Editorial
Article Type: Editorial From: Journal of Integrated Care, Volume 20, Issue 3
This issue concentrates on the interplay between commissioner and provider roles in the English system of health and social care, with a range of perspectives and evidence put forward by authors.
In a brief article in the weekly management magazine Health Service Journal on 8 December 2011, Andy McKeon controversially – and very deliberately – asked whether commissioning changes anything? He is clearly not convinced it does, and we should pay heed: he is a former senior civil servant in the Department of Health, and more recently the senior person responsible for health studies in the Audit Commission. He is now an academic. His argument was that commissioning does need to provide a more decisive role in the immediate future of the NHS, with £60 billion of taxpayer-provided funds now likely to be subject to an experiment in clinically-led commissioning. In this issue, some new evidence on the general point of the limited impact of commissioning is provided in the article by Bernard et al. focussing on long-term neurological conditions.
As readers of our previous issue will know well, several of the invited commentators on 20 years of health and social care collaboration noted that there has also been a failure to achieve effective joint commissioning too. These commentators were not convinced that the new infrastructure of Health and Wellbeing Boards is robust enough to do the job, particularly in terms of productive working by councils with clinical commissioning groups. This point is taken up in this issue by Alan Lotinga and Jon Glasby who have written an account of efforts in Birmingham to bring the new breed of clinical commissioners into contact with local authority commissioning. This seems like a good investment in the future.
McKeon noted in December the paradox that it was providers not commissioners who have made the running on integrated care, and that commissioners per sehardly have any sort of track record in promoting it. He cited Torbay –“the teacher’s pet of integration” as a journalist recently dubbed it – for his main example. It is a nice coincidence that the chief executive of Torbay Care Trust has written an overview of the current context for integrated care here. It is already well-known that, at its heart, Torbay Care Trust has been a provider-oriented organisation, innovating internally with local integrated teams, supported by health and social care coordinators (some now working from hospital wards), and with a single IT system. Externally, the horizontally integrated community health and social care service has worked in an operational partnership with its local secondary healthcare provider, South Devon Healthcare NHS Foundation Trust, which is, hardly coincidentally, one of the top-performing hospitals in the country. The local commissioners have not driven this: it is more how the providers have learned to work together to improve service responses, well supported by local GPs.
But Anthony Farnsworth’s article makes some more subtle distinctions,and reveals how a guiding mind of partnership has acted to sustain the whole system of care – this may be virtual joint commissioning? Do read this article: it opens a window on the impact of the more commercial approach to health policy pursued by the previous government as well as by the coalition,and it highlights the complexity of relationships needed to secure the outcomes. In fact, Farnsworth repeats a point made by McKeon: that it is system management and system leadership that seem to be the defining characteristics of success,not the purchaser/provider split. Torbay Care Trust had commissioning and provision under one roof until a year ago. Note that the point about leadership for integrated care is also examined in detail in another article in this issue,by Paul Williams. His early ground-breaking research identifies characteristics of organisational leadership which, with hindsight, were intuitively applied from 2004 in the formation of Torbay Care Trust.
David Welbourn and Alasdair Liddell’s article, which also serves to make the case for provider initiatives through an Accountable Care Organisation model borrowed from the USA, takes this debate to a new level. Intriguingly, their analysis recommends:
that responsibility for both the design and delivery of care should rest with accountable providers who are incentivised to meet the outcome needs of a clearly defined population and also accept responsibility for the risks.
In relation to risks, their perception may possibly be somewhat different from Farnsworth’s. But they may have touched inadvertently here on a key problem in our experiences of commissioning in England: that the job has been seen to be about contracts and specifications, which are then imposed on providers to force change. This may be necessary and appropriate sometimes, but recently, with my own eyes, I have seen two examples of problems for collaborating providers caused by laudable, but over-detailed, commissioning of systems of virtual wards as a means of bring primary and community health care together to help people with long-term conditions: provider initiatives had been effectively forestalled. As Welbourn and Liddell maintain, instead of doing this:
Commissioners should be free to focus on defining the population needs, the expected outcomes and securing the total budget for care provision to that population.
Their solution is that providers should collectively take up the reins of service improvement on behalf of the public and of service users, the importance of which is emphasised in our concluding article by Tessa Trappes-Lomax and Annie Hawton. Their work suggests that attentiveness to user views is essential to effectiveness, whether instigated by commissioners or providers.
Welbourn and Liddell make light of the apparent tensions between integration and competition, a point which has found favour in recent Kings Fund papers, but this does remain a fault line worthy of ongoing study. There is no doubt,however, that once the dust has settled after the damaging arguments over the Bill, there should be much scope for local innovation in integrated care.
Peter Thistlethwaite
