Commissioning for better health outcomes - September 2016 - Case studies - Local ...
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Commissioning for better health outcomes September 2016 Case studies
Foreword
Councils have a critical role to play in We have developed this guide with
securing good health outcomes for the commissioners from councils and partner
communities they serve. In the context of an organisations, building on existing learning
ageing population with increasing complex and resources and sharing new and
long term conditions, the need to address innovative practice developed by those
emergent concerns such as obesity and working to improve public health. We hope
oral health, coupled with a picture of health that it will help to support change and
inequalities across the country, this is a enable commissioners to have even more
significant challenge. of a positive impact on the health of the
communities they serve.
Councils, working with partners in health,
housing, leisure and the voluntary and
community sector, among others, have risen
to this challenge and are taking innovative
approaches to how they improve the health
of their citizens, some examples of which
you will see in this guide. Council leaders are
encouraging locally delivered solutions that
lie at the core of localism. These solutions
are based on an understanding of the
needs of local communities. They build on
local community assets, drawing together Councillor David Simmonds
communities and partners to develop a Chairman, LGA Improvement and Innovation
joined up, multi-faceted approach to Board
improving health.
Commissioners are vital in the process of
making the most of collective resources to
improve health outcomes. We acknowledge
that commissioners are experiencing a period
of change. Citizens are no longer seen as
passive recipients of services but enablers
of their own good health, supported by
the communities around them. The role of
commissioning has changed from identifying Councillor Izzi Seccombe
and procuring services for individuals to Chair, LGA Community Wellbeing Board
bringing people together to enable citizens to
live a fulfilling and independent life for as long
as possible.
2 Commissioning for better health outcomes
Contents
Introduction 4
The role of councils in improving health outcomes 5
What is commissioning? 7
Principles for good commissioning 9
Case studies 12
Commissioning an integrated 0-5s service in Cheshire East 13
Commissioning a new Healthy Lifestyle Service for Devon 15
Risk-Avert – a schools-based programme to help young people build
resilience and manage risk in Essex 18
Commissioning a new children and young people’s emotional health
and wellbeing service for Halton 20
Warm Homes, Healthy Homes in Leicestershire 23
Drink Less Enjoy More – an alcohol licensing intervention in Liverpool 25
The London Sexual Health Transformation Programme 27
Commissioning a latent TB screening service for Wolverhampton 29
Links to useful resources 31
Commissioning for better health outcomes 3
Introduction
Councils were given responsibility for public Common to all of the examples was the
health in April 2013. The initial focus was on enthusiasm for working in the council
ensuring a safe transition of staff, services environment, the opportunities it had brought
and contracts – and getting these into good to make better links between programmes
shape. Now, three years on, many councils and the mutual respect that had been
are moving to a phase of transformation with built up between colleagues from different
health being embedded in everything the professional backgrounds. Many also pointed
council does, including its commissioning. to the value of political leadership of the
health agenda and the critical role elected
Investing in prevention and better health
members played in ensuring momentum in
outcomes can be part of the solution to the
difficult times.
challenges of increasing levels of need along
with shrinking budgets. Effective preventative
interventions can reduce health and social
care costs and the need for welfare benefits.
Better health can also enhance resilience,
employment and social outcomes.
The financial climate for councils and their
partners is becoming increasingly tough,
making it ever more important to get the
best outcomes from the scarce resources
available. Effective commissioning is one
of the levers that councils can use to make
the most of the resources they and their
partners have.
This guidance is based around a set of
principles that make for good commissioning.
These were developed from a scoping
workshop with public health and procurement
staff, consultation with delegates at the
Local Government Association (LGA) and
Association of Directors of Public Health
(ADPH) conference and from the lessons
emerging from the case studies included in
this report.
The case studies have been chosen
to illustrate positive approaches to
commissioning being taken across the
country to address a wide range of public
health challenges.
4 Commissioning for better health outcomes
The role of councils in
improving health outcomes
The Health and Social Care Act 2012 Investing in prevention and better health
gave councils new duties to improve the outcomes can be part of the solution to the
health of local people. They formally took conundrum faced by councils of how to
on responsibility for public health in April meet increasing need with reducing funding.
2013. The focus initially was on ensuring a Helping people to stay heathy can reduce
safe transition. Three years on, councils are health and social care costs along with the
increasingly looking to transform the way that need for welfare benefits. Better health can
they and partners work to improve the health enhance resilience, employment and social
of local people. Effective commissioning outcomes thus keeping people independent
is one of the levers they have to deliver and reducing dependence on services.
transformation.
The influences on health go well beyond
Duties of councils under the Health and the delivery of specific services set out in
Social Care Act 2012 legislation, hence the focus on commissioning
• duty on upper tier and unitary authorities for better outcomes in this guidance (see
to improve the health of local people diagram overleaf). To address a complex
issue like obesity or giving children the best
• duty to have regard to guidance including
start in life, many different approaches may
the Public Health Outcomes Framework
need to be coordinated to produce the best
• regulations specify: impact. This could include the provision of
◦◦ National Child Measurement Programme services to support individuals, designing
programmes to create healthier environments
◦◦ NHS Health Checks and building additional social value into a
◦◦ sexual health services construction project, for example.
◦◦ provision of public health advice Commissioning for better health outcomes
to CCGs stretches well beyond using the public health
◦◦ information and advice on health ring-fenced grant to purchasing specific
protection services to using all the resources that a
system has at its disposal to have the biggest
◦◦ some of the Healthy Child Programme impact on outcomes.
is now also mandated following 0-5s
transfer in October 2015.
