1. Commissioning for effective outcomes
Fiona Hackland
I view commissioning as a collaborative process between commissioners, service users and service providers.

2. Lets unpack that! Commissioning Lots of definitions and models
Not always well understood
Looking at needs at the population level and making sure there is provision in place to meet those needs
Outcomes
Can get bogged down in numbers and targets
Needs to focus on the difference we want to see.

3. Who says what counts as effective?
Responsibility to the local population
Local democratic representatives
Service users
Family and friends
Service providers
Evidence from data and guidance
National and local strategy
Commissioners are based in Local Authorities which means that when thinking about effective outcomes they have to consider what everyone in the local population might think is effective.
This will often be articulated by councillors who will first represent their constituents. This varies from local authority to local authority in terms of how much they are involved in influencing commissioning decisions.

4. Challenges to effectiveness
Funding
Changing profile of substance misuse
Lots of changes in partner organisations
Reprocurement cycles
Not viewing the commissioner/provider relationship as a partnership
Public Health Grant is being reduced and will cease being ring-fenced by
£200 million salami sliced across budgets in
2.2% reduction in 16/17 and 2.5% in 2017/18
No specific indication yet of what will happen re crime prevention funding, certainly in London
Huge reduction in public sector funding.
Aging opiate using population, NPS
For us, the changes in probation/CRC have been challenging
Reprocurement cycles are challenging for providers, commissioners and service users. Public bodies have to comply with EU procurement directives and the UK Public Contracts regulations. Also has to be in line with the Socal Value Act.

5. How can commissioners ensure effectiveness?
Being clear about needs
Prioritising needs
Finding the best way to meet these needs
Specifying the service and outcomes we want
Procuring the service
While there are clearly generic needs around substance misuse, commissioners have to articulate the specific sets of needs for their local authority. Not everywhere conforms to the national picture. Newham examples – opiate use still rising, alcohol use denied but higher than average levels of hospital admissions due to alcohol specific and related conditions, very diverse population with massive population churn. Very little NPS use.
Are there needs we want to focus on? Given what I’ve said about the characteristics of my borough we decided that we still needed to focus on provision for injecting drug users. We have commissioned DBIU, which includes delivery of BI and a streamlined referral route into the substance misuse service. As well as actually delivering interventions it also offers us valuable data about the demographic make-up of drinkers and their drinking patterns in the borough that is otherwise completely inaccessible to us.
Designing a specification is a fine line between setting out what you want to meet your identified and prioritised needs and over specifying so there is no room for innovation and creativity in service providers in how they will fulfil the specification and meet those needs.
Don’t specify outcomes that are so vague as to be unmeasurable. As an example I’ve seen outcomes about raising public awareness and making them more accepting of substance misuse. How do we know what the current public knowledge and attitude is and how will we know it’s changed. And why is that the role of a treatment service anyway.?
Don’t overburden with outcomes – choose those that are going to have the most leverage in terms of meeting your needs. PbR – this is often required in LA contracts anyway and isn’t restricted to sub mis contracts. My own view is to start with a relatively small contract % and then raise the level over the life of the contract. Don’t apply PbR to everything that moves – it stops being a lever then and just becomes a cost recovery tool. In our local contract we have 12 high level outcomes, 6 of which have a PbR element.
Procurement – be really clear about what you want to evaluate and involve service users in the evaluation. This should include family members and carers.
Performance management –

6. Performance management
Using a wide range of data
Ensuring that the views of service users are included
Audits
Being willing to revise outcomes or their targets
It’s a partnership.
We are lucky to have NDTMS as this is a rich source of information to inform performance
Locally defined data in order to focus on the local priorities
Service user survey and sit on Partnership Board
Thematic audits – can focus on the basics that underpin the effective delivery of higher level outcomes. As an example, how do we maintain or improve outcomes such as successful completions or reduce the number of representations if needs aren’t assessed well and care plans aren’t recovery focused? We have conducted case file audits looking for both of those things.
While there are outcomes that we will want to focus on that are centrally set we can set our own local targets related to them, e.g. number of alcohol users in treatment. If there is a huge gap between one year’s performance and the next then the commissioner needs to critically evaluate whether that is achievable. However, if a provider manages to exceed a target and there is the potential to do better the there should be an open negotiation to stretch that target.
Finally, all of this works better if commissioners and providers see themselves as part of a system which is there to ensure that substance users and their families get the best possible service. Commissioners do need to manage budgets and make savings – that’s the environment we currently work in and is also part of their job as local authority staff who are accountable for spend and who are part of the decision making process about how the reductions in funding to local government are equitably spread when meeting the needs of the local population. Working with a provider who is willing to work in partnership with us allows us to look at innovative and creative ways to jointly work within those constraints.