible. A focus on personal budgets or direct payments, and services offered to self-funders, allow the council to indirectly fund non-regulated micro-businesses. This work required expertise and experience, a culture of innovation, permission, and strong leadership from both political leadership and senior officers and, at multiple levels, significant work with front line teams, relationship-building to generate trust, and strong relationships across strategic commissioners, those leading programme development, and the VCE infrastructure organisations. One thing to read How-To Guides for creating an asset-based area. TLAP. 2018 https://www.thinklocalactpersonal.org.uk/Browse/Building-Community-Capacity/how-to-guides-for-creating-an-asset-based-area/ Strategic Commissioning Approach 4. Citizen-centred commissioning Putting people in charge of care. Introduction to this approach This approach pairs with the ‘user and outcome-centred’ commissioning aspect and is about putting people in charge of their own care and making their assessment of whether they get what they needed the measure of success in the system. It begins with a view that services often get in the way of people leading their lives as they want to and make it hard for them to get the support they need. There are several perspectives on this. One is that the aim should be to shrink the state and let people get on with living their own lives or empower them through direct funding and creation of marketplaces. In this perspective, the council's role is to provide necessary information and advice for people who have social care needs to enable them to find their own sources of support. Service provision is for those unable to help themselves. This is care based on individuals and families caring for themselves. In these circumstances, the approach works best where community need is mostly minimal with only some deprivation, there is little community-led demand for significant public services, and political leadership is focused on reducing the state. There is also the highly person-centred approach provided in the case study provided in the pre-reading materials of a council and place that scores higher in the ‘user and outcome-centred’ commissioning aspect, where the locus of decision-making about care lies in conversations with the citizen and their own decision-making, through a combination of accessible community, universal, and self-funded services, and access to commissioned specialist services, where appropriate. This approach works best where a coalition can be built and its success demonstrated to key stakeholders, and where learning can expand across the whole health and care system. The ‘three conversations’ technique is an example of this. There is a broader approach to including citizen reports on outcomes and co-design into more traditional service provision, including, where appropriate, payment mechanisms (though there are risks inherent in ‘payment by results’ contracts which mean they should only be used by exception). This approach can be introduced contract by contract and become a part of ongoing practice, and link to front-line interventions. This works best where there are good relationships with providers and a good understanding of how practice works and are able to build learning and adaptation into provision. How to move towards this approach Perhaps more than other approaches, this requires a compelling vision for commissioning and the ability to communicate it, and requires connection with senior leaders including politicians, frontline practitioners, and providers including community support. Transformational change requires a shared vision of change from all, best driven by experiencing what is possible. It means shifting the basis on which services are purchased and resources allocated from units of service provision for pre-defined needs to what is needed to ensure that the outcomes desired by service users are met. The emphasis is on the results and learning, not the activity or intervention itself, and on empowering citizens to make their own choices. It can be challenging to win over senior leaders and to change the culture of assessment and design of plans. There are several, potentially new, skills that need to be developed across the system from how to distinguish outcomes from outputs, inputs and processes, how to engage with the public and how to utilise data and analysis. Good first steps are setting up real prototyping and building in “did you get what you needed?” and further qualitative questions to all service provision feedback. What to do, and what not to do, when you are pursuing this approach At its heart, this is about moving commissioning into a facilitative role, to aid people in their lives. So this means co-design, a careful approach to statutory duties (neither letting them dominate, nor neglecting them), and measures driven by what people say they want and their experience and results. It is important to note the risk of creating new ‘citizen-centred’ silos by building new services around specific needs, of adding to confusion and making services inaccessible by having a bewildering variety of choices, and to maintain a strengths-based approach. The main focus here is trust that individuals are their own best determinants of their care. Specific risks and issues Key risks include losing control of provision and being unable to learn about the system, by not building in connections back to practice and results – with obvious financial risks. At the same time, it is important to build in assurance that statutory requirements are being met. A ‘big bang’ approach is quite risky in this space, as it requires learning a new way to do these things, and unlearning some existing practices – small prototypes are useful. An alternative risk, though, is paying lip service to being citizen-centred, picking up the jargon without actually changing practice on the ground. There is also a risk of paying attention to the details of citizen engagement without being able to put in place the broader services that citizens need. This approach is vulnerable to lack of understanding across partners and leaders, including politicians, which means a requirement to engage them in the practice so that they understand the approach and its benefits, as well as risks. This needs to be ongoing work, with succession planning, because changes of officer or political leadership may mean you have to make the case all over again. There is also a risk of attempting to adopt this approach ‘under the radar’, which can work at small scale and to demonstrate new ways of working, but is risky at a strategic level, without appropriate authorisation. Considerations for commissioning skills and structure This approach requires an inversion of the normal structure, so is challenging to do across a whole council, therefore the structure is likely to be focused on adult social care, though inevitably an approach led by what people are trying to achieve in engaging with your services will require strong connections with internal and external partners. That inversion is about supporting and learning from practice, which in turn is led by the citizen. So commissioners need to be strong change managers and have the credibility to get the backing for quite radical experiments from senior leaders, and need to be very open to learning, and showing their working. They also need to be able to support front-line experiments while maintaining an overview of and approach to the whole service system. Examples of this approach in practice Co-production to transform mental health services: A council faced high rates of psychosis, Mental Health Act admissions, acute hospital admissions, and adults in high cost residential and inpatient placements. Working with their then Clinical Commissioning Group, they tested co-production on a large scale, putting citizens at the heart of their own care. A series of storytelling and co-design sessions helped set a bold and shared vision for a system focused on prevention rather than crisis care. A resource map, brought to life by trained peer researchers telling community stories, identified that little funding was going to services designed to help people live well in their communities. Four key changes were made: a collaborative across service users, GPs, providers and commissioners to drive the change, an empowered network of providers, support agencies, statutory organisations and others with a focus on ‘living well’, a jointly-funded organisation that manages funds for those who need personalised care and personal budgets, and a hub to provide easy, integrated access to services. The result was a 32 per cent reduction in referrals to secondary care, with 500 people now supported by the network, many of whom would not have previously had any support at all. The waiting time for support in secondary care reduced from one month to one week. Professionals recognised the integral value of working with people with lived experience of mental health problems, and the initiative saved 20 per cent against an original budget of £12m. Empowering users and their families to take control: A council needed to change the way that day services for people with learning disabilities were organised. The existing centres were increasingly seen as inappropriate, particularly for younger people. Families and carers were dissatisfied, but feared that the council would close the centres, depriving them of essential day-time respite. A campaign group – “Save our Centres” – was being talked about by a number of families and there was some political nervousness. The council decided to explore the potential for handing over the day centres to families and carers, who would form themselves into a user-led Community Interest Company. The commissioning team pulled together a council-wide working group to develop the business case, including estates, legal, and finance. They also sought a delivery partner to work alongside the family/carer group whilst they developed their skills and capability to manage the business. The centres were leased to the CIC, staff were offered a secondment to work with the new organisation, and a budget for service development was established. The CIC were then able to offer commissioned places via the community learning disability team and directly to service users and families.   Drug and alcohol service cost reduction and service improvement: A council identified the need to make savings while re-tendering for a drug and alcohol service and moving it to a new lower-cost building which presented opportunities for variation in service delivery. A commercial board was set up to govern the project, with procurement and commissioning staff, and approved a procurement route using a widened definition of ‘most economically advantageous tender’ (PCR 67 (4)): ‘The cost element may also take the form of a fixed price or cost on the basis of which economic operators will compete on quality criteria only.’ The specification was presented as a flow chart, tracing the value chain from resources to activities to delivery arrangements, outputs, near outcomes, and overall outcomes, and focusing on outputs such as ‘improved opportunities for non-opiate users to use the service’ and ‘opportunities for substance using parents with resident children to access treatment’, and near-outcomes including ‘high levels of successful completions of treatment’. The responses were evaluated primarily based on providers setting out their resources, activities, and delivery arrangements, effectively comparing the council’s logic model for what would achieve the outcomes with those of the potential supplier. The council was therefore able to identify a supplier with the most credible delivery model to meet the outcome specification, within a fixed budget which delivered the required savings. One thing to read Do Asset-Based Areas Commission? Public Service Transformation Academy. 