What are the different types of commissioning that we are using- the good, the bad and the indifferent?  Feel free to add to this list:

Transactional– conventional contracting of services for a specified period to an agreed standard

Transformational– using the full suite of commissioning options viz. contracting, partnering, piloting,  cultural positioning etc. to leverage a whole-of-system change

Co-commissioning-  an approach that sees the PHN engage with strategic partners to enact a whole-of-system improvement through purposeful co-investment

Scatter-Gun-  having a “thousand flowers blooming” in the hope that at least somebody will get a benefit at some stage.  This may have a role as part of a market engagement strategy or when “seeding” innovation.  I note that the PHNs’ small grants programs might be classified as a scatter-gun approach.

Broad-Brush –  we trowel on our scarce resources in the hope that something might actually “stick”.  This is about being busy for the sake of being busy and suggests that we don’t know what we are doing!  What some people like about this approach is that it allows them to indulge pet interests or concerns.

Fire and Forget-  a transactional approach with no performance management-  i.e  ready, fire, aim!!

Confrontational Commissioning –  whereby the PHN attempts to assert  its power inappropriately

Passive Commissioning- whereby the PHN abrogates its role and allows itself to be dictated to by an entity it funds

I would like to propose another one-  Commissioning with Precision – a type of transformational commissioning which serves as the converse to the broad-brush approach. I note that some of the Mental Health Commissioning  presented by PHNs at the recent Commissioning  Showcase incorporate elements of precision commissioning.

About Precision Commissioning

Precision commissioning offers the counterpoint to broad-brush, non-strategic commissioning.  It observes a gimlet-like focus on the desired outcome and the means by which it is to be achieved.

• It involves a carefully chosen suite of mutually reinforcing activities – that is, all activities are designed to support all other activities – in much the same way that a clock mechanism works.  If one activity is not supporting other activities it is not pulling its weight!
• It maintains an acute awareness of  the inherent scarcity of resources –  money, time, goodwill, patience, credibility,  provider attention, etc.
• It maintains an acute awareness of the difficulty of meaningful health system change

While I have reservations about the use of “war” metaphors the best analogy I can offer comes from my airforce days.  Precision commissioning is akin to a surgical pinpoint cruise missile strike whereas much of our conventional commissioning looks more like carpet bombing.  Precision commissioning conserves scarce resources, avoids collateral damage and is safer for those tasked with delivering the ‘payload’.

Please feel free to propose better analogies if you have them.

When would you use precision commissioning ?- the tests!

You would use precision commissioning when:

• the stakes are very high for all concerned- and there will be serious consequences if it is not done well
• the task is going to be difficult
• attribution is difficult so the PHN will find it hard to justify  the significant resources  to be expended
• the activity is consistent with the Board’s ‘Reform Appetite’
• external scrutiny is likely to be high
• the outcomes that are sought warrant the intensive investment
• co-commissioning or co-investment by other entities will be required
• the PHN has the time available to do it right
• there is a prospect of actual success!

Why Commission with Precision?

• It speaks clearly to the PHN’s ‘core three-point remit’ – i.e. improving the primary medical care for patients with complex care needs through health systems integration
• It allows the PHN to clearly demonstrate its role and value proposition
• It offers a clear unifying narrative to staff and external stakeholders-  they will know why the PHN exists, what we are meant to be doing and how we are going about it

What things are prerequisite for precision commissioning?

• A focussed awareness of the scarcity of resources available to a PHN-  this activity needs to prioritised, and by virtue of this, other things will need to be actively de-prioritised by the PHN  (I am not sure that all PHNs are prepared to do this though)
• Consensus from the participating clinicians as to model of care to be implemented and/ or tested (don’t assume that you have this- test  your assumptions to make sure)
• Agreement that only those who stand to benefit from the new service model are to be targeted – i.e. patients with complex care needs.  The principles of precision need to be maintained at all levels!
• There is full internal alignment –  no egos, no turf issues, no office politics, no backsliding (Again, I can hear people saying this is unrealistic and if this is true PHNs are in a world of trouble!)
• There is strategic alignment with key partner entities- most specifically those who will need to accommodate the changes in their operations
• All involved are committed to taking the necessary time working together to get a crystal clear vision of what is to be achieved, how it is to be achieved and very importantly why it is necessary!
• There is a commitment across the PHN to cross-leveraging other portfolio activities to support the over-arching outcome-  especially workforce development, event management, media management, stakeholder management, etc.
• There is a “disruptive” element- that is, the activity disturbs the status- quo in a way that makes it difficult to revert
• The PHNs Board is fully briefed and fully on-board!   Board Directors will necessarily need to play an active part- most likely in terms of facilitating relationships with counterparts in strategic partner organisations

The approach for precision commissioning

• ‘Work with the few first to bring along the many later’- use the insights from the Diffusion of Innovation Theory– it’s old but still holds!
• ‘Go with the flow”-  in the first tranche go with those whose natural “energies” draw them into the innovation conversation
• ‘No skimping’- over-resource the first tranche rather than risk under-resourcing.  This is made possible by the PHN jettisoning extraneous historical activities to permit the redeployment of resources (usually PHN staff)
• In the first tranche select  partners who will not incur heavy “switching costs’-  you don’t want the barriers to participation to be too great
• Prefer to work with resilient people in the first instance.  It will be easier to gain traction with the others after a measure of success has been achieved.
• Scepticism is healthy.  Avoid cynics if you can as they will try to shut you down.
• Knowing when and where to start is much better than knowing when to quit.  If things are too heavily stacked against you from the outset its probably best to defer to a more conducive time. 
• Once you do start “stay the course’ – you know that its going to get hard!

