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Never a better time to make integrated care happen

The journey towards integrated care is a difficult one, as 40 years of successive attempts to better align health and social care show. Yet, with consensus on the necessity of integrating care, our new report Options for integrated commissioning: beyond Barker argues that there has never been a better time to make the radical changes needed to make it happen.

The imperative to integrate care around the needs of an ageing population with a mixture of conditions and needs that defy service boundaries has never been greater. Yet, responsibility for commissioning has never been more fragmented and is now scattered across nearly 400 separate organisations.

The independent Commission on the Future of Health and Social Care in England, chaired by Kate Barker, pulled no punches in highlighting the deep fault lines between the NHS and social care in terms of funding, entitlements and delivery. The commission’s central recommendation was to move to a single ring-fenced budget for health and social care, with a single local commissioner. Few would agree that our current fractured commissioning arrangements are particularly effective, sustainable or even affordable, but one legacy of the Health and Social Care Act is that the NHS has acquired an understandable allergy to further national reorganisation.

So, are we stuck with the current structures or could we integrate commissioning without plunging organisations into the distracting turmoil of another structural upheaval? From our assessment of the evidence of previous joint commissioning initiatives, engagement with stakeholders and survey evidence, three options for local areas emerge.

The most obvious is to maintain the current policy framework and simply require local authorities and CCGs to find local solutions by working with existing processes such as the Better Care Fund. Some places are making progress in this way but it is much harder where there are poor relationships between local organisations or financial and performance challenges. Overall progress has been glacial – relying on local efforts alone will not deliver the scale, pace and consistency of change that is needed.

Another approach is to require that CCGs and local authorities agree among themselves who should be the single commissioner. This demands very mature local relationships and runs the risk of triggering a battle for control between councils and the NHS when their energies should be focused on collaboration. Past precedents in lead commissioning for learning disability and mental health services do not bode well for this option.

A third option is to revamp health and wellbeing boards and hand them responsibility for implementing the new arrangements. This would require a rebalanced membership, fresh powers and duties and support with commissioning capacity from the CCGs and local authority. This has the advantage of building on current structures but would be a profound step-change that would almost certainly require legislation and a robust capability assessment process to ensure each board is up to the challenge.

All of these options could work in some places but none would work everywhere because of diversity in local geography and circumstances. Rather than prescribe a one-size-fits-all solution, we therefore propose the approach should be agreed locally by CCGs and local authorities on the basis of a clear national policy framework developed by the Department of Health, NHS England and the Local Government Association.

The starting point for this should be to focus on the outcomes of integrated care through a new, single national outcomes framework. Local partners would be expected to agree which option would work best for them in achieving those outcomes and agree a local integration programme to establish a single commissioning function and integrated budget by 2020 (areas than can move more quickly should do so from 2017). The single budget should include all spending on adult social care, community health, primary care, mental health, public health and defined acute services. Local plans should bring together existing Better Care Fund plans so there is one plan, for one place with one set of oversight and support arrangements.

Moving to a single commissioner and single budget for health and social care would not address all the fault lines identified by the Barker commission. But it would be an important and essential first step on the way to the new settlement the commission argued for so persuasively.