Supporting innovation and outcomes through joint …issues, enabling agencies to better understand...

Supporting innovation and outcomes through joint commissioningJuly 2020

This paper has been co-developed by PwC and Commissioning NSW with the aim of providing advice and support to NSW Government agencies, and others interested in the practice of commissioning.

Governments are increasingly required to wrap a variety of services around population groups in a way that is joined-up and integrated. When done holistically and strategically, this is known as joint commissioning.

What is joint commissioning?It is increasingly appreciated that citizens and societies are complex, interconnected and often messy. Problems are multifaceted, with their determinants arising from a range of social and economical factors. This means that supporting individuals to have better, healthier and more productive lives requires clever, considered and integrated thinking. Governments are increasingly required to wrap a variety of services around population groups in a way that is joined-up and integrated. When done holistically and strategically, this is known as joint commissioning. This approach provides a way to work across agency, funding and program barriers to ensure outcomes are better supported and more likely achieved.

Joint commissioning of human services in NSW | 3

More than just agency collaboration or co-funding, joint commissioning can often be complex and challenging to deliver. At its core, it involves two or more agencies working together across the entire commissioning cycle to assess needs, allocate resources and enable services. This approach typically involves partnerships that are focused on:

Joint commissioning occurs on a spectrum of partnership and collaboration

Joint commissioning involves two or more agencies working together across the commissioning cycle.

1

2 3Achieving outcomes

for communities within shared geographical

catchments.

Achieving shared outcomes for people

where responsibility is dispersed.

Pooling and redistributing resources,

responsibilities, and decision making

to achieve specific outcomes.


All forms of joint commissioning have merit and value for commissioners and the populations they serve. The appropriate form and extent of joint commissioning will depend on the conditions and circumstances of each initiative, the strength of relationships between agencies, and their track record of partnering together.

Generally, the greater the overlap in client cohorts between commissioners, the greater the need for a joint approach. For example, client cohorts with complex needs that interact with multiple services are likely to benefit from an approach that takes their needs across different service settings into account.

Joint commissioning occurs on a spectrum ranging from increased consistency in language, approaches and tools, towards more explicit alignment around shared goals. In its purest form, it is evidenced by collaboration and shared contributions to goals. This requires strong foundational relationships between all involved, as well as:

• “Skin in the game” from all parties, whether that be co-funding arrangements, shared risk or other in-kind contributions.

• Shared accountability and decision making.

• Formalised partnership arrangements (e.g. through a Memorandum of Understanding, Service Level Agreement or other contractual instrument).

Figure 1 What is joint commissioning?

What is joint commissioning? What is not joint commissioning?

• Two or more agencies working together across the entire commissioning cycle.

• Consulting another commissioner as part of stakeholder engagement and management or co-design.

• Two or more agencies formally agreeing to jointly commission shared outcomes.

• Collaborating with another commissioner to undertake individual components of the commissioning cycle – for example needs analysis or service design.• Shared outcomes and strategic alignment

demonstrated through pooled resources, shared risk, and shared accountability and decision making.

Figure 2 Spectrum of joint commissioning?

Source: PwC and NSW Government, adapted from the Public Sector Commission Creating Collaboration Review1

1 https://www.psc.nsw.gov.au/reports---data/other-publications/collaboration-between-sectors

Consistency

• Common policy environment

• Shared language

• Aligned commissioning approaches and tools

Coordinate

• Multiple agencies involved • Independent contributions

to shared goals• Opportunities to cooperate

through co-design and other forms of consultation

• Shared provider landscape

Collaborate

• Established track record between agencies

• Shared contributions to • shared outcomes• Overlap in client cohort and

client needs• Co-funding• Shared risk and accountability• Formalised alliance

arrangements


Factors supporting the move to joint commissioningIt has often been said that commissioning is an art and not a science, and commissioning approaches and techniques have evolved with time and experience. Joint commissioning represents a continuation of this, driven mainly by three key factors.

There are compelling associated benefits for clients and wider stakeholders.

An increasingly enabling policy environment that provides the permission and foundations for commissioners to work together.

