Ficha Técnica de Alemania

Commissioning will be ineffective if the problem it is intended to address is poorly defined, so clear problem definition is an essential pre-requisite.

Commissioning involves the design of a system to efficiently and effectively deliver a service, including consideration of the following aspects:

 outcomes sought and performance measures;

 service specification;

 allocation of decision rights (who can decide what, and with what authority);

 eligibility;

 quality;

 price;

 sustainability;

 innovation; and

 monitoring, evaluating and learning.

Careful design, reflecting the characteristics of a particular service

Conventional markets work within a legal framework determined by government.³⁹ Standard market

mechanisms, operating within the legal framework, can be relied on to set prices, communicate information,

38 A proportion of the payment is made up front, irrespective of success, to reduce the financial risk faced by providers.

39 In New Zealand, this framework includes the Sale of Goods Act 1908, the Consumer Guarantees Act 1993, the Contractual Remedies Act 1979 and the Fair Trading Act 1986.

deliver a specified outcome for that individual.³⁸ For example, an unemployed client facing multiple disadvantages might receive a voucher for £11,000 payable to a provider who finds them employment that is sustained for two years.

Clients get to choose their provider, but cannot switch once that choice is made.

A feature of the proposal is the breadth of the proposed outcomes. The report envisages that vouchers would be issued for around 10 “king outcomes”. These are intended to span multiple bureaucratic silos, encouraging service prioritisation and integration.

Providers can be licensed for one or more king outcome. Licensing would be the responsibility of an independent regulator. Licensing would be intentionally “light handed”, encouraging new providers into the market.

Source: Haldenby, Harries and Olliff-Cooper, 2014.

resolve disputes, and provide incentives for investment and innovation. This approach is reasonably generic, in that it (relatively) rarely requires extension for specific products and services.

Social services markets are not conventional economic markets (Appendix F). Their characteristics typically mean that one or more framework parameters need to be administratively designed or specified. And as social services have varying characteristics, typically the framework needs to be customised for the specific social service.

Co-existence with other services

Commissioning, as described above, is mostly undertaken one service at a time. One could envisage a process started at the top of a master list of services, deciding on the best way to organise the first service, implementing the necessary changes, and then moving down that list.

Such a process, however, is unlikely to lead to the best overall solution. It risks a system with lots of unclear boundaries and accountabilities. It also risks inequitable outcomes. For example, the Disabled Persons Assembly pointed out:

New Zealand has two separate systems providing disability supports:

a. Accident Compensation Corporation (ACC) that covers people disabled by injury or accident, and b. Ministries of Health and Social Development, including the District Health Boards, that fund

people disabled from congenital factors or from ageing (sub. 54, Attachment One, p. 28)

Individuals facing the same condition are assigned to a system based on the causal mechanism. However, the two systems offer different levels of support:

…if a leg or sight is lost through diabetes, supports are likely to be much less than if sight or a leg was lost as the result of an accident. (sub. 54, Attachment One, p. 28)

As well as co-existing with other services, new or redesigned services have to fit with the wider policy environment (eg, income support obligations and sanctions) and other initiatives such as social marketing campaigns.

Service commissioning requires a wide understanding of the other services and activities that may complement or substitute for the service in question, and of how these services might interact. This is particularly important in the case of services for clients with multiple, interdependent problems that require integrated assessment and support (Chapter 10).

Information and incentives for efficient allocation

The markets for regular services have mechanisms for spreading information about service availability and quality. These include price, reputation, advertising, independent quality certification and third-party reviews. Social services lack some or most of these mechanisms, so it is likely that they will need to be designed as part of the commissioning process.

It is important for commissioning organisations to address information availability, reliability and dissemination. A client-choice driven service, for example, will not have the desired effect on provider quality if clients are ill-informed about provider quality.

In the Australian employment services system, each provider receives a star rating from the Department of Employment to reflect its success in achieving employment outcomes given the types of clients they are serving and labour market conditions where they operate. Star ratings are made public to inform client choices. They also influence the Department’s decisions on market share in each contract round (Chapter 3;

Appendix B).

