Mental health clients using services in the community can become commissioners in their own right, says Ailsa Claire

The Department of Health consultation document Commissioning Framework for Health and Well-being challenges us to commission for 'what outcomes people want for themselves and their communities'.

In Barnsley we have a strong, long-standing partnership with Barnsley metropolitan borough council; pooled budgets, lead commissioning, integrated adult and children's services (including mental health), joint appointments of social service directors and a joint public health department.

The partnership is moving to single assessment, integrated records and a single case management model within the context of broad strategic partnerships for adults and children. Client-centred services have resulted in outcomes such as no blocked beds, substantial reduction in residential and nursing home placements and low mental-health admission rates.

Service quality is good, with many skilled and experienced staff valued by the people they care for. Despite this, the view in Barnsley is that just improving the current models of health and social care is unlikely to meet the challenge set out in the commissioning framework.

As elsewhere, clients have low expectations of services. With the best will in the world, we still offer paternalistic services. Patient-centred care is provided once we have assessed the client and determined eligibility criteria and the care pathway. It is rare for us to ask the person about context and things that are important to them.

This is despite acknowledging that much of what supports and promotes health and well-being has more to do with personal action than care. Repeatedly public health reports tell us there is limited additional impact to be gained by continuing to tell people what is good or bad for them.

The outcomes people want for themselves and their community means them deciding what they want and controlling their own lives, rather than being served by organisations that only focus on small aspects of what is important to them. Easy enough to say, but this requires a major shift in power, responsibility and control.

It is a different sort of contract with the population, based on an assumption of self-care and personal responsibility, where there is an expectation of allowing the individual to maintain control.

Challenging perceptions

A common response to this concept is that people are unwilling or unable to implement self-directed support, despite that being what we want for ourselves. Barnsley is challenging this through its 'every adult matters' campaign, based on precisely these assumptions of self care and self-directed support. It assumes an individual is best placed to make decisions about their lives and various aspects of care, and that we should only intervene when the individual has limited capacity to do it themselves.

We want to give people the information to assist them in self assessment and decisions about services and the promotion of personal health and well-being. This is part of a whole-system that includes education and employment, housing, community well-being and public health.

The model focuses on supporting the people of Barnsley to have maximum control over their lives, with the focus on empowerment and partnership between individuals and service providers. Self-directed support will result in a move away from traditional care, which is often paternalistic and professional-controlled, to services which support the individual. We expect this to shift traditionally organised care away from home, such as day care, to a wide range of self-selected support.

Individual model

Health and social care support for individuals will be based on a model of maximum self assessment, self-managed care and individual budgets for care for planned services that can be spent to meet the outcome agreed.

We will commission broker/care navigators to support people, at their request, within a self enablement model. For people with deterioration issues such as cognitive decline there will be maximum use of advanced directives. The assumption of self management requires maximum supply of information on quality, outcomes and alternative sources of provision or care options.

Evidence shows that such a model results in increased health and well-being outcomes, client-focused services and outcome based commissioning, driving radical change in the nature and patterns of service provision.

But to make it work takes whole-system determination. There are significant implications of the individual-as-commissioner and care co-ordinator that challenge the way we are currently planning to commission and deliver services. The individual owns their care record, will determine who if anyone will help them, what services they want and who will provide them.

As institutional commissioners we have to recognise that this is not like commissioning acute services. There will be real plurality of providers, including neighbours and family, and it will drive completely different models of services.

We will need to continue to commission services where unscheduled access is required; for example, where we know x number of people require the service in any one year but we do not know their names.

To ensure plurality of provision we need to manage a market with accreditation or acceptable standards, and potentially a fee, but most likely without a contract for service. This is much like the private sector residential market, where providers are regulated and fees are set but payment only occurs if the client chooses to go there.

Needs assessment takes place by or with the client against a budget allocation process and outcome plan. As commissioners we can learn the lessons from individual budgets being rolled out in social care (including Barnsley's), which includes models of financial flows and activity verification that can be adapted for health.

Full engagement of practice-based commissioners is required as the money will flow from them into individual budgets, and integration of local authority and NHS financial systems.

Market moves

As commissioners we need to market manage care and broker management options to ensure choice.

The model drives a separation from care provision of assessment and care management, solving the age-old problem of multiple key workers and care managers and passing the client from one to another when needs change. It also creates role clarity and more effective and efficient services to support clients.

This is a challenge to the risk-adverse systems created in health and social care and existing governance models. There are local and national political issues as we deal with the tension between views that this is either personalised care or post-code lottery, client-driven free choice or privatisation

Providers will have to deal with the individual as a commissioner, creating much more flexible, contestable services capable of creating an individual response. In the face of real plurality of provision and service options, for the first time we may have the chance to create genuine client-centred care.

Different models of provision will require different models of management, with partnership as well as competition between providers and greater supply-chain management. It will also require providers contracting and costing compliance methodology based on unit costs and outcome criteria

This means a massive cultural change in organisations and the population we serve and will result in changing expectations of clients and staff. As commissioners our job is to hold this together, to manage by evolution, but quickly.

For more on the Barnsley project go to

HSJ is holding a pre-conference commissioning workshop on 24 September and a conference on commissioning health and well-being on 25 September. To find out more go to