2017 https://www.publicservicetransformation.org/2017/10/asset-based-areas-commission/ Strategic Commissioning Approach 5. Values-based/disruptive commissioning Changing the status quo Introduction to this approach This approach incorporates two very similar approaches and relates to the ‘information, insight, and innovation’ commissioning aspect and challenges the status quo, based on citizen perspectives and equity or innovation and creativity. Values-based commissioning is based on prior beliefs about what is the right thing to do, whereas disruptive commissioning believes in the value of innovation and learning and that better solutions will emerge. Disruption here should be seen not as commissioners disrupting the market (though that is possible), but more about a belief that it is OK for things not to always remain the same and creating a climate where it is possible for innovation to happen on an ongoing basis. Disruptive commissioning is named after ‘disruptive innovation’ – the introduction of new techniques, knowledge, products and services which emerge to change existing patterns and support the development of new models, markets and practices. Often this approach takes lessons from the world of technology where disruptive technology drives productivity, and can improve quality and reduce costs, from data and analytics to the ‘internet of things’ and market platforms. A disruptive commissioner is likely to seek opportunities (even small scale) to completely revolutionise practice and therefore, as well as seeking lessons from other markets and geographies, needs to be closely connected to practice, particularly when the disruption emerges from citizens (including self-funders), working with people who are willing to provide the support they need. They may also introduce approaches like citizen commissioners and citizen juries, and opportunities for supply-side innovation from negotiated bidding processes to hack days and innovation clauses in contracts. A disruptive approach will work well where commissioners have the freedom to act, where the council can take account of the need for strategic agility and recognise the costs of failure to adapt (and may have experience of this from the past). It will also thrive where there is good capacity-building and development for commissioners and all those who need to engage in innovation, and where the support for innovation can be sustained in the medium to long-term. Values-based commissioning reflects a more qualitative approach based on service user and carer experience and perspectives. This is closer to citizen-centred commissioning – shaping services that are about, and for, that person and their needs, not just commissioning services as an end in itself. Its scope is wider, thinking about how health and care provision can support the ‘levelling up’ of individuals and groups whose needs are not fully met by the current system. Values-based commissioning explicitly tries to achieve ethical outcomes and is likely to emphasise co-production and co-commissioning. This is likely to be emotionally appealing to many people involved in delivery, if it gets leadership backing. It is likely to represent something of a culture shift and therefore requires engagement and involvement from all those involved. How to move towards this approach Undertaking a strategic options appraisal and looking at room for manoeuvre in commissioning is a good first step to develop such an approach. For both values-based and disruptive methods, maximising commissioner capacity and capability and room for manoeuvre is critical, as is building credibility – through results. To be disruptive, it is also critical to begin to learn from practice and from other systems where innovation can result, and it can be demonstrated how improved outcomes have been achieved. What to do, and what not to do, when you are pursuing this approach It is important to work in an open and sharing way, inviting engagement and criticism of the picture you are creating, connecting to multiple sources of data, and understanding that all information is structured and interpreted, and so subject to different interpretations. Councils need to make their insight and drive for reform available and useful to everyone across the system. Commissioners need to be coalition-builders for change, taking people along, so that they have insights from understanding the system better and differently, and can see the benefits of change. Small-scale demonstrations of what is possible in real services are invaluable in this approach. Try not to fall into the trap of trying to create perfect knowledge of a complex system. It will be essential to maintain testing and proving it in the real world. Do not try to ‘boil the ocean’ by building everything into the model, and do not try to take all the responsibility or credit. The main focus here is the insight that will allow new and optimal solutions to be delivered. Specific risks and issues A clear risk here is plans for innovation that are either blocked because they are too radical and do not get buy-in, or are forced through without enough evidence of feasibility and end in disaster. It is important to balance small-scale demonstrations of disruptive working with coalition-building for shared values, and being open to challenge and critique. A balanced risk appetite is important. Considerations for commissioning skills and structure Commissioners in this model clearly need a sense of drive, an ability to engage, and to have or have close access to great data analysis and research and engagement skills. They also need to be able to build a case for change, balance risk, and support small-scale demonstrations of new ways of working. Commissioning might be organised into – or working across – broader themes to which social care and other services contribute, and is likely to be part of a wider policy and strategy conversation. Examples of this approach in practice Ethnicity and mental health – a new beginning: Analysis has shown a lack of parity between black and minority ethnic (BME) people and the white majority in access, experience, or outcomes of mental health care. This disparity has been demonstrated for over half a century, and yet little has changed in that time. Attempts to change established practices have largely created a sense of helplessness and pessimism, particularly in the absence of a national plan or strategy or other clear leadership focus. The Ethnicity and Mental Health Improvement Project (EMHIP) in Wandsworth, London, attempts to address this situation. It is a collaborative project involving the local mental health service, South West London and St George’s Mental Health NHS Trust (SWLSTG), and a BME