Goal specification and measurability

Service stewardship is an overarching responsibility for the monitoring planning and management of resources in such a way as to maintain and improve service performance (section 6.5). Relevant activities include performance monitoring, identifying barriers to and opportunities for beneficial change, and leading such change.

Key to this is having clear goals, clear service performance metrics, and a strong logic joining the two. A well-designed data infrastructure is essential for quick feedback on the chosen performance metrics (Chapter 8).

Allocation of decision rights

Decision rights define who can change what, and with what authority. The who is important, because different participants face different incentives, and have access to different information (Chapter 4).

Chapter 5 discusses the importance of carefully allocating the responsibility for commissioning.

The allocation of decision rights should reflect the desired balance between national consistency and local adaptation, and permit experimentation without compromising service outcomes. This is a hard balance to get right; but even harder if it is not treated as an explicit design decision. When contracting out, one useful framework is tight-loose-tight:

In our experience contracts that come closest to adopting a ‘tight, loose, tight’ high trust contracting framework gain the benefits of flexible service delivery and maintain government accountability. Tight in terms of specified resource, population and impact/outcomes; Loose in terms of how the provider is monitored to apply the model of care (assuming a foundation of evidence-based best practice), Tight in regards to evaluation and improvement. (Wise Group, sub. 41, p. 44)

Essentially, the commissioning organisation needs to decide the desired outcomes, the provider needs to decide the how of service delivery, and the provider needs to demonstrate their performance against those outcomes. This framework is applicable to most service models and is a good starting point for the

allocation of decision rights.

Client eligibility for services

Social services range from those that are at risk of being under-consumed (eg, drug and alcohol

rehabilitation programmes) to those that might be over-consumed (eg, elective surgery). In each case, an important commissioning task is deciding who the service is for.

Having decided that, the next question is how to ensure that the service is targeted to those people. This usually involves establishing eligibility criteria and deciding who will assess people against those criteria.

A further question is how the service deals with changing client circumstances, which may necessitate reassessment. An appeals mechanism may be required should clients be likely to challenge eligibility decision.

There is a trade-off between simplicity of eligibility criteria and accurate targeting through more complex criteria. Similarly there may be a trade-off between national consistency in assessment, and assessments that are more responsive to the particular situation of individuals and their local environment.

These issues are present in all service models, though the specifics may vary. See Chapter 11 for a discussion of eligibility in the context of client-directed budgets.)

Quality

Quality is inherently ambiguous and contested in many social services markets. In a conventional market, consumers judge quality, and trade it off against other service attributes (eg, price, colour, convenience). In social services markets, different participants may apply differing criteria when judging quality – and thus may make different trade-offs. For example, process integrity is an important aspect to quality from a government perspective, providers may be more concerned about the qualifications of the person delivering the service, and clients may care more about availability, friendliness and approachability.

Governments may be tempted to over-specify services to ensure quality on the dimensions they think important. This may, however, unnecessarily reduce the flexibility of providers and dampen innovation.

For the contracting-out and managed market service models, the regulation of quality is usually done by the funder and specified contractually. Quality regulation can be internal under in-house provision; however this risks conflicts of interest.

The regulation of quality can be more complex under other service models. Some form of independent quality regulation is often used. Occupational regulation is typical for some professional services. For health, this is supplemented by the Health Quality & Safety Commission.

The Health Quality & Safety Commission was established under the New Zealand Public Health &

Disability Amendment Act 2010 “to ensure all New Zealanders receive the best health and disability care within our available resources”. (HQSC, n.d.)

The Educational Review Office performs a similar function for schools.

Competition between providers on the basis of price runs the risk that providers skimp on quality (Appendix F). This will be of concern if quality is difficult to observe by those making choices between providers. The best response to this risk will depend on the specifics of the service and service model.

