Where next for commissioning and integrated care: can the NHS rise to the challenge?

At a recent joint Nuffield Trust and King’s Fund conference, everyone was agreed that there is a pressing need to transform the way in which health care services are delivered in the NHS, given the straitened financial times that now loom large. 
 
These tougher financial times, taken together with rising incidence of chronic disease among an ageing population, call for new forms of community-focused care that will tackle ill-health upstream, provide intensive support in people’s own homes, and seek to prevent unnecessary and costly hospital admissions.
     
What proved more difficult during the conference discussions was coming up with specific proposals about how local commissioners (primary care trusts and practice-based commissioners) could use their funding and purchasing ‘clout’ to bring about transformed community health services in their different local settings.

The conference took as its starting point two new reports from The Nuffield Trust and The King’s Fund that will be published at the end of March. In the first report the researchers use research evidence as the basis for examining current commissioning arrangements, analysing the nature of the ‘commissioning problem’, and setting out practical suggestions for how commissioning might be strengthened to meet the challenges ahead.  The second report examines the concept of the ‘integrated care organisation’ (ICO), exploring different models and considering what role these might play in the transforming of health services.
 
The Nuffield Trust’s Chief Executive, Dr Jennifer Dixon , opened the conference debate by setting out the overall policy context and challenges facing NHS commissioners and providers. She argued that better integrated care is vital as a way of addressing known concerns about the quality and co-ordination of care for people with multiple long-term conditions, and to bring about a much-needed focus on predicting ill-health and managing people’s care in a proactive manner before they end up in hospital.  
 
During my speech I set out why we need to avoid blaming commissioning for all the ills of the NHS; ills that are often more associated with issues in other areas of health reform, and the need to reframe commissioning as a key part of the solution.  
 
Commissioning is hard to do within any health system, and what is needed is a radical move towards clinician-led commissioning of care, along with stronger (and possibly fewer) PCTs that focus on allocating resource, and holding clinical and other commissioners to account.
 
The case for clinician-led commissioning – in the form of an ICO that is at once a commissioner and a provider, and that holds a global capitated budget for a specific population, was made by Richard Lewis, Senior Associate, The King's Fund.
 
He pointed out the need for such organisations to be developed in a way that avoids monopoly provision with little choice, and suggested that ICOs might compete for patients, or be subject to careful regulation to ensure that they are ‘kept honest’ and assure patients appropriate choice of services and providers.

Our focus then switched to two case studies which emphasised how local health economies are seeking to commission services in a radically different way, with the aim of developing better integrated and more appropriate care, especially for high needs and vulnerable people.  
 
Conor Burke from Redbridge PCT, and Lucy Moore from Whipps Cross University Hospital NHS Trust, explained how they are developing five local ‘polysystems’ which are led by local GPs and hospital doctors who hold a population budget, and work together to provide a new range of community-based services for local people.  
 
Rob Webster of Calderdale PCT then set out how his organisation is working in a shared leadership approach with local foundation trusts, borough councils and another PCT to commission transformed (and not ‘transferred’) community health services that concentrate on providing intensive support to the most vulnerable families in the area.
 
We ended with Anna Dixon, Acting Chief Executive of The King’s Fund, neatly summing up the main ingredients required for the development of better integrated services by commissioners: ensuring that accurate and real-time clinical data are available to local clinicians; developing robust clinical accountability for resource allocation; working to strengthen clinical relationships and behaviours across primary, secondary and social care; having a commissioning organisation that focuses primarily on the needs and health outcomes of users and the local population; and encouraging commissioners and providers to co-produce new models of care, but to always be alert to the risk of provider capture of such efforts.