community mental health organisation, Wandsworth Community Empowerment Network (WCEN). After a decade of work, it became clear that a fundamental reconfiguration of the mental health system was required. EMHIP started from an evidence base, bringing together experiences of service users and individuals from BME communities, examples of good practice across the country, evidence in relation to equitable and effective mental health care, and research findings and recommendations from inquiries and reports. WCEN developed an approach to situate the majority of mental health care in the community, through engaging community leaders and those sought out by people with mental health problems in BME communities, and who are well-placed to identify and support, with high-quality, professionally-accredited, mental health support training. Patient work over many years has begun to provide insight and understanding with a solid and professionally-developed evidence base which shows the effectiveness of this kind of intervention, which is the ultimate goal of the research. Shifting domiciliary care to local providers: In one borough, domiciliary care was commissioned through a framework on a zoned/locality basis, but this was found not to be effective. It led to thirteen providers, mostly based out of the borough, with only eight active and half of these had very small numbers placed with them, long travel times for carers, and reporting of data/outcomes was poor. The council let a contract to a single, borough-wide provider who sub-contracted other providers. This had led to improved monthly monitoring and a detailed analytical understanding of need and activity, and the provider is invested in the borough, both in terms of strengthened relationships and infrastructure which has paid dividends. The council currently has no service users waiting for homecare and most homecare workers reside in the borough. Neighbourhood approach to homecare and supported living: A council had a large number of homecare providers, and struggled with capacity, quality and price variation. Providers were struggling with recruitment and travel time/cost, and residents were unhappy with changing staff and a prescriptive approach to the delivery of support. The council developed a new framework, focused on robust testing of shared ethical values, commitment to collaboration, place, local investment and growth and centred around ‘I’ statements, co-produced with customers and carers. Homecare was reorganised on a neighbourhood basis, with a lead provider for each neighbourhood and collaborative relationships with adjacent providers to manage peaks in demand. The neighbourhood model enabled the introduction of walking routes, bringing new people into the homecare workforce, reducing carbon emissions and travel time and cost. This supported the utilisation of a consolidated hourly rate, underpinned by a co-designed pricing model. This local model meant that homecare workers knew and understood the neighbourhood and could better connect people to community assets and develop relationships with local partners such as primary care. 86% of the home care workforce now live in the place where they are delivering care, 45% of visits are delivered via walking or cycling routes and nearly half of the workforce are aged 30 and under. The success of the neighbourhood model has seen the same approach taken to the commissioning of supported living, strengthening customers’ connection to their local community while increasing provider resilience and reducing costs. One thing to read Human learning systems – Plymouth case study, https://www.humanlearning.systems/case-studies/#plymouth-alliance429 Strategic Commissioning Approach 6. Strategic procurement of services against needs Services that meet demand. Introduction to this approach This approach is paired with the ‘managing the policy and compliance landscape’ commissioning aspect, and is about providing services that meet demand. It begins with a view that the best way to deliver efficient public services is through excellent procurement practices. The council's role is to understand need, develop requirements, and to go out to tender for a carefully and strategically selected set of service. Commissioning is focused upon carefully designed specifications and effective post-procurement contract management that is both tough and fair, holding providers to account for achieving that which they have said they will do for service users, learning lessons and negotiating appropriate changes within the scope of the contract and the procurement, as and when required. This approach works best where there is an excellent team of procurement professionals, commissioners specialise in needs assessment and appropriate engagement with practitioners, providers, and people with lived experience, and political leadership is trusting of professionally-led commissioning. The approach is one of compliance and efficient delivery, and gaps in services are met through contract extensions, signposting services, and/or new contracts to ensure the care system is relatively coherent. There is a focus on service user satisfaction, predicated on getting the research right before specification design, and the necessity of fitting citizen needs into pre-defined service categories is recognised as one of the implications of appropriate scale and standardisation. However, there is a premium on good contract management and properly-managed change and adaptation of service delivery in-contract. The big opportunities for innovation and outcomes focus occur with big contract renewal, where aggregation or disaggregation and reinvention of the requirements are regularly considered, with good input from market knowledge, needs analysis (including unmet needs), feedback from people with lived experience, including those who draw on services, and benchmarking. How to move towards this approach This approach has historically been what many people have understood commissioning to be. It requires a sound process, which can be properly adapted for different types of requirements, and effective management of commissioner time and portfolios to ensure that all phases get due attention, and very close working