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Health Services Management CentreSchool of Public Policy

Towards World Class Commissioning Competency

Executive SummaryThe paper does not seek to proposeany new commissioningcompetencies that have not beenidentified by other commentators, butdoes emphasise particular aspects ofthe debate surroundingcommissioning competency whichmay have received less prominenceelsewhere.

In particular, it argues that ameaningful definition of competencymust take into accountorganisational, contextual andbehavioural factors, and not focusentirely on the knowledge, skills andcapabilities of individuals, or particulargroups of managers and clinicians.

The paper considers the overarchingobjectives of the UK healthcaresystem, and the ways in whichcommissioning was originallyintended to contribute to theachievement of these objectives.It also reviews a number of existingframeworks describing the activitiesof commissioners and thecompetencies required to performthese tasks effectively.

From this, fourteen domains ofcompetency for world classcommissioning are identified.It is suggested that many of the skillsrequired for effective commissioningare already present within the NHS,although they could be moreeffectively mobilised. Others are welldeveloped and clearly articulated inother sectors, but need to be morerapidly incorporated into thehealthcare commissioning workforce.A third category of competencies (inparticular those associated with up-stream interventions on the demand-side of the healthcare system) is stillin the process of being defined ascommissioning itself evolves.Developing these competencies willrequire innovation and creativity, risk-taking, and learning from doing.

The paper concludes that a one-size-fits-all approach to defining anddeveloping commissioningcompetency is unlikely to be optimal,and reiterates that competencydepends not just on knowledge andskills, but on values, motivation, andagency. This is an importantmessage for those involved incommissioning at all levels of thesystem.

A report produced for

West Midlands Strategic

Health Authority by the Health

Services Management Centre,

University of Birmingham

Juliet Woodin and Elizabeth Wade

December 2007

This paper is intended to assist thethinking of those currently seekinganswers to questions, such as: Whatare health care commissionersrequired to do? What knowledge,skills, attitudes and behaviours arerequired to do it well? Who (eitherwithin or beyond the NHS) is mostlikely to possess these attributes atthe moment? How should thesecapabilities be developed anddistributed in future?

It argues that defining and validatingcommissioning competency will beincredibly challenging because thereare no definitive answers to thesequestions. Existing evidence tells uslittle about the specific mechanismsthrough which commissioningcompetency does, or does not, leadto improved health system outcomes.

This does not undermine attempts toarticulate and develop commissioningcompetency. However,acknowledgement of this complexityand ambiguity should be seen as thestarting point for intelligent discussionof the issue.

2 Towards World Class Commissioning Competency

Foreword 2

Background and introduction 3

What is competency? 4Motivation, values and agency 4Organisational factors 4Context and environment 5Performance outcomes 5

Challenges in identifyingcommissioning competencies 5

Lack of direct comparators 5Organisational change an re-structuring 6Levels of commissioning 6Context specificity 6Impact of commissioning on healthsystem outcomes 6

The contribution of commissioning tothe achievement of health system goals 7

Health system goals 7The specific contribution of commissioning 7

Review of existing models andframeworks 8

Common ground 8Areas of difference 8Areas absent from all existing frameworks 9

A world class commissioningcompetency framework for healthcare 10

Domains of competency 11

Implementing the framework 14

Conclusions 15

Appendix 1 16The responsibilities, functions, activities,skills and competencies associated withcommissioning: a rapid review of recentpublications 16

Appendix 2 23NHS outcomes and generic health systemsoutcomes compared 23

References 24

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ForewordI have been working in commissioning at Director level or as a ChiefExecutive in the NHS for over 15 years. The last 15 months have been spentin the privileged position of working for an SHA within a leadership teamcommitted totally to commissioning development, and with colleagues inthe West Midlands and from across the country who are all highly motivatedtowards making the NHS the best healthcare system in the world. Somemonths ago,

I received a telephone call from one of the most distinguished of thoseexternal colleagues during which he said to me that from his experiencepeople just dont get it. The It was commissioning. Whether this was afair observation or not, I was prompted to think about the work which I shouldbe facilitating to build that understanding where it might be missing and tocontinue to support PCT leadership teams in their challenge to buildcommissioning capacity and capability. For me, this work needed to do anumber of things. First, we should have some realistic understanding ofwhat level of contribution (to borrow the phrase) world class commissioningcan be expected to make to improving population health and securing thebest possible patient experience of healthcare services. I start from aposition that it is one important factor but only one and that the bestcommissioners will understand this and demonstrate so in theirbehaviours. Second, what are the competencies which are required todeliver world class commissioning and how can PCTs build organisationsor partnerships or support systems which can deliver all of thosecompetencies? This is important because the health improvement orhealthcare service sector is recognised as probably the most complex areain which to commission and the skills to do so are in short supply. Finally,what is the appropriate response to those who say we need toprofessionalise commissioning and what does this mean?

I chose to collaborate on this piece of work with the HSMC at the University ofBirmingham because of the brilliance and in particular clarity which ChrisHam provides in his observation of other healthcare systems and whatmakes them work or not and because of the excellent work done previouslyby Juliet Woodin and Elizabeth Wade with Judith Smith on commissioning. Ithink this report, and the forthcoming accompanying review of theinternational evidence, more than justify the decision and I have been able toclarify my own thinking in a number of areas as a result of the reports. I amtherefore very grateful to Juliet, Elizabeth and Chris. I know that they wouldwant me to emphasise very strongly that the work on competency domainsand their elements is not intended to be prescriptive and PCTs should, and Iknow will, organise themselves to best suit their local circumstancesespecially the skills in their teams.

Finally, we started this work shortly before the launch of the World ClassCommissioning initiative but Mark Britnell encouraged me to press on andsubmit the report as a contribution to WCC. We are very pleased to do soand I think you will find the conclusions support that of the work being leadby Mark and his team.

Eamonn KellyDirector of Commissioning and Performance, NHS West Midlands

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Background and introduction

The separation of responsibility for planningand funding services from the task ofdelivering them has been a feature of the UKpublic sector for many years. While theextent of this separation (and theterminology used to describe it) has variedover time, location and service area, theconcept is certainly not new.

However, the recent consistency withwhich the role of the state has beenportrayed as that of commissioner (or insome contexts enabler or place-shaper)rather than provider is, perhaps,unprecedented. In particular, there hasbeen a shift away from commissioning beingseen as one of many functions carried outby statutory organisations, towards thedescription of these organisationsthemselves as strategic commissioners.At the same time, there has been a growingrecognition that if commissioning lies at theheart of what the public sector does thecapacity, capability and profile of individualsand organisations involved in commissioningmust be strengthened.

Current efforts to articulate the core set ofcompetencies required for effectivecommissioning, and to accelerate thedevelopment of these competencies at anational and local level, are intended tocreate and embed the foundations for thisstrengthened commissioning function.

As discussed below, even with a moreprominent role, commissioning should onlyever be seen as one part of the widerarchitecture of public policy and provision.It is clear that a variety of factorsdetermines the system-level outcomesachieved through public services, of whichthe competency of those performing thecommissioning role is only one.Nonetheless, if commissioners are to playtheir part within the system as effectively aspossible, it seems logical to suggest that ahighly trained, skilled, experienced andknowledgeable commissioning workforce isrequired.

The literature on UK and internationalexperience of commissioning actuallyprovides relatively limited evidenceregarding the skills and competenciesrequired by commissioners, butnevertheless provides general support forthe proposition that management skills andcapacity are factors relevant to theirsuccess. A study of the UK experience ofprimary care-led healthcare commissioningconcluded, for example: This review has

clearly demonstrated the link betweenadequate levels of management andanalytical expertise and the achievement ofcommissioning objectives (Smith et al.2004).

Evidence available from other sectors andcontexts, while not necessarily directlytransferable, also points to a relationshipbetween effective recruitment, talentmanagement, training and development andorganisational performance, reinforcing thecase for seriously exploring these factors inrelation to public service commissioning.According to research carried out by theHackett Group (2006), for example:

world-class procurementorganizations have fully-loaded wagerates that are 41% higher than typicalcompanies dedicate 74% morehours/year to training of procurementstaff than typical companies [yet] seeprocurement operations costs that are20% less than typical companiesand operate with nearly half the staff.They also see 133% greater return onthe cost of procurement operationsthan typical companies.