1

3

2 Increasing recognition that some outcomes cannot be achieved by singular agencies in isolation.

Three key factors


1 | The benefits of joint commissioning

Joint commissioning can offer a number of benefits to stakeholders.

Clients can benefit from more integrated and holistic approach to meeting their outcomes. Clients who have complex needs and access a range of services can benefit through increased coordination across the service continuum. This approach can better understand and address needs earlier, minimising the risk of a client requiring more intensive support later on. This might mean, for example, designing services that integrate primary and acute health care systems with broader interventions targeting the social determinants of health.

Providers are likely to experience greater consistency between commissioners and benefit from streamlined administrative and reporting arrangements. In addition, a stronger focus on outcomes, rather than outputs, support more meaningful interactions with commissioners on service effectiveness and where flexibility is required to adapting delivery models.

Commissioners can realise efficiencies by reducing liaison points with the sector. Commissioners can also gain value from access to resources held by another commissioner or their market of providers, such as subject matter knowledge, physical or intellectual assets, relationships, and financial resources.

Commissioners can also gain value from access to resources held by another commissioner or their market of providers.


2 https://www.facs.nsw.gov.au/resources/human-services-outcomes-framework

3 https://www.health.nsw.gov.au/integratedcare/Publications/strategic-framework-for-integrating-care.PDF

4 https://www.aboriginalaffairs.nsw.gov.au/working-differently/local-decision-making

3 | The current policy environment encourages greater collaboration

Policy frameworks in NSW, as well as industry standards (particularly across health and human services), provide the foundation for a joint commissioning approach across agencies. They provide an anchor point by setting expectations for what should be achieved and providing a common language to frame the approach. For example:

• The NSW Premier’s Priorities has created an incentive for agencies to work differently and together to develop new, more innovative and effective ways of breaking cycles of disadvantage and improving outcomes for people with complex needs.

• NSW Treasury’s Outcome Budgeting approach focuses attention away from outputs and activities towards outcomes, compelling agencies to focus on what matters and reframe their commissioning approaches towards achieving outcomes.

• The NSW Human Services Outcomes Framework2

and the Quadruple Aim3 provides a common language to describe outcomes and understand key issues, enabling agencies to better understand their key strengths and ability to address outcomes.

• Local Decision Making4 provides an overarching framework for how joint commissioning can occur between Aboriginal governance bodies and the NSW Government.

2 | A recognition that some outcomes cannot be achieved in isolation

The importance of agencies working together is well established - particularly when commissioning outcomes that could not otherwise be achieved in isolation. In reality, the boundaries that exist around agencies restrict their ability to truly support outcomes in any other way. Similarly, the joint-delivery of services by multiple agencies (and providers) is equally important in harnessing the unique benefits that each delivery body brings. This requires joined up delivery of services, such as a coordinated referrals to existing services, or joint commissioning of a single service which addresses multiple client needs.

For example, social housing tenants may be challenged to maintain their tenancies or to progress to affordable and mainstream housing without stability in their family situation and employment. Joint commissioning recognises the necessity for multidisciplinary approaches to complex issues and the importance of collaboration and partnership in achieving them. In this case, a joint commissioning approach could see the commissioner responsible for housing work with the commissioner responsible for employment to jointly commission a program which focuses on increasing the employability of social housing tenants.

Joint-delivery of services by multiple agencies (and providers) is equally important in harnessing the unique benefits that each delivery body brings.


Greater Manchester health and social care partnership

Joint commissioning was first referenced in the UK where it found favour in the health and social care as an approach to support the development of integrated services based on local needs.

A good example of this is in Greater Manchester where public services were commissioned by over 10 disparate agencies. This led to siloed commissioning approaches and solutions and citizens experiencing poorer health and social outcomes relative to national averages and standard:

• Two thirds of early deaths in the region were caused by issues such as smoking, alcohol dependency, poor diet and air pollution which are preventable through better support and lifestyle choices.

• Nearly 25% of the Greater Manchester population had a mental health or wellbeing issue.