relationships with procurement. Formal training on market management would be a strong first step, as would studying key contracts from elsewhere. What to do, and what not to do, when you are pursuing this approach Commissioners should make sure that they are actively creating the world in which they work, rather than being a victim of all the constraints they are under. Part of this will be to ensure an understanding of the goals of the place and the limits being work within, as part of a collaborative effort with service users, leaders, wider colleagues, partners, and suppliers. Be aware of the risk of focusing on what is not possible and limiting yourself to ‘only’ doing what is mandated. The ultimate goal here is a clear sense of purpose within known limitations, and to effectively present that to suppliers, to ensure clarity. Specific risks and issues Commissioners should set the right, well-informed risk appetite, and need to avoid being completely risk averse. It will be important to ensure that the understanding of ‘needs’ and ‘services’ is not prescriptively narrow but takes into account co-design with citizens, to ensure impacts both up- and down-stream of services. There should always be enough capacity for big contract renewal. Whilst building opportunities to co-design and test and learn into the system, caution will be required to avoid being sucked into ‘analysis paralysis’, and always trying to get the perfect specification. Considerations for commissioning skills and structure Commissioners need strong technical skills and abilities in engagement with service users and others, and will ensure active contract management and ongoing learning. Commissioning is likely to be quite closely coupled to service providers, and therefore adult social care focused. Good data on results and satisfaction will be required for analysis. Commissioners also need to be subject matter and policy experts, or work very closely with those who are, and have strong market-shaping and market engagement skills. Commissioners in this model need to be good research and engagement managers, and excellent at project management and time management. It is important that they support each other as a team to avoid overload and the risk of becoming blinkered and focused only on their allocated focus areas. Examples of this approach in practice Two councils in very different parts of the country developed a de facto social license putting constraints around the market for home care – requiring a Living Wage, services to be based in the borough, and creating small lots. This created a structure which met their compliance requirements and achieved their social and outcome goals. A county worked to implement a county-wide commissioning strategy and policy, driven by integrated needs analysis and clear policy-setting from the integrated health and care board, the children’s joint strategic needs analysis, the police and crime strategy and the local economic partnership. Working closely with district councils and other partners, their adult social care commissioning was therefore a clear part of overall county goals, enabled by strategy, and with clear connections to families, employment, crime, etc. A borough entered into shared commissioning arrangements across contractual partners to support implementation of a place-based plan. This meant lifting significant amounts of adult social care funding out of their own organisation structure, and spreading it across the new joint organisation, where much was operationally managed by partner organisations. This allowed a focus on the place-based plan and more flexible procurement while still meeting compliance requirements. One thing to read NSW Government Commissioning and Contestability Practice Guide. NSW Government. 2016 https://arp.nsw.gov.au/tpp16-05-nsw-government-commissioning-and-contestability-policy/ Strategic Commissioning Approach 7. Market management Creating conditions for best value and outcomes within financial constraints. Introduction to this approach This approach links with the ‘commissioning process’ aspect of commissioning, and is about using commissioning tools to drive best value outcomes given financial constraints. It begins from the perspective that the best way to deliver good results for the community is through plurality and a good mix of providers, vying with each other robustly but collaboratively – and that this shows up both in: Market making, where the council's role is to understand, map and develop the range of commercial and VCSE providers so that local needs are met; and Carefully structured procurement and management process (often tightly specified and let to a single provider, sometimes more broad-based and let on multiple lots or to a single consortium or alliance) to choose the most economic, efficient and effective provider. In both, commissioning is focused on understanding community need in the big picture and in requirements, and ensuring that there is enough capability, capacity, knowledge and appetite to provide that best value is assured. Despite fair cost of care requirements (and ambivalence about workforce costs), this still means achieving an optimum price, and despite increasingly collaborative arrangements, this still means maintaining the credible threat of alternative providers, based on the ability to measure whether delivery units are achieving the results they committed to, and ultimately the removal of the delivery unit and/or their management if not (sometimes referred to as ‘contestability’). Commissioning is focused upon encouraging providers through effective partnership, sharing strategic insights and future plans. In this way providers can mould themselves to the future needs of the community. User feedback is regarded as a key ingredient in assessing the performance of the providers into the future. Such an approach underpins all successful commissioning and is perhaps simplest and best where there is a focus on cost reduction and market resilience. Needs are relatively well understood and specified, and there is no strong ideological push to either insourcing or outsourcing; there can be a relatively neutral view of sourcing opportunities. This approach, at best, balances the