This apparent link between investment andreturn no doubt seems obvious to thosecurrently tasked with developing world-class commissioning within the NHS.However, the practical implications may beless clear. Up to now, while numeroustoolkits, frameworks and models have beendeveloped to describe effectivecommissioning, a common understanding ofwhat competent commissioning really looksand feels like has somehow remainedelusive. For example, the tool most recentlyused to assess the standard of PCTcommissioning (the Fitness for Purposeframework) provides a detailed account ofthe activities which comprise thecommissioning role. However, its focus isprimarily on the tasks and processes acommissioner should be carrying out, ratherthan on the workforce characteristicsrequired to perform such tasks, or on the fitbetween existing workforce characteristics,and the specific organisational requirementsof different PCTs operating in differentcontexts. The observation that scoresagainst the Fitness for Purpose frameworkdo not necessarily correlate withperformance against key national targetssuggests that there is at least a prima faciecase for examining other aspects of PCTsinternal and external environments that maybe relevant to their effectiveness ascommissioners.

Under pressure to establish acommissioning-led health system, but in theabsence of any well establishedspecification of commissioningcompetencies, NHS leaders recognise theneed for investment, but must first clarifyexactly what and who it is that they shouldbe investing in: What are commissionersrequired to do? What knowledge, skills,attitudes and behaviours are required to doit well? Who (either within or beyond theNHS) is most likely to possess theseattributes at the moment? How should thesecapabilities be developed and distributed infuture?

The following paper is intended to assist thethinking of those currently seeking answersto such questions. Its focus is on healthservice commissioning, but many of theissues raised may be relevant tocommissioners in other sectors. Its startingpoint is to recognise the huge amount ofeffort already expended in defining thecurrent NHS commissioning role, and theresources required to fulfil it. The Fitnessfor Purpose documentation referred toabove, and the more recent Framework forExternal Support to Commissioning (FESC)specification, for example, provide animpressive level of detail and, as the rangeof commissioning frameworks referred to inAppendix 2 illustrates, addressing this issuehas become a collective endeavourbetween policy makers, commissioners,providers, academics and other interestgroups. The Department of Healthsframework for World Class Commissioning(also due for publication in December 2007)will clearly be one of the most importantoutputs of this effort. It will not onlyarticulate the Departments understanding ofworld class commissioning competency, butwill also include an accountability anddevelopment framework designed to ensurethis world class standard is attained1.

The primary aim of this document is not,therefore, to propose a new or substantiallydifferent set of commissioning competenciesto those set out in existing or emergingmodels. Rather, it aims to emphasiseparticular aspects of the debate surroundingcommissioning competency, which mayhave received less prominence elsewhere.Specifically, it:

Considers the nature of competency andthe complex relationships betweenpersonal attributes, individual competency,and organisational performance;

Towards World Class Commissioning Competency 3

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Footnotes1 An early draft version of this paper was shared with thestakeholders involved in developing the Departments WorldClass Commissioning Framework



Highlights some of the problems involvedin identifying competencies for healthcarecommissioning;Re-visits the purpose of commissioning,exploring the specific contribution thatcommissioning is supposed to make to theachievement of health system outcomes;Refers to some international evidence onwhat constitutes effective commissioning,and the impact it has on systemoutcomes2;Collates and compares a wide range ofUK-based models of commissioning andcommissioning competency, alongsiderelated frameworks from other sectors(including procurement and supply chainmanagement);Synthesises the outcomes of thesereviews into a model that emphasises thepolitical and societal context within whichcommissioning takes place, and highlightsthe importance of organisationaleffectiveness to the development ofcommissioning expertise.

Some of the issues raised are complex and,as such, there is a risk they could be seenas complicating factors in an environmentwhere rapid delivery is critical. We wouldargue the opposite: that without asophisticated and realistic understanding ofthe complexity of the task, strategies foraction are likely to be flawed. As identifiedin a recent Institute for Health Improvement(IHI) report on Strategic ImprovementInitiatives (Nolan 2007), even withtremendous will and great ideas, strategicplans too often fall down in their execution,due to a failure to manage them effectivelyat a systemic level. Therefore, far fromunderplaying the challenge of defining anddeveloping commissioning competency in aninherently complex environment, wesuggest that acknowledgement of thischallenge is the starting point for intelligentdiscussion of the issue.

What is competency?

The notion of competency is central toresearch and practice across a range ofdisciplines including psychology, education,human resources and general management.However, there is no clear consensusacross or within these areas regarding thedefinition of competency, its theoreticalbasis, ways of measuring it, or itsexplanatory power as a concept. It is notpossible or appropriate to explore theseissues in depth here. However, it is

important to be clear on the definition ofcompetency being used for the purposes ofthis paper, and to at least highlight some ofthe implications this has for developing amodel of commissioning competency.The term competent is often used to refer tothe possession of the knowledge and skillsthat are known (or assumed) to be requiredby an individual to carry out a particular jobrole. As such, competency (the state ofbeing competent) is seen to be achievedthrough the acquisition or development ofone or more competencies:

descriptors of performance criteria,knowledge and understanding that arerequired to undertake work activities.They describe what individuals need todo, and to know, to carry out the activity regardless of who performs it. (Skills for Health 2007)

On this basis, competencies are often usedas the basis of job design, job evaluation,recruitment, training, performance appraisal,and similar individually-focussed humanresource activities.

We argue here that, while the delineation ofthe knowledge and understanding requiredby individuals is clearly important at anoperational level, this approach tounderstanding competency as the sum ofindividuals skills is limited. As such, itprovides an insufficient starting point forunderstanding the concept ofcommissioning competency, to be exploredin this paper.

The three key problems with this commondescription of competency are:

i) the focus on cognitive characteristics(knowledge and skills) and absence ofreference to behavioural characteristics(e.g. motives) and affective dispositions(values and attitudes) required foreffective performance

ii) the focus on individual rather thanorganisational-level capabilities

iii) the emphasis on describing what isrequired to carry out discrete tasks andactivities, without accounting for theirinteraction with each other, or thecontext in which they are performed

Motivation, values and agencyTo take the first point, definitions ofcompetency that restrict their scope toknowledge, skills and understanding imply alinear and unproblematic relationshipbetween cognitive abilities and performancewhich, in reality, does not exist. All

managers will be aware (from reflecting ontheir own practice as much as fromobserving others), that having the ability toperform a task to a prescribed standarddoes not mean that it will actually be carriedout to that standard consistently (or at all) inpractice. Knowledge, skill andunderstanding only have value whendemonstrated through behaviour and action,but action is mediated by values, emotions,incentives, self-perception and otherfactors. A definition of professionalcompetency reflecting this point is providedby Epstein and Hundert (2002) who identifythe cognitive, technical and integrative andcommunication skills required by doctors,but add to this a moral dimension to medicalcompetency the willingness, patienceand emotional awareness to use these skillsjudiciously and humanely.

The importance here of motivation as anelement of competency has been highlightedby McClelland (1973), who points out thathigh level competencies such as usinginitiative, analysing and intervening inorganizational processes, and makingcomplex judgements between alternativecourses of action are difficult anddemanding to enact. Consequently, suchabilities will often only be developed anddisplayed while people are undertakingactivities they care about or else findintrinsically satisfying.

Other writers have identified a range ofother factors that play an important role inwork performance, including self-efficacy -the belief that one possesses the skills andabilities required to perform a job well(Bandura 1977); self-determination theextent to which individuals feel they haveautonomy and freedom in their actions (Miller& Monge 1986); and sense of impact whether individuals feel they are making adifference in their organization (Ashforth1989). If a meaningful definition ofcompetency must take into account theapplication (and not simply the possession)of knowledge and skill, competency willdepend on the alignment of a certain set ofcognitive capabilities with these (and other)underlying motivational factors.

Organisational factorsThis in turn raises the point that individual-level and organizational-level competenciesare inter-dependent. While levels ofmotivation, agency, and perceived impactare to some extent internal characteristicsof individuals, they are also clearly shapedby organizational culture, leadership andstrategy. If it is accepted that affective andbehavioural characteristics must be included

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Footnotes 2 An accompanying paper exploring this evidence in detail willbe published separately in early 2008 by Professor Chris Ham.



within our understanding of competency,then so must the organizational andsystemic features that influence individualsreactions to and engagement with theirwork. The current paper does assume thisrelationship, and is actually concernedprimarily with such organisational levelcompetencies. It is acknowledged,however, that at some point individual levelcompetency frameworks must beconsidered to enable organisationalrequirements to be operationalised. Inreality, it is extremely difficult to considereither organisational or individualcompetencies in isolation.