These functions are supported by a ring-
fenced public health grant until 2018/19 when
funding from retained business rates is due
to replace the current local authority funding
system. Public health services that are part
of the comprehensive health service are
governed by NHS constitution and so,
for example, must be provided free at point
of use.
Commissioning for better health outcomes 5The benefits of investing in effective public health
Source: WHO (2013a)
Outcomes can be measured using the The public health outcomes framework 2013
national outcome frameworks for the NHS, to 2016 concentrates on:
public health and adult social care1. Using
these outcome measures councils and • increased healthy life expectancy
partners are able to benchmark performance • reduced differences in life expectancy
as an approach to making improvements. and healthy life expectancy between
The NHS Outcomes Framework sets out the communities.
outcomes and corresponding indicators that
will be used to hold NHS England to account The Adult Social Care Outcomes Framework
for improvements in health outcomes. (ASCOF) measures how well care and
support services achieve the outcomes
that matter most to people.
1 https://www.gov.uk/government/collections/health-and-
social-care-outcomes-frameworks
6 Commissioning for better health outcomesWhat is commissioning?
Commissioning is a term that is used The Cabinet Office Commissioning Academy
differently by different people, and is defines commissioning as the effective design
often used as shorthand for procurement and delivery of policies and services – so it
or contracting which are only part of is much wider than procuring services from
the process. There are many different an external provider. This definition works well
commissioning models and the language for public health challenges that are complex,
associated with commissioning differs across where there is no single silver bullet that will
sectors which can add to the confusion. solve the issue, and where prevention and
When talking about commissioning with early intervention at a population level are
partners it can be time well spent to explore often more cost effective than providing more
what everyone actually means. expensive treatment services to deal with the
consequences of unhealthy environments
and behaviours.
COMMISSIONING PLAN
ANALYSE
Legislation
Gap analysis
and guidance
Population needs
assessment
PURCHASING/ Commissioning
CONTRACTING strategy
Review service
provision Access individual
Develop service
needs
specifications and
Resource Identify intended contracts/SLAs
Service design
analysis outcomes
Analyse Purchasing plan
providers
OUTCOMES
FOR PEOPLE
Arrange services
Contract and support
monitoring
Capacity building Market/provider
Review strategic Review individual
development
outcomes outcomes Contract
management
Capacity
building
Review strategic
and market Manage
performance provider
relationships
REVIEW DO
A commissioning model
Source: Institute of Public Care, Oxford Brookes University
Commissioning for better health outcomes 7The Institute of Public Care model above shows commissioning as a complete process from understanding needs in the population, developing a strategy and designing the intervention, working with providers and reviewing performance. The procurement activities are inextricably linked with the overall procurement process and are needed at all stages of the commissioning process, not just during tendering for a service. The desired outcomes for the population are central to the whole process. The Commissioning Academy framework asks a series of questions linked to the stages of the commissioning cycle: • What’s the question? • Get to know and work with your customers • Define the outcomes and priorities • What will it look like? • How will you get there? • Measure the impact. They recommend spending significant time working with partners on the first two questions – being clear on the issue that needs to be addressed and understanding what will work for the people the intervention is intended to help – as this will increase the chances of a successful intervention being commissioned and potentially save resources in the longer term. 8 Commissioning for better health outcomes
Principles for good
commissioning
The range of work that councils are
undertaking to transform the health of their
1. Act as system leaders
populations is wide and varied. But some key to build the right culture,
themes and principles are emerging for what relationships and
makes commissioning most effective.
partnerships
These principles have been developed
from a focus group of public health and Commissioning is sometimes regarded
procurement professionals, from discussions as a narrow activity focused on securing
with delegates at the LGA/ADPH Annual services from external providers. All of our
Public Health Conference and from the case studies included some form of tender
lessons emerging from the case studies process but more importantly they were
included in the report. developed in the context of a wider strategy
sitting within a wider system. To commission
1. Act as system leaders to build the right effectively different parts of the local system
culture, relationships and partnerships (and often wider) need to be brought together
to identify the best solutions to complex
2. Have a clear focus on outcomes
issues. Building a culture of trust and strong
3. Take time to understand what is driving relationships is critical to success.
population behaviour
Some of our case studies illustrate clearly
4. Invest strategically and for the longer term how bringing different people into the
conversation has led to more innovative
5. Work with communities and build approaches being developed.
on assets
Devon drew on the skills of their digital
6. Work with providers as partners and transformation, social marketing and
shape the market communications teams in developing their
7. Commission across systems and for public-focused commissioning approach.
whole pathways from prevention to care Cheshire East are investing their energy
8. Use evidence of what works and build in working with their new provider for 0-5s
new evidence through evaluation. services post-contract award to develop
closer integration between health and early
years services.
All were convinced that a team approach,
valuing different skills and perspectives made
for more effective outcomes.
Commissioning for better health outcomes 92. Have a clear focus 4. Invest strategically and
on outcomes for the longer term
Building a clear, shared understanding of Complex population health issues are unlikely
why something is important and what you to be solved overnight by single interventions.
are aiming to achieve helps to maintain Commissioners will usually need to build
focus and momentum for the longer term. up a network of policies, programmes and
Elected members play an important role in services that together have the desired
determining and maintaining the emphasis on impact. Sustaining effort and impact over the
priority issues and outcomes. long term is important to success and this
may not be best served by recommissioning
London has defined clear health outcomes services every two to three years.
for its city wide sexual health transformation
programme. Essex worked with their procurement team
to secure a long-term co-design partner for
Leicestershire used the Public Health their programme to work with young people in
Outcomes Framework to identify fuel poverty managing risk. Their model also enables them
and reducing excess winter deaths as priority to generate commercial revenue that can be
outcomes. used to support the local programme.