• A quarter of a million people in Greater Manchester claimed benefits and many children were not socially or emotionally ready for school by the age of five.5

CASE STUDY

In April 2016, the Greater Manchester Health and Social Care Partnership was created to take charge of health and social care spending and decisions. The partnership is a collaboration of all Greater Manchester’s NHS organisations and councils, primary care, voluntary, community and social enterprise groups, NHS England, Healthwatch, the police and the fire service. This has meant the establishment of a single strategic, place-based commissioner across the clinical commissioning group and local authorities, and an integrated care organisation bringing together all the service providers in an area.

This change in structure has allowed:

• A clearer and more coordinated focus on outcomes.

• The pooling of financial resources to drive system change and enable greater flexibility in spend.

• Professionals from a range of services to work more closely together at a neighborhood level.

• Co-location of services, where appropriate.

Stakeholders credit the development of the new commissioning vehicle as being key “to establishing increased commitment to integration, significantly reducing the incidence of silo working, and placement of organisational priority before that of place and person”.

5 http://www.gmhsc.org.uk/about-devolution/the-bigger-picture/


Joint commissioning is more complex than traditional approaches, with challenges existing both in theory and practice. Understanding these provides some indication of why joint commissioning isn’t more prevalent. However, it also supports more purposeful and informed planning for agencies looking to investigate the viability of working in this way.

Commissioners experience both structural and cultural challenges in undertaking joint commissioning

Differing commissioning approaches and protocols Different agencies are likely to have their own approaches to commissioning, with nuances reflecting their own circumstances and experiences. As agencies work more closely together, differing approaches may create friction and challenges, especially if assumptions about what and how activities are undertaken are not made explicit.

Misaligned timelines and processes Different agencies may have different cycles of planning, budgeting and commissioning which reflect their own funding sources and obligations. These differences in timelines and process reduce the window of opportunities available for agencies to align strategic priorities and outcomes ahead of jointly working through the commissioning cycle.

Power asymmetry between partners A real or perceived power imbalance may occur when agencies involved in joint commissioning have significant differences in size, influence or resources for investment. Potential power dynamics might limit the attractiveness and effectiveness of joint commissioning initiatives, particularly if these concerns are not explicitly addressed. It is important to recognise the value and assets that each commissioner brings to the table, which could include influence, data, access or funding.


Lack of capacity and capabilityJoint commissioning calls for behavioural change, as well as the development of enabling tools and processes. Understanding whether mindsets have shifted within an agency, and whether the capability exists to develop the tools and processes for joint commissioning is important to understand before committing.

Investing in the relationships required to enable partnerships with other agencies takes time and resources. Joint commissioning initiatives can be challenged by insufficient allocation of resources.

Funding arrangements and conditions Some commissioners may have mechanisms which enable a flexible and rapid response and release of funds for new resources or work effort. For others, funding arrangements are more complex and cumbersome, and constrain the ability to move on a new potential opportunity. Trust between commissioners can be eroded when there is a perception that funds are not well managed or not being allocated in an appropriate and timely manner, thereby jeopardising future funding and undermining the broader sustainability of the effort.

Data sharing protocols and governance Commissioners are often challenged to share data and information due to real or perceived privacy risks, a lack of alignment in their individual data sharing policies and protocols, or the absence of appropriate data governance.

A common understanding of need, resources and the local service landscape is required to effectively work together to commission services. Developing a common understanding requires access to data which can take significant time and effort to access and harmonise, for example if different definitions are being used between agencies.

These factors make inter-agency coordination and joint commissioning difficult to achieve. Whilst complex, some barriers can be easily addressed through new processes, protocols or arrangements. Others may require changes to the perceptions, behaviours and mindsets of commissioners themselves.


Enablers for effective joint commissioningWe have identified five necessary conditions that enable successful joint commissioning and collaboration. Enablers include both foundational qualities as well as other factors that whilst highly desirable, can be prioritised as experience and maturity evolves.