Context and environmentThe third important point to make here is that,unlike knowledge and skills, whichintrinsically belong to an individual or teamregardless of their actual work demands,competency is highly context specific.Competency is not derived simply from thecombination of a particular set of attributes,but from the interaction between thoseattributes, and a specific set of jobrequirements. A person only possesses acompetency for as long as the skills,abilities, and knowledge they have enablethem to perform effective action within acertain workplace environment. Thus, onemight retain knowledge, a skill, or an ability,but still lose a competency if what is neededto do a job well changes. Thus,competency is integrated and relational,consisting of the complex structuring ofattributes needed for intelligent performancein specific situations (Gonczi 1994).

Performance outcomesFinally, there is a fundamental aspect to thedefinition of competency which explains theeffort organisations expend in identifyingand developing competency, and which is ofparticular significance in our attempt tounderstand commissioning competency.Boyatzis (1982) defines competencies ass

Characteristics that are causallyrelated to effective and/or superiorperformance in a job. This means thatthere is evidence that indicates thatpossession of the characteristicprecedes and leads to effective and/orsuperior performance on the job.

This definition brings into clear relief the factthat organisations do not seek to define andmeasure competencies simply so that theycan understand and describe their work.Rather, the aim is to identify and developthose attributes that are required forimproved or superior work performance.

As such, finding the links between particularindividual or organisational characteristicsand particular outcomes is usually a coretask in developing a competencyframework.

A definition of competency that incorporatesthe various elements discussed above mightbe:

The knowledge, skills, behaviours andcharacteristics required to carry out anactivity, or combination of activities, ina particular environment andorganisational context, in a way thatleads to effective or superiororganisational performance.

As discussed in the next section, whencompetency is understood in this way, itstarts to become clear why definingcommissioning competency presents sucha challenge.

Note

The term core competency is sometimesused in the organizational context, todescribe a competency which underpins anumber of its activities and is so crucial toperformance that it should be kept in-houseand never out-sourced (Prahalad & Hamel1990). This is, therefore, a specific aspectof organisational competency, and is notexplored in detail here. However, it will beimportant for PCTs to consider whetherthere are any core competencies for healthcommissioning, particularly in the context ofthe encouragement of PCTs to outsourcecommissioning activities either to externalproviders or to joint agencies of one type oranother. One model of the commissioningprocess (Wade et al. 2006) used themetaphor of conscience to describe thosefunctions of commissioning associated withsetting out what the system aims to achieveand how (as opposed to the eyes and earsfunctions of observing and reporting, andthe brain function of identifying andimplementing the optional solutions fordelivering stated objectives). Competenciesassociated with the conscience function ofcommissioning might be consideredcandidates for designation as core.

Challenges in identifyingcommissioning competencies

While defining competency is not entirelystraightforward, applying it in a useful wayto healthcare commissioning roles andresponsibilities is even more problematic.

If competency refers to the knowledge,skills, behaviours and characteristicsrequired to carry out certain tasks inparticular situations, it is clear that in order toidentify commissioning competencies, it isfirst necessary to articulate the full range ofcommissioning activities and the context(s)in which they are carried out. Immediately,here is an obvious challenge.

As noted above and illustrated in section Aof Appendix 1, numerous frameworks havebeen developed in recent years byGovernment departments, academics andothers, outlining the various stages of thecommissioning cycle, the responsibilities ofstrategic commissioners, and the key stepsin effective commissioning. The Fitness forPurpose (FFP) review process previouslyreferred to has probably gone furthest indetailing the activities, tasks and processesentailed in PCT commissioning in particular,and this is, undoubtedly, an invaluablestarting point for any exploration ofhealthcare commissioning competencies.However, FFP remains only one of severalframeworks and has not been without itscritics, with commentators arguing thatsome of the core functions of PCTs (inparticular those associated with the creationand representation of public value, andcommunity engagement through effectivecultural performance) are missing from themodel (Dickinson et al. forthcoming). Itwould seem fair to say, therefore, that fulland consistent agreement on the activitiesthat constitute effective healthcarecommissioning has not yet been reached.

There are number of reasons for this.

Lack of direct comparatorsOne obvious one is that commissioning hasa relatively short, highly unstable, and ratherunique history. Contrast this with thesituation of modern healthcare providers,such as hospitals and general practices(as primary care providers): like PCTs, thefunctions of such organisations arecomplex, numerous, and varied, and areevolving over time. Unlike PCTs, however, asignificant proportion of their core businessconstitutes certain well established tasksand activities which have been repeatedand improved in this country over manyyears, and also carried out by similarhealthcare providers across the world,providing the scope to develop globalstandards of evidence-based practice.Healthcare commissioners in the UK not onlyhave less internal history to draw on thantheir local provider organisations, but findthemselves without peers carrying outdirectly comparable roles in other countries.

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While other health care systems do ofcourse share certain features of the UKcommissioning model, the type, size,constitution and responsibilities ofpurchaser or funding organisations variessignificantly. Opportunities for PCTs to learndirectly from other world classcommissioners may simply not exist. To alarge extent, commissioners are definingtheir roles through the process ofperforming them.

Organisational change anre-structuringMany within the system would argue thatour difficulties in defining commissioningroles have been exacerbated by thefrequent re-organisation of the demand-sideof the NHS over the last 15 years.Organisational intelligence gets lost orforgotten, and progress stalled, whenenergy is focussed on restructuring, andwhen key individuals leave the service. Asa result it is possible that, in some areas,experience in and understanding ofcommissioning may actually havediminished, rather than steadily grown overthe years.

Levels of commissioningA further complicating factor is that healthservice commissioning takes place at anumber of different levels within thehealthcare system. While PCTs mightcurrently hold statutory responsibilities forhealth commissioning in England, many otherorganisations and individuals are involved.In particular, current policy advocates thatpractice-based commissioners should take alead role in making commissioning decisions,while certain specialist tasks should beaggregated across a number oforganisations, and yet others should beshared with partners, such as LocalAuthorities. Over time, individual serviceusers are also likely to be more involved invarious aspects of commissioning. It mightbe argued that this should not alter the taskof specifying commissioning activities butsimply means that, once specified, theymust be carefully allocated to theappropriate organisations and individuals forexecution. Again, however, in realityspecification and implementation areoccurring concurrently: commissioningactivities are in the process of beingdesigned, defined, enacted and modified bymultiple actors, with different perspectiveson the purpose and objectives of theircommissioning role and, therefore, on theknowledge, skills and competencies theyrequire.

Context specificityLinked to this is a third point: that thespecific commissioning tasks to beperformed by health service commissionerswill be determined by contextual factors,and will therefore vary over time andlocation. Cox (2001), for example, identifiesfour different possible relationshipsbetween purchasers and suppliers,determined by factors such as the structureof the supplier market, and levels ofcompetition. As discussed above,competency depends on the context inwhich an activity is being carried out, soeven though certain tasks and activities(e.g. contracting) might be common to allcommissioners, different types ofrelationships with suppliers will demanddifferent competencies and resources fromthe purchasing organisation for this activityto be carried out in an appropriate andeffective way. For example, differentcompetencies may be required in a largeconurbation with a number of competingacute trusts, from those necessary tomanage relationships in a remote rural areawith only one acute provider. Similarlydifferent competencies may be required tocommission primary care from thoserequired to commission secondary ortertiary care.

