Contracting: bringing budgets together to develop coordinated care

The approach and contracting model implemented in local areas will ultimately depend on the local partnerships, provider landscape and required outcomes. The more complex the services, the more complex commissioning a single pathway model becomes. There are several procurement and contract model approaches for commissioning for outcomes.

The main ones are shown here.

• Personal budgets Open

  Characteristics

  

  A personal budget can be allocated to an individual to purchase the services that are believed to be best suited to achieve the desired outcomes.

  Local government has created over 400,000 individual social care budgets through which individuals and their carers have been able to choose and – in many cases – employ the care that they know is required. This puts the individual in complete control of purchasing their own care around their own pathways of need. In February 2015, NHS England also promoted this contracting model through personal health budgets.

  Criteria for use

  Individuals’ needs are amenable to a range of provision and there is extensive choice in the markets. Care needs are not complex and can be understood by people who use services.

  Case study

  Kent Council and CCG

• Federation Open

  Characteristics

  

  Individual commissioners hold contracts with a range of providers. Providers work together (either formally or informally) and have joint responsibility for the delivery of outcomes. While most health and social care providers are used to providing services separately, they recognise that different organisations pick up the subsequent aspects of care when their intervention ends. For example, a hospital whose patient has their discharge delayed will recognise that there is a need for care at home to enable the discharge to take place. A federation develops, when these providers recognise that they have to work together, despite the fact that different contracts for episodic services are held by the commissioner.

  Primary care federation toolkit (The King’s Fund)

  Criteria for use

  Suited to complex care across a number of settings, but predominantly used to deliver within one sector, such as health or social care.

  Case study

  South Worcestershire

• Alliance Open

  Characteristics

  

  A number of commissioners (which could be both NHS and local authority commissioners) commission jointly and/or independently a range of services from various providers under a discrete commissioning contract.

  An alliance agreement (which supplements the individual commissioning contracts) documents how all parties are to work together to achieve agreed overall outcomes in respect of a defined patient group or set of conditions. Providers agree to share responsibility for delivery of those outcomes, and are jointly incentivised to work together to do so in a coordinated fashion. Commissioners and providers considering adopting an alliance approach are advised to contact the NHS Standard Contract team and NHS England, who are developing a template alliance agreement.

  Criteria for use

  Best used when a range of services from different sectors are required to deliver specific outcomes for a defined patient group or range of conditions.

• Prime contractor Open

  Characteristics

  

  The commissioner has one contract with one provider who then subcontracts services to other organisations to deliver specified outcomes.

  Joint commissioners hold a single contract with one provider who has the accountability to provide outcome-based pathways of care through a range of other providers with whom it subcontracts. The accountable provider will then have complete responsibility to ensure that all individual providers deliver care that forms a complete pathway. In other industries, this accountable provider would be known as a supply chain manager.

  NHS RightCare

  Criteria for use

  Can be used for commissioning care for cohorts of patients with co-morbidities, such as older people.

• Single contractor Open

  Characteristics

  

  A single contract is held with one provider who delivers services that, on their own, achieve a specified outcome.

  Criteria for use

  Suited for very specialised, highly complex services.

  Case study

  Isle of Wight CCG

Case studies: contract models that facilitate coordinated care

• Personal budgets Open

  Evidence suggests that people get better outcomes when they have input into how their budget will be spent .

  The Kent Money Management programme sets out a joint approach across health and social care.

  It includes a single point of contact for advice that individuals access to support their decisions about how personal budgets could be spent well. The council and CCG have also adopted the same payment processing systems and aligned monitoring timescales to ensure a consistent approach.

  For more information about how to optimise personal budgets across health and care, please see the Personal Budgets Minimum Process Framework .

• SW Healthcare Open

  SW Healthcare is a GP Federation set up to strengthen primary care in South Worcestershire, deliver better services for the 303,000 patients in the region and help practices to generate new income streams and reduce costs. All 32 practices within the CCG are now signed up to the federation, which works closely with the CCG to ensure delivery of the group’s vision for primary and community services. Successes to date include working with drug companies to more effectively source and utilise the support on offer, such as a diabetes nurse, and securing income to fund the overheads of the company, through the provision of dermatology and ear nose and throat (ENT) services across the group.

• Bedfordshire CCG Open

  Bedfordshire CCG faced problems with its musculoskeletal services, including fragmentation, quality variations, uncoordinated care and long waiting times, leading to an inefficient service which did not support patients as well as it should. To better integrate services, the group decided to adopt a prime contractor model for its musculoskeletal provision, and chose Circle Integrated Care (formerly Circle Health) to act as the prime contractor.

  As part of the arrangement, Circle has been in charge of organising the system and integrating all the providers around a central service. Circle takes accountability for both financial control and the delivery of high-quality systems of care by managing the supply chain. Any patient requiring treatment for a musculoskeletal condition is referred to a hub for specialist triage by their GP - ensuring that all are referred on to the right care. Patients are offered a choice over who provides the service, being able, for example, to choose which hospital they attend.

  Although not without challenges, the scheme as a whole has seen significant improvements in terms of reductions in secondary care referrals and unnecessary diagnostics and interventions, as well as improved patient experience and outcomes. Circle is now also the prime contractor for musculoskeletal services in Greenwich, showing the replicability of the model and the opportunity for new areas to adopt a similar approach.

• Isle of Wight single contractor model Open

  Isle of Wight CCG, Isle of Wight NHS Trust and Isle of Wight Council, Contracting for Services.

  The Isle of Wight has the only combined hospital, ambulance, community and mental health service in the country.

  It is the largest offshore island in England with a population of 140,000, 24 per cent of whom are over 65 years old. The Isle of Wight’s population is older than the English average and the number of people on the island aged over 65 with a long-term condition is expected to increase by 64 per cent by 2033. The single contractor option was chosen to help deliver integrated care due to the small population.

  Currently, the Isle of Wight CCG has joint commissioning arrangements in areas such as domiciliary care for learning disability clients, and the group has put in place a joint commissioner for carers. The CCG follows an ‘any qualified provider’ (AQP) procurement process which enables providers to qualify to deliver a specified service for a given price. Any provider that meets the qualification criteria can provide the service. This process is used to enable patients to have a choice of community services provider, where quality has been assured and the provider has a contract which is awarded with the NHS.

Checklist for effective contracting

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