Ian Keys has worked in the public services area for more than two decades in a number of roles, including trade union officer, senior local government officer, think-tank director and board director of two specialist public service provider companies. He is co-founder and currently managing partner of Gradus Consulting, which specialises in supporting health, social care and local authority sectors in their delivery of commissioning.
More than 60 years of unresolved relationship issues between government and the health and social care system have followed the inception of the NHS. The underlying tension between operational and political control remains today, complicated by the increasing concentration of operational power in the reducing number of provider organisations.
Commissioning performs various functions: it identifies and determines ways of meeting need; engages with service users; negotiates with suppliers; builds the capacity of local organisations; and makes decisions on which services, at what quality and in what quantity, to fund. Politicians, providers and managers alike sense that commissioning will finally resolve relationship issues by structuring decision-taking as close to the patient possible.
For the first time in UK public policy, the acceleration of commissioning into health and social care will enable effective local debates on the deployment of resources. Central diktats and the ‘one-size-fits-all’ approach will become less important as the public begins to see that investment will improve the lives of the many rather than the fortunate few. This fundamentally democratic issue is seldom aired and even more rarely structured into the way our public services operate.
What will those myriad local investment decisions be informed by? In short, by the values held by recipients and providers. These firstly need to be recognised and then a way forward negotiated to determine the service response. As health and social care moves inexorably towards individual budgets, values-based commissioning will constitute a necessary underpinning of the process.
Some values are universal, such as the right to life or freedom from degrading treatment, but even these can be contentious in health care: the right to life cannot be considered a right to be kept alive at any cost. Other values may be synonymous with ethical principles, such as justice, best interests or autonomy. Yet others go beyond universality and ethics: wishes, beliefs and wellbeing, for example. The commissioning process provides the opportunity to debate the differences between values, whether clinical, social or organisational. Where values conflict, there is an opportunity to share the reasons for those differences, to achieve a resolution that is acceptable to all parties.
Resource constraints mean that not everyone’s expectations can or will be satisfied. However, values-based commissioning is effective because it provides a process that is transparent, fair and balanced. Presently, values-based commissioning is building an impressive track record in mental health – one developing example is in the West Midlands, where a joint values-based commissioning group has been established by the Royal Colleges of Psychiatry and General Practitioners.
Offer patients or members of the public a choice between continuing with the present but flawed system or taking a leap of faith in the prospect of something better, and most people will choose imperfect reality rather than trust a promise, particularly if the promise is being made by a politician. It is this innate public scepticism that is the real barrier to transformation in health and social care, and perhaps elsewhere in public services, too.
Pose the choice in different terms – how to effectively put the patient’s and public’s values into practice through local commissioning – and the outcome will be different: ‘how’ questions are much easier to understand and embrace.
