Commissioning for better health outcomes - September 2016 - Case studies - Local ...

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Commissioning for better health outcomes - September 2016 - Case studies - Local ...
for better health
September 2016

Case studies
Commissioning for better health outcomes - September 2016 - Case studies - Local ...

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
Commissioning for better health outcomes - September 2016 - Case studies - Local ...

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
Commissioning for better health outcomes - September 2016 - Case studies - Local ...

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
Commissioning for better health outcomes - September 2016 - Case studies - Local ...
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.
                                                   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      5
The 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.


6        Commissioning for better health outcomes
What 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
                                                                             Gap analysis
                                  and guidance

                           Population needs
                                                     PURCHASING/                          Commissioning
                                                     CONTRACTING                          strategy
                    Review service
                    provision              Access individual
                                                                   Develop service
                                                                   specifications and
                Resource               Identify intended           contracts/SLAs
                                                                                                Service design
                analysis               outcomes

                                     Analyse                              Purchasing plan
                                                       FOR PEOPLE
                                                                           Arrange services
                                       Contract                            and support

                                                                      Capacity building         Market/provider
                  Review strategic          Review individual
                  outcomes                  outcomes              Contract
                              Review strategic
                              and market                                     Manage
                              performance                                    provider

  REVIEW                                                                                                           DO

A commissioning model
Source: Institute of Public Care, Oxford Brookes University

                                                                Commissioning for better health outcomes                 7
The 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

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.
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        9
2. 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 outcomes
Cheshire 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
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        11
Case 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      13
What 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     
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
the biggest impact, rather than the “us and
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 outcomes
Commissioning 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     15
The 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 outcomes
Links 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
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.                     

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      17
Risk-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 outcomes
already 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
being for the programme to be cost-neutral.
                                                    Further information
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       19
Commissioning 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 outcomes
In 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
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

                                                 Commissioning for better health outcomes       21
Working 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

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.

Simon Bell
Public Health Commissioning Manager,
Halton Borough Council

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      23
for 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
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 outcomes
Drink 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
                                                      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       25
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