Mick Ward: Commissioning through influence

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  • Posted:Tuesday 06 February 2018

Speaking at our Partnership models in the NHS event on 6 February 2018, Mick Ward, Chief Officer, Transformation and Innovation, Adults and Health, Leeds City Council, explains how developing partnerships can transform the way commissioning is implemented.


Morning everybody.  Interesting, that job title is relative new, I only took on this role a few weeks ago and it’s worth mentioning my previous jobs; I was the Deputy Director in Leeds, which was a joint appointment across the three CCGs and the council, and in that role,  I was responsible for all adult social care commissioning, public health, housing support and the Lead Commissioner for health, mental health, learning disability and dementia.  So, quite a broad role and I’ve the joint commissioning role for several years.

    Well, one of the things that we became really aware of in Leeds is we were delivering that core commissioning, and I will be talking a bit about that as well, was the real potential of what I’m going to be talking about today, which is commissioning through influence.  And the real key thing now, particularly as you look at commissioning through outcomes and the importance of communities and so on, is that you have to move away from the traditional focus on service specifications and procurement and contract management.  All those things have a value, but if you’re going to be really moving forward at pace and making advantage of things around innovation and community-led services, it’s all about relationships.  And that has to be a new shift in how we do commissioning and relationships between commissioning providers and, as I’ll be saying, wider partners.

    So, it really is about that relationship model.  A huge mantra in my commissioning role and in my new role now with my team, is simply to get out there, spend a lot of time encouraging people in my team to go out there and engage with a whole new set of people, a new set of organisations, a new set of potential partners, new set of communities.  And yes, at the heart of that has always been that health and social care and Leeds, like many other cities and we were hearing about Manchester earlier, have been on that quite strong integration pathway for some time, particularly between social care and NHS organisations.

But, I would argue there’s a chance now to go much, much wider in terms of some of the partners.  And what we’re increasingly finding is a whole range of organisations who can potentially help the health and wellbeing of the cities and of any place, and crucially there is a lot of joint potential here.  And that actually there are many joint benefits by us working together and that we can support that range of providers in meeting our aims as well as supporting ourselves.

And importantly I’m going to really end with a very strong message; this is not just about partnering with organisations, it increasingly has to be about to partnership with citizens, with those people based within those communities that we serve.

So, you’ll be pleased to know I’m not going through the dreaded commissioning cycle.  I’m assuming those in the room are commissioners, or even those who are providers will have come across this.  It’s been across for some time, since world class commissioning.  I just want to pick out two or three things.

I don’t think it’s entirely coincidental it looks like a washing machine cycle, because that’s what it is.  It’s a process that people went through and it’s a process that drove commissioners inter-plating it as a process.  And that’s being generous, I also think commissioners developed this because they were process obsessed, because they weren’t too certain what else to do.  

And I have come across people who will literally, because they can use this model, will commission eye care in the morning and MSK in the afternoon, and they have little passion for either and have little relationship with either, because what they are there to do is this process.

And what you do if you follow a process like this and you don’t have those relationships or that passion is you count things, because that’s all you can do.  You just count things.  And I think we’ve now discovered that just counting things is not enough.  And if you’re a proper commissioner and properly interested in delivering change and outcomes, you have to move away from counting things to actually true relationships.

And the other thing that always wound me up about this model; people would always say, oh yes, patients are at the centre, or the public is at the centre.  Well, they might have been at the centre of this model, but they were so far at the centre they never engaged with anything where the work was going on and the outside, I assure you.  Apart from the very occasional bit of consultation or token person put on a group or a bit of discussion.

In theory, they were at the centre, but at the centre is a way of keeping them away from where the work was going on.

This, I found a bit more useful, so this is what we use in social care.  ADAS is the directors of adult and social services, so this work we did a couple of years ago with Birmingham University and certainly my commissioning team, this is what we judged ourselves on.  So, we would publish these standards, we put them into everything we did, we used them appraisals, in one-to-one working development, and what you’re seeing there is both directly talks about relationships, but relationship is a massive thread that runs all the way through this.

So, we’ve been talking around person-centred and outcomes-base for a very long in social care.  What I would say, and as the NHS moves more and more towards outcomes focus commissioning, it is incredibly simple which makes it really complicated.  So, if you look at outcomes that you’re really interested in; people being safe, people being well, people being connected, phenomenally difficult to monitor through traditional commissioning procurement contract monitoring methods.  You only can do that through relationships, through the people being served and those organisations doing it.

You can’t do co-production without really strong relationships otherwise you do end up with token people sitting on a board or the quick consultation before you finally publish something out for procurement or remembering at the end of an evaluation we better ask some patients about it, you have to have deep engagement with citizens to proper co-production.

Well-led, I would argue, is probably the one good thing that commissioning brought to the issue.  So, that it brought people to a wider view about what you’re trying to achieve in a broader strategy, whether that’s mental health, eye care, whatever it is.  I think commissioning did bring that, but you can only do well-led if people are prepared to support you, and again, that has to be done through a constant relationship business.

