A bit over a week ago, I went to the EXCO conference. EXCO stands for EXcellence in COmmissioning for opioid use disorder services and it was organised by the Expert Faculty on Commissioning, chaired by Mark Gilman and supported by Camerus.
There are lots of things that I could write about as a result, and I want to apologise that this post won’t be uplifting. That’s not because there weren’t huge numbers of positive, impressive people there; it’s more about the wider context we’re working in. The fact that I have something to write about is in itself a ringing endorsement of the conference, which I found very useful – and I think the Faculty could go on to genuinely improve commissioning. However, I want to focus here on some of my concerns.
Most of the attendees were commissioners of treatment services, with some service users and one or two provider representatives. As a result, a large part of the conference felt to me like a mutual aid group – but for commissioners. Or perhaps more accurately a mutual moan group. That is, lots of us spent our time lamenting the difficulties of a world where people have complex lives, complex problems, and the provider and commissioner landscape is complex (think of primary care, secondary care, mental health care, housing, employment, etc) and all this is complicated by one key simple fact: there’s not enough money.
I started the day stuck in my usual default pessimism, wondering if we’d move beyond that. There’s a value in a problem shared, but there are already plenty of forums for moaning; I was more interested in action.
But of course this was a conference, not a decision-making forum; it was a place to share ideas. And the most powerful point, for me, was made by Annemarie Ward from Favor UK: “You guys work in isolation, conflict and competition”.
The immediate implication of this statement, particularly when we’re discussing commissioning, is to think about 3 year cycles of tendering and how providers are reluctant to share innovation because it could be the way they win the next contract.
I certainly have some concerns about this – and my pessimism prior to the day was partly because I’m disillusioned with the whole idea of commissioning. There’s the procurement element, which I’ve written about before, which I think includes a huge amount of waste and disruption, but the same pattern applies once contracts are in place. While it’s not impossible, the job of a commissioner in managing contracts is challenging: responsibility without (direct) authority. How many times can you ask a provider to do something? Is the threat of withholding some funding powerful? Is it effective to appeal to the provider’s better nature that we’re all trying to do ‘good work’? Would a reluctant provider ever really believe you were going to terminate their contract and reopen the procurement process when you only got one or two bids last time round?
(And that’s not to mention the issue that you can’t change the conditions we’re working under: for example, it’s simply not straightforward to recruit nurse prescribers into substance misuse treatment at the moment.)
All these are the classic questions of management: what techniques are most likely to bring change and good practice – but they’re applied without the usual levers available to direct managers or leaders.
And that’s the rub: partnership is more difficult than leadership or management.
And that’s why I think Annemarie’s point can be understood more broadly than just being about competition in procurement. It’s not just about providers competing; it’s about how well commissioners work with providers and it’s about how well commissioners work with each other (as well as other organisations).
The importance of this, not just locally but nationally, was made (indirectly) by Rosanna O’Connor of PHE. I think most people in the sector are aware of the concern that everyone involved in the creation and analysis of data – from the service user describing their situation to their keyworker through to the Minister (or even Prime Minister) – wants to say and hear that everything is OK and progress is being made. But if the reality on the ground is that cuts or commissioning practice is making life difficult, how do we expect this to be believed if the story of the data is still so glowing and smooth? There are still hardly any waiting times over 3 weeks recorded in the system…
Resolving this kind of issue needs open, honest partnership, so we’re not just telling well-intentioned lies or talking past each other.
And at some level, this is what EXCO or the Expert Faculty is (or should be) about: commissioners working together to share best practice and good ideas. And that’s fine. I think it could be. There were interesting perspectives shared by a range of speakers on the day about how they’ve approached various problems, and some of the most useful elements I took away were from 1:1 conversations in breaks with other commissioners, describing how they had dealt with particular situations.
But, apart from the obvious critique that PHE, particularly through its regional structures, should be doing this work of sharing good practice already, I have a concern. Mark Gilman described part of the role of the Expert Faculty as being a counterpart voice to Collective Voice and the NHS Substance Misuse Provider Alliance. They are the ‘go to’ organisations for the experiences of providers. There are also service user organisations (including Favor UK who were represented at the conference), but Mark made reference to a ‘sister faculty’ for service users.
This sounds like a kind of corporatist approach: you could consult all the groups in the field and then triangulate their positions. And there’s certainly a strength in that. But if we go back to that idea that we “work in isolation, conflict and competition,” it’s not clear how this will resolve this. There’s a value in seeing oneself as having a specific role or even being a cog in a machine, where each cog is specifically made to fit its unique purpose. But if we look at the sector today, is that really how these organisations feel (or make us feel)?
I worry that rather than resolving that competitive, adversarial approach by fostering an idea of partnership, these organisations will serve to set us apart from each other, leading to less communication and collaboration. (I’m not saying this will happen, and this is definitely not the intention, but my pessimism makes me worry.)
And, perhaps just because of where I find myself professionally and psychologically, I worry about a personal, ego-driven element to all this.
Sharing of best practice is helpful, but in my experience the discussions between partners are (counterintuitively) more productive when people come with problems, not solutions. Then the person concerned will probably start by finding that they’re not alone in having this issue, and we can all find ourselves contributing and feeling useful.
Too often, when we start by ‘sharing good practice’, the conversation becomes a lecture where one individual broadcasts how they’re a brilliant and influential innovative problem-solver. I felt this happened one or two times at EXCO. This is no criticism of the conference, it’s inevitable of any such discussion - and even more so when there are invited speakers who have effectively been asked to ‘broadcast’ their experiences (which, like the data, tend to focus on achievements more than challenges).
But why does this frustrate me so much? It’s not just because these ‘broadcasts’ are often misleading. (Is it a victory to have cut £2m from your treatment budget before the cuts even hit?) It relates to why, although in some ways the sharing at EXCO led me to feel more optimistic, it also left me a bit deflated personally. I completely understand the impulse to boast and broadcast (why else would I have started this blog and continued to publish academic articles after leaving academia?), and I know it can take a bit of humility to see that you’re not that unique or innovative.
I don’t mean that it dawned on me, sitting at the conference, that there are these great geniuses doing perfect work while I’m bumbling around. I mean that it was a reminder that all commissioners are mere mortals, more or less bumbling around doing the same stuff and occasionally striking gold.
So why, if I’m not intimidated by the ‘geniuses’ on show with their ‘best practice’, is this frustrating?
Well I don’t find it uplifting that we’re all bumbling around individually; I find it depressing and a waste of time. We’re all facing the same challenges, (re)inventing solutions, and actually despite (because of?) this, things aren’t that great.
So this isn’t just about ego or even psychology more broadly – those feelings come from somewhere for a reason: things really aren’t that great, and we know it.
A forum to share ‘best practice’ or develop shared solutions is potentially useful (though again I don’t see why PHE isn’t already serving this function) but it’s a sticking plaster to deal with the fundamentally flawed approach of ‘commissioning’ in the first place. It props us this approach of seeing providers, commissioners, service users, regulators/advisors as separate entities with their own interests, rather than a truly innovative approach of people treating people as people.
So without this post ending like a cry for help, I want to finish with a question that’s really designed for other commissioners, but perhaps other people in the sector too.
When I don’t believe in the structures or roles that frame the potentially valuable work that can be done, when I don’t trust that we have the right resources in the right place, and when I’m not sure it’s possible to find meaning in this work (commissioning at least), what use is there in continuing the job?