Integrated commissioning and provision

Definitions

The UK Cabinet Office and the Commissioning Academy give the following explanation of commissioning: ‘We "commission" in order to achieve outcomes for our citizens, communities and society as a whole; based on knowing their needs, wants, aspirations and experience.'

Integrated contracting and commissioning present an opportunity for commissioners to work with providers to ensure that gaps in services are addressed and improved experiences and outcomes for service users are promoted.

Joint funding arrangements have, to some extent, supported the drive toward joint commissioning but practical application of this has varied across areas. On the pathway to integration, integrated commissioning processes can be viewed as an indicator of embedded integrative principles.

Integrated commissioning can take a number of forms:

• Strategic involving the complete integration of the processes and governance of the member organisations
• Geographic covering all services with a certain place or for a group of people; this can involve virtual arrangements where activity is aligned but not under single management
• Commissioning can take place at system, team or locality level, or at the level of the individual service user
• It can involve clinical commissioners joining with council commissioners, and/or commissioners and providers

Different service areas have different commissioning rules or requirements:

• The 2012 Health and Social Care Act split responsibilities for health commissioning across clinical commissioning groups, councils and NHS England
• NHS services are governed by rules set by NHS England
• Adult social care is largely governed by 2014 Care Act
• The Health and Social Care Act 2012 require local authorities to provide certain public health services
• Other public health functions are commissioned by NHS England under the National Health Service Act 2006

Integrated provision

• This term covers the joining of providers from different sectors, such as community health and social care, to create a single delivery unit – see Care Models and Organisational Form section

Frequently asked questions

What are some of the mechanical arrangement in commissioning?

• Section 75 agreements are made between local authorities and NHS bodies and can include arrangements for pooling resources and delegating certain NHS and local authority health-related functions to the other partner/s
• Virtual integration requires only that the organisations work closely together.
• Structural integration requires that different organisations either merged or have some sort of formal partnership or joint-venture arrangement.

What are the most common issues faced when beginning integrated commissioning?

• Health and care services have different legislative and commissioning frameworks, accountability structures and expectations, which must be reconciled in joint arrangements
• Identifying the spend
• Whilst commissioning budgets are separate or arranged on a ‘charge back' basis (e.g. section 75 agreements) there is the potential for funds to be withdrawn/withheld by either party

What are popular models for integrating commissioning?

• Outcomes-based commissioning not only involves a focus on outcomes rather than outputs but also the use of a population approach, metrics and learning, payments and incentives, and co-ordinated delivery across providers; it places a greater focus on the strategic and planning elements of commissioning, leading to changes in the commissioning cycle as well as engagement of service users and providers
• Personal health and social care budgets give an individual a pot of funding from which they can commission their own services; the NHS is testing this approach through the Integrated personal commissioning programme

What is the Better Care Fund?

• The Better Care Fund is a national programme which requires local authorities and CCGs to pool defined budgets through a section 75 arrangement; the pooled funds are used for interventions which reduce non-elective admissions to hospital and untimely discharge from hospital

What contractual forms are used to develop integrated services?

• Another way to achieve collaboration across organisational boundaries is through the utilisation of alternative models of contracting
• When commissioning services attention will need to be given to the best form of contract for the service that will be provided
• Examples include alliance contracting, prime provider contracting and outcome based contracting
• To some degree they all shift risk to the provider, rather than the commissioner, which has been viewed as a means of incentivising providers to seek innovative ways to achieve the aims of the service contract through improving integration, or particular outcomes, and achieving better value for money

Case studies and examples

• NE Lincolnshire CCG acts as lead commissioner for all health and social care services (section 75 agreement):
• Sheffield Council and CCG have established a joint commissioning and management structure utilising section 75 agreement for some service pathways
• Torbay Care Trust has pooled budgets for health and social care services, including a fully integrated model that provides care for the elderly and people with diabetes through a single-point-of-contact co-located MDT system (used by NW London as a case study)
• Salford Integrated Care Programme the council, CCG and NHS trust formed an alliance bringing together commissioners and providers to enable the provision of more integrated care and services and to share risk

LGA support and resources

• Better Care Fund resources a range of tools and guidance to support implementation of this national programme
• Productivity and commissioning hub a range of resources to support more effective and efficient commissioning
• The Better Care Fund: How to...bring budgets together and use them to develop coordinated care provision covers pooling budgets, risk sharing between commissioners, and selecting payment and contracting models

Selected tools and resources from our partners

• Cabinet Office: The Commissioning Academy: framework document a high-level summary of commissioning
• King's Fund Options for Integrated Commissioning assesses evidence of past joint commissioning attempts, studies the current policy framework and local innovations in integrated budgets and commissioning, and considers which organisation is best place to take on the role of single local commissioner
• Journal of Health Services Research & Policy: Integrating funds for health and social care: an evidence review examines whether integrated funds facilitate coordinated care
• Health Foundation: Need to Nurture an examination of outcomes-based commissioning to date
• NHS RightCare Programme has a collection of tool, including commissioning for value data packs providing benchmarking tools
• The King's Fund: Place Based Systems of Care argues that less organisational autonomy and more collaboration through place-based systems of care offers the best opportunity for the NHS to tackle the growing challenges that they are faced with
• Grafton Group: Clinical contracting considerations seeks to identify the main contracting mechanisms for use when procuring clinical services and to provide a "road map" as to when the differing contracting mechanisms may be best applied
• NHS commissioning: The NHS Standard Contract a guide for clinical commissioners
• Nuffield Trust: Provider chains: lessons from other sectors learning from multi-site organisations from sectors outside the NHS to learn what makes a successful chain
• The Personalised Health and Care Framework guide for LAs and CCGs shows how they can use Integrated Personalised Commissioning and personal health budgets as key ways for providing people with a more personalised approach to their health and social care.