Impact of commissioning on healthsystem outcomesUnderpinning this whole discussion is, ofcourse, a much bigger question regardingthe nature of the relationship betweencommissioning activity (competent orotherwise) and the achievement of healthsystem objectives. As suggested in theintroduction to this paper, while it might seemself-evident that the competency ofcommissioners is critical to theeffectiveness of a commissioning-led healthsystem, at best, this will only ever be one ofmany factors. In reality, there is noconclusive evidence base demonstratingcausal links between the organisation ofhealthcare through the separation ofpurchasers and providers, the competencyof those carrying out the purchasing role,and the long-term outcomes of thehealthcare system. Furthermore, it wouldbe extremely difficult to ever demonstratesuch relationships should they exist, giventhe number of different contributing factors.Goals such as high quality healthcare, forexample, will be achieved through thecombined efforts of practicing clinicians,provider managers, professionalorganizations, researchers designing newtechnologies and therapies, the actions ofcommissioners or purchasers in stimulatingchanges using market mechanisms, and

regulatory bodies taking action. They willalso depend on factors such as thewillingness of tax-payers and governmentto increase healthcare funding. In thiscontext, identifying the precise contributionof commissioners in achieving such goalsmay well be impossible. We are certainlysome way from being able to describe thecausal relationships between particularcharacteristics of commissioners, andspecific commissioning outcomes, thatBoyatzis would require for a definition ofcommissioning competency.

In summary, despite the extensive effort thathas gone into developing and articulatingcommissioning frameworks in recent years,there is no straightforward answer to thequestion what are commissioners requiredto do? Inevitably, identifying commissioningcompetencies, or what is required to doit? is challenging, when it remains socontested.

This is not to say that there is nothing to bedone; that no further action can be taken toidentify an appropriate competencyframework for commissioners. It does,however, have two important implicationsfor the way in which this task isapproached:

i) it is clear that a focus on the developmentof commissioning needs to remain part ofa wider framework of investment in thedevelopment of the system as a whole.

ii) in the short term at least, the delineation ofcompetencies for commissioning mustdepend largely upon a combination ofinference, judgement and experience,rather than on hard-facts and indisputableevidence.

The remainder of this paper takes this line,combining a top-down approach (deducingcompetencies from the goals of thehealthcare system, and the specificfunctions and responsibilities ofcommissioners within that system) a bottomup approach (building from and synthesisingitems identified in existing competencyframeworks relevant to health servicecommissioning, including those in the field ofprocurement of non-clinical goods andservices), with the expert opinion ofpractitioners in the field.

The next section sets out the top-downanalysis, establishing an account ofcommissioning, which identifies its purposeand objectives as well as its main functions.

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The contribution ofcommissioning to theachievement of health systemgoals

Health system goalsThe goals of health care commissioningneed to be considered in the context of thegoals of the health care system as a whole.

Although the organisation of health systemsacross the world varies considerably, andindeed has been subject to considerablereform and change over the past 25 years,a number of international organizations haveidentified high level health system goalswhich are accepted as meaningful, relevantand sustainable across many healthsystems, whatever their architecture .

Three examples are given below in Boxes13.

Box 1. World Health Organization(Musgrove et al. 2000)

Three overall goals of health systemsGood healthResponsiveness to the expectationsof the populationFairness of financial contribution

Box 2. Organization for EconomicCooperation and Development (OECD2004)

Main health policy goals shared byOECD countries

High quality health care andpreventionAccessible health careResponsive systems that satisfyhealth-care patients and consumersSustainable costs and financingValue for money

Box 3 Commonwealth Fund. (Davis etal. 2007)

Dimensions of a high performancehealth system:

Quality- Right (or effective) care- Safe care- Co-ordinated care- Patient-centred careAccessEfficiencyEquityHealthy lives

Although these expressions of goals are notidentical, can be interpreted differently, andare often in tension with each other, theysuggest that health systems need to aim toachieve:

Good health outcomesHigh quality and safe careGood accessResponsive and patient-centred careEquity and fairnessContained costsEfficient use of resources

There have been various expressions of theobjectives of the NHS in both strategic policystatements and more operationally orienteddocuments. Appendix 2 maps a recentstrategic expression of NHS principles(updated 2006) and a more operational setof outcomes in the form of National Targetsand Local Delivery Plan requirements fromthe 2007/8 Operating Framework, againstthe health system outcomes listed above.The table demonstrates a high degree ofconsistency between the generic outcomesdescribed above and the sorts of outcomesthe NHS is expected to achieve, with themain difference being the NHS inclusion ofan internal outcome, relating to managementof the health systems own staff. Thisanalysis suggests, therefore, that thegeneric health system outcomes list is avalid and relevant statement of the overallsystem outcomes to which commissioning inthe NHS must contribute.

The specific contribution ofcommissioningIf these are the outcomes that the healthsystem must produce, what is the specificcontribution that commissioning must make?Indeed, why do we have commissioning atall?

Mays and Hand (2000) identify the mainreasons behind the reforms whichintroduced commissioning into healthsystems as follows:

to improve technical efficiency byallowing purchasers to select the bestvalue provider accessible to theirpopulations, including private andvoluntary sector providers, thereby givingpurchasers some control over providers

to allow those charged with determiningthe future pattern of health services inrelation to the needs of the population toconcentrate on this task unhindered bytheir previous responsibilities formanaging health care institutions and, atthe same time, to allow the providers tomanage their own affairs with theminimum of unnecessary interferences


to act as a counterweight to decades ofprofessional dominance of servicespecification and to challenge traditionalpatterns of resource allocation andsectional interests (active purchasingrather than passive funding orbureaucratic planning)

to improve allocative efficiency bypermitting purchasers to negotiate a newbalance of services with providers

to encourage providers to respond moreaccurately and effectively to the needs ofindividual patients in order to retaincontracts from purchasers

to facilitate clear lines of publicaccountability for the performance of thepurchaser and provider roles in the healthsystem

to clarify providers costs and the amountspent in each service area by comparingthe services and costs of each provider

to make priority decisions more explicit

The ambition of these reform objectives setalongside the breadth of health systemobjectives suggests a huge challenge forcommissioners and one which would, inany estimation, require extraordinarycapacity and wisdom to achieve.

It is perhaps therefore unsurprising thatthere is little evidence of these ambitionsbeing realised. Ham (2007), summarisingthe evidence from a number of healthcaresystems, refers to the lack of any workingmodels of health care systems wherecommissioning is working effectively acrossthe whole system (p.8) Research evidencefrom the NHS internal market of the 1990s(based almost entirely on primary care ledcommissioning; there is very little evaluationor evidence from Health Authoritycommissioning) leads to similar conclusions.Evidence from primary care commissioningsuggests that purchasing or commissioningduring this period had some limited impact onthe responsiveness of services - such asshorter waiting times - and resulted in someinnovation in primary and community care.Clinical engagement and financial incentiveswere important in achieving these gains.However there was no evidence thatcommissioning had any significant orstrategic impact on secondary careservices. In relation to the efficient use ofresources, there was evidence of reducedprescribing costs, but transaction costswere increased (Smith et al 2004).

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The extent to which this lack of impact is theresult of basic flaws in the system or afailure to invest in the capacity ofcommissioners is not clear. Nevertheless,the experience of commissioning during theearly period of public sector reforms,together with an account of the goals it wasintended to achieve, do provide pointers tothe competencies likely to be required bycommissioners. They suggest thatcommissioners will need competencies inboth financial and clinical (or health)domains, will need close engagement withpatients, and will need skills in prioritizationwhich pay attention to outcomes, and thevalues of fairness and equity.

The next section of the paper now seeks toidentify key messages about commissioningcompetencies through a review andsummary of existing models andframeworks.

Review of existing models andframeworks

A rapid review was undertaken to identifyrecent models and frameworks eitherreferring specifically, or with somerelevance, to health/healthcarecommissioning competencies. Thosereviewed are summarised in Appendix 1.

Some of these, in Section A, are accountsof the functions or activities comprisingcommissioning, from which competencies atthe organizational level can be inferred.

Section B sets out a small number of directreferences to competencies required at theorganizational level for effectivecommissioning, mostly derived fromacademic or practitioner literature.

Finally, in Sections C and D are extractsfrom some existing relevant frameworkswhich deal with competencies at theindividual level. These include both health/social care specific frameworks (C), andsome relating to non-health and social caresectors (D). These individual levelcompetency frameworks are detaileddocuments which provide tools for jobdesign, job grading, recruitment,performance appraisal, and so on. Due totheir length, only extracts, or an overview oftheir key elements, are included here. Whilethis paper is not aiming to produce anindividual level competency framework,these frameworks map back toorganizational level competencies andprovide useful pointers to competencieswhich may need to be included.

The following paragraphs briefly outline themain similarities and differences betweenthe various frameworks, and highlightcertain aspects of commissioning that, in theauthors view, may be under-represented inthese existing models.