Responses could include:

 changing who makes the choice between providers (eg, allowing clients to choose their provider rather than being assigned to one by a bureaucracy);

 collecting and publishing information on provider quality;

 fixing prices administratively, so that competition shifts to other observable service attributes;

 increasing peer monitoring; or

 licensing and regulation to set minimum quality standards.

Consultation and feedback

Consultation during service commissioning has three distinct purposes. First, consultation is a means of finding information held by others that can be used to clarify objectives and design a better service.

Second, consultation is a means of building wider support for, and ownership in, a service design. Third, consultation may be necessary to meet a wider requirement (eg, a Treaty relationship).

Providers, client representatives and commissioning agencies may hold different views about the purpose of consultation. Service commissioners should be clear why they are consulting and convey this clearly to those consulted. This avoids imposing unnecessary costs on those consulted.

Feedback has three important purposes. First, it provides information that supports ongoing fine-tuning and service evaluations. Second, it can identify incidents of unsatisfactory service performance. Third, it can identify individuals who are poorly matched to a service, with the aim of redirecting them to one more suitable.

Provider consultation

The importance of early consultation of service providers and user groups has long been recognised. For example:

It is fundamental that potential and actual service user needs form the basis for the specification and monitoring of social service delivery contracts. Consultation with service providers and user groups and regular surveys of individual users should be an inherent part of agencies’ systems and procedures for formulating contract specifications and performance monitoring criteria. (Deloitte Ross Tohmatsu, 1993, p. 15)

While the benefits of consultation are recognised, implementation appears patchy. For example, Health Care of New Zealand Holdings considered:

There is an important opportunity prior to going to market to work with the sector to define the requirements so that the best outcome is achieved for the community. This kind of sector collaboration prior to such processes is not happening often enough or in a way that improves the quality of the process. (sub. 51, p. 13)

Many are attracted to the concepts of “co-production” and “co-design”, which includes wider involvement in design, governance and on-going service management and delivery (Box 6.3).

The concept of co-production overlaps with devolved architectures (Chapter 5), the shared-goals service model (section 6.2) and devolution to Mäori organisations (Chapter 13). Readers should refer to those parts of this report.

Co-design can be valuable for complex services where expertise and information is widely dispersed, and where it is crucial to build wider support for, and ownership in, the service design. Service commissioners should be very clear about the limits within which co-design operates; that is, which aspects of the service are being co-designed and which remain the responsibility of the service commissioner. Failure to be explicit will likely frustrate participants (Appendix D).

Consultation can cause delay, and involves costs. Commissioning agencies should therefore target those most affected by the service and match the amount of consultation to the size and complexity of the service to be supplied, and the value expected from that consultation.

Client consultation

Service clients should be consulted by commissioning agencies for the same reasons that providers should be consulted. Clients can have information that no-one else has. So it makes sense to access and use that information. However that information can be difficult to access. Service providers may be the best proxy of client views for some difficult-to-access clients (eg, homeless people). On the other hand, there are capable and effective advocacy groups for some service users (eg, people with disabilities).

Clients may be better able to judge service quality than can service commissioners. This ability can be exploited through choice of service model (eg, vouchers).

It is unreasonable to expect clients to be professional service designers. If service commissioners lack professional capacity, they should deal with that problem directly rather than relying on consultation to fill gaps in expertise. Commissioners should seek the combination of client-held information and professional expertise that leads to the best service design.

Box 6.3 Co-production and co-design

Matahaere-Atariki et al. (2008) described co-production in a Mäori context:

Co-production is more than a “bottom up” community development model and does not aim simply to promote community planning and user-focused services. It involves a more active role for iwi and Mäori authorities in designing and delivering local services, as well as providing the opportunity to influence the policy process by working with government to invest in shared outcomes for Mäori. (p. 34)

The concept of co-production was developed by a group of academics at the end of the 1970s in reaction to what they considered were problems with dominant theories of the time about urban governance and centralisation, and to address the failure of conventional development

programmes... These academics were concerned with the idea of engaging citizens in both the design and production of public services. At the same time, Edgar Cahn was developing his concept of an alternative currency he termed “time dollars”. Cahn developed a theory to explain why and how this currency could change the dynamics of social welfare programmes, which he too termed co-production... Both models have similar aims: to give responsibility to and involve those who have in the past been regarded as “the problem” in creating solutions for themselves.

