Following on from Commissioning Blog #7 Scoring System is the Key, it might sound obvious, but being clear about KPI’s and which ones to choose is paramount. This clarity has two important components:
Commissioners procuring public health services have a very tricky balance to achieve. Principally, they want assurance that the provider is achieving certain outcomes and it seems prudent to clearly state those at the beginning of the contract, or before providers even bid. However, given the complexity of behaviour change in the context of the real, lived-experience, it is difficult to find KPI’s that can be collected easily that demonstrate the kind of change that is likely to elicit sustainable outcomes.
In ‘The Tyranny of Metrics’, Jerry Z. Muller points out that the programmes that are transformational are the least easy to measure and those that are the easiest to measure are often the least transformational. Public Health interventions designed to change behaviours sustainably, fall into the former category i.e. hard to measure due to the myriad of factors that can contribute to the present situation. It is absolutely imperative that whatever metrics are selected in order to demonstrate effectiveness of a service, they should be used in conjunction with human judgement. There are few places where this is not the case. Even in pharmacological trials, where the statistics are all important, the data exists to be interrogated and to have questions sensibly asked of it to determine what it could mean. Human judgement allows the nuance and unpredictability inherent in working with groups of often complex individuals, to be a significant the focus of the intervention, allowing more genuine engagement on the real issues facing the members.
I recently saw an aspirational and inspirational tender for a public health service, however, the KPI’s they chose were all the market had to offer, and they did not match the rhetoric or ambition of the service specification. Without sensible discussion about what it takes to achieve long-term change, taking into account the wider/social determinants of health, metric fixation created a perverse incentive to not act in the best and long-term interests of the people being served.
At BeeZee Bodies, we are working with commissioners who want reciprocity and dialogue about how to achieve long-term change, not just meeting short term KPI’s. To use weight loss as an example; if you were helping someone with a complex home life and long history or weight issues to lose 5% body weight in the short term, you would support them to make willpower-based changes that amounted to gradual weight loss over 12 weeks. If your KPI was less fixed in time and more fixed in principle, it frees you up to focus on the whole person. Instead of focusing on and talking about weight straight away, for more complex folks you begin by exploring how they are feeling, their home life, employment, relationships, social support, etc. All the things we know impact the long-term ability to create an environment that supports healthy changes that are sustainable.
At BeeZee Bodies, we focus on people in this way in conjunction with our commissioners who value the long term outcomes and recognise the messy nature of supporting people in a holistic way. For some people (many people), it takes time and it isn’t linear!
If you are a commissioner, can you set the parameters of what you are trying to achieve and trust that the relationship with a provider will lead to long-term behaviour change? By focusing on the same KPI but removing the time limit, you allow passionate, talented public health professionals to flex their delivery to suit the needs of individuals.
Does this sound like I am trying to encourage commissioners to get rid of KPI’s? If it does, it shouldn’t. The question is if you don’t have the trust in your provider to do what is right by the people on whose behalf you are commissioning, are they the right provider?
Trust is a rare commodity. And the way the public health industry has evolved is largely about tying every detail down, so that there is no need for trust… it’s all set out contractually! But when you start from a position of building trust between commissioner and provider, amazing things happen. We have done this with all of our commissioners in the past, but our experience in the past 5 months in Gloucestershire, working with Julie, Sue and Angelika, has been built expressly around the principle of building trust, and it’s been great.
They are building their trust that we will involve them in decisions, be transparent and act in the best interests of the people we are working with. We are trusting that they are not going to hammer us if we fail at any point whilst engaging with this innovative and difficult process. As I mentioned in a previous blog, failure is where all of the best learning is done. We agree the principles we are using before we use them and we both believe in the evidence underpinning the action. This allows us to be genuinely interested in the learning we can take from the results. They have either created, or are lucky to have found themselves in a political environment that trusts them to do what is in the best interest of their populations. This is critical. If you don’t have a politically supportive environment from Councillors and executive officers in your organisation, it can be hard to afford trust to providers. Enter KPI driven culture without the flexibility of judgement.
‘The Speed of Trust’, by Steven Covey is worth reading and asking yourself whether you have this trust in your providers and them in you. If you are willing to engage in the complexity of an industry that is pushing short-term KPI’s hoping that they will lead to long-term results (some might!), you might just be surprised how much is possible!
We regularly provide support to commissioners as they are preparing to go to tender for behaviour change services. If you are interested in a chat we would love to hear from you.