The role of commissioners of healthcare cannot be limited to specifying needs, issuing contracts and paying invoices. They must adopt the role of “market-builder” alongside “buyer” if the ambitions for integrated health and social care are to become a reality. By John Copps
To meet the long term challenges to the NHS – financial and clinical – everyone from politicians to doctors agree that a closer union of health and social care systems is part of the answer. Despite universal consensus on this idea however, progress on the ground has been slow.
The trouble is that the government’s ambitious plans around integrating health and social care describe a market that doesn’t exist yet. The service offerings, commissioning structures, and relationships needed to support integrated healthcare are very different to what we have at present.
Local context adds to the complexity with the jurisdictions of Clinical Commissioning Groups, NHS trusts and local authorities different wherever you are.
This is something that those at the sharp end are finding out.
They must take an active role in shaping the market
CCGs face perhaps the biggest challenge. As custodians of care at a local level, they are at the centre of the NHS and social care jigsaw.
They are the ones that must fund integrated care and they are the ones ultimately responsible for patient outcomes in their patch.
Since the reforms which divided the role of commissioner and provider in the NHS, it has been tempting for CCGs to look at themselves simply as “buyers” of care.
But when it comes to integrated healthcare, CCGs cannot just be buyers. They must take an active role in shaping the market, and work with fellow commissioners and providers to determine what the future models of care look like.
Plan of action
So, how should CCGs behave in this emerging market for integrated care?
1. They need to invest in relationships with social care commissioners. It is no good having different parts of the system pulling in different directions, or where it is more advantageous for one provider to act in a way that contradicts another. The logical conclusion is to have pooled budgets and outcomes-based contracts but there needs to be sensitive discussions around governance, decision-making and liabilities.
Cornwall, at the forefront of integrated commissioning, is in the throes of a major transformation programme to bring together its adult health and social care, with a single budget under the leadership of the local CCG, NHS Kernow. Relationships form the bedrock of the deal.
When the council and CCG started discussions around integration, goodwill and common ground naturally coalesced into a will for change. A source in the council described it as a “meeting of minds”.
The conversation moved from institutional interests to what better coordination of care would look like for individuals and communities
Very quickly, the conversation moved from institutional interests to what better coordination of care would look like for individuals and communities. The lynchpin of this was a real life example, a man called ”Keith” who had not left his house for two years and was a frequent user of services.
His aspirations were simple: he wanted to walk his dog on the beach. The question then became how the council and CCG could work together to make this happen and led to the Cornwall’s highly regarded “Living Well” programme.
2. CCGs should collaborate with their providers. Few on either side have experience of truly integrated care and so everyone needs to learn.
CCGs should resist the temptation to dictate too much and be judicious when throwing their weight around in the early stages. Once outcomes are defined, it will be tempting for commissioners to issue a tender and leave providers to get on with it.
Yet CCGs should help shape the emerging models. Procurement rules are not an excuse here: the EU Public Contracts Regulations were revised in 2015 to allow scope for a more involved conversation.
CCGs should help shape the emerging models
In Cornwall, the CCG and council have held a number of “Open Provider Forums” bringing together local organisations to discuss the implications of joined up care. Their aim was not only to share the intentions of the commissioners but to give providers a chance to meet over coffee and spark new conversations.
As the billing suggests, they were intended as “open” events, to seek wide input and co-design the plan for the future. To enable the dialogue to flow freely and ensure the discussions were also patient focused, they were co-hosted by Healthwatch Cornwall.
3. CCGs should seek to create a stable environment for providers, where expectations are understood and they feel able to invest in services. There is nothing markets hate more than uncertainty and healthcare is no different.
There needs to be trust and not the suspicion that CCGs will pull the rug from under the providers
Commissioners need to commit to testing out new ideas and establish an equitable sharing of risk with providers. For integration to thrive, there needs to be trust and not the suspicion that CCGs will pull the rug from under the providers.
It’s too early to judge how this will work in Cornwall. With just one CCG and one (unitary) authority, it is perhaps more conducive to stability than other areas working towards integrated care – but there’s bound to be bumps along the way. The length of contracts will be a key aspect of the commissioner-provider relationship, as will any outcomes-based payment mechanisms.
Integrated care poses a fundamental challenge to how commissioners of healthcare operate. Their role cannot be limited to specifying needs, issuing contracts and paying invoices. They must adopt the role of “market-builder” alongside “buyer” if the ambitions for integrated health and social care are to become a reality.
John Copps is senior consultant for Mutual Ventures, a consultancy that specialises in alternative delivery models for public services, and that works with local authorities, NHS bodies and the third sector