Joint commissioning

Consumers of health and social care increasingly demand high quality care, expect choices, personalised services and seamless provision.

This new and increasing public demand, coupled with a much more challenging financial environment, puts joint commissioning of appropriate and premium health and social care services at the heart of the drive to transform health and wellbeing outcomes.

The Accelerated Development Programme was developed by Commissioning Support for London’s Improving Integration Partnership initiative with the capital’s Joint Improvement Partnership (Department of Health) to create a step change in health and social care commissioning and provision across London. The programme is also aimed at reducing health inequalities at a local level.

Throughout 2009, the ADP:

• Developed and supported 13 pilot joint primary care trust and local authority projects. This was designed to accelerate joint commissioning and establish good practice, grouped under the Department of Health 2008 next stage review themes, which were: Supporting People to Shape Services; Continuously Improving Quality; Locally Leading Change and Promoting Healthy Lives;
• Staged a series of seminars led by experts in commissioning and personalisation;
• Hosted a major conference for senior health and social care leaders in October 2009, with presentations from London PCT and local authority chief executives, ADP pilot project presentations and panel discussions.

Why joint commissioning is important: policy context and drivers

“From the beginning of my career when I was a social worker, I quickly saw the need to move away from the notion of health and social care services being delivered separately. The end goal should always be to commission and offer a single service.  While we are putting lots of energy into reviewing the structure of health commissioning arrangements in London…we should also not lose sight of their function, that is how the design of care pathways contributes to their effectiveness and improves local peoples’ health and social care outcomes.”
Michael Scott, chief executive, NHS Westminster

For PCTs and local authorities in the capital, a key priority over the coming two years will be the implementation of Healthcare for London, including:

• The transformation of primary and community care;
• Polysystems incorporating a personalised approach to prevention;
• Integrated care for people with long term conditions and people with complex health needs.

This will require new levels of collaboration across all care settings and sectors; with innovators, educators, providers and commissioners collaborating to develop integrated care pathways from prevention through to end of life care.

There are a number of factors driving this shift. Residents have rising expectations of public services and have a growing desire to control and shape the services they receive. Services must be joined up and responsive to consumer needs.

For example, the roll out of polysystems incorporating community care pathways is a critical opportunity to offer an increasingly seamless and easily accessible health and social care service.

To achieve this, PCTs will need to work in partnership with local authorities through a joint strategic needs assessment. This will enable them both to identify current and future needs and to provide and deliver services to address those needs.

Joint commissioning is a key enabler of that process. Both local authorities and PCTs are increasingly monitored and assessed on joint outcomes. This is carried out through local area agreements, comprehensive area assessments and world class commissioning performance regimes.

At the same time, local authorities and PCTs alike are working under significant funding constraints over the coming period. The scale of this funding challenge requires agencies to combine efforts, avoid duplication and make the most of their combined resources. Joint commissioning can deliver significant operational efficiencies.

It is also inevitable that some decisions on access to health and social care will raise concerns with local residents. The concerns may include the involvement of eligibility criteria or the movement of some non-urgent hospital care into the community.

Well thought out joint commissioning strategies will significantly assist trusts and authorities in mapping out a cohesive strategy. This will help residents see why decisions are being made and how they will benefit from these changes. These joint commissioning strategies are rooted in rigorous JSNAs and will include appropriate public engagement.

The basis for joint commissioning must nevertheless be the imperative for providing a more responsive and personalised service for the patients. Delivering better quality health and social care outcomes alongside operational efficiencies is a primary driver for entering joint commissioning agreements.

Meeting the challenge

“The difference in commissioning arrangements between the NHS and the local authority can feel like two continents separated by a common language.”

Susanna White, chief executive for NHS Southwark and director of health and community services, Southwark Council

Meeting the joint commissioning challenge

Leadership

One of the key points that were highlighted in the ADP projects was how strong senior local leadership and ownership are critical to effective delivery. The projects that achieved the most were where the leaders fully signed up to the agenda and the objectives between organisations were clear and agreed upon.