Devon designed their procurement process London are developing a pan London sexual
to enable co-development of outcomes and health transformation programme. Long term
outputs with the successful provider. contracts are being put in place to enable
Cheshire East is linking financial incentives providers to make the investment needed to
to the achievement of desired outcomes transform the service delivery model.
3. Take time to understand 5. Work with communities
what is driving population and build on assets
behaviour This can lead to a better understanding of
the issues facing communities and what
The Commissioning Academy emphasises approaches are likely to work. Working with
that spending time on the early parts of the the assets that communities hold such as
commissioning process by understanding the skills and networks within the community
issue being addressed and what works for as well as facilities can lead to more
specific communities is vital to the success of sustainable solutions and avoid creating
the whole process. dependency on services.
Devon used Mosaic analysis to segment their Devon worked with focus groups drawn
population into different groups and then from different population groups to develop
worked with focus groups drawn from these their integrated lifestyle service.
groups to understand how they would best
engage with lifestyle services. Essex and Halton have built strong
relationships with schools and built their
Liverpool used behavioural insight to design capacity to address risk-taking by young
their campaign to reduce the sale of alcohol people and mental health issues.
to people who were drunk.
Halton and Cheshire East used in depth
work from their Joint Strategic Needs
Assessment (JSNA) and the Director of
Public Health (DPH) Annual Report in the
design of their services for children.
10 Commissioning for better health outcomesCheshire East is bringing council children’s
6. Work with providers services together with the 0-5s healthy
as partners and shape child programme to deliver more integrated
the market services.
It is a myth that commissioners should keep Wolverhampton has needed to identify and
a clear separation from providers. Whilst it plan for increased treatment workload arising
is important to treat all potential providers from a latent TB screening service. Their
fairly throughout a tender process, innovative voluntary sector partner has been critical to
approaches can be achieved through ensuring patients continue with treatment.
engaging a range of potential providers in
the design of services and through working
collaboratively with them once a contract has 8. Use evidence of
been awarded. what works and build
Devon held a discovery day and market new evidence through
days to encourage providers to develop
more innovative responses to their tender for
evaluation
lifestyle services. The resources section of this guidance
provides links to a wealth of evidence of
Halton held market development days and
what works to improve outcomes. Good
encouraged collaborative bids from providers.
commissioners will make the best use of what
Cheshire East are working collaboratively with is already available and also evaluate their
their community 0-5s provider post contract work to add to the evidence base.
award to develop more integrated services.
Wolverhampton used national evidence to
identify that screening for latent TB was an
effective intervention, and evaluated their pilot
7. Commission across programme to identify how their local at risk
systems and for whole population could be reached most effectively
pathways from prevention and supported through their treatment.
to care Liverpool used international evidence
to identify a promising intervention for
A commissioned programme does not exist in reducing heavy drinking in city centres. They
isolation. Many of our case studies identified independently evaluated their campaign to
how they had created links to other related inform future local commissioning.
programmes to maximise reach and impact.
They also identified how it was important to Devon retained a specialist stop smoking
plan for the whole pathway from prevention service as a component of their integrated
through to treatment. lifestyle service having reviewed the evidence.
Leicestershire has built links from its Warm Effective commissioning depends on being
Homes, Healthy Homes programme to other really clear about the issue to be addressed
housing support and created multiple referral and bringing the right team together to
routes into the service. Securing funding identify the most cost-effective solutions. Our
for housing improvements will increase the case studies show the benefits of working
impact of the programme. with the public, services users and providers
as partners, and also the benefits of bringing
Halton has brought together previously separate together the skills and experience of a
prevention, early help and treatment approaches wide range of council officers and elected
to develop an integrated children and adolescent members with the shared goal of improving
mental health service (CAMHS). health.
Commissioning for better health outcomes 11Case studies 12 Commissioning for better health outcomes
Commissioning an integrated 0-5s service
in Cheshire East
Councils formally took on commissioning The priorities identified are transition to
responsibility for the 0-5s Healthy Child parenthood, parental mental health, child
Programme in October 2015. Cheshire East mental health and the two-and-a-half year
Council re-procured its services for children review. The group have started work on the
aged 0-5 ahead of the formal transfer with a co-location of services and making better use
view to working with the new service provider of the estate available across the children’s
to transform services and better integrate centres and NHS properties.
them with council in-house early help
provision and children’s centres. They have Progress on integrating IT has been slower
consciously adopted a partnership approach but they are looking to implement common
to transformation with their provider, aiming systems across the NHS and council for the
to achieve systematic change and build on universal offer and safeguarding work.
good practice that had been there in isolated The transformation group are now focusing
pockets previously. on the important steps along the parent’s
journey, five of which are the mandatory
health checks. The journey identifies roles
What approach was taken? within the system, what information, advice
and guidance should be available at each
Cheshire East Public Health team worked
stage and when additional targeted support
with NHS England to re-commission the
is needed. The aim is for the service to
0-5 services following the same timeline as
be more systematic with active follow-up
Cheshire East’s re-commissioning of 5-19
of families that have not engaged, as well
services. The service specification followed
as better information-sharing between
the national model, adapted to ensure local
professionals. Work on mental health has
needs were addressed. This was informed
engaged the two maternity providers for the
by the JSNA, the Director of Public Health’s
area and has made progress connecting up
(DPH) Annual Report, and joint work with
pathways, strengthening onward referral and
the Children’s Directorate. Joint market
improving access to peer support services.
