Commissioners have been given greater scope to think differently and to experiment with alternative approaches to commissioning and contracting as a way of driving integrated care.
This report describes how clinical commissioning groups (CCGs) in England are innovating with two broad models – the prime contract and alliance contract. It draws on experiences from five geographical areas, covering different population and disease groups (cancer, end-of-life care, musculoskeletal services, mental health rehabilitation, and older people’s services).
It concludes by highlighting four lessons that CCGs, other commissioners and providers should keep in mind as they embark on new models of commissioning and contracting to support integrated care.
CCGs and other commissioners need to carefully consider whether a contractual solution is appropriate and proportionate for addressing the particular problem they want to solve. The contractual vehicle is merely the ‘scaffolding’; there are no shortcuts to building trust or nurturing the relationships needed to deliver high-quality, cost-effective care.
There are three main ambitions that should underpin contractual developments to deliver service integration: holding providers to account for outcomes; holding providers to account for streamlining the delivery of patient care across the gaps between service providers; and shifting the flow of money between providers.
While commissioning and contracting to support integrated care offers many potential benefits, it also brings substantial risks. Some partnerships will be more complex, involving financial interdependencies and flows of money between providers. The costs of developing and operating these contractual approaches can be high, and commissioners should enter into such arrangements with their eyes open.
Commissioners should continually engage and communicate with providers, patients and the wider community to define the problem and identify appropriate solutions. This process will ensure that all partners develop a shared vision setting out what they want care to look and feel like – and can then work back from that point to build a model that delivers these aspirations.
Transactional as well as relational approaches are important. Nurturing trust and building relationships between providers will be just as important (if not more so) to delivering integrated care as the overarching contract or type of partnership.
Payment mechanisms and incentives need to be aligned across providers. Commissioners can take advantage of opportunities for local variation and flexibility to overcome the legacy of fragmentation.
Providers need to develop appropriate governance and organisational models. Providers are best placed to develop interorganisational forums and processes for decision-making, risk-sharing and mutual accountability.