The links between problems like homelessness, substance misuse, mental ill health, violence,domestic abuse and extreme poverty often go unrecognised by services and systems mostly designed to deal with one issue at a time. As such, people rarely get the help they need and cycle in and out of chaos. But in dealing with one problem at a time we often miss the opportunity to address these problems as a whole.
Last week NLGN and Revolving Doors presented a workshop at the second Tackling Multiple Disadvantage Summit. The conference brought together researchers, policy makers, people with lived experience, service providers and commissioners. It provided an opportunity to bring skills and experiences together, helping to work as a collective to tackle multiple disadvantage.
Our workshop began by looking at the whole person and how many of people’s different problems are interlinked – as are the journeys towards positive outcomes. We looked at the challenges people face but also their assets. A person’s strengths can be social, material or cultural in nature, such as social networks, skills and employability, and motivation. But commissioning with all these factors in play can be challenging.
The current style of commissioning focuses on cohorts or people – as this is more efficient. We look at what people have in common and commission for that thread that brings them together. But everyone is different. We all have distinct parts of our personalities that make us, us and we all have different life journeys and stories. Very often commissioned services only look at one part of that journey.
But more than that, commissioning process often define success through KPIs: absolute measures where success is defined in black and white terms: for example a person who has completely overcome a drug problem and has completed their journey to ‘recovery’. But this discounts the complex journeys that people take to get to success and pushes those delivering contracts to design services around key measurable outputs rather than around the whole person. Those facing complex problems are not likely to take continuous steps forward, rather two steps forward and one step back. But our commissioning process (generally for ease of measurement) assumes a linear process.
The ‘one size fits all’ approach of the current commissioning process is not appropriate for people who require flexible, adaptive services that meet their complex needs. Commissioning in this way can lead to ‘failure demand’. Costs build up if people do not get the right support at the right time, and their problems become more critical, costly, and harder to address.
To counter these challenges and ensure that people are supported, NLGN has proposed a whole system change. Achieving whole system change for a place is about joining up services around both the strengths and the needs of the individuals within that system. To implement this system change, we argue that local authorities and the VCS need to use a whole system approach to commissioning.
Whole system commissioning starts with considering the individual and the support they need to thrive, before zooming out to understand how all parts of the public and voluntary sector can collaborate to provide that support. In our report ‘All Together Now’, supported by Lankelly Chase, we outlined several recommendations of how to do this.
Continuous ongoing collaboration, trust and early dialogue between all partners and stakeholders in the commissioning process is essential and will help to foster an ongoing positive relationship between the VCS and local authorities. It is also important to make sure that the expertise and experience of service user and service providers helps to define the challenges and parameters before the contract is tendered.
But perhaps more important is a change to the commissioning culture. In our current system we commission for cohorts and define success by individual measurements, but for whole system commissioning we need to commission around the individual and define success around cohorts. The ‘whole system’ needs to be incentivised not the organisation. Commissioners can do this by measuring performance through system level or population-level outcomes, rather than service level outcomes. A system that creates happy, healthy people rather than one that solves one silo-ed problem at a time.
A whole system approach to commissioning will require councils and partners to act as changemakers. A commitment to population-level outcomes requires different behaviours from stakeholders in which they act as part of a whole system and in which collaborative relationships are incentivised. We will all need to act collaboratively and creatively to make sure service users can determine the direction of their own journey.