And it’s always been a whole system approach.  I don’t know anything that we did in social care commissioning that we did on our own.  It always had to be with who are the other key partners here that we need to engage with, and crucially increasingly using evidence.  It seems a bit of an obvious one, I think it’s fair to say that we weren’t that evidence-based for a long time.

Public health, coming into the council or back into the council for those of us with a bit of a memory, was a really positive thing.  I think that’s helped but increasingly using stronger partnerships, people like the universities.  But again, much of this evidence lies with providers and with communities.

And we need a really diverse and yet sustainable market, which can be a bit of a contradiction.  When I talk about a diverse market, I’m not talking about breaking up the existing market.  What I’m talking about is stimulating new options for people.  Things like social enterprises, micro enterprises, particularly that’s about delivering very different types of services, particularly can shift towards the front end to whole early intervention prevention agenda.  And that’s where we’ve put our investment in Leeds over the last few years.  And that’s still got to provide value for money.  And that, as we call it in Leeds, it’s the left shift, moving towards prevention and does drive that value for money and I will end if I remember with a one liner on that.

And crucially this is a really key thing for us, we want a workforce that can move across the systems nowadays, but increasingly you want people who have an understanding of health and of social, but wider.  So, in Leeds in the new home care contracts is a requirement that people have local knowledge of third sector organisations, that’s built into that spec.  We do 20,000 home care visits a week in Leeds and for many people that might be their only contact with the system, but that is a real chance that home care worker to spot something or to have a conversation about the luncheon club up the road or we’re doing a quick-fire safety check.

So, we need a much more diverse workforce, but most important of all, it’s about positive engagement with providers.  I always remember when the PCT split between commissioner and provider and a week after they’d split, there was a meeting with the community health care provider about a slight shift in something we wanted to do, and at this meeting turned up five people from the community health care, the key people running the service; the service manager, a HR advisor, and a finance officer and legal advice, and on the other side of the room sat a similar amount of people from the CCG and thrashed through this work for two hours.  Where, a week previously, these were all people in the same organisation where you could have just rung them up and asked them to do something a bit different.  And crucially it is providers where it’s at.

I always remind my own team, this is a bit undermining my own commissioning practice, it’s providers who do the delivery.  You will be always more nervous if providers were on strike or there was a crisis in the provider market than you would do in commissioning.  I think we’d all manage a bit without us for a few days.  So, providers are crucially the key people in any of this partnership and don’t ever forget that.

And I just want to talk a bit about new partnerships and I’ll just use four very different examples.
So, Leeds has an ambition to be the best city in the UK to grow old in.  It’s a great ambition, but you cannot deliver that on your own, and so we have a very strong age-friendly Leeds partnership.  It actually goes all the way back to the NSF.  I know people remember the National Service Framework for Older People, it was something I was responsible for helping deliver in Leeds and standard 8 was called healthy and active life, and in many places that was a bit of the forgotten standard because the focus needed to be on mental health and general hospital care and stroke.

In Leeds we got quite interested in standard 8, we used to jokingly call it the political wing of the NSF, because what that was actually talking about was older people’s lives, what people really cared about.  Because yes, having really good health and social care services is important, but what matters in people’s lives is being able to get about, being able to go shopping, not to be lonely, to be connected to people, to have neighbourliness, all those things are actually what matter.  They also have a massive impact on health and wellbeing.

So, the age friendly Leeds partnership, it’s a requirement for the directors of every directorate in the council to attend that and report on what they are doing. So, what are parks doing to make Leeds an age friendly city.  What are city centre management doing, what are planning doing, what are housing doing, what are sports doing?  We’ve extended that further and further to a range of third sector and private sector organisations, all saying this is our contribution to make the Leeds the best city to grow old in.  And that is what actually the citizens of Leeds want, but it also reduces demand on health and social care services.

The academic health partnership is probably the most formal of those, but that is bringing together the three universities in Leeds, the council, the commissioning CCG organisations and, of course, all of the providers.  Big, big focus on innovation, workforce and research.

And I think it’s fair to say, and Leeds is known as a bit of a university town, but seven years ago there was no connection between the universities and health and social care.  They had their ivory tower, we had a bit of a concrete tower and it wasn’t until we started to see those mutual benefits.  But what’s been interesting, although we have that now as a formal partnership, it’s starting to drive that further down.  So, the manager of a care home will be thinking oh, can I contact the university, can I have a student placement.  People in different bits of the university, the school geography, the school transport are thinking what’s our contribution to the health and wellbeing of Leeds?

And of course, digitally it’s a really interesting one.  And some of that is thinking about those challenges around digital, because the reality is moving at a faster pace than we are in the world of commissioning or service delivery, so how do you respond to that?