engagement events were held with NHS
England. The procurement was carried out by The group are beginning to engage parents
Cheshire East Council. The assessment panel with the development of the parent journey
for the bids consisted of representatives from and to work with the Council for Voluntary
NHS England (Quality and Immunisation and Service to strengthen the qualitative
Vaccination Lead), the councils public health information from parents in the JSNA.
team and children’s services staff, a CCG
representative and a local GP. Incentive payments (of up to 5 per cent of
the contract value) have been built into the
A transformation group comprising public contract with the provider and these have
health, the community trust provider, council been linked to Key Performance Indicators
prevention and early help services and (KPIs). Early payments are related to the
children’s centres is leading the ongoing work. establishment of the service, however, in
future years they will be more closely aligned
Their main focus has been on making practical
to improvements in health outcomes.
changes that will support a more integrated
service. This has included workshops involving
council and NHS staff working together to
build relationships and identify local priorities
based on national guidance.
Commissioning for better health outcomes 13What impact did it have? Frontline staff transferred from the previous
provider and it has been particularly
Relationships are already much improved important to ensure they feel engaged in
both at management level and between the transformation. The workshops were
frontline council and NHS staff, creating a a useful start to this, but different types of
productive environment for transformation. engagement with more local teams may
Staff are increasingly working from co-located have been better. Commissioning staff have
venues and opportunities to make more cost- also spent time shadowing frontline staff
effective use of property have been identified. which has helped build trust and for them to
understand local needs better.
Baseline data for services was limited but
there is a desire to work towards a more The DPH Annual Report was important in
outcomes based contract. Early KPI’s illustrating the impact of parental and child
specified in the contract were linked to the mental health on longer term outcomes. This
process of getting the new service into place. helped with understanding the issue and
For next year, this will shift to progress on getting it higher on the agenda.
the service priorities such as establishing a
Partnership governance and strong elected
baseline position for mental health.
member leadership have helped keep the
The increased profile for children’s and focus on transformation and integration and
parental mental health needs has led to this ensure that links are made with other related
being a focus for joint work on healthy schools. programmes. The transformation group works
within the frameworks provided by the Health
and Wellbeing Board and the Children’s Trust
What has been learned? and is linked to the Joint Commissioning
Leadership team.
Establishing a culture of openness and
investing in the relationship with the new Contact
provider has been vital. There are a limited Lucy Heath
number of providers in this market and the Consultant in Public Health,
style of leadership, capacity to work with Cheshire East Council
partners and openness to transform services
are important discriminators between lucy.heath@cheshireeast.gov.uk
providers. Further information
Working on relationships is helping to create a DPH Annual Report 2013/14
sense of “we are all in this together” to make
www.cheshireeast.gov.uk/PDF/Annual-Public-
the biggest impact, rather than the “us and
Health-Report-2014-FINAL.pdf
them” culture. Seeing providers as colleagues
in the system rather than having a purely
contractual relationship has helped with this.
14 Commissioning for better health outcomesCommissioning a new Healthy Lifestyle Service
for Devon
Devon, like many areas, had commissioned Starting from the perspective of the user was
individual lifestyle services to support lifestyle important. This approach was initially shaped
change, eg smoking cessation and weight using Mosaic analysis of population data to
management services, for many years. define three key groups to work with – Inform
These services were largely commissioned Me, Enable Me, Support Me.
from NHS providers on the basis of funding
available and outputs rather than outcomes.
Services were reaching a small proportion
of those who could potentially benefit – with
3 per cent of current smokers accessing the
service each year for example.
When public health transferred to the council,
elected members took the view that as
these services had never been subject to
market testing they should be retendered
to ensure the most cost-effective services
were in place. It also came at a time when
the Five Year Forward View was calling for a
radical upgrade in prevention and the council The council then held a “discovery day”
was reviewing its role as a commissioner, involving about 100 local people and
enabler and connector. The public health organisations. The focus was an open
team took the opportunity to review the whole exploration of what could be done to reduce
approach to delivery of these services, rather premature deaths and long term conditions
than simply tweaking the existing service rather than homing in on what services were
specifications and retendering. There were needed. Discussions were geared around
risks associated with this, but the risk of not “personas” that had been developed to
changing was seen to be greater. represent the key Mosaic population groups.
This led to a different, more innovative,
conversation with providers who would
What approach was taken? traditionally have been asked to respond to a
detailed service specification.
The design principles for the new model
were that the user should be at the centre of They also held focus groups drawn from the
the service, and there should be a focus on ‘Persona’ population groups following the
outcomes and earlier intervention. discovery day. Again the conversation was
quite different as instead of asking questions
The public health team were fortunate to about where and when people would access
have a social marketing lead within the team services they discussed what was important
and, with the move to the council, they were to them in their lives – what made them happy,
able to make strong links with people who who they talk to and who is important in
they had not worked with previously such as their lives. They found the three groups were
the digital technology lead and staff running very different in their needs with the Inform
the community directory. This led to different Me group being motivated to change and
conversations and much greater potential for reacting well to self-help, whereas those in
integration and innovation. the Support Me group wanted face-to-face
interaction and didn’t really trust the NHS,
for example.