This meant outlining and understanding the roles of each agency by reaching beyond local political processes and existing organisational and resource boundaries.

Projects here can learn from the Total Place programme which looks at how whole area approaches to public services can identify and avoid overlap and duplication between organizations. It also looks at how to lead to better services at less cost.

A recent report for London Councils suggests that closer working between the NHS and council care services could save up to 18 per cent of the costs of chronic care; http://www.londoncouncils.gov.uk/aboutus/corporatepublications/totalplace.htm

For full information on Total Place, including details of Lewisham’s pilot project on commissioning health and social care services for children and adults, visit www.localleadership.gov.uk/totalplace.

Case study

60 per cent of adults in Newham are inactive, with consequent serious health problems. Newham Council and NHS Newham recognised the problem, but did not have the strategic objectives or the detailed delivery plans and mechanisms needed to make a comprehensive physical activity care pathway a reality.

The ADP project therefore initially looked to increase understanding and then practical commitment at the highest levels in the PCT, the council and across the local strategic partnership, rather than focusing immediately on details. Leadership secured at this level enabled joint healthy living and physical activity programmes to take off. This helped the joint commissioning plans to move forward and significantly increase investment.

Organisation

Joint commissioner posts are critical but it is also clear that broader joint commissioning systems are necessary if the process is to be effective with partnership agreements. This includes agreed governance and reporting structures, which enable commissioners to work across organisational cultures. One model is children’s trusts, with joint commissioners reporting to a multi-agency board often with pooled or co-aligned funding arrangements.

Understanding the different dynamics of clinical governance in PCTs in relation to community leadership in local authorities is important. Where there are competing objectives, the experience from the ADP projects is that this can create a “burn out” effect, leading to commissioner fatigue.

Case study

Barnet addressed a mixed history of joint working. Not only did it do so with high level strategic commitment, but also with extra resources and decisions to recruit to joint posts. It also agreed on formal working arrangements, with lead responsibilities identified and shared work plans outlined.

The key joint posts are now in place and both organisations have a clearer and stronger shared agenda and work plan. The agenda included reporting higher levels of communication, better mutual understanding and progress initially on a joint specification for the learning disabilities service and a review of joint voluntary sector funding. The agreed approach is to start small, building on success towards a whole systems approach.

The four Ps: prioritising, planning, project managing, public engagement

For many ADP projects, this was a first attempt at joint working. Staff turnover, capacity and competing or changing local priorities all impacted on delivery, while some areas suffered from overload. Aligning the initiative to jointly agreed priorities is essential to success, as well as ensuring that the numbers of priorities are manageable.

Several ADP projects focused on short-term preventative and reablement support across health and social care. For example, most boroughs have an ageing population, with increased demand for health and social care. This area is often characterised by similar types of services offered in silos. Joint commissioning offered clear opportunities to collaborate in achieving high quality personalised services and a more efficient use of resources.

Every organisation has resource constraints. It is advisable to keep a focus on a smaller number of high impact areas. Initiatives should be properly resourced, ideally with adequate project management capacity, rather than tagged onto busy commissioners’ and middle managers’ day jobs. A number of boroughs have project management offices which can be used to drive delivery and monitor progress. Appointing senior “sponsors” at board level also helps maintain momentum and prioritisation.

Public engagement is also a key driver for co-working across health and social care. Involving your Local Improvement Networks and other engagement forums in joint commissioning is critical both to the effective design of care pathways and to maintain the momentum around integrated health and social care.

Case study

In looking to agree on comprehensive benchmarking, monitoring and reporting of quality metrics, Westminster focused on stroke care as its pilot pathway.

Links were established with other stroke projects and groups such as Healthcare for London and the North West London Stroke Steering Group. Regular meetings were held for staff across the pathway, from primary care to in-hospital treatment and community rehabilitation teams.