need for good value with long-term resilience and the need for competition, with the ability to put long-term contracts in place to generate real continuity and security of provision. How to move towards this approach A strong understanding of needs (including from citizens and frontline practice), of contractual routes for delivery, procurement and contract management, and learning approaches are all needed for this approach. Councils must consider how to integrate this into the necessary ‘plate spinning’ most active social care commissioners have to undertake, managing various different pieces of work at different stages simultaneously while trying to support coherence between them. What to do, and what not to do, when you are pursuing this approach Councils need to make sure that ‘commissioning’ is not seen as just a narrow function within social care, but that all relevant technical experts (procurement, legal, finance etc), and partners and citizens – as well as providers and potential providers – see themselves as an active part of the process. It is important that commissioners do not get so stuck in the process that they are simply recommissioning without seeing the bigger picture. Allocation of time and resources must be managed so that ‘commissioning’, that is, strategic procurement, does not take all of the focus, and contract management, learning, insight, and partnership working are all invested in. The ultimate goal of this approach is really well-specified services drawing from an engaged, active, innovative supply side. Specific risks and issues There is a significant risk of getting caught in narrowing down the definition of commissioning to competitive procurement, so ensure that co-design and shared learning and collaboration play their role. There is also a risk of commissioning services in isolation, so consider using colleagues’ expertise to support partnership-led commissioning, and focus on market and context shaping and the knock-on implications of commissioning decisions. Considerations for commissioning skills and structure To be most effective, the commissioning function is likely to work across internal and external boundaries, engaging in a lot of partnership working and co-commissioning. Commissioners therefore need to combine technical excellence with an openness to see themselves as enablers, not owners. This could include commissioners working as a whole-council function or even wider, but certainly as a bridge-builder as well as a technical expert. At the same time, they need to be able to draw clear boundaries and not be seduced into trying to ‘fix everything’ through commissioning. Commissioners in this model need to demonstrate expertise, experience, and ability and eagerness to learn. They need to draw their credibility from clearly understanding what good technical process and expertise can guarantee, and from being able to estimate and engage with the uncertainty beyond that. Examples of this approach in practice A council commissioned a ‘rich picture’ infographic of their adult social care commissioning services, intending to use this as a mechanism to engage the public and partners. They found that having to map out all of their commissioned services and pathways was actually a powerful learning exercise for commissioners too, revealing some overlap and confusion. It identified the potential to spread good ideas more widely. Despite reduced demand post-COVID, a council found itself faced with providers threatening withdrawal of services and even bailiffs if not paid. This led to a realisation that caseload was disorganised, officers did not see their role in the bigger picture, and systems were not supporting practice. Critical information was in the heads of individuals and time was being spent firefighting, creating a vicious cycle. Rather than blame and restructuring, they engaged in an exercise to pull together an overview of their work, share the bigger picture in terms of strategic goals and purpose, and implement simple IT systems to pull together data so everyone could see the whole story at a caseload level. One London borough is implementing a Dynamic Purchasing Vehicle, following some success in rough sleeping transformation and a realisation that supported living procurement was being limited by existing governance and process. A clear vision was presented to Cabinet along with progress on regularising existing contracts and other steps to get things better structured and organised internally. After a nine-month process of making the case and proceeding through decision-making, a Dynamic Purchasing Vehicle is now going out to tender which will allow much more flexible call-off of services. The process will start with supported living, then single vulnerable adult services, and move on, with learning embedded, to residential care, extra care, and shared lives, meaning that the onerous approval process does not have to be repeated, and a new fit-for-purpose commissioning process with more room for flexibility and learning can be developed. A city council adult social care commissioning function was faced with the challenge of working in partnership across other council services and implementing the Care Act provisions which required flexible and effective commissioning. Over the course of a year, a Chartered Institute of Procurement and Supply (CIPS)-qualified commissioning lead supported a complete reorganisation with a strong commercial focus and significant upskilling. The service now has responsibility for service design, market shaping and ensuring effective supplier relationships. It also establishes the most appropriate routes to market, defining tendering procedures under the Light Touch Regime and tender evaluation methodologies. The council’s contract management function also includes management of major corporate contracts, and covers around one third of the council’s total spending. Approaches have included an award-winning, partnership-based advocacy service tender, Light Touch procurement (piloted with drug and alcohol treatment), implementation of a Dynamic Purchasing System, a new approach to voluntary sector procurement involving the creation of a single borough-wide consortium, with associates, using an outcome-based contract designed to support prevention, and brokering the sale of a vacant residential home to a new provider in order to maintain local capacity which was then block contracted to the local authority. One thing to read Market Shaping Toolkit – supporting local authority and SME care provider innovation and collaboration. Institute of Public Care, DH, ADASS, LGA, The Care Provider Alliance. 