Approach 4: Citizen-centred commissioning

June 2025 teaching template, slide 53

Approach 4 Citizen-centred commissioning

Empowering citizens within the system

June 2025 teaching template, slide 54

Approach 4: Citizen-Centred Commissioning

Introduction: Puts the individual in charge of their care and prioritises personal outcomes as success measures.

How to move toward: Develop a compelling shared vision and embed feedback like “Did you get what you needed?”

What to do: Enable co-design, empower personal choice, and align services around lived experience.

What not to do: Avoid tokenistic engagement or overwhelming citizens with too many disconnected choices.

Risks and issues: Risks losing system oversight or statutory compliance if not well-integrated.

Commissioning skills and structure: Requires change agents with high credibility, openness to learning, and system navigation skills.

June 2023 adult social care pre-reading, approach 4

Strategic Commissioning Approach 4. Citizen-centred commissioning

Putting people in charge of care.

Introduction to this approach

This approach pairs with the ‘user and outcome-centred’ commissioning aspect and is about putting people in charge of their own care and making their assessment of whether they get what they needed the measure of success in the system. It begins with a view that services often get in the way of people leading their lives as they want to and make it hard for them to get the support they need. There are several perspectives on this. One is that the aim should be to shrink the state and let people get on with living their own lives or empower them through direct funding and creation of marketplaces. In this perspective, the council's role is to provide necessary information and advice for people who have social care needs to enable them to find their own sources of support. Service provision is for those unable to help themselves. This is care based on individuals and families caring for themselves. In these circumstances, the approach works best where community need is mostly minimal with only some deprivation, there is little community-led demand for significant public services, and political leadership is focused on reducing the state.

There is also the highly person-centred approach provided in the case study provided in the pre-reading materials of a council and place that scores higher in the ‘user and outcome-centred’ commissioning aspect, where the locus of decision-making about care lies in conversations with the citizen and their own decision-making, through a combination of accessible community, universal, and self-funded services, and access to commissioned specialist services, where appropriate. This approach works best where a coalition can be built and its success demonstrated to key stakeholders, and where learning can expand across the whole health and care system. The ‘three conversations’ technique is an example of this.

There is a broader approach to including citizen reports on outcomes and co-design into more traditional service provision, including, where appropriate, payment mechanisms (though there are risks inherent in ‘payment by results’ contracts which mean they should only be used by exception). This approach can be introduced contract by contract and become a part of ongoing practice, and link to front-line interventions. This works best where there are good relationships with providers and a good understanding of how practice works and are able to build learning and adaptation into provision.

How to move towards this approach

Perhaps more than other approaches, this requires a compelling vision for commissioning and the ability to communicate it, and requires connection with senior leaders including politicians, frontline practitioners, and providers including community support. Transformational change requires a shared vision of change from all, best driven by experiencing what is possible.

It means shifting the basis on which services are purchased and resources allocated from units of service provision for pre-defined needs to what is needed to ensure that the outcomes desired by service users are met. The emphasis is on the results and learning, not the activity or intervention itself, and on empowering citizens to make their own choices. It can be challenging to win over senior leaders and to change the culture of assessment and design of plans.

There are several, potentially new, skills that need to be developed across the system from how to distinguish outcomes from outputs, inputs and processes, how to engage with the public and how to utilise data and analysis. Good first steps are setting up real prototyping and building in “did you get what you needed?” and further qualitative questions to all service provision feedback.

What to do, and what not to do, when you are pursuing this approach

At its heart, this is about moving commissioning into a facilitative role, to aid people in their lives. So this means co-design, a careful approach to statutory duties (neither letting them dominate, nor neglecting them), and measures driven by what people say they want and their experience and results.

It is important to note the risk of creating new ‘citizen-centred’ silos by building new services around specific needs, of adding to confusion and making services inaccessible by having a bewildering variety of choices, and to maintain a strengths-based approach. The main focus here is trust that individuals are their own best determinants of their care.

Specific risks and issues

Key risks include losing control of provision and being unable to learn about the system, by not building in connections back to practice and results – with obvious financial risks. At the same time, it is important to build in assurance that statutory requirements are being met. A ‘big bang’ approach is quite risky in this space, as it requires learning a new way to do these things, and unlearning some existing practices – small prototypes are useful. An alternative risk, though, is paying lip service to being citizen-centred, picking up the jargon without actually changing practice on the ground. There is also a risk of paying attention to the details of citizen engagement without being able to put in place the broader services that citizens need.