Commissioning for better health outcomes 15The outputs from the focus group and the There will be an online digital service, as well
discovery day were fed into a market warming as telephone and texting service to reach and
day with potential service providers. This was support Inform Me and Enable Me individuals
a well attended event with over 30 providers as well as services that reach out into specific
from public, private and voluntary sectors – communities providing face-to-face advice
far more than would typically get engaged and support to those who need more support
in more traditional procurement approaches. (Support Me). A targeted specialist stop
The questions providers were asked were smoking service has also been retained as
deliberately open – how would they reach part of the offer given strong evidence of
these people and what would they offer? effectiveness. High level outcomes have been
included in the specification but there is a
As a result, the specification for the service
commitment to co-production with providers
has been constructed differently to give
post award.
more scope for working collaboratively with
providers to shape and define outcomes and
outputs after the contract has been awarded.
The integrated lifestyle service model for Devon
Source: Devon County Council
16 Commissioning for better health outcomesLinks have also been made with national Mosaic data helped define characteristics
programmes such as the Public Health of groups that providers could design
England’s One You campaign which also services around. NICE evidence supported
targets people in mid-life and, through the effectiveness of specialist stop smoking
community directory, links them to community services which were retained as part of
assets such as local rambling groups. the model.
As with any new and different approach there
What impact did it have? was inevitably some nervousness about the
level of risk involved. Acknowledging the
The tendering process closed at the challenges of taking a more radical approach
beginning of April 2016 so it is too early and involving people early in the process
to identify health outcomes that have helped to reduce anxiety in the system,
been achieved. However, the approach as did having allies who bought into the
has already been successful in attracting approach from the start. It was also important
different providers into the marketplace to emphasise the risk of not changing and
and introducing a more collaborative getting sub-optimal outcomes was actually
approach to commissioning. greater than the risk of change. Involvement
of the chair of the HWB and the inclusion of
There has been wide interest across the Healthwatch has helped to ensure leadership
council and among partners in building on and support across the system.
the approach for other programmes. The
council, in collaboration with the South West It is important to bring the market with you.
Forum made a bid to the Cabinet Office The discovery day and market-warming day
for funding to test how social value can be helped attract providers and to bring them
better embedded within the commissioning on a shared journey.
process. The funding enabled the authority
Contact
to work with the South West Forum to ensure
social value was a prominent narrative within Steve Brown
the commissioning process, including being Assistant Director of Public Health,
explicitly written into the service specification Devon County Council
and tender questioning. steve.brown@devon.gov.uk
What has been learned?
For the different approach to work, it has been
important to be open as a commissioner,
which meant letting go of the notion of being
custodian of all the answers.
Putting the user at the centre was critical to
setting the tone for the whole process.
Using evidence and data effectively helped
shape the commissioning process. For
example, data showing how few people
who could benefit were accessing current
services helped shift the focus to how do we
engage with people who don’t use services.
Commissioning for better health outcomes 17Risk-Avert – a schools-based programme to
help young people build resilience and manage
risk in Essex
Essex is a large, diverse county with a term programme. The steering group were
population of 1.4 million. It has 12 district/ looking for a partner who provided the right
borough/city councils, two neighbouring fit, understood their vision, had the skills
unitary councils (Southend on Sea and and experience to develop the programme
Thurrock) and, before the transition of public and establish it as a commercial entity, and
health to councils in 2013, was served by was able to work well with the council and
five primary care trusts (PCTs). The move of wider partners. As this was breaking new
public health into the council enabled stronger ground, the advice of the procurement team,
links with children’s services and between particularly in developing a suitable format
drug and alcohol, sexual health and mental for the tender and the subsequent contract
health commissioners. It also presented an was invaluable. The legal team have also
opportunity to commission programmes been helpful in working through issues about
across the whole county at scale. intellectual property and copyright which
were important to ensure that the programme
Essex had a history of commissioning school-
retained commercial value.
based programmes to address specific risks
that young people may encounter, such as The successful bidder to become a co-design
drugs and alcohol. These were mainly one- partner was The Training Effect (TTE). They
off programmes commissioned using small worked with the steering group to build an initial
pots of money. Evidence of sustained impact product that was tested in a small number of
was often lacking. They identified a need schools. The model was refined and has been
for a more sustainable approach that was rolled out across secondary schools in the
embedded in the way that schools work and county. The approach is to screen all pupils in
addressed the underlying reasons that led to Year 8 for their attitudes towards risk-taking.
a range of risk-taking behaviours. Those with high scores then take part in a six
session programme delivered by teachers in
the school. The teachers involved received
What approach was taken? training in delivery of the programme and will
have annual refresher training. They also have
In 2013, the initial concept was submitted to access to online resources and support. Wider
the Safer Essex Partnership (the Pan Essex partners such as the Family Solutions Team
Community Safety Partnership) who provided (the Essex Troubled Families provider), Pupil
set up funding. A steering group involving the Referral Unit and the Police School Liaison team
Police and Crime Commissioner, the Safer have also been trained so they are familiar with
Essex Partnership, public health and health the aims and content of the programme.
partners scoped out what they wanted to
achieve with the programme. They worked Initial set up funding for the programme
with the procurement team to commission a came from the Safer Essex Partnership. The
co-design partner who would work with them ongoing funding has been provided from the
to create and evaluate the programme. public health budget, with a longer term aim
of making the delivery of the programme in
This was a different approach as it was Essex cost-neutral by selling the programme
about establishing a long-term partnership to other local authorities.
with a view to developing a commercially
viable entity, rather than commissioning The programme has been linked to the
an organisation to simply deliver a short existing Healthy Schools Programme that
18 Commissioning for better health outcomesalready had effective links into schools across to enable them to provide the best advice on
the county. This has enabled a managed suitable vehicles for doing this. In this case,
roll-out of the programme over the course knowing that the longer term aim was to
of two years, allowing capacity to be built develop a commercially viable product with
slowly and minimising the need for additional the partner organisation was important to the
marketing. Schools are represented on the way the tender was set up. It is also important
steering group responsible for the ongoing to anticipate legal issues such as copyright
management of the programme. so that advice can be sought as early in the
process as possible.