Perhaps most important is the ‘no-skimping’ point.  The PHN needs to over-resource  its change champions to maximise the chances of realising the benefits quickly enough to prove the naysayers wrong.

PCMH Readiness-  “Going in before going out”

This is a worked example of precision commissioning

In this example the PHN needs to make their GP community ready for the Patient Centred Medical Home (PCMH) model of care, designed for patients with complex care needs.  This is achieved by first “going in” and working intensively with the change-ready practices and then catalysing wider whole-of -system by “going-out” through these practices’ natural referral networks – that is, their pharmacies, allied health providers, aged care providers,  diagnostic providers, acute hospitals, etc.  Once the PCMH model of care is established and working then the early adopters will showcase their success to help the PHN recruit the next tranche of participants.

Step 1-   Satisfy the ‘tests’ for a precision commissioning activity

In this step the Executive team and Board ensures that the activity is suitable for a precision commissioning approach.  PCMH- Readiness is extremely important as it reflects the future model for GP- delivered care for the country.  Its implementation at scale will require a very significant application of the PHN’s resources over time.  It will also require a significant investment on behalf of participating practices themselves with individual GPs needing to rethink their modes of clinical practice.  This is a big ask for all concerned.

Given its importance, and with regard to the Board’s reform appetite, the PHN has decided that a precision commissioning approach is indicated.

Step 2-  Establish the conditions for success

With the decision to proceed made, the Executive and management team next gives consideration to the prerequisite conditions that need to be established to maximise the chances of success.

In this example the PHN identified a particular part of their region which was more conducive to the PCMH model.  Consistent with  the diffusion of innovation theory,  the PHN also engaged those few practices naturally aligned to the PCMH MoC-  that is to say the ‘early adopters’.   This first tranche of practices had:

• Consensus among its clinical staff that the PCMH MoC held the promise of improving care outcomes for patients with complex chronic conditions
• A commitment to doing more of the  local ‘heavy lifting’ for patients with multi-morbidity
• A willingness to explore block funding arrangements for an enrolled patient cohort
• An effective relationship with local acute services
• A preparedness and interest in serving as a demonstration practice to encourage other practices to adopt the PCMH model
• An existing  network of allied health providers who are professionally aligned with the PCMH Model of Care (i.e a supportive natural referral network)

To maximise chances of success the PHN:

• ‘Cleared the decks’ by desisting from historical activities that no longer aligned with the ” PHN’s three point remit”.  e.g. disease specific CPD training already offered by a multitude of other providers
• Reserved significant capacity for associated workforce development and events – to ensure that these functions were available to support the precision commissioning activity and prevent unhelpful ‘competition’ for the attention of time-poor clinicians
• Assigned responsibilities across the organisation to ensure that a clear ‘unity of purpose’ was achieved  e.g. eHealth supports, practice systems supports,  clinical practice supports, etc.
• Actively addressed and resolved the inevitable internal turf issues
• Mobilised Board Directors to use their prestige to engage strategic partners

Step 3-  Realising the benefits 

So,  by “going in” to those GP practices that are already change- ready the PHN was able to “go out”  through the practice’s natural referral network to catalyse change through the wider healthcare system.-hence the  instrumentality that precision commissioning affords.

The benefits obtained include:

• The PHN delivered manifestly on its three point remit-  supporting clinicians to improve services for patients with complex care needs through purposeful system integration  – A huge tick from the Commonwealth!
• It represented an economic application of scarce resources- for the PHN and its partners
• It allowed the PHN to establish an attributable return on investment  – as the enrolled patient group will be amenable to study – Another huge tick from the Commonwealth!
• The instrumentality of the approach allowed the PHN to better anticipate and mitigate unintended consequences
• It provided a legitimate platform for the focussed pursuit of the PHN’s national priorities:
  • eHealth including My Health Record adoption
  • Aged Care including Advance Care Planning
  • Aboriginal and Torres Strait Islander Health as they will be naturally represented  in the enrolled patient cohort due to their over -representation in patients with complex multi-morbidity

Also, the staff of the PHN were able to participate in a unifying piece of work that was challenging but meaningful and it brought them closer together as a whole-of-organisation team.

Step 4-  Scaling up to catalyse whole-of-region change 

The precision commissioning approach was purpose- designed to provide the platform for scaling up the new model of care to catalsye whole-of-region change.

• It demonstrated the the new model of care could actually work (i.e. stick)
• It provided the demonstration sites that could be used to showcase the model to prospective recruits for subsequent tranches
• Provided the learnings (in a controlled environment) so that implementation issues could be addressed before wider scale-out
• Built the PHN’s reputation as an effective and confident health system reform leader

Conclusion:

Personally, I would like to see PHNs do a lot more precision commissioning.   It’s smarter and shows that we are in command of our space.