This approach is vulnerable to lack of understanding across partners and leaders, including politicians, which means a requirement to engage them in the practice so that they understand the approach and its benefits, as well as risks. This needs to be ongoing work, with succession planning, because changes of officer or political leadership may mean you have to make the case all over again. There is also a risk of attempting to adopt this approach ‘under the radar’, which can work at small scale and to demonstrate new ways of working, but is risky at a strategic level, without appropriate authorisation.

Considerations for commissioning skills and structure

This approach requires an inversion of the normal structure, so is challenging to do across a whole council, therefore the structure is likely to be focused on adult social care, though inevitably an approach led by what people are trying to achieve in engaging with your services will require strong connections with internal and external partners. That inversion is about supporting and learning from practice, which in turn is led by the citizen. So commissioners need to be strong change managers and have the credibility to get the backing for quite radical experiments from senior leaders, and need to be very open to learning, and showing their working. They also need to be able to support front-line experiments while maintaining an overview of and approach to the whole service system.

Examples of this approach in practice

• Co-production to transform mental health services: A council faced high rates of psychosis, Mental Health Act admissions, acute hospital admissions, and adults in high cost residential and inpatient placements. Working with their then Clinical Commissioning Group, they tested co-production on a large scale, putting citizens at the heart of their own care. A series of storytelling and co-design sessions helped set a bold and shared vision for a system focused on prevention rather than crisis care. A resource map, brought to life by trained peer researchers telling community stories, identified that little funding was going to services designed to help people live well in their communities. Four key changes were made: a collaborative across service users, GPs, providers and commissioners to drive the change, an empowered network of providers, support agencies, statutory organisations and others with a focus on ‘living well’, a jointly-funded organisation that manages funds for those who need personalised care and personal budgets, and a hub to provide easy, integrated access to services. The result was a 32 per cent reduction in referrals to secondary care, with 500 people now supported by the network, many of whom would not have previously had any support at all. The waiting time for support in secondary care reduced from one month to one week. Professionals recognised the integral value of working with people with lived experience of mental health problems, and the initiative saved 20 per cent against an original budget of £12m.
• Empowering users and their families to take control: A council needed to change the way that day services for people with learning disabilities were organised. The existing centres were increasingly seen as inappropriate, particularly for younger people. Families and carers were dissatisfied, but feared that the council would close the centres, depriving them of essential day-time respite. A campaign group – “Save our Centres” – was being talked about by a number of families and there was some political nervousness. The council decided to explore the potential for handing over the day centres to families and carers, who would form themselves into a user-led Community Interest Company. The commissioning team pulled together a council-wide working group to develop the business case, including estates, legal, and finance. They also sought a delivery partner to work alongside the family/carer group whilst they developed their skills and capability to manage the business. The centres were leased to the CIC, staff were offered a secondment to work with the new organisation, and a budget for service development was established. The CIC were then able to offer commissioned places via the community learning disability team and directly to service users and families.  
• Drug and alcohol service cost reduction and service improvement: A council identified the need to make savings while re-tendering for a drug and alcohol service and moving it to a new lower-cost building which presented opportunities for variation in service delivery. A commercial board was set up to govern the project, with procurement and commissioning staff, and approved a procurement route using a widened definition of ‘most economically advantageous tender’ (PCR 67 (4)): ‘The cost element may also take the form of a fixed price or cost on the basis of which economic operators will compete on quality criteria only.’ The specification was presented as a flow chart, tracing the value chain from resources to activities to delivery arrangements, outputs, near outcomes, and overall outcomes, and focusing on outputs such as ‘improved opportunities for non-opiate users to use the service’ and ‘opportunities for substance using parents with resident children to access treatment’, and near-outcomes including ‘high levels of successful completions of treatment’. The responses were evaluated primarily based on providers setting out their resources, activities, and delivery arrangements, effectively comparing the council’s logic model for what would achieve the outcomes with those of the potential supplier. The council was therefore able to identify a supplier with the most credible delivery model to meet the outcome specification, within a fixed budget which delivered the required savings.

One thing to read

Do Asset-Based Areas Commission? Public Service Transformation Academy. 2017 https://www.publicservicetransformation.org/2017/10/asset-based-areas-commission/