Commissioning for outcomes


All commissioning decisions should be judged by the impact they have on children's outcomes, says Richard Selwyn.

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

An outcome can be the tangible change or result for a child, young person or family. At the other end of the spectrum, we can also define outcomes for the population, for instance wellbeing, happiness or length of life.

Commissioners want to know:

  • Why is a service needed?
  • Who should we help?
  • If the service didn't exist, how would the outcome be met?

Very often these questions are skipped and we just buy the same service while cutting the budget. But if we pay attention to these questions we often find the real efficiencies.

Here are four examples of outcomes-based commissioning:

  • What is the outcome of the health service? What do we get for our £120bn annual investment?There are two main outcomes: length of life and quality of life.
    I raise this because of the importance of measurement and how it influences systems. In the NHS, I suspect length of life was easier to measure - and therefore became the most important thing. Over time we've become good at prolonging life but perhaps without the quality. Sensibly, we have now changed the outcome measure to "quality-adjusted" years of life. What we measure and how we talk about outcomes is critical to how services and organisations perform.
    What about the outcomes for education from the £68bn invested each year? Again, there has been a recent change in how we measure outcomes from GCSE grades, to "progress". This is a step in the right direction but does not fully reflect the real outcomes we want, such as social outcomes, health and wellbeing, inclusion and life chances in adulthood.
    Until we find a way to measure these real outcomes, we will be stuck with schools forced to focus on a narrow curriculum, exams and certificates. At the extreme, it can lead to gaming behaviours, such as pushing parents of low-performing or disruptive pupils to withdraw children for home education.
  • Wiltshire Council is interesting in how it defines outcomes. Commissioners worked with older people to design the Help to Live at Home service - looking at what makes a difference in later life and how to incentivise providers. In the end they defined 37 personal outcomes such as the ability to make toast, or to wash yourself, or use public transport.
    There are two commissioning tricks here: first, defining measures in a contract by what the "customer" values. Second, aligning the incentives between the end user, the provider and commissioner. In this case, providers who deliver any of the personal outcomes receive a higher payment - incentivising creativity such as helping the older person to access support from the local community.
  • For an example closer to home we can look at early years. The catch-all outcome is that a child is ready for school, i.e. that brain development, motor skills, learning to learn, understanding social barriers and emotional wellbeing are sufficiently developed.

Imagine you are a children's centre commissioner that has been asked to save £1m. We immediately think about closing centres and services - most of our attention is on statutory services, then we think about the market of early years providers, and then perhaps support and courses for parenting. The blue graph above shows where a commissioner would traditionally focus.

 

Now let's return to the outcome question: How is school readiness actually achieved? Research has shown that parents are responsible for influencing 70 to 80 per cent of a child's outcomes by five years of age. In other words, we sometimes give least consideration to the factor that has the greatest impact on a child's outcomes (see the green graph, above).

Perhaps this indicates that our focus should be on spending more time asking: how can we help parents to do more, how can we reduce the boundaries between the setting and home learning environment like they do in west Scotland, and how can we mitigate the cuts to services with a better community response?

So the questions we ask, and the outcomes we set, are critical. We discussed last month the austerity challenge and how we overcome 50 per cent cuts to children's services. I have worked with enough services across government to assert that the majority of the answer lies in this column. Everything in commissioning is window dressing if we don't get the outcomes and value right for children, young people and their families.

Richard Selwyn is a member of the Association of Directors of Children's Services resources and sustainability policy committee

@rjselwyn

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