Given the concerns the team had about the
lack of evidence of effectiveness for these The council brings valuable contacts to
types of programmes, they have placed the partnership that make it work, such as
a strong emphasis on evaluation. They access to the healthy schools programme
have funded a PhD studentship with Essex and its established links into schools, making
University and have also commissioned strategic links to other interventions, as well
aspects of the evaluation from two other as funding.
academic partners.
Academy groups within Essex have been
interested in commissioning the programme
What impact has it had? for schools they operate elsewhere as they
value having access to a quality, evaluated
The first evaluation report from the programme product backed up by support.
shows that it was being successfully delivered
Whilst there are multiple providers who were
in 30 secondary schools reaching around
interested in selling off the shelf training
6,000 pupils. 94 per cent of pupils felt more
programmes for schools, there were only a
confident about managing risks and 74 per
small number who were interested and able
cent had a more positive relationship with
to work with the council in a developmental
their teacher. 86 per cent of teachers rated
partnership. Providers will need to become
their improvement in knowledge of risk-taking
more flexible as councils increasingly look for
behaviour at over eight out of 10.
partnership models.
Awareness of the Risk-Avert brand has
Effort has had to be put in to keeping the
developed and gained credibility amongst
programme at the forefront of organisations’
partners. It is now being used to link
memory to sustain momentum. Elected
up complementary programmes such
members and wider partners have been very
as addressing hidden harms like child
supportive of the programme and this has
sexual exploitation, a healthy relationships
been important to sustaining energy and
programme aimed at Year 8 pupils, a primary
commitment for the longer term.
school resource pack, and resources for
emotional health and wellbeing. Contact:
The programme has been sold to several Ben Hughes
other local authorities. This external income Head of Commissioning, Public Health
has offset 20 per cent of the programme and Wellbeing, Essex County Council
costs in Essex already, with the ultimate aim ben.hughes@essex.gov.uk
being for the programme to be cost-neutral.
Further information
www.risk-avert.org
What has been learned?
It is important to spend time with procurement
colleagues so that they understand what is to
be achieved across the life of the partnership
Commissioning for better health outcomes 19Commissioning a new children and young people’s
emotional health and wellbeing service for Halton
Halton is a unitary authority in the Liverpool After their early work, approval to proceed
City Region, serving a population with high with procurement of a jointly commissioned
levels of deprivation and poor health. It is service was given in October 2014.
coterminous with NHS Halton CCG and
there is a long history of public health teams Halton had already developed a specific JSNA
working collaboratively across Cheshire and for children and young people and this was
Merseyside through Champs Public Health used as the starting point to understand in more
Collaborative. depth the differing needs across age groups.
Additional work was done jointly with the
Local mental health and wellbeing services neighbouring boroughs of Cheshire West and
followed a traditional tiered model with public Chester and Warrington to further understand
health responsible for Level 1 and some level the specific needs of young people involved
2 services, the Local Authorities Children and with the youth offending service.
Young people’s team commissioning some
Level 2 provision and the CCG responsible There was early and continued engagement
for Level 2 and 3. Services had problems with of young people in the process through
long waiting times and there was confusion in engagement events with the Youth Parliament
how to access the most appropriate support, and school councils, an online survey and
with schools, for example, having only limited so on. Providers in the NHS and third sector
access to early intervention. NHS Halton CCG were also actively involved in the process
made the decision to recommission the level 2 through a series of engagement events.
CAMHS service and this was identified as an What emerged was a broad, system wide
opportunity to review all the children’s mental approach to children and young people’s
health services in the borough to develop emotional and mental health and wellbeing
a more integrated model which placed an and the development of an Emotional Health
emphasis on promotion, prevention and and Wellbeing Plan. The plan focused
early intervention to better meet the needs of attention on getting the right help in the right
children and young people. The new model place, and had an emphasis on prevention,
moved away from traditional levels and tiers early identification and access to services.
of service towards the development of an This in turn led to a service specification
integrated Emotional Health and Wellbeing that, as well as providing a targeted service
service that worked across the continuum of for young people with high levels of need,
need. also included a community and schools
programme that had a wider reach and a
strong emphasis on promoting positive mental
What approach was taken? health, prevention and early intervention.
The work was carried out under the remit of The integrated Emotional Health and
the Children’s Trust and started in the summer Wellbeing service specification included
of 2014. An integrated commissioning team both school and community based social
was formed early on with input from children’s and emotional wellbeing training for front line
services, public health and the CCG. This staff (including teachers, GPs, school nurses
was critical to the success of the process as and social care staff), specialist counselling
it enabled a sense of joint endeavour, working and therapeutic interventions, the targeted
together in the best interests of the local youth offer provided by the council’s youth
community and getting the most out of the service and public health early intervention
Halton pound. and mental health awareness programmes.
