Commissioning for outcomes

For commissioners, the outcome is King. It’s the discovery of outcomes that underpinned Every Child Matters, genuine co-production with families, and kindled the spark of systems thinking in children’s services.

An outcome can be the tangible change or result for a child, young person or family. Or at the motherhood-and-apple-pie end of the spectrum, we can also define outcomes for the population, for instance wellbeing, happiness or length of life.

Commissioners are terminally inquisitive. We want to know:

  • Why is a service needed?
  • Who we should help?
  • And crucially, if the service didn’t exist how would the outcome be met?

Very often these questions are skipped and we just buy the same service whilst cutting the budget. But if we pay attention to these questions we often find the real efficiencies – such as short breaks that are inclusive activities in the community instead of overnight stays. Or social care that draws in the extended family and local resources to sustain change.

Let’s run through a few examples.

  1. Easy one to start… What’s the outcome of the Health service? What do we get for our £120bn annual investment? There are two main outcomes – length of life and quality of life.

    I raise this because of the importance of measurement and how it influences systems. In the NHS I suspect length of life was easier to measure – and therefore became the most important thing. Over time we’ve become good at prolonging life but perhaps without the quality. Sensibly, we have now changed the outcome measure to quality-adjusted years of life.

    What we measure and how we talk about outcomes is critical to how services and organisations perform.
  2. How about education? £68bn each year and again there has been a recent change in how we measure outcomes from GCSE grades to Progress. This is a step in the right direction but doesn’t fully reflect the real outcomes we want, such as social outcomes, health and wellbeing, inclusion and life-chances in adulthood.

    Until we find a way to measure these real outcomes, we will be stuck with schools that are forced to focus on narrow curriculum, exams and certificates. And at the extreme, gaming behaviours, such as pushing the parents of low-performing or disruptive pupils to withdraw their children (for elective home education).
  3. Wiltshire are interesting in how they define outcomes. Commissioners worked with older people to design the Help to Live at Home service – looking at what makes a difference in later life and how to incentivise providers. In the end they defined 37 personal outcomes such as the ability to make toast in the morning, or able to wash yourself, or use public transport.

    There are two commissioning tricks here — first defining measures in a contract by what the customer values. Second aligning the incentives between the end user, the provider and commissioner. In this case providers who deliver outcomes receive a higher payment – incentivising creativity such as helping the older person to access support from the local community.
  4. And closer to home with early years. The catch-all outcome is that a child is ready for school, i.e. brain development, motor skills, learning to lean, understanding social barriers, emotional wellbeing, etc.

    Imagine you are a children’s centre commissioner that has been asked to save £1m. We immediately think about closing centres and services — most of our attention is on statutory services, then we think about the market of early years providers, and perhaps support and courses for parenting.

    Now let’s return to the outcome question: How is school readiness really achieved? Research has shown that parents are responsible for influencing 70 to 80 per cent of a child’s outcomes by five years of age. In other words, we sometimes give least consideration to the factor that has the greatest impact on a child’s outcomes. So perhaps our focus should be turned around by spending more time asking: how can we help parents to do more, how can we reduce the boundaries between the setting and home learning environment like they do in West Scotland, and how can we mitigate the cuts to services with a better community response?

So the questions we ask, and the outcomes we set, are critical. Everything else in commissioning is window-dressing if we don’t understand and set the outcomes right for children, young people and their families.

First published in CYPNow: