How commissioning is supporting community development and community building

Asset-based commissioning is an approach to “Enabling people and communities, together with organisations, to become equal co-commissioners and co-producers, and also via self-help, make best complimentary use of all assets to improve whole life and community outcomes’ (Asset-based commissioning: Better outcomes, better value).

Ten years ago, A Glass Half Full recommended that commissioning should develop approaches to supporting community development and community building, suggesting that world class commissioning could:

• be aligned with initiatives focusing on place-shaping and wellbeing
• support population-level involvement, which means not only in the process of commissioning but also in deciding what activities are commissioned
• foster co-production of health care with third sector organisations and users
• consider how to invest in long term outcomes and quantify impact.

Three separate ‘policy strands’ in health, social care and community development have promoted these proposed changes with variable success.

Policies supporting asset-based commissioning 2010-2019

Equality Delivery System (EDS) dashboard in 2011, increased commitment of clinical commissioning groups to identify equality gaps. The 2014 Care Act, the Better Care Fund and the Five-Year Forward View promoted reconceptualization of commissioning as achievement of wellbeing, taking a holistic cross-sectoral approach that includes social and community networks. Integrated health and social care, promotes local devolution and community responsibility for establishing networks of care.

Department for Digital, Media, Culture & Sport and Office for Civil Society. February 2017. Guidance for commissioning social action

National Institute for Health and Care Excellence. March 2017. Guidance on community engagement.

Ministry of Housing, Communities and Local Government. July 2019 Green Paper calling for more co-designed commissioning and procurement

Next Steps on the NHS Five Year Forward view. January 2019. Calling for more emphasis on prevention and public health, explicitly linking health service funding to community-based services via social prescribing. In a 2016 King's Fund Event on how to involve patients and communities, a nationally recognized patient expert said, “I’m still not quite sure why in 2016, two years after the five year full review was put forward, where it said that patients have got to be involved or the public’s got to be involved in co-commissioning [that] we’re still talking about it, we’re still trying to justify why it should happen.”

When viewed on a continuum, commissioning should be shifting from services based on organisational assets to services based on community and people assets, we continue to be challenged to co-design, co-deliver and co-evaluate services with communities. There are indications that commissioners are ‘asset aware’, e.g. able to draw upon the assets of people and communities to improve or modify an existing service. But in some areas a top-down approach that uses statutory services as the starting point is still being taken, which embodies a consultative rather than co-produced approach. A step change is required where services are re-engineered in response to what is already available in communities - while maintaining an ongoing alignment as new assets are identified to ensure that services compliment what is there and being developed.

The Ministry of Housing, Local Communities and Government believes there is a consensus on the common barriers to asset-based commissioning, which include

• a short-term focus
• siloed working
• inability to leverage additional funding
• a top-down approach
• transactional decision making.

These barriers have been consistently identified across national evaluations of integrated health and social care (Early evaluation of the integrated care and support pioneers programme (pdf) and Developing new care models through NHS vanguards (pdf)). Short-term funding cycles for completion of specific projects limit the ability to develop longer term partnerships across voluntary and statutory sectors, which is further hindered by a tradition of working in silos within sectors. Although the integration of health and social care has successfully promoted more cross-sector working, progress on integration of budgets has been slow.

Perhaps most important, progress needs to be made on fundamental changes in the world class commissioning model. Commissioning has traditionally been based on a ‘state and market paradigm’ which organises services along the lines of professional specialisms, for example mental health or social care. Categorising services in this way means that people’s problems are defined by specific needs and treated by specialists – effectively limiting recognition of the person as an expert in their own right. Professionals define the components and outcomes of each service and commissioners develop the specifications and measures of accountability.

The world class commissioning model has been annotated to describe the processes that need to be incorporated into a commissioning cycle.

The annotated commissioning cycle

• 1. Insight, in which commissioners aim to get beyond service data to develop a rich picture of how resources could be most effectively used
• 2. Planning, in which commissioners co-produce the outcomes framework and measurement approach with citizens, work with providers to build their awareness of social action and capacity to co-produce, and make decisions about funding and procurement
• 3. Delivery, in which commissioners monitor social, economic, and environmental value, gather insight to improve and adapt services over time, and co-produce service assessments with people who use the services

These qualities, however, continue to be mapped onto a planning and procurement cycle that reflects commissioning for statutory services.

