With around 400 separate local organisations each responsible for commissioning different health and social care services, the current organisational landscape is fragmented and unsustainable. Support is growing for a new settlement based on a single ring-fenced budget and a single local commissioner – as recommended by the independent Commission on the Future of Health and Social Care in England, chaired by Kate Barker.
This report explores the options for implementing that recommendation. It assesses evidence of past joint commissioning attempts, studies the current policy framework and local innovations in integrated budgets and commissioning, and considers which organisation is best place to take on the role of single local commissioner. The paper draws together findings from a body of work including a survey of existing joint arrangements, current evidence and examples, a seminar with pioneers of integration developments, and a national conference on integrated commissioning.
A strong message from this work is that integration is not an end in itself but a means to better outcomes.
Examples of fully integrated commissioning are limited, with the nature and success of joint arrangements varying significantly depending on the area.
Many local organisations consider that health and wellbeing boards have the potential for a greater commissioning role but lack the skills and resources required. Local authorities were overall more positive about this potential than NHS partners
Few health and wellbeing boards show readiness to provide a system leadership role, to take on executive decision-making over an integrated local budget, or to command the confidence of CCG partners.
We feel that in their current guise, health and wellbeing boards are not yet ready to take on the role of single local commissioner.
The starting point should be a single national outcomes framework for integrated care to achieve joint accountability between the NHS and local government. This should be implemented via a local integration programme drawn up between CCGs and local authorities.
From 2017, local authorities and NHS partners should establish a single local commissioning function, with a single integrated budget. This should be in place everywhere by 2020 at the latest.
National bodies should work with CCGs and local authorities to develop organisational templates, based on the options in this report, through which local arrangements can be made, including enacting the ‘health and wellbeing board plus’.
A single integrated national health and care budget stream should be established in central government, making one department responsible for negotiating and implementing the spending review settlement.
The key principles set out in the report are:
No top-down reorganisation
One size does not fit all
Change must happen at scale and pace
A national outcomes framework for integrated care
A single national outcomes framework for integrated care should be agreed. This should describe what it is that local commissioning arrangements should achieve, not the ways in which to achieve them.
A requirement to integrate
Local authorities and clinical commmissioning groups (CCGs) should be able to demonstrate how those outcomes will be achieved for their local population through a single commissioning function and a single integrated budget. These arrangements should be in place by 2020 at the latest, with the organisational model developed and agreed locally from 2017.
Local decisions about how best to integrate
Recognising that there is no one-size-fits-all solution, CCGs and local authorities should agree locally how best to integrate commissioning, responsibilities and budgets.
The report offers three options for CCGs and local authorities to consider:
Option 1 – build on existing arrangements
This option involves no significant changes to current structures. Health and social care funding would continue to be routed separately to CCGs and local authorities with an expectation that they reach local agreements on how to align funding and commission services.
|- No disruptive organisational change - Builds on local relationships being developed through Better Care Fund and Pioneer Programme
|- Depends on good relationships between local organisations - Could perpetuate poor co-ordination and fragmentation of care - Unlikely to deliver change at the scale and pace required
Option 2 – CCG or local authority takes the lead
This option involves giving lead responsibility for all health and social care commissioning to the local authority or the CCG. The decision about which of the two should take the lead could be made at a national or a local level.
|- Single local body with clear responsibility and accountability
|- Could trigger a battle between local government and NHS at a time when collaboration is vital - Would involve organisational change Could result in very different arrangements across the country
Option 3 – a new vehicle: ‘health and wellbeing boards plus’?
The report concludes that, in their current guise, most health and wellbeing boards are not yet ready to become the single commissioner. However, with some changes they could become the local executive decision-making body for the integrated budget.
|- Builds on existing role of health and wellbeing boards - Continuing role for local authorities and CCGs - Minimises organisational change - Similar arrangements being pursued in Greater Manchester and Scotland
|- Requires legislation to give the board adequate legal powers - Profound step-change for existing health and wellbeing boards; would require robust capability assessment
A combined budget for health care, social care and public health
Finally, at a national level, spending on the NHS, social care and public health should be brought together in a single ring-fenced funding settlement. Responsibilities for social care funding should be transferred to the Department of Health which would then be responsible for agreeing how all the funding should be distributed to local areas.
The case for change in commissioning health and social care services is overwhelming – the current fragmentation of commissioning arrangements is not sustainable.
As the Commission on the Future of Health and Social Care in England acknowledged, ‘moving to a single budget with a single commissioner is not a sufficient condition to tackle the myriad problems that face health and social care. But we believe it is a necessary one.’
Forty years of successive attempts to achieve closer alignment between health and social care resources underline the scale of the challenge, but with widespread support for the goals of integrated care there has never been a better time to make this happen.