Clearly defined and shared outcomes1

Relationships, relationships, relationships2

Leadership at all levels driving collaboration3

A strengths based approach to roles and responsibilities supported by dynamic governance

4

A commitment to the initiative that is kept5


Agreeing a clear definition of success, or a “flag on the hill,” creates alignment across commissioners and their stakeholders. This provides a shared and measurable definition of success, enabling agencies to build clarity through all activities. It also helps to better determine who should be involved, when, and to what extent. This can in turn reduce the potential for volatility, confusion, and disharmony across stakeholders. Clearly defined outcomes also enable parties to clarify and delineate the individual actions that each commissioner will undertake to independently contribute towards the shared outcome.

The flag on the hill provides a singular vision of success that all agencies understand and are committed to. This can be motivating to the parties involved, particularly when tackling complex challenges over an extended period of time where individuals may change but organisational outcomes remain the same. Definitions of success also help frontline staff understand the rationale for changing processes and how their individual role contributes to an overarching goal.

Agreeing a definition of success is often challenging within a single organisation, let alone across multiple ones. Definitions may be developed and agreed overtime, as agencies combine to work closer together and leverage their respective knowledge and understanding of issues and potential opportunities.

A vision for health in Murrumbidgee

In October 2019 Murrumbidgee Primary Health Network (MPHN) and Murrumbidgee Local Health District, together with providers and consumers in the west of the region, co-designed a new care pathway to support people with chronic disease (congestive heart failure and chronic obstructive pulmonary disease) to better manage their health. While MPHN and MLHD are still in the process of identifying the specific services and outcomes to be jointly commissioned, their ability to do so is underpinned by a shared commitment to developing “one health system” in the region. This was formalised following multiple forms of collaboration between the agencies in recent years. Each collaboration opportunity strengthened their working relationships, provided clarity of their respective strengths and helped inform how a more formal commissioning partnership might work.

1 | Clearly defined and shared outcomes

CASE STUDY


All relationships require an investment of time, transparency, honesty and consistency. A wide and diverse set of relationships between commissioning agencies is also critical, as turnover among staff presents a risk to their sustainability.

An enabler of any successful relationship is communication between commissioning agencies.6 When communication is not effective, clear, consistent or regular, it can reinforce traditional silos and result in misinterpretations and misunderstandings. Joint commissioners need regular formal and informal contact points to maintain transparency, build trust, and minimise surprises.

Relationships are strengthened when there is a perception of equality among stakeholders and low self-interest from individual stakeholders. In practice, this means that each commissioner may need to limit the extent to which they lobby for their individual interests, and instead focus resources towards the goals and interests of the collective.

The Greater Sydney Commission Place-based Infrastructure Compact (PIC)

The Greater Sydney Commission piloted a Place-based Infrastructure Compact (PIC) for the Greater Parramatta and Olympic Park (GPOP) region to trial a strategic planning model that looks holistically at planning for the precinct to better align growth with the provision of infrastructure and services. The PIC involves 10 government agencies spanning infrastructure, environment, health, culture and social services, among others. This required significant effort to initially establish constructive and meaningful relationships. To do this, PIC initially gathered all the commissioners involved to attend fortnightly, half or full day meetings. This investment of time was considered critical to forming working relationships, and building trust. These foundations were critical to ongoing success, particularly when agencies were required to share data, information and insights that informed the precinct’s needs analysis and business case.

2 | Relationships, relationships, relationships

6 Maniatopoulos et al, 2018. Sourced from: “https://journals.sagepub.com/home/hsr”

CASE STUDY


Responsibility for joint commissioning is vested in staff at all levels. Specifically, both senior leaders and frontline staff have roles in laying the groundwork for collaboration and successful cross-agency relationships. For example, senior leaders need to set and maintain a clear overall vision, whilst also inspiring momentum and engagement. One commissioner noted “Having a visionary Deputy Secretary who continued to demonstrate passion in the face of constant ‘negative Nancies’ was critical to ensuring success.’’ Equally, junior leaders are critica to adopting and promoting the mindset and process changes that are required to support collaboration.

The following diagram illustrates how all levels of leadership contribute to joint commissioning efforts.

