I heard it again – in a discussion on last Tuesday’s BBC Radio 4 Today programme, Nick Herbert’s piece about the civil service – the problem is that silos remain .
Most of us have never seen a silo in real life, although those who have spent time on farms know that it is a really big tank or pit for storing grain or animal feed. But we learn on our MBA courses and from our management textbooks about the curse of the silo mentality. They say we need to drive silo working out – we need to work across boundaries, we need to collaborate, work in partnership. So much of what is wrong with how we do public policy is blamed on working in silos.
Couple this with the popularity of separating those that steer from those that row and we find an increased importance placed on commissioning. For several years consultants have dined out on their ability to tell us that commissioning is not the same as procurement, for procurement is just one important aspect of the complex but vital process of commissioning. But, they tell us, the worst thing you can do is commission in a silo. No no. We need to commission jointly, with others. Why? Well, two reasons. First, because the world is complex and cannot be solved by the efforts of one department or organisation alone. Second, all the reform and hollowing out of the last decades has meant our public services are fragmented in terms of budgets and decision making capacity. So joining up how we commission is a no-brainer.
Is it any wonder, then, that we ended up with the marriage of the concepts of joint and commissioning. But as a compound: ‘Joint commissioning’. It is rather an ugly and unwieldy pairing. But both concepts are viewed as desirable and essential, therefore joint commissioning is the solution. Nowhere was joint commissioning seen as more desirable or essential as in health and social care.
People’s needs for support or treatment do not neatly divide across how we organise health services and care services. While not everybody requiring acute health treatment requires social care, many with long term chronic illnesses require both. Nowhere is this more apparent in what happens when older or vulnerable adults are discharged from hospitals. So, often, it makes sense that within localities decisions and priorities should be commissioned jointly, and over the last decade, structures and practices have been aligned in the name of joint commissioning. However, such reforms can be expensive, destabilising and reveal profound professional tensions.
Various changes occurred over the last 10 years in the name of joint commissioning, with localities introducing social care partnerships, pooled budgets and, in some, full blown care trusts. The structures imposed depended on the discretion of local authorities, the PCTs and the Council. Some chose to share chief executives. Service users and carers might have seen no difference, or perhaps were confused by the change in logos and livery. The staff involved in the change, with their strong professional identities as occupational therapists, district nurses, social workers, care home managers, were told that this was an opportunity to work differently. In some cases, the changes were symbolised by lifting and shifting to a single site, to new purpose built office locations – no more NHS or Council badges – there’s a new ID card in town, swinging from a fresh corporate lanyard.
But to what avail? The shift to joint commissioning means that we also have to be interested in evaluating. Not just the processes, but the outcomes. With further integration on the horizon, the question on everybody’s lips is what good this has brought. Was it worth the effort? The answer to the question has to go further than populist or political expediency: did it save money or did more people get seen sooner?
To answer the question we need to start by asking – what do you want from this joint commissioning? When you explore the ambitions for these joint arrangements in literature and in conversation with professionals, not one but a whole range of competing aspirations arise. In a project funded by the SDO and led by colleagues at HSMC, I had the opportunity to do just this – to capture the range of aspirations for joint commissioning. A full report of the research and the findings, published earlier this month, can be found here.
In terms of what joint commissioning meant to different people, four broad points of view emerged. Yes, predictably, there were timely aspirations about productivity, saving money, efficiencies. In contrast, though, there were those who focused on implications for people, service user and carer involvement, personalisation, choice. A third set of aspirations focused on what comes from partnership – the development of synergies, the benefits of closer working, joint location; and a fourth set revolved around aspirations and implications for professions – developing professional empathy of the challenges faced, but also concerns for maintaining professional identity and autonomy.
And it’s here that we get to the problem of motherhood and apple pie – so often an issue in public policy. Read off a list of 40 aspirations for joint commissioning – synergy, empathy, cost saving, choice, user involvement, and we’ll say yes to all, all of the above please. But spend some time in conversation with people working in joint commissioning arrangements and it soon becomes apparent that there are different priorities that can easily conflict, either implicitly or explicitly.
Joint commissioning, like so many policy ideas, is what Cornwall and Eades call a ‘buzzword that has become a fuzzword’, one that clouds rather than clarifies understanding. The turning point for our research was when we asked our respondents, those working in joint commissioning across England, to prioritise differing (competing?) outcomes. They rank ordered them using a tool called POETQ. We found two things. First, that everybody is unique, that everybody had a different take on what was more important. But second, and perhaps most importantly, there were patterns. Taken as a whole we found five distinct viewpoints (page 87 of the report) on what they thought joint commissioning would achieve. The technique allowed us to cut through the nebulous language that collects around policy ideas. It also challenged our assumptions that people think according to their professional group or position in the hierarchy. These insights then guided the remainder of the project and our visits to our five case study localities.
The current reforms that focus on integrated working and the creation of Clinical Commissioning Groups are in some part a shift in emphasis and in some part a renewal of language. If there is one thing I have learnt from spending time thinking about joint commissioning, it is that we need to accept that public policy labels activity and coins and fosters policy ideas. Some of these ideas are old wine in new bottles, or existing bodies in new raincoats. But not everybody involved has the same memory or associations. For some these approaches are genuinely new. Therefore whatever approach we take, we need to ensure that it allows us to unpick and clarify these policy ideas and their associated meanings: this should be our first priority. While we cannot easily predict what will be the next big idea, what we can be sure of is that analogies like ‘silo mentality’ run deep and will shape new policy ideas yet to be coined and fostered. But when the next big idea appears on the horizon we needn’t shy away from nebulous language or accept notions without question. Assisted with tools like POETQ, next time we’ll be ready.
This article gives the views of the author, and not the position of the INLOGOV blog, the University of Birmingham or National Institute for Health Research (NIHR).
This research is discussed at greater length in the article Beyond the Berlin Wall?, by Helen Dickinson, Stephen Jeffares, Alison Nicholds, and Jon Glasby, published in Public Management Review. The article can be viewed here.
Stephen Jeffares is a Roberts Fellow in the College of Social Sciences based in INLOGOV, Institute for Local Government Studies. His fellowship focuses on the role of ideas in the policy process and implications for methods. He is a specialist in Q methodology and other innovative methods to inform policy analysis.