Integrated care must start with a new single national framework

Former NHS England boss David Nicholson famously described Andrew Lansley’s NHS shake-up as “so big you could probably see it from space”.

Five years on the consequences are much more down to earth, with an organisational landscape so complex that, rather like the peace of God, it passeth all understanding.

‘Responsibilities for commissioning different pieces of the jigsaw has never been more fragmented’

The imperative to integrate care around the needs of an ageing population with a mixture of conditions and needs that defy service boundaries has never been greater.

Yet, responsibilities for commissioning different pieces of the jigsaw has never been more fragmented and are now scattered across nearly 400 separate organisations.

The independent commission on the future of health and social care, chaired by Kate Barker, pulled no punches in highlighting the deep fault lines between the NHS and social care in terms of funding, entitlements and delivery.

The commission’s central recommendation was to move to a single ringfenced budget for health and social care, with a single local commissioner.

‘The Barker review pulled no punches in highlighting the deep fault lines between the NHS and social care’

While few would agree that our current fractured commissioning arrangements are particularly effective, sustainable or even affordable, a further legacy of the Lansley reforms is that the NHS has acquired an understandable allergy to further national reorganisation.

So, are we stuck with the current structures or could we integrate commissioning without plunging organisations into the distracting turmoil of another structural upheaval?

Not ready for a seismic shift

This is the primary question we address in our latest paper Options for Integrated Commissioning – Beyond Barker. From our assessment of the evidence of previous joint commissioning initiatives, engagement with stakeholders and survey evidence, some clear options and conclusions emerge.

For some, health and wellbeing boards are the obvious candidates to take on the role of single commissioner – established with the raison d’etre of promoting integration, they have become the latest poster boy of partnership working.

Yet most surveys indicate very strongly that in most places boards that are barely two-years-old are far from ready to take on what would be a seismic shift in their role and responsibilities.

This would demand substantial new capacity, expertise and support. And they have yet to win the confidence of NHS partners that often regard them as another council committee rather than genuinely equal partners.

‘Relying on local efforts alone will not deliver the scale, pace and consistency of change needed’

But there are other options. The most obvious is to maintain the current policy framework and simply require local authorities and clinical commissioning groups to find local solutions by working with the grain of existing processes such as the better care fund.

Some places are making progress in this way but it is much harder where there is history of poor relationships or financial and performance challenges.

Overall progress has been glacial - relying on local efforts alone will not deliver the scale, pace and consistency of change that is needed.

A clear national framework

Another approach is to require the CCG and the local authority to agree amongst themselves who should be the single commissioner.

This demands very mature local relationships and runs the risk of triggering a battle for control between councils and the NHS, when their energies should be focused on collaboration. Past precedents in lead commissioning for learning disability and mental health services does not bode well.

A third option is to revamp completely HWBs so they become a new vehicle in their own right with a rebalanced membership, fresh powers and duties and support with commissioning capacity from the CCG and local authority.

This would be a profound step-change that would almost certainly require legislation and a robust capability assessment process to ensure each board is up to the challenge.

All of these options could work in some places but none would work everywhere – because of the sheer diversity in local geography and circumstances.

‘Local plans should bring together existing better care fund plans’

Rather than prescribe a one size fits all solution, we therefore propose the approach should be agreed locally by CCGs and local authorities on the basis of a clear national policy framework developed by the Department of Health, NHS England and the Local Government Association.

The starting point for this should be to focus on the outcomes of integrated care through a new, single national outcomes framework.

Local partners would be expected to agree which option would work best for them in achieving those outcomes and agree a local integration programme to establish a single commissioning function and integrated budget by 2020 at the very latest (areas than can move more quickly should do so from 2017).

The single budget should include all spending on adult social care, community health, primary care, mental health, public health and defined acute services. Local plans should bring together existing better care fund plans – so there is one plan, for one place with one set of oversight and support arrangements.

Forty years of attempting to integrate health and social care leave us under no illusion about how hard this journey would be, but with consensus on the necessity of integrating care, there has never been a better time to make it happen.

Richard Humphries is assistant director of policy at the King’s Fund