3 | Leadership at all levels driving collaboration

Source: PwC

Staff

Joint commissioning outcomes

Scene setting• Establish vision and define outcomes• Set pace of change• Clarify roles and relationships

Relationships• Develop senior relationships

Culture• Provide authorising environment• Drive accountability• Remove barriers

Scene setting• Provide local knowledge• Identify important nuances• Identify opportunities for innovation

Relationships• Establish and develop peer level

relationships• Taking communities and providers on

a journey

Culture• Escalate systemic risks and barriers• Adopt necessary changes to mindset

and behaviours• Embody collaborative culture

Senior leaders

Front line commissioners

Figure 3 Leadership in joint commissioning


Successful joint commissioning requires the strengths and capabilities from each agency to be understood and utilised. A strengths based model requires a strong understanding of the assets of each commissioner, and translates these into stated roles and responsibilities. This approach also allows the best leader to come forward at different stages of the commissioning cycle.

Clear roles, responsibilities and governance also mitigate the risk of experiencing bystander effect in a joint commissioning initiative, or the risk that no one steps forward to take ownership of a particular risk, issue or initiative. Moreover, each commissioner requires a clear understanding of their scope of control so that they can readily step forward (and backwards) in line with their agreed roles.

Governance arrangements that bear strengths and roles in mind, and are developed specifically for the initiative, can help support this. As joint commissioning activities may range in duration, governance should be regularly revisited to ensure that the structures are able to adapt, and that the right commissioner is involved at the right time to utilise their strengths.

4 | Strengths based roles and responsibilities, supported by dynamic governance

Logan Together

Logan Together is an initiative of over 100 organisations, including state and local government, to help over 5,000 children in the Logan area to thrive by 2025. When it was established in 2014, Logan Together pulled together existing assets in the community to establish fit-for-purpose governance arrangements supported by a small, multi- agency collaborative to coordinate action.

As the initiative has grown, these governance arrangements have been revisited, with Logan Together now considering the development of a more permanent, formalised and independent joint commissioning entity.

CASE STUDY


The NSW Integrated Service Response (ISR)

The ISR is a whole-of-NSW government initiative to support people with disability who have complex support needs and are at risk of crisis through improving local coordination across government and non-government services, including the National Disability Insurance Scheme.

The NSW Department of Premier and Cabinet (DPC) provides high level oversight and support, with NSW Health hosting the ISR on behalf of Government. The ISR has worked at the grassroots level to ensure the right parties are at the table to address challenges faced by participants:

“We made it clear that there was no other commissioner or individual that could address the need, and challenged the participating agencies to answer the question of “If not you, then who?”

With DPC support and a Memorandum of Understanding signed by the Secretaries of relevant agencies to gain buy-in, the ISR has been able to support co-ordinated responses to address or better manage complex situations for vulnerable people.

The ISR identifies the appropriate agencies required to address the consumer need, demonstrates persistence in advocating for the desired outcome for the consumer, and provides an enabling environment for a collaborative working relationship and culture across agencies.

CASE STUDY

Joint commissioning can take time as it requires new behaviours, better relationships and different ways of working across agencies and partners.

A formalised commitment supports continued investment, longer term changes in mindset and skill development, and the continued iteration of underlying processes. This can be done through a Memorandum of Understanding, a Service Level Agreement or another binding arrangement which confirms the terms and duration of the commitment.

Such a commitment towards a shared goal also helps minimise the risk of reverting to the status quo, or leaving individual commissioners with additional responsibility and risk. This can help parties stay the course whilst providing boundaries for flexibility.

5 | A commitment to the initiative that is kept


Where to from here?

Increasing instances of joint commissioning are likely as collaborative efforts to address complex challenges grow. By starting now and engaging purposefully, commissioners can learn valuable lessons that can contribute to larger scale joint commissioning exercises. To further build competency and capability it is recommended that agencies:

Start now, start small and learn

Strong relationships and a history of successful partnership are indicators for success. Commissioners should seek to identify opportunities for formal and informal collaboration with other agencies, which will help develop professional relationships, establish working practices and identify opportunities for broader collaboration. This could include working together strategically on a joint needs assessment, participating in a placed based initiative, or more locally in undertaking joint problem solving.