It is the opposite of deficit thinking and offers an alternative to only public or only private service provision... (p. 35)

The Wise Group supported a co-design approach:

…generally described as “a product, service, or organisation development process where design professionals empower, encourage, and guide users to develop solutions for themselves. Co-design encourages the blurring of the role between user and Co-designer, focusing on the process by which the design objective is created”. (sub. 41, p. 17)

F6.5

Consultation with service providers and users during service commissioning can discover information that can be used to clarify objectives and design a better service, and to build wider support for, and ownership in, a service design. But consultation can cause delay, and involves costs.

R6.5

Commissioning agencies need to be clear why they are consulting and convey this clearly. Agencies should target those most affected by the service and match the amount of consultation to the size and complexity of the service, and to the value expected from consultation.

Complaints and feedback

Direct feedback from complaints is also very helpful. The literature states that only 4% of people dissatisfied with a disability support service will actually make a complaint about it – so complaints provide vital information that the other 96% are unwilling or unable to provide for a host of very good reasons. (National Services Purchasing, sub. 111, p. 8)

A very strong and clear message [from] service users … was that above all they needed to be treated with respect by service providers. (Kay Brereton, sub. 9, p. 1)

Empowerment is not only about engagement in individual or collective decision-making processes. It also includes mechanisms for making complaints and seeking reviews. Brereton contended:

An important safeguard for people using the social services of statutory agencies is the statutory access for review and appeal rights as well as to watch dog agencies such as the Ombudsman. (sub. 9, p. 2) Brereton further cautioned that if a service is contracted to a non-government provider, it is important to ensure that the contracting-out process does not create barriers to review and appeal mechanisms for clients.

The Auditor-General recently described the benefits of well-functioning appeal and complaints systems:

Public entities that welcome complaints signal to citizens that someone is listening to them and that they can influence public services. For the entities, complaints are a free source of advice. Complaints can provide valuable insight into poor service, systemic errors, or problems with specific processes.

Complaints also give public entities an opportunity to understand the motives, feelings, and expectations of the people using their services. (OAG, 2014b, p. 4)

The Commission agrees that good consultation and complaints mechanisms are part of a well-functioning learning system (Chapter 7) and signal the commitment of an organisation to empower its clients.

F6.6

Complaints mechanisms are part of a well-functioning learning system, and signal the commitment of an organisation to empower its clients.

Price

Many systems need to establish prices through administrative mechanisms. At least two prices matter – that paid by clients and that paid by the funder to the provider. Setting prices – or determining who will set them and on what basis – is part of the commissioning process.

Client prices

Client prices are often set to zero to encourage uptake by those targeted. But this may be an insufficient incentive to get all of those in target groups to take part. So it may be necessary to subsidise some transaction costs, make the service compulsory or to bundle an activity with income support. Respective examples include:

 paying a client’s transport costs to a health clinic;

 free, compulsory schooling; and

 obligations to seek work.

Client prices at zero can encourage over-consumption. So a rationing system and/or differential pricing may be needed for different groups of clients. That, in turn, requires the specification of eligibility criteria and to define who is in what group.

Price discovery

Regular markets determine prices through many interactions between buyers and sellers, each motivated by private interest. These interactions and incentives are limited in social services markets, so alternative means of determining an efficient price may be required.

In particular, contract markets with a dominant purchaser, mission-oriented suppliers and/or limited

In particular, contract markets with a dominant purchaser, mission-oriented suppliers and/or limited

In document Alemania como posibilidad de mercado para la miel mexicana. (página 90-94)