Common groundDespite differences in terminology andemphasis, most of the frameworks insection A and some in sections B, C and Dinclude activities which are explicitly orimplicitly grouped into three phases:

strategy making or planning, whichincludes assessments of populationhealth needs, demands for services, therange, quality and effectiveness (clinicaland non-clinical) of existing services andproviders, and designing of the requiredservices

securing the services, which in mostaccounts is a market-based processoften referred to as purchasing orcontracting, involving shaping anddeveloping the market, bringing supplierson board (often through tendering), andestablishing formal agreements orcontracts

monitoring performance ofprovision, including activity, finance,clinical and non-clinical quality

It is noticeable that many of the frameworksenvisage the securing of services phaseas a primarily purchasing and contractingphase in a market environment. This isconsistent with the thinking behind theseparation of commissioners and providersand the new public management ethos ofusing competition to stimulate better use ofresources. It could be argued, however,that in its broadest sense commissioningdoes not only involve securing servicesthrough such mechanisms. In-sourcing,establishing joint ventures, collaboration andpartnership working, and exploring othermodels of service production could all formpart of the commissioning role but, withsome exceptions, these make, buy orpartner decisions were rarely identified inthe frameworks reviewed.

Areas of differenceThere are three particular functions oractivities which are not universally present.

Priority-setting, or prioritization, a keyelement of strategy making and planning, isnot included in several of the frameworks,generally those which relate to localgovernment or social care commissioningrather than health commissioning.

The prominence given to engagement withpatients and public is also variable. In someframeworks it is not listed as one of theprimary activities (although is usuallyincluded in more detailed discussion of howthe activity is to be conducted); in some it isincluded within one or more of the threephases of activity (e.g. patient feedback aspart of monitoring); in others it is presentedas a commissioning function in its own right(as in A3, A4, A6).

This difference is also present in theindividual-level competency frameworks insection C and D. The non-health and socialcare frameworks pay relatively little regardto relationships with customers or endusers.

In some of the functional frameworks,demand management, or care pathwaymanagement as it is also called, is animportant and separate function. Again thistends to differentiate the health frameworksfrom the non-health ones. The emphasisgiven to care process and service design inthe health frameworks particularly mayreflect the fact that products in the healthsystem are less easy to define than non-clinical goods and services and thereforerequire effort and attention to specify them.The emphasis on outcomes, rather thanservice inputs, in some of the frameworks,is also a reflection of the difficulty ofdefining the health and care product.

The distinctive nature of health (and publicsector commissioning generally) is alsoreflected in the references to politicalsensitivity and political awareness in theframeworks in section B.

The non-health and social care competencyframeworks are extremely detailed andhelpful in their descriptions of knowledgeand skills required for the supply/suppliermanagement functions of commissioning. Itis particularly noticeable that they placeemphasis on relationship management withproviders in the context of many of thepurchasing activities that they cover. Whilethere is some mention of this in health andsocial care frameworks less emphasis isplaced upon it.

A final observation is that some of theframeworks refer to broader organisationalattributes and managerial skills which whilenot commissioning-specific are consideredto be important to the delivery of thecommissioning task. Examples of this aremaking it happen accountability,leadership (which is mentioned severaltimes), management, self and


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management, team. Indeed, the individuallevel competency frameworks contain manyreferences to generic management skillssuch as project management, informationmanagement, planning and organisationalskills. This suggests that the developmentof world class commissioning in England willdepend on competent organisations andwell developed managerial skills andleadership, as well as specificcommissioning competencies.

Areas absent from all existingframeworksOne aspect of the commissioning role thatdoes not come out clearly from the existingframeworks is the place of commissionersas definers and shapers of public value,and the political dimensions of this role. Asdiscussed above, competencies associatedwith stakeholder engagement, publicconsultation, and the involvement of localcommunities in decision-making are identifiedto some degree in most of the public servicespecific frameworks. However, the waythese activities are articulated tends to implythat commissioners role here is primarily inrepresenting or creating value for serviceusers and the public (e.g. finding out whatservice users want, so that commissionerscan better match local supply to userspreferences). While this is undoubtedly afundamental part of the commissioners role,in a forthcoming paper, Williams et al (2007)suggest that commissioners also have acritical role to play in shaping peoplesdefinition and understanding of public value;not just responding to, but deliberatelyinfluencing peoples views and expectationsof what their taxes should be spent on.This is linked to upstream work to engageindividuals in improving their own health andthat of their families and communities, butgoes much further. It is also an inherentlypolitical role, requiring engagement withcommunities to explore complex societaltradeoffs, and shape perceptions of equityand social justice. Acknowledging this roleis to accept the fact that public bodies donot exist only to serve individuals andcommunities, but also, in some respects, toconstrain them. The competencies requiredto carry out this task effectively are likely tobe drawn from a number of differentcompetency domains, but the function itselfseems to warrant separate consideration.The motivational and affective aspects ofcompetency appear to be particularlyimportant when considering how best tofulfil this type of commissioning role.

Perhaps somewhat surprisingly,competency in partnership and collaborationis also missing from many of the existingframeworks. Although several refergenerically to relationship management thisis usually in the context of the supply chain.There are also references to workingeffectively with stakeholders, which wouldencompass partnership with othercommissioners to some extent. However,the need to commission jointly andcollaboratively either with other PCTs, withPractice Based Commissioners, and withother agencies such as Local Authorities is such a significant feature of healthcommissioning that it perhaps meritsinclusion as a specific competency in itsown right.

In conclusion, the review of existing activityand competency frameworks suggests that:

non-health and social care competencyframeworks for purchasing andprocurement are well developed, andcontain many elements relevant to partsof the health and social carecommissioning processsupply-side management competenciesare particularly well developed and theycould be adapted and applied to thehealthcare context without the need forsubstantial new workthe emphasis on relationship managementon the supply side is striking even withinthe competitive market context for whichthe non-health and social careframeworks were designedexisting individual level competencyframeworks do not adequately reflectelements of the health and social carecommissioning task which derive from itspublicly accountable nature, the politicalenvironment, and the difficulties ofdefining the product which is to becommissionedSpecifically, competencies connectedwith the need to take difficult andpotentially controversial decisions aboutpriorities, the two-way engagement withthe public and patients to both influenceand respond to conceptions of publicvalue, the need to commission inpartnership, the emphasis on managingdemand, and on redesigning services, allneed to be further developed for healthcommissioning.There are a number of genericcompetencies connected withorganisational and managerialeffectiveness which while they are notcommissioning-specific, are equallyimportant to the development of worldclass commissioning.


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A world class commissioning competency framework for healthcare

Synthesising the material already reviewed in this paper, the following definition of health care commissioning competency is suggested.

Healthcare Commissioning Competency = the ability and motivation to effectively mobilise and apply generic management skills to thecoordination of specific tasks and activities required for healthcare commissioning, in the context of the enablers and constraintsdetermined by government and society.

The diagram below shows in summary form a model for commissioning competency, which reflects this and combines the main messagesemerging from the top-down and bottom-up reviews described above.

Social and political context Management skills and organisational capabilities Commissioning tasks and activities


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At the heart of the model is a four boxmatrix, in blue, representing the notion thatcommissioners require competency in bothclinical/health and financial/commercialarenas, and that they need to apply thiscompetency to the both the demand side ofthe healthcare system, and the supply side.The four quadrants titles (Engaging thepopulation in their own health; Quantifying,costing and structuring demand; Ensuringservices are clinically effective and highquality; and Securing services at theoptimum cost) represent a summary of thespecific tasks and activities involved in eachof these aspects of healthcarecommissioning.

Surrounding the matrix in yellow aremanagement skills and organisationalcapabilities which are fundamental to anyeffective organisation. Commissioningcompetencies need to be practiced withinan organizational context whichdemonstrates these capabilities in order tobe effective. Some of these general skillsand capabilities will clearly take on specialsignificance because of the specificdemands and requirements of thecommissioning tasks. Information andknowledge management, for example, willrequire particular skills around modelling andpredicting healthcare costs and utilisationwhich would not be common to allorganizations. Similarly, effectivestakeholder engagement, while based ongeneric communication skills, will have to betailored to the specific task of involvingpatients, the public, and clinicians.

