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Unlocking Commissioning: a new approach to commissioning

There is increasing acceptance that there is a major challenge facing health care, or rather, that health care is a major challenge facing the UK. The challenge is usually summarised as comprising:

• increasing longevity is leading to greater care needs
• increasing care possibilities are available as a result of ongoing technological innovation
• the decreasing ratio of tax payers to recipients of care, as the population includes fewer wage earners and more pensioners, means fewer per capita resources will be available.

Framed in these terms the challenge is often met by proposals to ‘have a grown up conversation’ with the public about limiting the kinds of care available from the NHS; or to ‘tackle the vested interests of producers’ (clinicians and managers) by increasing competition or by making commissioning more powerful; or by simply requiring health care organisations to make massive savings on ‘an unprecedented scale’. The challenge is seen as urgent, and indeed this way of looking at it could be called a crisis lens.

However, without naysaying any of these underlying concerns, we could also observe that every UK resident contributes very significant amounts towards the NHS over their lifetime (either directly or through the generosity of other tax payers) and that few draw upon a fraction of this sum; that there is very considerable good will towards the NHS from the general public; that within healthcare organisations we have many of the most knowledgeable, skilful and creative individuals in the country; and that the challenge of meeting the needs of an ageing population is an exciting and noble one.

Thinking more positively and with less alarm we can look for ways of unlocking the creative and compassionate energies of all of those involved. We can identify and unlock resources that have become trapped - trapped in buildings and in services that were once the best and most cost effective of their day but are no longer. We can also identify and unlock resources that are captured by processes that do not actively contribute to good care. We could call this way of looking at it an unlocking lens.

Looking through this unlocking lens we are purposeful and determined but also non-judgemental and non-punitive, understanding that all those involved in offering health care are sincerely trying to meet the needs of patients and believe that their approach is effective. We understand too that in the current climate (the crisis lens) many may feel embattled as they see their motives impugned, their resources cut, and their autonomy progressively reduced. Feeling this way they are unlikely to cooperate in thinking afresh and anew about how the service will be able to offer, into the future, care of a nature and quality they are pleased to offer to the increasing number of patients needing it.

This suggests there is a real danger that further use of the crisis lens will make things worse, and will lead, not to the best use of limited resources, but to rationing of inefficient, non-compassionate care. It is time we tried instead the unlocking lens.

We could describe the most critical role of clinical commissioners as that of unlocking the creative compassionate energies of the health care professionals in provider services, and releasing resources that have become trapped in buildings and in services whose design has not evolved as their context has changed. We could also describe this as the most critical role of the managers and clinical leaders of provider health care organisations themselves.

However we do not develop the abilities of our commissioners, organisational managers and clinical leaders to unlock these creative energies.

To do so requires a capacity to genuinely understand the world as seen by others, to empathise, to care about others and about what they care about - as well as about the bigger picture. This can only happen through face to face conversations, conversations between people who often, currently, see each other as uncooperative and difficult, or as lacking credibility or the ability to understand or add value.

So we need a new approach to such conversations: conversations between GP commissioners and their provider colleagues across the system and that will require new behaviours based on new insights into communication that brings people together instead of driving them apart.

Unlocking Commissioning: a radically different Learning Set for Clinical Commissioners

The ‘unlocking’ learning set

This programme is a collaborative learning opportunity for clinical commissioners who sincerely want to meet the challenge of offering more and better care by unlocking resources and attitudes that are currently captured:

• resources that have become trapped in buildings or services whose design has not evolved as the context has changed
• resources that are captured by processes that do not actively contribute to good care
• attitudes that have become rigid, hostile or defeatist
• potential that is being stifled.

Its aim is to enable those participating to:

• have productive face to face conversations with clinical colleagues across organisational boundaries, that forge a connection and develop a creative collaborative energy
• be credible to the people they are seeking to engage in conversation
• use relevant data expertly and credibly as a vehicle for discussion
• draw also on non-codifiable information convincingly
• maintain a firm but gentle pressure for change while allowing ways forward to emerge from the conversations (rather than going in with their own solutions)
• help others re-engage with their sense of meaning and purpose
• keep a focus on enabling all concerned to flourish - at a time when external pressures may encourage more punitive or belittling stances
• feel supported in this endeavour and connected to a wider initiative and purpose.

It will draw upon recent insights from neuroscience and ancient insights about mindfulness, evidence based leadership theory and practice, chaos and complexity theory and the evidence about the vital role of conversations that are radically challenging as a result of their roots in empathy.

Each monthly meeting will be a rich mixture of short introductions to highly relevant theory, exercises in practising key concepts and developing familiarity with them, reflections on the current practical commissioning experiences of participants and constructive explorations of these. The content will mix predefined concepts with those that address issues as they emerge.

This mix of theory, practice and experience has been demonstrated to yield new thinking, new approaches and long lasting results.

Valerie Iles
Summer 2012

Read some Rules of Real Commissioning

Download the Unlocking Commissioning Learning Set as a pdf

To discuss support for CCG Boards, CCG Board members or development programmes on a wider basis that support challenge and enable individuals and groups to achieve real change please email Valerie.