20 Commissioning for better health outcomesIn addition there was a realisation that the Links have also been made with other
service needed to capitalise on new methods health pathways such as that for healthy
of engaging with young people through the weight, enabling children with a high BMI to
provision of online resources and support, have specialist support including cognitive
such as online counselling. behavioural therapy, as well as self-harm and
eating disorder services, crisis resolution and
Following a comprehensive procurement
mindfulness.
process, a contract was awarded in summer
2015 to the Five Boroughs Partnership NHS The quality and depth of the partnership
Foundation Trust, (the local NHS mental health that has been built also provided a strong
provider) working in partnership with Kooth, platform for Halton to submit a proposal for
a third sector organisation with expertise in the National CAMHS Transformation Fund.
working with schools and providing online They were selected as a national pilot site for
support to young people. As well as providing the Schools Link programme, a new initiative
the new service, the provider was also able designed to provide additional training and
to integrate its existing Level 3 specialist resources for schools and to improve the
provision into the local offer. This enabled a liaison with local services.
much wider reach than previously possible
which focused on the needs of the child and
operated a “no wrong front door” policy. What has been learned?
Establishing an integrated commissioning
What impact has it had? team early in the process and ensuring there
was support from the Children’s Trust and
The new integrated approach to working has elected members was critically important.
transformed what was previously a collection The team developed a strong partnership
of loosely affiliated commissioners and from working together which enabled it to
service providers into a focused and dynamic adapt effectively to changing circumstances.
team with a true commitment to working During the procurement process, the council
together to improve the emotional health and experienced a surge in numbers of children
wellbeing of young people in Halton. The requiring care which meant that the service
service has been operational for less than a specification and the funding available for the
year and is already starting to make a real CAMHS tender had to be rapidly reviewed.
difference. Waiting times have reduced and The strength of the partnership meant that
more children are able to access help and a difficult situation could be discussed
support than ever before. and resolved constructively without unduly
delaying the tender.
The new service has been able to facilitate
professional support networks and has The CCG is the major funder of the service,
provided “twilight” training sessions to staff but they utilised the council’s procurement
in schools to increase their awareness and team for the tender process as they
confidence in mental health issues. Kooth is recognised the value brought by the local
also developing additional in school provision knowledge and skills of the team.
as well as an innovative approach to online
support.
Commissioning for better health outcomes 21Working with young people to design the service helped to develop a service which was much more geared to their needs. The positive experience from the CAMHS procurement process has meant that young people have since been more closely involved in the design and tendering process for other services, such as the new school nursing service. Involving providers and potential third sector partners with insights into the needs of children and their families through “soft” market testing is invaluable. The best people to design a service are those who have experience of delivering services. Creating an environment where good quality co- production can thrive is a key role for the commissioner to ensure that services meet the needs and aspirations of local people. Contact: Simon Bell Public Health Commissioning Manager, Halton Borough Council simon.bell@halton.gov.uk 22 Commissioning for better health outcomes
Warm Homes, Healthy Homes in Leicestershire
Health in Leicestershire is generally better than and on reliable tradespeople. The team have
the national average, however two indicators also provided awareness and training for
in the Public Health Outcomes Framework professionals working with vulnerable people
(PHOF) stand out as needing attention– fuel to help them identify who would benefit from a
poverty and excess winter deaths. With elected referral into the service.
member support, it was decided that public
health should lead the development of a They have also now embedded the scheme
sustainable approach to tackling fuel poverty into the Lightbulb Project, which is funded by
in the county. The council’s work on affordable DCLG Transformation Funding, and is working
warmth had previously been led by adult social to integrate the various housing support
care using short term pots of funding that were services provided by the county and the
coming to an end. The consultant in public seven district councils into a coherent offer
health, who is leading the programme, came that is easier for residents to understand.
into public health with extensive experience Funding for housing energy efficiency
of working on housing and fuel poverty in the improvements now largely comes via energy
voluntary sector. companies and is not targeted at the most
vulnerable. A key development of the
scheme has been securing funding from the
What approach was taken? National Energy Action (NEA) Warm Homes
Partnership Fund matched by the Better
Reducing excess winter deaths had been
Care Fund (BCF) that is enabling physical
identified as a strategic priority by the HWB,
measures, such as new boilers or insulation,
informed by the JSNA and the DPH Annual
to be installed for over 150 of the most
Report. NICE guidance had also been
vulnerable households. They are identified by
published on reducing excess winter deaths
risk stratification using housing, social care,
and illness. Unlike many health issues, there
GP and hospital discharge data and then
is not a strong link between deprivation and
contacted directly with an offer of advice and
excess winter death, and in Leicestershire many
support. Evaluation to demonstrate impact on
older people live in large, difficult to heat homes.
health and social care use is important to see
External funding sources had come to an end if the scheme warrants the allocation of local
and so £100,000 of public health funding funding to sustain and expand it.
was identified to support the programme. The
public health team worked with colleagues
in adult social care and housing colleagues What impact has it had?
based in district councils to develop a healthy
The move to the council has enabled public
housing referral service. The service was put
health to build closer links with adult social
out to tender and awarded to the Papworth
care and housing colleagues which have
Trust in partnership with National Energy
been essential to getting the scheme running
Action (NEA), the national fuel poverty charity.
effectively and making links between services.