The requirements for organisational levelcompetency are also shaped by the externalpolitical and social context within whichhealth commissioning organisations operate(represented by the pink border). Inparticular, commissioning organisations mustpay special attention to the way in whichprioritization and decision-making is carriedout, managing clear and systematicprocesses, assuring compliance with legaland other requirements, and taking andcommunicating decisions in an open andaccountable fashion. The external contextalso has implications for leadership style,with commissioning organisations requiringleaders able to navigate a highly politicisedterrain, and manage the power relations thisimplies with sophistication and credibility.

Most fundamentally, it is critical to recognisethat the context in which commissioning iscarried out will always be an importantfactor determining the extent to whichcommissioners can influence health systemoutcomes. Policy-makers both enable

commissioners, giving them the powers toact, and constrain them. While they canstrive to improve individual skills andorganisational capacity, and to influence theway in which policy is developed andimplemented, commissioners can ultimatelyonly act within the legal, political, andfinancial regimes established for the healthsystem as a whole. Consequently, whilethe focus of the current paper is on theorganisational-level, it proposes that thesystem-level not only shapes, but actuallyforms part of a comprehensive model ofcommissioning competency.

Domains of competencyIn total there are 14 domains of competencyidentified in the model at the tasks andactivities-level and organisational-level.Based on Thompson, Stuart and Lindsay(1996) competency domains are definedhere as: areas of activity regarded asimportant foci for performance excellence.The critical areas of activity forcommissioners to focus on, then, are:

1. Prioritisation and decision taking2. Engaging the population in their own

health3. Quantifying, costing and structuring

demand4. Ensuring services are clinically effective

and high quality5. Securing services at the optimum cost6. Stakeholder engagement7. Strategy and planning8. Collaboration and partnership9. Information and knowledge management10. Innovation and best practice11. Governance, compliance and

accountability12. Project and process management13. Leadership14. Culture, attitudes and behaviour.

The following pages develop thecompetencies and consider briefly whereeach competency may currently be found,and where it might be located in thehealthcare system in future. It is importantto emphasise that suggestions regarding thelatter are based on a very rapid brain-storming process and, as such, are notintended to be comprehensive, prescriptiveor exclusive. There will undoubtedly beexisting sources of expertise not fullyacknowledged; where it is proposed thatexpertise may be sourced from outside theorganisation (from consultants, Universities,insurers etc.) this is not to suggest that PCTstaff and Practice Based Commissionerscould not, or do not need to develop anyexpertise in these areas themselves;conversely, where it is suggested that PCTs

should hold the expertise, this does notpreclude the possibility this situation mightchange over time, or vary according to localcircumstances.

In particular, it is noted that the relationshipbetween PCT and Practice BasedCommissioning (PBC) level expertise andresponsibilities is not well developed here.The devolution of responsibilities from PCTsto PBCs varies quite significantly across thecountry and, in the timescales for producingthis paper, it has not been possible toexplore this in any detail. As such, wherethe PCT is identified as the source orrecommended host of a competencydomain, in many instances this should beinterpreted as a partnership between a PCTand its PBCs, to be determined at local level.

It is acknowledged that the distribution ofcompetency within the system warrantsfurther attention, as it not only impacts onthe affordability and efficiency of thecommissioning infrastructure, but alsoraises fundamental questions aboutcommissioners core competency (i.e.those functions that should never beoutsourced).

In summary, the competency domains andtheir elements are currently in outline only,are not intended to be prescriptive, and willrequire further development with the input ofa wider range of stakeholders.


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Domain of competency 1: Prioritization and Decision Making

Domain elementsKnowledge of and expertise in theuse of tools, techniques,frameworks and processes forprioritization and priority-settingdecision makingKnowledge and expertise inprogramme budgetingAwareness of the role of ethics andvalues in prioritizationCritical appraisal ability to analyse,synthesise and use complex data toinform decision-makingCultural efficacy ability tocommunicate effectively with localpeople to gain their trust, andengender a sense of sharedresponsibility for resource utilization

Where can this expertise befound?

Public health professionalsPrimary care professionalsDepartment of Health (DH) e.g.programme budgeting projectLocal AuthoritiesUniversities/AcademiaNICELawyers

Where should it be placed withinthe commissioning system?

PCT, drawing on specialist expertisewhere necessary

Domain of competency 2: Engaging the population their own health

Domain elementsAwareness and understanding ofpopulation dataSocial marketing techniquesCommunicationsHealth promotion and preventionCommunity developmentUnderstanding of trends in citizenhealth-related attitudes andbehaviour


Public health and health promotionprofessionalsPrimary care professionalsMarketing, communications andpublic relations professionals

Local Authorities and voluntarysector for community developmentwork expertiseMarket research organisations anduniversities for attitude andbehaviour dataVoluntary and community sectororganisationsUser representative groups


PCT, calling on specialist resourcefor marketing expertise and researchdata as necessary

Domain elementsUnderstanding of population level(including epidemiological) dataUnderstanding of service utilizationdata and trendsExpertise in demand managementtechniques e.g. risk stratification,modellingUnderstanding of referral practicesUnderstanding of use of incentives indemand management


Commissioning managersPublic health professionalsPrimary care professionalsPrivate health insurersProvider managers and cliniciansUniversities/academia (includingeconomists)Service users and user-groups


PCT, calling on specialist expertisewhen necessary

Domain of competency 3: Quantifying, costing and structuring demand

Domain of competency 4: Ensuring services are effective and high quality

Domain elementsUnderstanding of operationalmanagement of primary, secondaryand tertiary services (operationalprocesses, workforce issues)Understanding of clinical servicedeliveryKnowledge of clinical effectivenessevidence baseExpertise in service redesign (lean,capacity and demand, utilizationreview, process mapping, etc)Methods of monitoring clinicaloutcomes and user experienceManagement of critical incidents


Experienced Trust and Primary Caremanagers and cliniciansPublic health professionals forclinical effectivenessNHS Institute for Innovation andImprovement (NHSI)/Serviceimprovement specialists


PCT for clinical effectiveness,operational managementShared arrangements between PCTsto cover all clinical specialtiesPCT drawing on specialist resourcefor redesign and improvementexpertise

Domain elementsClinical engagementPublic and patient engagement(including engagement in shapingand defining of public value withlocal communities)Consultation


Clinical professionalsSpecialists for patient engagement insome PCTs, plus CPPIH, Centre forPublic Scrutiny, NHS Centre forInvolvement, Local Government,Voluntary Sector


PCT drawing on specialist advice

Domain of competency 6: Stakeholder engagement



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Domain elementsUnderstanding of what services costDetailed knowledge andunderstanding of PBR and paymentsystems for non-acute, social andprimary careAbility to understand and interpretTrust and business accountsSupplier portfolio analysis includingpower analysisMarket development andmanagement techniquesProcurement processesContracting processes, includingincentives and penalties andperformance managementSupply-Chain ManagementHighly developed professionalnegotiating skills


Finance specialists (especially inTrusts for PBR and paymentsystems)Procurement organisations (NHS, DH,Commercial Directorate, RegionalCentres of Excellence, OGC,commercial procurement specialists)LawyersPublic health professionalsHealth economists


PCT for financial expertise inpayment systems and accountancyShared or external specialistresource for procurement,contracting and negotiating skills,with a training and knowledgetransfer role in the longer term

Domain of competency 5: Securing services at the optimum cost

Domain of competency 7: Strategy and Planning

Domain elementsUnderstanding of the commissioningenvironment (national andinternational economic, political andsocial trends, European Unionpolicies, NHS policies, widergovernment policies, local partnerand stakeholder positions)Horizon scanning for newdevelopments, changes in publicattitudes and behaviourUnderstanding of the purposes androles of strategy and techniques formaking strategyExpertise in using tools andtechniques for involvingstakeholders, including patients andthe public, in strategy development


Department of HealthPublic Health/Regional OfficesSHAsUniversities/AcademiaConsultanciesMarket research companies


PCTs, calling on specialist expertisefor horizon scanning, environmentalanalysis, and public involvement

Domain of competency 8: Collaboration and Partnership Domain elements

Knowledge of responsibilities andcultures of other sectors and partneragenciesUnderstanding of rationale andconditions for partnership workingAbility to work across organizationalboundaries and culturesExpertise in developing outcome-based partnershipsCredibility with partners


