Commissioning has been described as a cyclical and iterative process that ensures the needs of the population are effectively met through the provision of social care services (1–3). Commissioning involves assessing the needs of a population, responding to the highlighted needs, and designing and implementing care pathways around those needs (4). In an attempt to become more responsive to the needs of the population, the concept of providing individuals with a ‘voice’ via stakeholder involvement has been advocated within English health care policy for several decades (5–7). The need for patient involvement was flagged in the 1982 Working for Patients white paper (8). However, moves to increase stakeholder involvement in care decision-making have accelerated in recent years in response to two major factors, one being that politicians demand greater efficiency from services and an effective use of public funds; and, secondly, due to members of the public demanding increased involvement in decisions about their care and services (9, 10).
The 2007 world class commissioning (WCC) framework (11) was one of the first policies that explicitly charged commissioners within the English National Health Service (NHS) with the task of pursuing ongoing and meaningful involvement with stakeholders (12). The WCC framework was superseded by the Health and Social Care Act 2012 which required Clinical Commissioning Groups (groups of general practices) in England to work together to plan, design and manage health services within their local areas. Clinical commissioning groups were also tasked with enabling patients and members of the public to participate in the process of commissioning (6).
More recently, Transforming Participation in Health and Care (6), the NHS England guidance Patient and Public participation: in commissioning health and care, and the 2019 NHS Long Term Plan (13) have set out key actions on how to embed the involvement of members of the public and stakeholders in their work (7). Indeed, the NHS Long Term Plan (13), alongside the Think Local act Personal partnership, shows the support which exists for greater personalisation of health and social care (14) where citizens and patients have a greater role in policy-making and shared decision-making in health and care settings (15).
There are several perceived benefits of involving stakeholders in commissioning. Stakeholder involvement has the potential to present everyone involved in commissioning and decision-making to different perceptions and standpoints which facilitate a broader understanding to be obtained regarding the community context that exists (16–18). Additionally, it may strengthen democracy and enhance the credibility of services by promoting an understanding of the issues, reducing uncertainty and promoting trust and legitimacy on behalf of service users (4, 19) which in turn could improve the sustainability of public health services if stakeholders have confidence that services are endeavouring to meet their needs (20–22).
Elliott and Williams (23) have argued that the experiential wisdom that lay people hold is a form of legitimate expertise which can become ‘the basis for a powerful form of knowledge production’ adding an extra dimension within the commissioning process (4). A lay person is a person who is not trained, qualified or experienced in a particular subject or activity (24).
Despite the perceived benefits of stakeholder involvement, the process of involving stakeholders in the commissioning process can be complicated as any individual can be considered a stakeholder if they are affected by or can affect an issue (i.e. alcohol) (25). Furthermore, the identity of individual stakeholders is not fixed, the level of interest an individual has regarding an issue and the ability to influence may fluctuate. An array of terms such as patient, client, service user and customer are interchangeably used in health and social care contexts (4). The multifaceted nature of alcohol use and misuse lends itself to individuals encompassing multiple identities where needs are managed across statutory and voluntary services covering both health and social needs. The varied collection of terms serves to emphasise how it is possible for confusion to arise when trying to establish who stakeholders are regarding alcohol use/misuse and alcohol service provision.
When considering alcohol service users specifically as potential stakeholders in commissioning, the extent of alcohol use/misuse is varied. It is estimated that 10.4 million adults consume alcohol at levels that increase their potential for health related harms (26), many individuals who fall within this category would not consider themselves to have a problem and would not contemplate attending specialist services (4). An estimated 595,000 adults may need treatment for alcohol dependence although Rehm and Roerecke have identified that the majority of alcohol related mortality and morbidity is as a result of heavy (though not necessarily dependent) alcohol consumption (27). This highlights a challenge for commissioners when considering intervention options across the entire prevention, treatment and recovery continuum.
Types of stakeholder involvement can vary significantly from a one off consultation to engaging in continual exchanges of ideas and negotiation regarding the planning, design and management of services (28). Arnstein’s (1969) ladder of participation (29) represents one version of how stakeholder involvement can be interpreted (Fig. 1). Commentators such as Feingold (30) Burns et al (31) and Wilcox (32) have redesigned Arnstein's model to fit their respective contexts that they are working in. Different commentators acknowledged that different levels of involvement are appropriate at different times to meet the expectations of different stakeholders involved in the process (33).
Arnstein’s ladder is used within this paper, it illustrates eight potential ways that stakeholders and community members can participate in decision making. Arnstein argued that only the top three rungs of the ladder - partnership, delegated power and citizen control - represent genuine participation with people, with the five rungs below symbolising tokenism (4). Tokenism is understood to mean the process of only making a symbolic effort to do a particular thing, such as only targeting a small number of individuals within a ‘hard to reach’, vulnerable or excluded group, in order to give the appearance of equality (34). The ladder emphasises that there is a substantial distinction between an individual having the required level of power and influence to affect an outcome within a decision making process and the symbolic ritual of participation (29). This study did not aim to refute Arnstein’s model or propose it as an ideal model to be adopted within alcohol commissioning, it was used to contextualise the different levels of involvement described as taking place within the commissioning process.
However, despite increased attention in recent decades, a number of commentators have identified that, within many public health and clinical settings, stakeholder involvement remains rhetorical and could be considered to be tokenistic, according to Arnstein’s ladder as described above (35–37). A number of studies report inconsistencies between the stated levels of stakeholder involvement that occur and the actual extent of involvement taking place in the multiple stages of the commissioning process (37–41).
In the context of the study reported in this paper, the term stakeholder involvement was used to denote participation or engagement at any level in the design, development and delivery of services. This paper uses the example of alcohol services to explore the experiences and perceptions of stakeholder involvement in the planning and commissioning of publicly funded services offering treatment and care to adults in need of support for alcohol related problems.