The initial programme provided a range of
The team have also maintained good links
routes of referral into the service, including
to the NHS and are in a better position to
via First Contact Plus, the council’s referral
influence change across the whole system.
hub for a range of services. The team at
Papworth Trust provided basic energy advice Being able to work as a team across public
and more complex cases were referred onto health, adult social care, housing and
a caseworker. In many cases, people were procurement was a real strength. The public
able to afford to pay for improvements but health team brought experience of working on
needed advice to identify what needed doing fuel poverty, understanding of the evidence
Commissioning for better health outcomes 23for what works, a picture of local needs and change her to a more competitive tariff,
their NHS links to the team. Adult social care fixed for a longer period of time saving her
brought their learning from running affordable approximately £96 over the course of the year.
warmth programmes and direct links with Meter readings were also submitted to ensure
vulnerable residents and housing were able she was not paying more than necessary.
to link up other programmes through the
Lightbulb Project to increase the impact. The
advice of the procurement during the tender What has been learned?
process on documentation, timescales and
evaluation of the tenders was invaluable. Working across two tiers of local government
is complex but the challenges this creates
The approach being taken in Leicestershire can be overcome through building good
to housing support is now more coherent and relationships, having clear goals and the
affordable warmth is embedded in this and is right attitude to working together. Good
seen as a key component of BCF work. governance structures and processes help
with this. Having a strong partnership with
clear goals helped Leicestershire to secure
Case Study external funding to expand the project as they
could demonstrate to funders that they knew
Miss Q who lives alone in a two bedroom
how to use the funding effectively.
bungalow had been without suitable heating
or hot water for two years as her boiler had Planning for the whole pathway from
developed a fault and she could not afford the identification to the provision of support is
upfront cost of repairs. A Resident Support important. Once funding was secured for
Officer from her local authority referred physical improvements the programme was
her via the Leicestershire First Contact able to have a bigger impact.
service (a referral pathway for participating
organisations to put people in touch with Evaluation is important to making the
relevant services). case for sustainability and expansion of
test programmes. Case studies are useful
Papworth Trust contacted Miss Q and alongside the numbers for making evaluation
arranged a home energy advice visit to see more real.
what help could potentially be available.
As Miss Q has mobility and mental health Contact
conditions, the benefits she received qualified Rob Howard,
her for funding that Papworth Trust hold on Consultant in Public Health, Leicestershire
behalf of the Foundations Independent Living County Council
Trust. Papworth Trust was able to apply to rob.howard@leics.gov.uk
the SSE Warm at Home Fund and Gas Safety
Charity funding to cover the majority of the Further information
cost of the works to repair the boiler using a
local contractor.
It was also identified that Miss Q was eligible
for the Warm Homes Discount (£140 credited
to her electric account) and an application
was submitted over the phone by contacting
her supplier. At this time she was also added
to the Priority Services Register as she keeps
medication in the fridge which could be
affected by a power cut.
Additionally her supplier was able to
24 Commissioning for better health outcomesDrink Less Enjoy More – an alcohol licensing
intervention in Liverpool
As part of its strategic approach to tackling message was that drunks won’t get served in
alcohol-related harm in the city, Liverpool City the city and they and their friends could have
Safe Partnership developed an intervention their night out cut short. Campaign messages
aiming to address the culture of drunkenness were tested with the target audience and
in the city centre at night and reduce levels the campaign was designed around the
of intoxication. It centred on increasing lead up to the night out and the journey
awareness and enforcement of the Licensing into the city centre. It included radio adverts,
Act 2003 which created an offence of serving adverts in off licences, on public transport,
or buying alcohol for someone who is drunk. at arrival stations and on walking routes to the
Evidence from Stockholm suggested it was pubs and clubs. There was a social media
possible to have a significant impact by campaign and support from the local press.
implementing a multi-component intervention
including public communications, police The police sent letters to all bars in the city
enforcement and bar staff training. centre alerting them to the campaign and
advising that they would be actively enforcing
the Licensing Act legislation. Bar staff were
What approach was taken? trained about the legislation and how to
refuse to serve a drunk customer by Trading
The City Safe Partnership worked with Standards staff. The campaign ran during
Liverpool City Council Public Health team and November 2015.
Liverpool CCG to fund and trial a campaign
An independent evaluation of the campaign
Say No to Drunks in 2014. This mainly
was commissioned from Liverpool John
focused on training bar staff, and to a lesser
Moores University.
extent police enforcement. Evaluation showed
limited impact and made recommendations
for an accompanying public communications
campaign and for more proactive police
What impact has it had?
enforcement. The intervention has been independently
evaluated by Liverpool John Moores University
Behavioural insight work was commissioned
(LJMU). They used a validated Actor Study
to identify the target audiences for the public
Research Tool, where actors mimic severe
communications work. This identified four
drunkenness whilst attempting to be served,
groups of people who were at the greatest
to test whether bar staff would serve alcohol.
risk of alcohol-related harm: the Chardonnay
The work replicated the methodology used
socialite, ritual relaxer, drinkers in denial and
in a previous LJMU national study in 2013. In
balanced bingers. Balanced bingers were the
2013, 84 per cent of attempted purchases
group who mainly drank heavily at weekends
were successful, compared with only 26 per
as part of their night out and were selected
cent after the intervention in November 2015.
as the target audience for the design of the
The same method was also used in a survey
intervention.
in another large city in October 2015, where
The group was made up mainly of 18 to 30 there was little movement from the 2013
year olds coming into the city on stag and national figure of 84 per cent.
hen dos from the Liverpool City Region and
A survey of night life users before the
students. Their main aim was enjoyment with
intervention showed that over 70 per cent
friends, which far outweighed any health
of participants: expected their level of
concerns – hence the change of name of
drunkenness to be high when they left the
campaign to Drink Less Enjoy More. The core
Commissioning for better health outcomes 25You can also read
