Building trust: bringing budgets together to develop coordinated care

Moving forward to a new way of working together

Person-centred, integrated care requires new ways of working across organisations and between system leaders. Over recent years, great progress has been made to jointly fund, co-commission and deliver new models of care. A key lesson has been learned: successful initiatives are anchored in a common vision, narrative and set of objectives, co-created by the whole system – leaders, operational managers, clinical and frontline staff, service users and communities.

The common vision should set out what people want and need.

Developing strong foundations may seem self-evident, but is often ignored when the focus shifts to immediate delivery. Engaging widely to develop, review and refresh outcomes and goals will:

• anchor discussions of funding in a shared vision, with clearly defined objectives and a common language for how to deliver long-term gains for the local population
• build a business case for change, which can be signed up to by commissioners, providers and communities
• establish a shared understanding of how to achieve the intended benefits and investment.

• Case study: Building trust to develop an outcomes-based payment model in Tower Hamlets, London Open

  In Tower Hamlets, outcomes-based commissioning has facilitated stronger joint working across health, social care and community services by identifying and agreeing a single set of outcomes and associated indicators for the system to jointly work towards. The Tower Hamlets Together programme had a key aim to shift the focus from commissioning specific services for primary, secondary and tertiary care, to jointly tackling local risks to mortality across all care settings.

  Being a multi-specialty community provider (MCP) vanguard site, Tower Hamlets has been supported by NHS England to develop a new model of care which integrates a range of primary care and community-based services under a single place-based budget. Developing a jointly-designed outcomes framework sets a central tenet for all the services to work towards, shifting the focus to more proactive, preventative and joined-up care around the individual.

  To engage providers and build trust in the new model, Tower Hamlets Clinical Commissioning Group (CCG) and the East London NHS Foundation Trust acted as joint leads on the project. In this way, both commissioners and providers were represented at the most senior level. An outcomes reference group was established – with representation from lay partners – to help develop the framework, and engagement and communication workstreams enabled leaders to reach out to different groups across the locality.

  Outcomes-based commissioning in Tower Hamlets has redefined contracts, such as the innovative Community Health Services contract, so that providers are rewarded for improving population outcomes, rather than delivering activities. A certain percentage of each contract will be tied to the achievement of specific outcomes, so that providers will have the incentive to focus on preventative approaches that reduce the need for secondary and tertiary care.

  With the programme ending in 2018, Tower Hamlets Together is reporting a number of benefits and positive outcomes for their residents, including an improved system-wide approach to children’s and family services, agreed data-sharing practices between health and social care, the development of a population-based payment mechanism and an emerging culture of ‘multiple partners, one way of working’.

  Our vanguard story: Tower Hamlets together

Creating a shared vision, objectives and language

Time spent on developing a shared vision will pay dividends later on. Providers should remember to do the following:

• Clearly diagnose the as-is situation and define the need for change. Consider how the need is likely to develop over time in a ‘do nothing’ scenario. Use existing evidence, including local data, joint strategic needs assessments, health and wellbeing strategies, sustainability and transformation partnerships (STPs) and national policies and resources.
• Set out in detail the outcomes that are expected, and what the objectives for the proposed changes are. What will be different for people and communities? How will that impact the system of funding, commissioning and provision? For the vision to be meaningful, it needs to be shared by stakeholders across the system – from leaders within health and care to operational managers, frontline staff and citizens.
• Pay attention to language. Too often, different terms are used by different stakeholders to articulate goals and plans. The language used by health and care organisations often has subtle differences in meaning. Providers should ensure they use similar language to describe the change they want to achieve. For more information, refer to How to… lead and manage better care, particularly the section on ‘engagement and communications’.

Building a strong business case to overcome financial barriers across organisations

Managing finances in health and care is tied to formal lines of accountability and statutory responsibilities. With their different governance systems, we know that joint budgeting and whole-system financial approaches can be complex to develop. However, such approaches are adapting to the need to deliver population health and care in a joined-up way, and local solutions are being developed rapidly. Many CCGs and local authorities have established joint commissioning functions to respond to the pooled funding offered by the Better Care Fund, and the introduction of STPs and ICSs across larger footprints is encouraging such approaches to be scaled up.

Bringing budgets together requires a strong business case, with:

• clearly articulated goals and a robust plan for what, how and when benefits will be realised
• a detailed plan for implementation, with a realistic assessment of the resources required to deliver it
• measures of success with clear links to how and when the investment will generate returns for the stakeholders involved. For more information, refer to How to… understand and measure impact.

Forming strong relationships across organisations and at all organisational levels

Although the technical details of funding arrangements are important, relationships between individuals and teams are key to enabling joint commissioning to function effectively. The King’s Fund report, Options for Integrated Commissioning: Beyond Barker examines how collaborative partnerships, such as Health and Wellbeing Boards, can facilitate joint commissioning arrangements.

Although local government and NHS staff can share similar values, it is important to recognise that their organisations work in different ways. In addition to cultural differences between the sectors, local government is accountable to locally elected members, whereas the NHS is accountable to national organisations and politicians. This means that the responses of people working in local government can be different to those of people working in an NHS organisation.

Both parties need to be aware of these differences and work together to develop joint commissioning relationships despite the challenges. Further information on how to make joint working a success is included in How to... work together to achieve better joined-up care.

In the integrated world, the key is to get the best value for the public pound, and that’s a cross-organisational aim. Finance staff should be driven by, and support, what’s good for the whole health and social care system rather than what’s good for their organisation alone. They should be enablers, not blockers. They should help empower change through participative budgeting; a focus on outcomes; transparent presentation of the long-term effect of decisions; and should encourage, not discourage, the taking of appropriate risks. For example, the right thing may be to invest in new models of care that may not yet have a strong evidence base – because, in the face of current pressures, the risk of doing nothing is greater.

Rob Whiteman CIPFA, Chief Executive, CIPFA