Commissioners can identify opportunities for such activities when developing strategic and annual business plans, or strategies to respond to reform. This will ensure they take a strategic and considered approach to gaining partnership experience, making future joint commissioning initiatives more likely to be identified and successful.

Cultural change is inherent in this recommendation, with the need for agencies to create an authorising environment for frontline commissioners to identify and progress opportunities. Moreover, the culture of the organisations will evolve as each develops more experience collaborating with other commissioners.


Make a plan to advance joint commissioning maturity

The most mature forms of joint commissioning will not happen “organically” or overnight. They require a considered approach and a long-term plan. For example, the North Coast Primary Health Network and the Northern NSW Local Health District have established a Joint Governance Board comprised of representatives from the two agencies and local government. The Partnership Agreement and Strategic Plan which govern this collaborative:

• Were endorsed by the individual boards of each agency, making the commitments of the collaborative binding.

• Clearly state the outcomes and services that the collaborative will commission together, and the timing for their commissioning activities with a staggered, three year horizon.

• Provides complete transparency regarding the source of funding and how funding will be used over the three years.

• Is complemented by service mapping and modelling completed in the region to assist the collaborative to prioritise local needs and plan their collective response.

The plan should focus on the immediate next steps, horizons and priorities required to progress the joint commissioning relationship. Whilst the plan can be treated as a compass towards the shared goal or flag on the hill, it is not a map that will dictate the detailed method for joint commissioning. Commissioners must recognise that environmental factors often necessitate continuous review and updates to the plan. However, the act of setting a plan ensures stakeholders are committed to long term partnership and have a course of action.

Drive accountability and performance

Greater accountability is required to incentivise commissioners to jointly contribute towards outcomes outside of their traditional remit or control. As the saying goes, “what gets measured, gets done”. Accountability can be built by expanding both responsibility and recognition for performance and contributions to shared outcomes. NSW Treasury’s Outcome Budgeting approach seeks to “encourage public sector agencies and service providers to coordinate and collaborate with each other so that resources are optimally pooled and programs appropriately targeted to inclusively service the needs of everyone across NSW’s communities.”7 Commissioners should be held accountable for this vision if it is to be achieved. Beyond simply adopting outcomes based budgeting, accountability speaks to the need for performance measures and incentives which drive collaborative behaviours and discourage siloed commissioning responses. These principles apply equally at a sector, agency, team and individual level, with all players requiring greater accountability for their respective roles in joint commissioning.

A genuine focus on a broader set of outcomes would represent a significant cultural change for many NSW Government agencies, which would see commissioners move away from mindsets like “patch minding”, “us vs them”, “me first”, and “not my problem”, towards a culture where collaborative behaviours, joint problem solving and shared services are recognised and rewarded.

7 https://www.treasury.nsw.gov.au/budget-financial-management/reform/outcome-budgeting


Commissioning NSW has been established to support public sector commissioners in their work. If you’d like more information about joint commissioning, commissioning, or if you need some practical support, you can:

• Join the Community of Commissioning Professionals: https://www.comprac.nsw.gov.au/Communities-of-Practice/Commissioning-Professionals

• Contact Commissioning NSW at [email protected]

© 2020 PricewaterhouseCoopers. All rights reserved.

PwC refers to the Australia member firm, and may sometimes refer to the PwC network. Each member firm is a separate legal entity. Please see www.pwc.com/structure for further details.

This content is for general information purposes only, and should not be used as a substitute for consultation with professional advisors.

Liability limited by a scheme approved under Professional Standards Legislation.

At PwC Australia our purpose is to build trust in society and solve important problems. We’re a network of firms in 157 countries with more than 276,000 people who are committed to delivering quality in assurance, advisory and tax services. Find out more and tell us what matters to you by visiting us at www.pwc.com.au

127076938

PwC are leading thinkers in commissioning and delivery reform, bringing a dedicated team of experts with frontline experience in the government and non-government sectors.

For more information, please contact [email protected] or [email protected]

Supporting innovation and outcomes through joint …issues, enabling agencies to better understand...

Documents

Transcript of Supporting innovation and outcomes through joint …issues, enabling agencies to better understand...