The shaping, influence and support given to the local health and care sector by the commissioning system, which includes providers of care, local people and communities.
Traditional notions of commissioning are no longer guiding their way of working. Instead, these areas are focusing on new ideas around how commissioners can add value to local systems: bringing stakeholders together to make decisions; fostering close operational partnership between commissioners and providers; simplifying financial arrangements; and offering improvement support to providers.
Commissioning is the process through which public bodies assess the current and future needs of their local populations, make decisions about which needs will be met and which ones will not be a priority, identify the most effective approaches to address these needs, and then invest in the associated services through contracting with appropriate providers. Commissioning is a cyclical activity in which monitoring and evaluation data from service provision is used to assess impacts and review service models to review the quality of providers and identify opportunities to improve the overall model. People with lived experience of such needs and professionals with practice insights should be actively engaged throughout the commissioning process.
Joint commissioning refers to arrangements in which public bodies look to undertake this planning and implementation cycle collaboratively – this could be for a whole population or in relation to people with particular needs (such as those with a complex disability) or facing common challenges (such as being homeless). This can involve the organisations ‘pooling’ their related budgets so that the funding available to meet these needs is shared or ‘aligning’ budgets so that the funding is more transparent but is still held by the individual organisation. Increasingly, commissioners are looking for additional public or social value from their investments alongside the delivery of the core service specification.
What is joint commissioning? (Integrated care)
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Why does joint commissioning matter for integrated care?
Commissioning collaboratively as a system enables benefits to be realised for the whole system but this needs to deliver for all in terms of improved outcomes and experiences for people, cost avoidance, cashable savings, and better access to services.
Funders investing in services which are not sufficiently joined up through their basic design and care processes has been a common reason why individuals do not experience integrated care. In the past contracts generally held services accountable for successfully delivering only their aspect of care with restrictive rules about how flexibly funding could be used. Integrated care is facilitated by commissioners seeking to design and invest in pathways which are person-centred and then hold organisations jointly accountable for the overall experience of individuals and families. Such contracts provide a more supportive context for professionals and services to have the opportunity and incentives to collaborate.
Joint commissioning provides a process through which people with lived experience, communities, and professionals can be actively engaged in setting the overall priorities for an area and designing pathways which reflect local needs and opportunities. This includes the development of performance management frameworks which consider not only activity and quality of individual services but also the extent to which people experience more integrated care based on what local people say matters most to them. Joint commissioning looks for opportunities to use the financial and workforce resources available to support local populations in the most effective means possible through ensuring that service models are well co-ordinated and provide continuity of support.
What does joint commissioning need to succeed?
The key message from citizens is that whilst safety is important, approaches must be based on human rights, equality, and justice. Change needs to be about independent living, the right to an ‘ordinary’ life, equity of outcomes and choice and control for all people. The voice and experience of citizens must be central and so commissioning for the future must be shaped by their specific concerns and hopes.
Procurement processes are being simplified wherever possible. Areas are using competitive procurement as a tool of last resort. At the same time, financial arrangements between commissioners and acute providers are being simplified – through block or aligned incentive contracts – to tackle incentives that create tension within the system.
Joint commissioning needs to be based on a common vision for an area which has been developed with local people and communities, and has involved providers and professionals. This vision and its underpinning values can then be translated into shared outcomes which are the basis for agreeing new service models and specifications. Collaboration and co-production should be embedded throughout joint commissioning, including within accountability processes, tendering of contracts and investments, and in monitoring and review. Transparency in what resource is available and how this is used, and sharing of risks and successes, are important enablers to building and maintaining trust between funding organisations and with providers.
Alongside developing the overall design and pathways, commissioners must also ensure that there is sufficient capacity and relevant skills within health and social care staff to deliver these successfully. This involves them liaising closely with local providers to understand their workforce issues and with training organisations to ensure that any skill gaps can be met. In relation to allocating contracts and thereby funding to providers, joint commissioners consider more collaborative approaches which bring together different providers alongside the traditional procurement processes based on individual competition. Micro-commissioning, i.e. of individual support packages is often completed by frontline practitioners and related support teams and it is therefore important for such staff to be encouraged and skilled to commissioning such packages collaboratively.
Joint commissioning is a highly skilled and complex practice in which commissioners are enablers of transformational change through bringing together different stakeholders in a system to achieve more integrated care. There is though no one route through which people move into commissioning roles and it is important therefore for relevant training, peer support, and developmental reviews to be provided for commissioners. Ensuring that commissioners from different organisations are encouraged to collaborate through regular meetings, shared offices and/or joint training and development will encourage new ways of working together.
What is the evidence for outcomes and impact?
Our findings also highlighted the need to strengthen the evaluation culture and capacity, and ensure that evaluations are effectively embedded in the local commissioning process. Robust evaluations, particularly of integrated care programmes, have proved to be not only beneficial but also highly valued by commissioners and providers.
Securing significant local change to health and social care services (either separately or together) will always be difficult and require sustained and detailed attention on many fronts. Competent commissioning may help ensure appropriate monitoring and review of current services, the design and planning of necessary changes, and setting of priorities for funding.
Much of the research to date is more definitive of the context and processes which support joint commissioning rather than the impacts which can be achieved. Being clear on what outcomes are expected and maintaining commissioner oversight of the implementation processes relating to models of care can help to ensure that new ways of working become embedded in local practices. Local case studies suggest that with a shared strategic vision, a culture of openness and collaboration, and good analytical support it is possible for joint commissioning of new integrated models to improve experience and quality of care, and to make aspects of the health and social care system such as hospital discharge and support for people in care homes more effective. The evidence is mixed on the ability of joint commissioning and in particular pooled budgets to impact on key metrics such as admission of people to hospital, with some studies suggesting that such activity can increase in the short term due to unmet needs being identified.