2015 https://ipc.brookes.ac.uk/publications/market-shaping-toolkit-supporting-local-authority-and-sme-care-provider-innovation-and-collaboration Strategic Commissioning Approach 8. Delivery model design Effective delivery models enabling effective practice. Introduction to this approach This approach is paired with the ‘models and tactics’ commissioning aspect, and is about designing effective delivery models to support effective practice. It begins with a view that there are real savings and improvements to be made at the level of delivery model design. At its extremes, it can support an ideological view of how care should be delivered, but in general it considers that how the work is organised, governed, and delivered, is critical. This sees commissioners moving into, or working closely with those in, the service design space, undertaking customer journey mapping, empathy work, ‘citizen safaris’, ‘mystery shopping’ and so on, to understand the experience of care and to look for improvement opportunities at the process or organisational level. Such an approach works best where there is enough access to services to work closely with those drawing on them, and enough control or flexibility to be able to direct their adaptation. This requires good working relationships between commissioners, managers, and practitioners. How to move towards this approach Building engagement with services and the skills to analyse structure and processes are critical for this approach, as is relating the ‘architecture’ of individual services to the bigger picture. An outward-facing view is also important to pick up examples of innovative models and technology – and lessons learned – from elsewhere. It is important that time and focus be allocated to delivery model design and therefore building examples of success and demonstrating the business case is critical. What to do, and what not to do, when you are pursuing this approach It is important to connect social care practice with strategic commissioning, and to be open to innovative use of technology and new business models to deliver, thinking carefully about how these are implemented. Consider yourself as co-designing with staff and service users, and seek to connect small experiments with larger, well thought through changes. Do not get so focused on practice and structure that you lose sight of the gaps between different delivery models, and do not get so excited by innovative ideas that you end up implementing them for their own sakes. Quality delivery, connecting with citizens as the main source of innovation, is at the heart of this approach. Specific risks and issues To be effective in this approach requires the freedom and credibility to engage at both social care practice and executive decision-making level. Be aware of risks of interfering with people’s power bases or disrupting expectations and ideology. Take the cost of change and the capability, learning, and engagement of the workforce seriously, and spend time thinking about the real practicality of new ideas. Ensure you are scanning the landscape beyond your own council and learning lessons from elsewhere. Considerations for commissioning skills and structure To be strong in this approach, you will need sufficient expertise, experience, and credibility amongst commissioners to engage effectively with the social care workforce and their managers, and for commissioning to be seen as a partner to delivery. You will also need good data, feedback loops, and shared learning across delivery and commissioning. A commissioning structure which follows the existing service structures is likely, and commissioning is likely to be more focused on adult social care. For that reason, you will need good mechanisms focused on working with and identifying gaps between services, and monitoring and understanding the whole journey of service users. You also need commissioners who are full of bright ideas and constantly scanning the horizon, but practical. They need the credibility with senior managers and politicians that they can be trusted and deliver results, and need to build strong relationships with parts of the council like legal and procurement, and similarly manage partner relationships well. Examples of this approach in practice Review of discharge to assess which identified that people were not being contacted following their discharge (along with other practice issues), and put in place alternative mechanisms to contact them as well as addressing other issues. One borough introduced technology-enabled care at home to reduce the requirement for residential care. This was introduced through service design study of homecare interactions and research into citizen needs, combined with an understanding of the potential of technology, and a business case for investment to reduce overall costs. A commissioner carried out interviews with service users in their own homes – seeing them in context and understanding their lives as a whole helped to significantly inform her work, and fed directly into small but significant changes to requirements when homecare was re-commissioned. A council was paying extremely high prices for mental health supported accommodation from specialist providers, and despite significant engagement, was not able to shape the offer from those providers. They therefore took the service in-house, starting on a small scale, using housing stock and both in-house and contracted provision for care. They have cautiously scaled up the service and are still learning the lessons from practice to feed into the overall model. One thing to read A radical new vision for social care – how to reimagine and redesign support systems for this century. Hilary Cottam. The Health Foundation 2021 https://www.health.org.uk/publications/reports/a-radical-new-vision-for-social-care