Approach 5: Values-based/disruptive commissioning

June 2025 teaching template, slide 60

Approach 5 Values-based/disruptive commissioning

Changing the status quo

June 2025 teaching template, 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Introduction: Uses values or innovation to challenge outdated models and promote new solutions.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.

June 2023 adult social care pre-reading, approach 5

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