This new paper shares findings from small-scale research into the perceptions and experiences of third sector organisations in NHS and local authority-led commissioning of mental health services.
The role of the third sector is of particular interest, given current policy directions towards greater integration, parity of esteem, personal health budgets, community mobilisation and cross sector working.
The report notes that services provided by third sector organisations now typically includes: advice; counselling; education; advocacy; employment; respite and home support.
The research, by from the Third Sector Research Centre at the University of Birmingham, underpinning the report consisted of three elements:
- a literature review carried out in 2012
- a set of interviews from a case study area incorporating 3 local authorities
- an online survey of third sector organisations.
There are some limitations to the research, notably, the small sample sizes of the interview and survey samples – in total, 23 organisations feature in the sample, which seems low; however ,the authors acknowledge limitations of the the different distribution methods. Also, the case study area, a conurbation, may not be representative of more rural areas. The authors note that interviews took place from early summer to autumn of 2013, and it would be interesting to follow up at a later date to get a feel for how structural reforms may disrupted local arrangements and relationships, and therefore influenced responses.
The authors suggest that the perception of what commissioning should involve varies, arguing that it may be more useful to view as a continuum rather than a cycle, with “intelligent/collaborative” commissioning on one side, with “commissioning on price/procurement” on the other side. The report notes that the reality of commissioning is often different to the standard commissioning cycle, with third sector organisations frequently reporting a lack of engagement and involvement in the full cycle. There is also concern that mental health is particularly vulnerable due to the focus on block contracts.
In terms of how commissioning currently works, it is suggested that the standard approach (e.g. standard national contracts) used frequently may disadvantage smaller organisations who feel unable to compete with larger organisations (whether NHS, private or third sector) – framework agreements were seen as beneficial. It was also suggested that the focus on quantitative targets missed an opportunity to monitor service user experience and more qualitative measures. There is clearly a balance to be achieved between robustness and flexibility.
The research was conducted in England and it is noted that the combination of funding pressures and recent structural reform have had an impact. The authors did find some instances of long-term relationships and contractual arrangements, characterised by continuity and strong relationships which help “smooth out disruptions” caused by structural and policy changes.
There are some important lessons for commissioners in the reflections of third sector organisations:
- Organisations reported some concerns with procurement processes, including delays in issuing tenders, signing contracts and confirming extensions; poor communication; lack of engagement on changes to reporting and monitoring requirements.
- The opportunity to work more collaboratively is often lost with third sector organisations sometimes perceiving an imbalance in relationships. A lack of coordination across public sector organisations exacerbates this, causing confusion over roles and responsiblities.
- The report questions the need for more training and development for commissioners, particularly around their ability to broker agreements; technical contracting and procurement knowledge; and communication skills.
- The transformation needed to shift the focus from treatment to prevention and from acute to community services, is difficult when commissioners don’t have the whole system oversight and accountability – within England, the Better Care Fund has of course come along since the research was conducted and although there are concerns about expectations, in some areas, it may be a useful enabler towards greater integration and shared governance. The impact of personal health budgets and outcomes based contracts are noted and may further drive the transformation needed, as demonstrated in some early projects using alliance contracts for example.
Communication and relationships are strong themes throughout the report and commissioners may wish to reflect on tackling barriers and enablers to working more effectively with the third sector.
Rees J et al (2014) Public sector commissioning of local mental health services from the third sector, Third Sector Research Centre, University of Birmingham, Available at : http://www.birmingham.ac.uk/generic/tsrc/documents/tsrc/working-papers/working-paper-122.pdf.