PCTsLocal GovernmentUniversitiesSpecialised consultancies


PCT

Domain of competency 9: Information and knowledge management

Domain elementsKnowledge of sources of healthservice data, data quality and datacollection processesSkills in use of relevant analytical andreporting softwareExpertise in statistical analysisAbility to understand and interpretquantitative reportsAbility to ask the right questionsSensitivity to soft intelligence


NHSDHUniversitiesBusiness sectorSpecialist consultancies


PCT drawing on shared and/orspecialist external resource

Domain of competency 10: Innovation and Best Practice

Domain elementsTechniques for supporting andstimulating innovationBest practice awarenessNetworking


NHSI and partnersAcademiaConsultanciesCommercial sectorHealth service providers


PCT drawing on specialist resource



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Domain of competency 11: Compliance and Accountability

Domain elementsOperate within the lawOperate within budgetComply with external audit, reportingand inspection standards andprocessesDesign and operate fair andtransparent decision makingprocesses


PCT finance staffPublic health professionalsPCT Board SecretariesLawyersPCT managers


PCT

Domain of competency 12: Project and process management

Domain elementsProject managementProcess management


Trained project managers in a varietyof sectors

PCT commissioning managers andassistants


PCT

Domain of competency 13: Leadership

Domain elementsSee Leadership Qualities FrameworkParticular emphasis of politicalleadership - ability to operateeffectively in a political environment


NHS and other organisations andsectors


PCTsPCT shared servicesSHAsDH

Domain of competency 14: Culture, attitudes and behaviour

Domain elementsPolitical awareness and sensitivityNon-adversarial relationshipmanagementValue baseMotivated staffTeam workingPersonal credibilityEmotionally resilient staffSupport structures for staffSensitive and appropriateinteractions with patients


NHS and other public sectororganisationsHuman Resource and OrganisationalDevelopment experts


PCT

Implementing the framework

As noted in the introduction, the aim of thisreview of commissioning competencieswas not to generate new knowledge aboutcommissioners roles and responsibilities. Ithas, however, synthesised a wide varietyof different perspectives on thecommissioning function, and re-presentedthem in a form that highlights particularaspects. In particular, the modelemphasises that there are (at least) threelevels to consider in relation tocommissioning competency: the specifictasks and activities involved incommissioning health services; theorganisational-level capabilities that providethe infrastructure and the motivationrequired for these tasks to be performedeffectively; and the political and socialcontext that determines the way in whichcommissioners must discharge theirresponsibilities, simultaneously enabling andconstraining their action.

A second feature of the analysis is that itconsiders where in the systemcompetencies already exist, and where theymight need to be developed and embeddedin future. As noted above, this element ofthe framework requires further developmentthrough consultation with practitioners. Atthis stage, its primary value may simply be tostimulate the debate. It is already possible,however, to identify three broad categoriesinto which the identified competencydomains might fall in this regard:

i) competencies that are already presentwithin the commissioning workforce (inparticular among public healthpractitioners and in some partneragencies) but that could be moreeffectively mobilised to supportcommissioning in future

ii) competencies that are well developedand clearly articulated in other sectors(e.g. those relating to supply chainmanagement), that do not need to be re-invented, but do need to be more rapidlyincorporated (through training of existingstaff, or recruitment/contracting ofcapacity from other sectors) into thehealthcare commissioning workforce

iii) new competencies that are still beingdefined and developed, and requireinnovation and creativity, horizonscanning across other sectors,research and development, and newforms of partnership and engagement.


This last category seems to particularlyrelate to the management of the demand-side of the system, where large-scaleupstream interventions (e.g. socialmarketing) are starting to be explored, butare yet to be tested. This is arguably thearea where there is most complexity, andleast knowledge and experience of exactlywhat needs to be done. It is increasinglyclear that commissioners must find ways toinitiate and support widespread changes inattitudes and behaviours, and that this willdemand systematic interrogation ofpopulation data at the most granular level,alongside a re-focussing on populationhealth at the most global. However,identifying the best way to actuallyintervene will require significant innovation,some risk taking, and the development ofcompetencies through learning by doing.

With growing recognition of the scale,breadth and depth of commissioning, aquestion has recently been raised as towhether there is a need for a more formalrecognition of commissioning as aprofessional discipline in its own right. Thismight take the form of some kind ofmembership organisation, or even thedevelopment of professional standards andaccreditation. Again, this is a matter thatrequires further debate. It is clear thatcommissioners (as individuals andorganisations) do require mechanisms forincreasing their influence, profile andcredibility, and for developing their skills andcapabilities. Professionalisation might be ahelpful step in this regard. However, theanalysis set out in this paper presents somegrounds for caution against a rigid or overlyformalised approach. The reasons for thisare:

i) It would clearly not be possible for anindividual to possess all of thecompetencies required for effectivecommissioning as set out in this, andother frameworks. The idea that anindividual could become a professionalcommissioner may undermine the notionof public sector organisations ascommissioners, and divert attentionaway from the need for the highestdegree of organisational capability tocoordinate a diverse range ofcommissioning tasks.

ii) This approach could also reinforce theidea that commissioning is amanagement function that does notconcern other professionals, at a timewhen, in healthcare commissioning atleast, the opposite message is required;primary care practitioners are beingencouraged to see commissioning as a

core part of their existing professionalrole, rather than a new profession theyneed to enter.

iii) The context-specific nature ofcompetency means that differentindividuals and organisations will needvery different development interventionsin order to become competent. Definingstandardised qualification oraccreditation criteria might detract frommore focussed activity to address veryspecific local development needs.

Thus while the development of a moreprofessional approach to commissioningcould only be supported, it is questionablewhether the development of a newprofession is the best way to achieve this atthe current time.

Conclusions

In conclusion, this review has demonstratedthat the NHS already possesses many ofthe competencies that are likely to berequired for effective commissioning,although there is much that could be done tomobilise these more effectively, and to bringin new expertise from elsewhere.

However, it has also highlighted the fact thatwe know relatively little about the specificmechanisms through which commissioningcompetency does, or does not, lead toimproved health system outcomes. Thisindicates the need for a much moresophisticated analysis of the particular setsof competencies that will be required toimprove performance in particular contextsand environments, and suggests that a one-size-fits-all approach to defining anddeveloping competency is unlikely to beoptimal.

At the same time as seeking this greaterclarity though, it must be acknowledged thatthe complex cause and effect relationshipsat play here will never be fully understood.In practical terms then, commissioners mustaspire to a best-possible, rather than aperfect fit between their organisationalresources and environment.

Finally, this report emphasises the fact thatfocussing on the commissioning functionalone will never be enough to produce goodoutcomes all parts of the healthcaresystem need to adopt appropriatecompetencies and behaviours for thesystem as a whole to work. The point wasmade above that competency depends notjust on knowledge and skills, but on values,

motivation, and agency. Individuals andorganisations will not perform at their best ifthey know what to do, but are notempowered and motivated to do it. Thismessage should have resonance at alllevels: for individual commissioners seekingto develop incentives for their providers; forthe leaders of commissioning organisationsseeking to get the best from their teams; andfor all those engaged in designing a healthcare system with world class outcomes.


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Appendix 1

The responsibilities, functions, activities, skills and competencies associated with commissioning: a rapid review andsummary of recent publications

A. Descriptions and models of commissioning functions and activities

Commissioning cycle Purchasing/contracting cycle Purpose, demand and supply review Analysis of data

Review market performance Feedback into strategy

Consult Conduct cost benefit analysis Design commissioning strategy

Devise a procurement/commissioning plan

Budget management and market facilitation

Implement the purchasing process Contract management

Strategy monitoring and review

Contract monitoring and review

Department for Education and Skillsand Department of Health (2006) Jointplanning and commissioningframework for children, young peopleand maternity services

1. Consider the current pattern and recenttrends of outcomes for children andyoung people in an area, againstnational and relevant local comparators

2. Look within the overall picture atoutcomes for particular groups ofchildren, young people and parents-to-be (e.g. disabled, special educationalneeds, looked after children), as theymay require a differentiated approach toservice provision or additional support

3. Use all this data and the views ofchildren, young people and their families,local communities, and front-line staff todevelop an overall, integrated needsassessment

4. Agree on the nature and scale of thelocal challenge, identify the resourcesavailable, and set priorities for action

5. Plan the pattern of service most likely tosecure priority outcomes, consideringcarefully the ways in which resourcescan be increasingly focussed onprevention and early intervention

6. Decide together how best to deliveroutcomes, including drawing inalternative providers to widen optionsand increase efficiency

7. Develop and extend joint commissioningfrom pooled budgets and pooledresources

8. Develop the local markets for providingintegrated and other services, andproduce and implement a localworkforce strategy covering serviceand role re-design, and the necessaryways of working to support delivery

9. Monitor and review to ensure servicesand the joint planning and commissioningprocess are working to deliver the goalsset out for them

Department of Health (2006a) Healthreform in England: update andcommissioning framework.

