Local health and care systems are increasingly working in different and more collaborative ways to make best use of resources and achieve positive outcomes for their local populations. This involves working across organisational boundaries and rethinking the distribution of activities between organisations across a footprint.
- All of the contributors we spoke to were clear that strong, local relationships between clinical commissioners, providers and other system partners form the basis for more collaborative ways of working. A prescriptive approach to integration is unlikely to succeed given the complexity of local relationships and variation in the needs of the populations local systems are seeking to meet.
- While new, collaborative approaches between clinical commissioners and providers raise considerable opportunities to deliver efficient, high-quality care across a local system, it is essential that partners understand the legal basis of their decisions and take care to ensure they fulfil their respective duties. It is important to note that while this report explores the potential for CCGs to devolve activities to a lead provider or group of providers, CCGs cannot delegate their duties to such providers (Gov.UK, 2012).
- Where local systems have strong relationships, a focus on collaborative working is changing behaviours and prompting a shift in focus in how CCGs and providers relate to each other. With CCGs looking to perform a strategic commissioning function, some providers are adopting more responsibility for 'tactical' aspects of commissioning activity previously undertaken by NHS England or CCGs, such as redesigning pathways of care or introducing new services.
- Language is important. While contributors readily related to the concept of strategic commissioning based on population health management across a larger geography, few contributors understood the term 'tactical commissioning' which has been used in some national policy documents to describe the activities which could move from CCGs to providers in the context of system working.
- Though the evolution of the commissioner/provider relationship explored in this publication is not yet widespread or necessarily embedded in those areas discussing new ways of working, it is clear from the contributions to this report that commissioning is undergoing a process of significant change. This report includes case studies to provide systems with working examples which we hope will provoke local conversations and highlight early success factors.
Contributors identified the following key areas for systems to consider which can either enable or impede the evolution of local commissioning models:
- Strong leadership
The type of leadership required to drive forward system working is different from traditional leadership models that focus on leading individual organisations. Contributors highlighted the importance of:
- Collaborative leadership which is capable of transcending traditional organisational boundaries, and developing a shared vision and values across system partners. It takes time and continued concerted action to build the trust required to enable this.
- Clinical leadership across both commissioner and provider organisations. Clinically-led decision-making provides credibility and draws upon clinicians' close links to local populations. Putting clinicians at the heart of commissioning is a valued benefit of the 2012 Health and Social Care Act which helps to build public confidence in new models of care.
- A 'bottom-up' approach
Leaders in systems with more robust local relationships tended to welcome the permissiveness of the current policy environment in enabling them to develop new ways of working. Other contributors, often those in challenged health economies, sought more backing and a clearer sense of the national policy expectation around system working, including commissioner/provider relationships.
- Involving all system partners
Some contributors flagged the value of securing input from a wide range of organisations. Changes to local arrangements will need to consider the role of all organisations involved in the local commissioning and delivery of health and care, including local authorities and the voluntary and independent sectors.
- One version of the truth
Open book accounting, shared data and establishing 'one version of the truth', both in terms of the financial position and a shared evidence base, was seen as fundamental to collaborative working. The main barriers to achieving this were seen to be a lack of trust or shared purpose between partners and lack of confidence and insight in applying information governance requirements.
- Supporting the workforce
Contributors almost universally identified the importance of mobilising and flexing the local workforce over time in support of system working. The changing relationships between CCGs and providers also raise questions about whether providers may need additional capacity or new skills in-house to take on activities previously undertaken by a CCG. However, the severe workforce shortages facing the health and care sectors at the moment means that 'bandwidth' for changing ways of working is limited given the pressures staff face. Encouraging individuals who associate their employment with one organisation to consider themselves working for a place or population would additionally require a significant cultural shift.
- Governance and accountability
Contributors flagged the complexities of ensuring that robust governance mechanisms and clear lines of accountability underpin collaborative working within the existing legislative framework. This includes clear recognition of the different legal duties placed on commissioners and providers, and the fact that CCGs are accountable for commissioning for the outcomes and care of a population whereas provider boards remain accountable for the quality of the services they deliver
- Regulatory behaviour
Many felt that detailed oversight and regulatory regimes, including the nature and volume of data requests from the national bodies, inhibits innovation and perpetuates the status quo. Contributors felt that there was a need in some parts of the country for more supportive behaviours from the centre, and to ensure the oversight and regulatory frameworks for CCGs and providers align with expectations of local system working.
- Contractual mechanisms
Aligned incentives contracts and block contracts provide two mechanisms for commissioners and providers to reduce perverse incentives and balance system risk. However, putting in place a risk share is challenging and some contributors felt that their local system did not have the capacity or relationships in place to support this approach at the current time.
- Previous system failures
Deep seated challenges within a local system and previous organisational failures understandably often lead to a return to a 'fortress mentality' where attention focuses on individual organisational performance. Some urged systems to make use of these crisis points to rebuild relationships and drive innovation.
Some contributors felt that the current legislative framework, with its emphasis on competition and a strict purchaser-provider split, is prohibitive and deters local partners from developing new commissioning models and ways of working. Others held the view that where there is a clear case for change, and where relationships between local partner organisations are strong, legislation is not a barrier.