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Thinking place: integrated commissioning

Julie Das-Thompson, head of policy and delivery at NHS Clinical Commissioners (NHSCC), talks us through the key ingredients for place-based integrated commissioning and its implications for working at scale.

Following the prime minister’s commitment to a long-term funding plan for the NHS, Jeremy Hunt recently expressed his desire for “full integration of the health and social care system” as part of this plan, providing a better deal for patients, taxpayers and NHS staff.

The move towards integration across local areas has already begun. In February, we learnt that sustainability and transformation partnerships (STPs) are to be at the heart of a reformed NHS. According to NHS England’s ‘Refreshing Plans for 2018-19,’ STPs will take “an increasingly prominent role” in planning and managing efforts to improve services in the next financial year and beyond. In practice, this means ensuring a system-wide approach to operating plans, a prominent role for clinical leadership, and pinpointing opportunities for greater efficiency on a bigger scale.

At NHSCC, we feel this is a move in the right direction. For our members, the commissioning landscape is evolving at pace. Our two recent reports on the move to strategic commissioning demonstrated a real appetite amongst our CCGs for stronger place-based working in order to deliver excellent care for patients and ensure the future sustainability of  the NHS.

Conversations with our members have also highlighted the  importance  of  ensuring we have commissioning at a larger scale without losing a locality or neighbourhood focus. Many CCGs are therefore actively engaged in developing new models of care on the ground as well as working at scale through collaborative commissioning arrangements.

There are already some fantastic examples of where commissioning and provision is being joined up in local areas. In Greater Manchester, for example, plans are well underway to set up single commissioning functions for health and social care at both borough level and across the city through the Greater Manchester Commissioning Hub.

The region-wide integration is complemented by local collaboration too: by local care organisations that coordinate integrated care at a borough level, and by primary care and general practitioners at a neighbourhood level. There has been significant investment in keeping care closer to home and a strong focus on standardised care across hospital sites so that, wherever you live in Greater Manchester, the delivery expectations and patient experience of health and social care is the same.

Above all, what Manchester gives us is an example of a strong place-led ambition for its population. Replicating that across the country,  in various guises, is critical to us  all achieving more as health and social care commissioners.

How to achieve success

Successful place-based working across the whole health and social care system, like they are doing in Greater Manchester, requires a number of elements to come together.

Firstly, we need a strategic commissioner to ensure we keep a focus on the needs of the wider population, as well as patients, and take responsibility for long-term planning. The purchaser function must not be underestimated as it is vital for bringing accountability and contestability to place-led decision-making.

We are already seeing this. Some areas have a single commissioning function working across health and local authority commissioning, while others have separate commissioners who work very closely together. Either way, a commissioning function that sits at a larger geography than the CCG will create the breadth and strength of resources to transform the way care is delivered and create more standardised approaches.

It is vital to have ambitious plans at place level as health and care leaders expect more for their local population. In order to develop a clear vision, leaders in these areas need the time, resource and space for transformation planning, away from the day-to-day pressures of managing health and social care services. Unlocking this through additional transformation investment is one method which supports areas to sustain current services and double-run for a period while new delivery models are established. Our members also tell us that a reduced burden from centralised reporting would help to ensure they can confidently plan for the future.

A strong definition of place is clearly imperative to successful place-based working and everyone involved needs to be clear which place they are referring to. As we have seen in Greater Manchester, the flexibility to integrate care at different levels – from neighbourhood to borough to city or county – will open up opportunities to scale and implement innovative working.

The pooling of budgets  between  differ ent organisations within an STP footprint means shared risk as well as shared funding. A more supportive single regulatory framework which mirrors the way integrated provision will work on the ground is essential to give more flexibility to do this. This is about system working, not organisational working, and how this can be exemplified at all levels –   whether that is commissioning, delivery or assurance.

As well as these systemic elements, we mustn’t forget that people are at the heart of health and social care. Our leaders – whether clinical, managerial or elected members – must be supported to develop the right behaviours for working across delivery and commissioning and to help them manage change in their local area.

While our members tell us that CCG leaders have high morale at present, it’s important that they are equipped with resilience and collaboration skills to help them through changing times. The scale of change involved in developing integrated care systems and STPs requires new skills and tools, such as data gathering and analysis, predictive modelling, succession planning and organisational development, which we need to support all our leaders in accessing.

Whilst these plans for greater integration are ambitious, they are not unattainable. STPs are moving in the right direction, but we need to ensure everyone moves at the same pace and to the same end point. This is why NHSCC is working with the Local Government Association, NHS Providers, NHS Confederation and ADASS to develop a refreshed health and social care integration vision which will be launched in November. We hope this will support our respective members to push place-level working much further.

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