Commissioning for values is as important as commissioning for outcomes

Abstract

Richard Shircore FRSPH, Professional Adviser in Public Health to the Burnham Health Protection Trust and Shirley Shaw, the Trust's Operational Manager, consider how simply focusing on commissioning for outputs or outcomes fails to understand the crucial importance of values in effective, acceptable and sustainable public healthIntroductionThose working in health and social welfare have become accustomed to the language of results based commissioning. Contracts are written containing all number of specific output measures required of the provider, whether it be waiting times for an outpatient appointment, number of persons quitting smoking, or prescribed weight loss over a given period. The rationale for such an approach often refers to the need for commissioners to get 'value for money for the public purse'. From a managerial perspective such an approach has also been justified as an example of how to demonstrate the efficiency of the organization in delivering relevant end results.The current situationRecently the target driven outputs of commissioning have come in for considerable criticism. The argument being that the focusing on outputs and targets has led to professionals focusing solely on contract criteria and losing sight of the bigger picture. Of equal concern is that the use of targets and outputs has resulted in complex organizations being assessed on a very narrow band of criteria.In response to this criticism the Department of Health (DH) has refined the language of commissioning by introducing the broader notion of outcomes as opposed to simply outputs. The details of this approach are contained in a policy document, NHS Outcomes Framework 2012.1, 2 This redefinition seeks to define success more broadly by looking at outcomes and processes and what these mean in more practical terms. The Outcomes Framework focuses on three key aspects of service delivery: efficacy, the potential to do good; effectiveness, the level necessary for competent service delivery; and efficiency, measured by a cost benefit analysis. Outcomes based commissioning is defined under five headings which reflect service priorities:* Prevention of premature death* Helping people recover from episodes of ill-health* Enhancing the quality of life for those with long-term conditions* Ensuring a positive experience of care* Caring for people in a safe environmentWhat is the purpose of commissioning?This question was raised by the Trustees of the Burnham Health Promotion Trust (BHPT).i The BHPT is an endowed charity located in Burnham, South Bucks, and the Trust commissions a wide range of local programmes from the clinical to social, internal to the external and in partnership with other commissioners.With the expected loss of NHS and Local Authority service funding to local agencies and the likely pressure on the Trust to make up any shortfall in statutory funding, the need to understand local expectations of commissioning was all too apparent. The Trustees were keen to know what type of commissioned activity was felt necessary by partners and service users in order to generate the greatest health gain. To seek answers to this question Health Impact Assessments (HIAs)ii were carried out on four different types of commissioned activity:* Out and About Club - externally commissioned for an 'at risk' population (e.g. isolated pensioners with mobility restrictions)* Citizen Advice Bureau - externally commissioned for the general publica local service provided from local medical centre* Burnham Dance Project - internally commissioned for the local general public-aimed to increase physical mobility* Intergenerational Project - internally commissioned for specific populations - bringing together pupils from a primary school with residents in an old people's homeThe outcomePrior to this study the Trust viewed commissioning as simply paying money to get something done; a way of budgeting and managing money. …