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Single pooled budgets for health and social care in 'every area' by 2020

A single pooled budget for health and social care services should be in place for every area by 2020, recommends the King’s Fund – but NHS Providers warns that commissioning decision must remain clinicially led.

A new report, Options for integrated commissioning: Beyond Barker, argues that the fragmentation of commissioning is a major obstacle to integrating health and social care and improving outcomes for people.

It also recommends that the Department of Health be given control of the national budget for social care, currently under the purview of the DCLG, and that central government should establish a single outcomes framework setting out what an integrated health and social care system aims to achieve.

The report follows on from the final report of the independent Commission on the Future of Health and Social Care in England (the Barker Commission), chaired by economist Kate Barker, which called for an end to the historic divide between the NHS and social care.

It recommends that all areas of the country work towards having a single local commissioner and single budget for health and social care by 2020. This would be an essential step, it argues, towards delivering the new settlement for health and social care outlined by the Barker Commission.

The report sets out the key principles that should drive these changes including:

• no top-down reorganisation – any changes in commissioning arrangements should be locally led, not managed as a top-down reorganisation;
• one size does not fit all – there are different options for implementing integrated commissioning so local authorities and CCGs should work together to choose the best approach for their area;
• change must happen at scale and pace – areas that can move quickly should do so from 2017, and all areas should implement new arrangements by 2020.

The report was written following extensive stakeholder engagement and analyses evidence from previous joint commissioning initiatives. It identifies three main options for moving to a single commissioner and single budget:

• maintain current structures and develop local agreements, building on existing initiatives such as the Better Care Fund;
• require areas to assign responsibility for commissioning to either the local authority or CCG;
• revamp health and wellbeing boards so they have the membership, capacity and powers to take on the single commissioner role.

Rather than prescribe a single model, the report recommends the approach should be agreed locally by CCGs and local authorities, based on a clear national policy framework.

Richard Humphries, assistant director of policy at The King’s Fund, and the lead author of the report said: “As the Barker Commission set out, the case for change is overwhelming. Commissioning is more fragmented than ever, at a time when the imperative is to integrate around the needs of an ageing population with a mixture of conditions that defy service boundaries.

“Forty years of attempting to align health and social care leave us under no illusion about the difficulty of the journey to integrated commissioning, but with a consensus on the necessity of integrating care, there has never been a better time to make it happen.”

Miriam Deakin, head of policy at NHS Providers, said the report was a “valuable addition” to the debate about how the new models of care described in the Five Year Forward View can best be delivered at local levels. “Exploring the options for commissioning will be fundamental to ensuring that all types of providers have the right frameworks in place to develop more co-ordinated models of care,” noted Deakin. The report’s focus on local flexibilities, existing case studies and the options for integrating commissioning is therefore particularly welcome, as we are clear that localities must retain flexibility to develop arrangements best suited to their populations. 

“Encouraging increased joint working at local health and care economy levels will be essential, but it is fundamental that commissioning decisions remain clinically led with clear lines of accountability for the investment of considerable sums of public money to deliver the best possible outcomes.”

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