Context: the commissioning cycle andeffective commissioning

Assessing needsReviewing service provisionDeciding prioritiesDesigning servicesPCT prospectusShaping the structure of supplyManaging demand and ensuringappropriate access to careClinical decision makingManaging performancePatient and public feedback

Department of Health (2006b) Fitnessfor purpose commissioningdiagnostic

Context: assessing the developmentneeds of PCTs

Strategic planning:- Financial review- Health review- Quality review- Patient experience review- Progress review- Engagement- Integration of areas- Population health goals- Quality goals- Patient experience goals- Financial goals- CPM plan- Contracting- Completeness- Prioritisation- Outsourcing- Financial plan

Care Pathway Management- Referral management- Optimise A & E/Emergency care- Manage LTCs- Case Management- Intermediate Care- Patient Pathway Design- Improve Access to diagnostics- Health Improvement/Protection &

Equity- Other initiatives- PBC

Commissioning cycle Purchasing/contracting cycle

Cozens (2007)

Context: a taxonomy of commissioning inthe Local Government context

Strategic needs assessmentArea profilingMarket mappingCommissioning strategyCommissioning frameworkProvider identification and developmentTactical procurement and call offarrangementsWorkforce planningQuality monitoring and reviewManaging decommissioning and marketfailureCollecting evidence of better outcomesand unmet needs

Care Services Improvement Partnership Key activities in commissioning socialcare, 2nd edition (Kerslake 2007)


Provider management- Data gathering and analysis- Strategy setting- Negotiation- Provider capability

Monitoring- Data management- Financial balance- Invoice review- Invoice adjudication- Investigation- Third party referral- Effective payment- Activity volume- Access to care- Patient satisfaction- Quality outcomes- Clinical processes- Health status

Department of Health (2007b)Commissioning framework for healthand well-being

Context: eight steps to help drive moreeffective commissioning

Putting people at the centre ofcommissioningUnderstanding the needs of populationsand individualsSharing and using information moreeffectivelyAssuring high quality providers for allservicesRecognizing the interdependencebetween work, health and well-bingDeveloping incentives for commissioningfor health and well-beingMaking it happen accountabilityMaking it happen capability andleadership

(Department of Health 2007a)Framework for Procurement ofExternal Support to Commissioners

Context: description of the functions ofcommissioning for which externalcommissioning expertise might be procured.

Assessment and planning- Health needs assessment- Reviewing service provision (with

LA)- Deciding priorities- Designing services- Shaping the structure of supply- Managing demandContracting and procurement- Primary care services- Extended primary care services- Secondary care services

Performance management, settlement andreview- PbR transactions- Budget and activity management- Performance management- PBC operating processes- Patient feedback and GP intelligencePatient and Public Engagement

PCT prospectusReferrals and advice on choicesPatient initiated petitionsEngagement strategiesCommunications strategies

National programme for third sectorcommissioning (Idea/Cabinet Office2007)

Context: Eight principles of goodcommissioning

Understanding the needs of users andother communities by ensuring that,alongside other consultees, you engagewith the third sector organisations, asadvocates, to access their specialistknowledge;

Consulting potential providerorganisations, including those from thethird sector and local experts, well inadvance of commissioning new services,working with them to set priorityoutcomes for that service;

Putting outcomes for users at the heart ofthe strategic planning process;

Mapping the fullest practical range ofproviders with a view to understandingthe contribution they could make todelivering those outcomes;

Considering investing in the capacity ofthe provider base, particularly thoseworking with hard-to-reach groups;

Ensuring contracting processes aretransparent and fair, facilitating theinvolvement of the broadest range ofsuppliers, including considering sub-contracting and consortia building, whereappropriate;

Ensuring long-term contracts and risksharing, wherever appropriate, as waysof achieving efficiency and effectiveness;and

Seeking feedback from service users,communities and providers in order toreview the effectiveness of thecommissioning process in meeting localneeds.

Commissioning Friend for PCTs(National Primary and Care TrustDevelopment Programme 2004)

Context: key steps in commissioning

Health needs analysisHealth equity auditNational targetsCurrent pattern of serviceCapacity planningComparative performanceLocal delivery planService level agreements

National Offender ManagementService (2007) NationalCommissioning Plan 2007/08:Commissioning Framework.

In a developed commissioning system,commissioners will be

1. Regulating the environment:- setting national minimum service

quality and equality standards;- accrediting providers wishing to

access public money;- licensing services so that a greater

proportion of public money is spenton services which work and havean evidence base or whoseeffectiveness is being evaluated.

2. Influencing demand:- working with sentencers and

offender managers, who commitNOMS financial resources throughthe sentences they pass andsentence plans they prepare, to alignthe services demanded by them withwhat is needed.

3. Allocating resources:- deciding which kind of services are

most needed and setting priorities forinvestment in line with availablefunding;

- selecting providers to deliverservices who offer best value formoney;

- challenging existing providers todemonstrate value for money andseeing what other potential providershave to offer;

- working towards open bookaccounting in line with OGCguidelines.

4. Creating fertile conditions forimprovements in service quality andcost effectiveness:- working with providers so that the

services delivered closely matchwhat is needed and demanded bysentencers and offender managers;


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www.hsmc.bham.ac.uk

- creating an environment whichencourages potential providers ofrelevant, appropriate and effectiveservices to offenders to work forNOMS;

- using Service Level Agreements andcontract negotiations/management todrive up performance;

- promoting and applying procedureswhich incentivise good

- performance;- building capacity to assist providers

of specialist services that redressinequalities.

B. Lists of competencies at a general or organizational level

Association of Chief Executives ofVoluntary Organisations (acevo)

Context: behaviours required by strategiccommissioners to drive up service qualitythrough the involvement of the third sector:

Developing knowledge and understandingBuilding trust through communicationShowing commitment to service qualityPromoting innovation

Better Commissioning LINCommissioning e-book(Bamford)accessed 18.08.07

Context: what skills do commissioners ofcommunity care need?

Strategic analysisUnderstanding of the supplier marketFinancial acumenKnowledge of negotiating techniquesSpecifying servicesContracting skillsPolitical awarenessAbility to involve service users and buildpartnerships with providers

Digings (2007)

Context: commissioning skills likely to beneeded in response to Strong andProsperous Communities (local government)White Paper (2006) and research reportpublished by the Centre for LocalGovernment in parallel

Population needs assessmentCustomer intelligence (citizen insight)Demand forecastingMarket mappingMarket dialogueOption appraisalSmart procurementMarket shapingManaging through networks

Light (1998)

Context: comparison of US and UKcommissioning organizations

Salary and bonus packages designed toattract the best and the brightestData systems analysts and programmersClinical epidemiologistsClinical managersOrganizational expertsFinancial specialistsLegal advisers

NERA/NHS Confederation (Bramley-Harker & Lewis 2005)

Context: Responsibilities of a StrategicCommissioner (includes description andrationale for aggregation which is oftenbased on specialist skills)

Planning- Short term demand forecasting- Long term demand forecasting and

capacity planning- Market management- Financial, risk managementPurchasing- Procurement

Wade et al (2006)

Context: Developing commissioningcapacity

LeadershipData capture, processing and analysisProcurement and contracting- Market management: marketing

market research and marketdevelopment

- Competitive tendering and contractlaw

- Supply chain management- Strategic partneringExternal communications: public relationsand public engagement- Marketing and public relations- Public engagement

Woodin (2006)

Context: review of international literatureabout commissioning

NegotiationPolitical sensitivityKnowledge of needs and demands of thepopulationQuality managementService improvementAwareness of evidence on effectivenessand cost-effectiveness of differentinterventionsTeam workingUnderstanding of ethicsLeadership

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