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Pioneers: On the joint commissioning curve

We asked three pioneers of commissioning across healthcare and social services to share their experiences and provide their top tips.

We created a joint commissioning ‘unit’

Dr Amit Bhargava, chair of Crawley CCG, has been involved in joint commissioning projects between the local authority and NHS since 2006

Six years ago we started with the intention of improving the health and wellbeing of the frail, the elderly and the vulnerable, and reducing health inequalities across Crawley. These were areas where we had a common purpose, based on need and use of resources. There was also a lot of variation in care and outcomes, so joining up made sense.

In our experience, it’s easy to get agreement on principles and visions across health and social care. But it becomes much more difficult when you get down to the details and delivery.

The national politics and bureaucracies of the NHS are very different from the local politics and bureaucracies of local government and the third sector. The ways we measure success, allocate money and organise governance are very different and surprisingly difficult to reconcile. The aim of seamless joining and delivery takes great resolve, tenacity and leadership.

The journey has been bumpy over the past six years and we have had to stop, reflect and change many times before we could move forward again. We are fortunate that we have had a very effective partnership manager, Malcolm Bray. Getting the right person for this position is vital as cross-boundary working is strongly person- and relationship-dependent.

The Joint Commissioning Unit (JCU) in West Sussex was conceived in around 2010. It includes children and maternity services, elderly services and mental health, and has a commissioning budget of about £330m for a population of roughly 800,000. We have had mixed success. Although the ideas and the intentions were right, our ambition has been greater than the delivery. It’s very important when working across boundaries that the leadership is strong and focused. You also have to be clear about what you are going to deliver specifically and have a clear timeline, and we didn’t do this well. 

We have now set up a joint working group involving key senior members from local government, the PCT, clinical commissioning and public health to improve the performance of the JCU and also look at section 75 with West Sussex County Council. The intention of the three CCGs in West Sussex is to make joint commissioning and the JCU work, but the JCU will need to recognise the varied and full geography of West Sussex, the differing priorities of each area, the joint strategic needs assessment and the commissioning plans of the CCGs.

Joint commissioning at tier 1 or tier 2 local government levels is not about the investment of sums of money, but rather about making the limited funds stretch further by true collaboration, co-production and holding each other to account.

It is important to decide from the start how to line up savings and what will happen with the common resources. This is something we have still not got to grips with.

We have to be ultimately accountable to the population for incremental improvements in their health and wellbeing.

top tips

• Embrace joint commissioning.

• Be very clear – both about what you want to joint commission and about key performance indicators and delivery times.

• Keep measuring. Strategies are very easy to create – but it’s all about delivery and implementation.

The biggest health and social care budget in the country

Arash Fatemian, Oxfordshire county councillor, explains how communication and relationships have proved key factors.

For years, Oxfordshire has had the largest health and social care pooled budgets in the country, amounting to around £250m. We’ve developed close working relationships between health and social care as well as joint management groups, which have stood us in good stead now we’re setting up a health and wellbeing board. It has helped that in Oxfordshire all the GP practices have come together as one CCG aligned across the county boundaries.

We’ve done a lot of joint commissioning for mental health, older people and people with learning disabilities, which has meant that we have been able to support nearly all adults with a learning disability in supported housing. 

For the past year, the county council’s director of adult social care has been spending two days a week working with the chair of the CCG, which I think has been the key to success. He has a desk at the PCT and this has led to a much closer working relationship between health and social care. We also have joint management groups that have one lead commissioner, but also representatives from social care and healthcare.

We have many forums where strategic decisions can be made, including a regular health liaison meeting comprising the chief executive of the county council, the leader of the council, the chief executive and PCT directors and the chief executive of the local hospital trust.

While there will always be disagreements about how to do things, we are all broadly agreed on the direction we should be going in. Health and wellbeing boards will help to crystallise and formalise the work we’ve done. We are well placed in Oxfordshire because our existing joint strategic needs assessment is highly regarded nationally.

When working collaboratively, there may come a point where there is disagreement and someone has to say: ‘This is what we are going to do.’ This can potentially sour relationships. We haven’t experienced that in Oxfordshire, but it could be a problem for joint commissioning.

We already had a health and wellbeing partnership board in Oxfordshire and moving towards a slimmed down, more efficient board may potentially lead to problems, but we’re working through those. The key to getting through any problems is having good working relationships and keeping the lines of communication open.

top tips

• Make sure that all the people around the table can get along with each other – you need good working relationships.

• Keep the information flow wide open right from the start. It’s important to let the others know of any potential problems from the beginning so there are no nasty surprises six months down the line.

• Focus on the person at the centre of everything – the patient or service user, and their carers. How can we improve outcomes for them? Don’t focus on the needs of individual organisations unless they support this ultimate goal.

Joint working without pooling budgets

Phil Harrison, Oldham councillor and lead member of adult social services and health, on how joint working has saved £1.7m

Partnership work with the NHS has been well established in Oldham for a number of years through joint strategy groups around a number of key areas including mental health, learning disability, health and wellbeing, and older people. 

To formalise this joint approach, a joint commissioning strategy was agreed between NHS Oldham and Oldham Council in December 2010 to bring improved outcomes.

The chief executive of Oldham Council, the managing director of NHS Oldham and the CCG accountable officer have agreed the development of closer working arrangements and an integrated commissioning function.

We brought public health into the council in January, with the director of public health becoming part of the integrated management arrangements for health and social care as well as taking a wider role across the council.

We also have programme leads working on priority areas across both organisations. At first there was some wariness between clinical commissioners and local politicians, but it’s turned out we don’t have any problems working as a team.

Budgets are not pooled, but we have a financial model agreed for allocation of joint efficiencies and are working together on the development of budgets. This enables us to understand the spend across the health and social care system and work together on streamlining our commissioning processes, which helps us avoid duplication and minimises the impact on each other’s services. We are now developing a local integrated commissioning hub with commissioning leads across the NHS and the council.

It has overall responsibility to provide support and direction for specified commissioning activity. The hub will ensure all levels and types of commissioning are fit for purpose and will maximise opportunities for collaborative working and the delivery of improved outcomes and efficiencies.

We’re focusing on developing preventive services at community and primary level with the aim of reducing dependence on more costly secondary care and specialist services while ensuring better outcomes for patients.

We have already seen substantial savings from the joint commissioning workstreams – £1.7m as of January. We have a combined £2m joint commissioning savings target for 2011/12, which is in addition to efficiency savings identified by each organisation.

A joint value for money review is under way on continuing and complex care, with recommendations being implemented around improvements to joint panels, joint approach to procurement, streamlining processes and developing policies to prevent delays. Another is being undertaken around children’s and young people’s mental health.

We are also developing single contracts for voluntary-sector services where both health and social care organisations fund the same provider – for example, Age Concern.

top tips

• Focus on the outcome, not just the efficiency.

• Keep talking even when the going gets tough.

• Stakeholder engagement is critical – provide regular updates and opportunities to contribute.