Learning from the learning: what works? an update from the latest research on commissioning

1. Learning from the learning: what works? an update from the latest research on commissioning Gerald Wistow Visiting Professor in Social Policy. LSE ADASS/BGS Conference 2nd July 2012

2. Latest Research • National Survey of Social Care Commissioning, Fernandez et al, PSSRU, LSE. • Joint Commissioning in Health and Social Care: An Exploration of Processes, Services and Outcomes, Dickinson et al, HSMC. • National Evaluation of the Department of Health’s Integrated Care Pilots, Final Report: RAND Europe, Ernst & Young • Integrated care: a story of hard won success, Vize, BMJ. • Social Care, Fourteenth Report of Session 2010–12, House of Commons Health Committee.

3. Research Findings • ‘the development of each service was usually considered in isolation, and it could not be said that there was an overall plan for the development of services for the elderly in any of the authorities studied’ • ‘when asked how the substitutability of related services had influenced plans for his authority, he added: ‘that sounds too logical, and in fact was not how it happened’

4. Research Findings • the more significant bar to co-operation was the division of responsibility without a clear-cut division of function. Too often this led to failure to develop a service because each side could argue the other should do it’ • The local authority associations …….warned that if they were not able to meet the extra expenditure needed to expand their services, the Minister’s hospital plan would be imperilled

5. My Source • Greta Sumner and Randall Smith Planning Local Authority Services for the Elderly 1969 • Study of planning in 24 authorities in response to joint planning circular of January 1962 • Circular described hospital development as • complementary to the expected development of the services for prevention and care in the community and a continued expansion of those services has been assumed in the assessment of hospital provision to be aimed at’ • Local authorities enable hospital re-configuration through integrated planning (commissioning)

6. Integration Today While many people told us of excellent care, we heard alarming stories, particularly from the most vulnerable, of poor access, falling through gaps between services and being unable to understand how to navigate their way through the convoluted ‘system’. We heard from people who had experienced delays and come to harm. The universal feedback was that the current system is fragmented and all patients, regardless of their circumstances, want a more joined‐up and integrated health and social care service, planned around their needs (Field 2012 p.9).

7. Integration and Quality • ‘Sadly……..we have been told repeatedly that the system, as it stands, often does not deliver the integrated package of care that people (with complex problems) need. It doesn’t deliver their desired outcomes either………There are often wide gaps between services…. The often inefficient and unreliable transitions between services result in duplication, delays, missed opportunities and safety risks…………and we know the recent scandals in hospitals, home care, and care homes will not go away if we don’t change the way the system works.’ (Integration Future Forum 2012)

8. The traditional framework • Statutory duties to work together • Coterminous boundaries • Coordinating structures • Joint plans • Financial incentives • Permissive powers • Bridges between parallel organisations rather than integration of mainstream business processes • Seamlessly joined not woven together

9. Integration has not worked……… • ‘Despite repeated attempts to “bridge” the gap between the NHS and social care……..little by way of integration has been achieved over this 40 year period’. • Long line of initiatives to design new frameworks for integration, each beginning with recognition that the last had limited results • Some success: contribution to closing long stay hospitals and creation of islands of good practice often despite ‘the system’ • Can the latest statutory framework succeed where others didn’t?

10. Time to Face the Facts? • Consistent weaknesses raise questions of systemic failure and fitness for purpose • Implementation deficiencies or flawed design? • Both: institutions of structure, process and culture create the spaces within which implementation is conducted with more or less skill, creativity and commitment • Those institutions, in turn, are rooted in decisions at foundation of NHS and 1974 reorganisations • Institutions of NHS and local government designed to be different and separate not similar or integrated

11. ………we always knew it was sub optimal • Organisations primarily based on • ‘Skills of professionals not needs of clients’ • A place, local variety and functional coordination • The service, national uniformity and functional specialisation • Coterminosity ‘an attempt to get as near as possible to the advantages of…..unification by creating “two parallel but interacting structures” (Joseph) • A ‘miserable middle way’ (Crossman) • Need outward looking ‘community governance’ (Stewart)

12. ……….and integration has become more difficult • Unilateral redrawing of boundary between health and social care as NHS ‘withdrew’ from continuing care and concentrated on acute interventions • Intensified boundary disputes; extended means testing to growing numbers of owner occupiers; increased levels of dependency and financial pressure in social care • Social care funding gap a product of NHS cost shunting as well as unequal growth rates • Stronger hierarchy (‘targets and terror’) reinforced internal not joint agendas and made NHS even more hospital centric

13. …..but we need it more than ever. • Less hospital centred care and support systems with proper investment in community networks and informal care, together with shift to prevention, early intervention, wellbeing and independence • Meeting Nicholson challenge through shift in responsibilities and resources • More effective use of resources: address suboptimal balance of national spending; community budgets locally; reduced support costs • Personalised commissioning: more choice, control and joined up services

14. Some learning • No silver bullets but there some critical elements to the mix • No clear link between joint commissioning and better outcomes • Structure and process put before purpose and outcome • If integration is the answer, what is the question? • How to secure optimal outcomes by meeting needs holistically and ensuring that the “right” services are available at the “right” time from the “right” people, in the “right” place • Means moving resources, high and low politics, power as well as technical competence

15. Some learning • Multileveled commissioning for whole systems and joined up service delivery • Hierarchy normally trumps partnership: optimal balance between opposing vertical and horizontal forces • Structure and agency important: build the necessary institutions and relationships • Process of reform disrupts existing relationships and focusses attention on internal organisational concerns rather than external relationships and better outcomes for individuals and communities • Expect slow and limited progress • The omens are not good

16. Case for Deeper Change • Rebalancing investment, new service models and removal of fragmented service delivery needs improved integration • The conventional model of integration has failed repeatedly across five decades • We can do better but it tends to be by working across the grain of mainstream systems and processes • ‘It seems perverse to attempt to build integrated service delivery on a fragmented commissioning system’ • Single point for commissioning, single budget and single accountable officer necessary for deep change

17. How can we commission better health and social care services? • Research tells us more about what doesn’t work than what does • Integrated commissioning generally not working • Integrated commissioning is necessary but not sufficient • Person centred as well as systems centred commissioning • Local leadership necessary but not sufficient • We can make small improvements within space organisational settlement allows but probably not the radical changes to service structures and investments needed • Continuing tale of provider power and ineffective government • Can local leaders make central government an offer they can’t refuse as Griffiths did Thatcher • Episodic and long term care rather than health and social care

18. How can we commission better health and social care services? • We can make small improvements within space organisational settlement allows but probably not the radical changes to service structures and investments needed • Continuing tale of provider power and ineffective government • Can local leaders make central government an offer they can’t refuse as Griffiths did Thatcher • Episodic and long term care rather than health and social care

19. Thank you gerald.wistow @btinternet.com