Momentum was maintained through regular reporting to project sponsors, with a clear focus on achievable outcomes and shared objectives. The mapping of data sources were outlined across the pathway, identifying gaps and key areas where the different agencies could work together to improve the services available.

Key skills for the project

Ensuring that commissioning organisations have the appropriate competencies and skill sets is critical. For joint commissioning, this goes beyond traditional “block purchasing” expertise to encompass both management of a higher volume of lower cost contracts for personalised services. The need to drive the rapid development of a supply side market of potential providers, including social enterprises and the thirdsector may itself have a role in co-commissioning.

The skills to conduct JSNAs are also pivotal. This enables commissioners to understand the whole spectrum of health and social care needs across their community.

The ability to conduct rigorous analysis and develop new markets is central to reducing duplication. It ensures the right providers are in place, maximising productivity gains and establishing fair, competitive unit prices for personalised services.

Case studies

To take forward personalisation in health as well as social care, Kingston Council built on its existing relationships with voluntary and user-led organisations, including Kingston Centre for Independent Living which was already experienced in delivering direct payments to service users.

A consortium of third sector organisations has now been established to the take the project forward. The development and project workers were funded to co-ordinate, support and monitor and evaluate brokerage arrangements. This helped personal budget holders plan and set up their own care services.

In seeking to improve health outcomes for a large local Gypsy and Traveller community, Bromley PCT and Bromley Council needed to reach beyond the joint strategic needs assessment which had identified that community as having the poorest health. The assessment paid particular attention to mothers and children, and highlighted the significant difficulties that the community has in accessing services.

The project successfully engaged this hard-to-reach community through positive links forged with community groups and the borough’s existing Gypsy and Traveller project. It is now established as integral to existing community engagement efforts, with its findings feeding into the boroughs’ overall Gypsy and Traveller strategy.

Tailoring services to suit local communities

While all boroughs can learn from successful partnerships, each will need to develop bespoke solutions to their local population’s health and social care needs. This aims to always provide the most accessible services for local people, including single points of access, based on clear evidence and needs assessment.

Budget alignment can operate without formal or legally binding arrangements. It can facilitate the ability to respond quickly to changes in financial climate, policy developments and need assessments within local communities.

Boroughs can also use the National Health Service Act 2006 powers to pool budgets under formal legal arrangements, an arrangement currently operating in Lewisham through a Section 75 Agreement under the Act, and offering in principle greater flexibility and reduced transaction costs.

A further option is the integration of PCT and local authority “back office” functions. An example of this is at its maximum is the full integration approach, which is now being implemented in the London Borough of Hammersmith & Fulham. The full benefits of this new approach have not yet been fully evaluated, but it offers clear potential for seamless working.

Top Ten Tips for Joint Commissioning

1:Awareness of the bigger picture: Total Place, national policy drivers, the wider determinants of health and the different roles of the PCT and local authority;

2:Focus on the outcomes, not the constraints of existing political, organisational and resource boundaries;

3:Build from local strategic partnership and local area agreement arrangements to develop agreed joint strategies, with visible shared leadership setting the vision and ambition;

4:Establish a clear joint agenda with agreed, achievable priorities and objectives; choose your targets carefully in accordance with overall priorities.

5:Sort out governance and legal issues from the outset;

6:Get shared commissioning plans and posts in place, with clear delivery chains, project and performance management arrangements;

7:Make sure your middle managers are proactive, empowered, committed and connected effectively to work together across all partnership organisations;

8:Check that you have the skills and competencies required, but learn from each other as well.

9:Be flexible and sensitive to local circumstances, and involve citizens and service users at the heart of commissioning;

10:Be honest and open. Share risks, problems, successes and acknowledge difficulties without blame. Learn from best practice, encourage and reward innovation.

For more information about the Accelerated Development Programme, including detailed project reports and downloadable presentations from the seminar series and conference, see http://www.commissioningdevelopmentprogramme.co.uk/integrationpartnership/pages/default.aspx.