Public Health England has now moved away from conceptualising asset-based approaches as part of a planning cycle, to mapping types of community engagement and proposing a model where service commissioning is only one facet of assets-based community development.

More detailed guidance has been produced by the Royal College of General Practitioners, Think Local Act Personal, and the Commission for Collaborative Care for commissioning community development for Clinical Commissioning Groups and sustainability transformation partnerships. This sort of community commissioning will in future take several forms, where community/statutory partnerships focus on geographic assets and/or particular services, and partnerships have the power to commission discretionary and/or core services.

There are signs that commissioning plans are beginning to adopt holistic, person-centred perspectives and a life-course perspective rather than just focusing on specific conditions.

For example, Doncaster has established an integrated commissioning plan, working with local communities via integrated neighbourhood teams and assets-based community development to co-ordinate access to health and social care.

Kent County Council has established partnering agreements and a strategic partner network, where activities are identified by stakeholders and commissioned using a social value framework.

Five steps commissioners can take to be more asset-based

• 1. Shift your focus – move your thinking from only considering services as assets to a place-based lens that aims to shape and build people’s, and communities’ assets as well, including the voluntary, community and social enterprise (VCSE) sector.
• 2. Recognise contributions of people – rather than seeing organisations as the only producers of outcomes recognise that outcomes are achieved by people, communities and organisations together.
• 3. Share the decision-making – rather than organisations consulting people and communities before making decisions, make sure people and communities are equal decision-makers from the start and throughout, with investment in community groups to help this process.
• 4. Develop relationships – rather than keeping organisational suppliers at arm’s-length, commissioners should ensure greater collaboration with organisations and view VCSE bodies as co-commissioners
• 5. Commissioning processes – rather than being mostly centralised devolve commissioning to the lowest practical scale, enabling neighbourhood level decision-making.

Responsive and joined up services have now become even more important with the onset of the COVID-19 pandemic.

Commissioning with a holistic focus now needs to include the concept of responsiveness – acknowledging that many are going to experience huge changes in their life course.

Finally, commissioning needs to align to an even greater degree with the support networks that communities have now developed and consider how to dedicate funding to maintaining local networks which have demonstrated that they are essential in managing the pandemic.

Conventional commissioning: default approach

• Focuses on buying tightly defined services and activities that are specific to the service: for example, grass cutting twice a month
• Closes down space for social action because commissioning is highly prescriptive and specifies which activities and outputs should be delivered and what the service should look like.
• Focuses on unit costs and short term efficiencies which encourages a race to the bottom on price and often represents a false economy. Social environmental value is seldom assessed or scored during procurement and preventative activities are deprioritised.
• Has a poor level of insight into what works and does not. Data requirements are led by needs and deficits, asking only what is wrong with an area or group.
• Is hierarchical and paternalistic: people who use services are not part of planning or delivery and solely professionals hold power.
• Is rigid and inflexible: bids for services form the basis of contracts with set activities and outputs. Deviation from these is often considered a breach of contract. Little flexibility exists to adapt to changing local circumstances or ideas.
• Is competitive and operates in silos: providers are in competition with each other and have little incentive to cooperate or work in partnersip. Public sector organisations commission services separately with little awareness of overlapping outcomes and activities.

Commissioning for social action: changed approach

• Focuses on commissioning for social, environmental and economic outcomes with the service and for the wider community.
• Promotes innovation and enables social action by moving away from over-specified services and asking providers and people using services to come up with ideas and activities to achieve the outcomes.
• Promotes the creation of long-term value across social, environmental and economic costs and benefits, and emphasises the importance of prevention, with an awareness of false economies.
• Uses a range of methods to develop insight, exploring needs, assets and aspirations to build a picture of what works and current strengths, as well as what support is needed.
• Has co-production at its heart: the commissioning process is co-produced with citizens and it is expected that providers will begin to co-produce their services with those intended to benefit from them.
• Is iterative and adaptive: continuous reflection and evaluation creates flexibility for services to be adapted to the interests of local people.
• Is collaborative: promotes strong relationships across and between public sector organisations, the VCSE, civic groups and residents. Often involves public sector partnerships, joint commissioning and opportunities for providers to form alliances or consortia.