And I’ve just picked up two providers there; other digital providers are available.  But about the scale of it, but they are both very similar in some ways, so you have those big, big providers, Samsung, IBM, all that sort of stuff, who are very interested in getting into the health and wellbeing market.  But interestingly, struggle to sell to individuals.  A lot of these companies have spent their time selling to councils or the NHS.  Weirdly, we’re a route to market for them in a way that they haven’t yet considered.  We’ve also got massive expertise in that area that they haven’t got, so we’re very interested in working with some of these people about both enabling them to become a bit more effective, but what we get out of that.
So, I’m currently working with a big tele-care provider who, in effect, are funding us so that they can test out models in Leeds.  So, we get the advantage of early implementation and testing out and a free service, and they get the advantage of saying if it works in Leeds, we can go sell it round the country and indeed around the world.

But you can also pull out tiny little companies, so i-up is a little start-up technical company in Leeds, we’re just doing a bit of work with them at the moment and they are wanting to develop in effect a digital platform for intergenerational letter writing.  But they are doing it for free because they just came across the idea and thought that would be nice.  And a lot of these small start-ups, people doing gaming, are really interested in what they can do to contribute to a city, to an area, so are wanting to encourage all that as well.  And using our knowledge and skills of the market and our connection.

So, I’ve spoken to the individual companies who want to get a group of older people together, that’s very easy for us.  If you want to get a group of older people with diabetes in Leeds we can do that in a couple of e-mails, they don’t have that ability, but we want to see what we get out of that as well.

One of my favourites, the Leeds Dementia Cultural Partnership.  That’s about the potential, once you start thinking about who else can help.  A few years ago, I was lucky enough to hear the director of MOMA in New York, Museum of Modern Art speak, and she talked about their dementia art group which is an art appreciation group, and she showed this video of people with dementia sitting in front of these incredible Roussel-Bergs and Pollacks.  And these people with quite advanced dementia in some cases were just talking about how that picture made them feel, about it’s when I learnt to drive, or crikey that’s like a bar that I used to drink in.  It was really inspiring.

So, the next day, I didn’t know the director of Leeds Art, but I did know the director of the Museum, so through here I rang up the director of Leeds Art Museum and we set up our own version of that within a month.  That then started to stimulate other cultural organisations in Leeds, so they formed a band together, probably the most impressive which now is West Yorkshire Playhouse, which is the world’s greatest theatre for dementia and are celebrating that with a major event funded through the Arts Council next year.

Every single play that goes on at the Playhouse has a dementia friendly performance, they have two people with dementia recruited to team who helped develop that and work that.  They have try on the costume sessions for people with dementia.  They have a look at the background behind the scenes thing for dementia and they run a theatre group for older people.  That has spilled down to a whole load of cultural organisations in Leeds.  Leeds had an ambition to be European City of Cultural 2023, that’s been stumped because of Brexit.  However, we’re just going to do it anyway.

But what’s interesting in that group that’s overseeing that, is I’ve been asked to be on that because we want to make that a city of culture for everyone in Leeds and that includes older people, people with learning disability, people with long term conditions.  And what you’re seeing is those people engaging in those cultural activities have massive health and wellbeing benefits, but that stuff is funded through arts money, through sports money, through cultural money.
On the back of this, I met with Leeds United a couple of years ago, something very dear to my heart, and became the first dementia friendly football club.  It was just an ask of them, that’s all we did.

And finally, as I’ve said, this has to be extended to citizens.  I will read this out.  There’s a lot of talk in the system at the moment about asset-based approaches and in fact, part of my new role is particularly focused on that, this is why that bit is very important.  So, no society has the money to buy upmarket prices what it takes to raise children, make a neighbourhood safe, care for the elderly, make democracy work or address systematic injustices.  The only way the world is going to address these social problems is by enlisting the very people who are now classified as clients and consumers by converting them into co-workers, partners and rebuilders of the core economy.

That’s a really, really important message in terms of engaging with people to become the solution, because what it says is there are things that we do, or have been doing, that maybe we should never have done.

I managed for years and years a day centre, I confess.  What an idiotic idea that you think you can solve loneliness in older people by driving them seven miles across Leeds to sit in a room together.  What an insane idea?  That is not how you solve things by loneliness.  In the same way, if you really think you’re going to solve delayed transfers of care by shoving another five people in A&E or opening up another few care homes, that is not going to do it.  How you solve those issues is by people being engaged in those communities, by the communities themselves becoming those solutions.  That’s where we need to put the investment, in the actual people themselves who become their own solutions.  They really are our new partners.

And I’ve said I’ll end with a bit of finances.

So, we’ve been doing this approach now in Leeds for a few years.  During the big crisis as it hit the councils, we held our nerve and maintained our funding in the third sector and, indeed, have increased it and we maintained our focus in about what does Leeds mean for the rest of it.  As a result of that, Leeds now spends less on residential care and home care for older people than all our comparators by some way.  And we are fairly certain it’s because this is where we’ve put our investment; in new partnerships, in new citizenships.

Thank you.