Organisations need to collaborate in order to to improve health and health care for the populations they collectively serve, believe Chris Ham and Hugh Alderwick

The NHS in England is in crisis. It faces growing pressures on services while rapidly running out of money to pay for them. Quality of care is likely to suffer as a result.

‘Commissioning in the NHS must become more strategic and integrated’

The NHS is trying to overcome these pressures in the context of the Health and Social Care Act and its legacy of structural arrangements more complex and fragmented than at any time in its history. These arrangements have left a vacuum in the leadership of the NHS at a local level with a sense that “no one is in charge”. The fragmentation of commissioning responsibilities has added to the chaos.

The perennial question for those working in the NHS is how to make the existing system work better, without going through another round of damaging and distracting reforms? The added challenge is that time and money are both in short supply.

Our suggested response is for providers of services to establish “place-based systems of care”, working together to improve health and health care for the populations they collectively serve. This means organisations collaborating to manage the common resources available for providing care in their area.

Common principles

We set out what this means in practice in a new report, Place-based systems of care: a way forward for the NHS in England. Rather than being imposed from Whitehall, we argue that the approach taken to developing systems of care should be determined by local organisations and the populations they serve, based on a common set of principles.

‘Organisations will need to cede some of their own sovereignty and agree how decisions will be made collectively’

These include establishing an appropriate governance structure, developing a sustainable financing model, creating a new form of system leadership, and designing a single set of measures to support improvements in care.

In developing a new governance structure, organisations will need to cede some of their own sovereignty and agree how decisions will be made collectively. They must also be willing to see some of their own resources invested elsewhere in order for this to result in better outcomes. And if organisations fail to play by the agreed rules of the system, they will need to agree the consequences. None of this will be easy in today’s NHS which was not designed for working in systems.

To support this kind of approach, commissioning in the NHS must become more strategic and integrated. This means commissioners developing capitated budgets covering the whole of a population’s care for providers to manage over a number of years, with payments linked to the delivery of outcomes. It will also mean commissioners working in footprints much bigger than those usually covered by clinical commissioning groups today.

Emerging examples

Emerging examples of place-based systems of care can be found across the country. In the Isle of Wight, for example, NHS organisations and the local authority are changing the way that they are organised as part of their work as a primary and acute care system vanguard. A joint commissioning board and a joint provider board have been established, with the aim of commissioning and providing care for the local population with a “one island £”.

Lessons can also be learnt from other countries where these ideas are more established. A good example is Canterbury, New Zealand, where those involved in delivering health and care services have formed an alliance called the Canterbury Clinical Network, collectively leading service improvements under a ‘one system one budget’ approach.

Removing policy barriers

Developing systems of care is not simply a local responsibility. Government and national bodies have a role to play in removing the barriers that get in the way of working in this way, while also supporting the new policy mechanisms needed to make it happen.

‘National bodies themselves will also need to work in a more coordinated way when intervening in local health systems’

These barriers are all too familiar. They include fragmented commissioning arrangements, payment systems that reward organisational activity rather than collective outcomes, and regulation and performance management focused too heavily on individual organisations.

National bodies themselves will also need to work in a more coordinated way when intervening in local health systems. But above all, they must give the freedom to local areas to develop their own approaches to improving services.

Simon Stevens outlined one way that areas could be encouraged to work in systems of care in a recent speech at The King’s Fund. He suggested that increases in NHS funding in 2016/17 would be held back until NHS organisations and their partners came forward with agreed plans for improving health and care in their areas.

Avoiding the fortress mentality

Making these ideas happen will be neither simple nor easy. In some areas, there will be challenges in defining the “place” being served, and in others it may be difficult for leaders to rise above organisational loyalties.

If these challenges cannot be overcome, the risk is that a fortress mentality will prevail, which could ultimately descend into a “war of all against all”.

Chris Ham, is chief executive and Hugh Alderwick senior policy assistant to the chief executive at The King’s Fund

Place-based systems of care can be downloaded at: