Making sense of joint commissioning: three discourses of prevention, empowerment and efficiency

Dickinson, Helen; Glasby, Jon; Nicholds, Alyson; Sullivan, Helen

doi:10.1186/1472-6963-13-s1-s6

Cited by 18 publications

(29 citation statements)

References 47 publications

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“…Lead commissioning with aligned incentives‘Reinvestment payments’ to providers based on quality of care and reduced costs of emergency care1 scheme North West London Integrated Care Pilot (England)

Note : PACE, Program of All-Inclusive Care for the Elderly; PRISMA, Programme of Research to Integrate Services for the Maintenance of Autonomy; POPP, Partnerships for Older People Projects.

Some schemes used more than one financial integration mechanism.

Typology adapted from: Audit Commission (2009), 19 Carson (2010), 20 Department of Health (2013), 5 Dickinson (2013). 21

…”

Section: Resultsmentioning

confidence: 99%

Integrating funds for health and social care: an evidence review

Mason

Goddard

Weatherly

et al. 2015

J Health Serv Res Policy

150

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ObjectivesIntegrated funds for health and social care are one possible way of improving care for people with complex care requirements. If integrated funds facilitate coordinated care, this could support improvements in patient experience, and health and social care outcomes, reduce avoidable hospital admissions and delayed discharges, and so reduce costs. In this article, we examine whether this potential has been realized in practice.MethodsWe propose a framework based on agency theory for understanding the role that integrated funding can play in promoting coordinated care, and review the evidence to see whether the expected effects are realized in practice. We searched eight electronic databases and relevant websites, and checked reference lists of reviews and empirical studies. We extracted data on the types of funding integration used by schemes, their benefits and costs (including unintended effects), and the barriers to implementation. We interpreted our findings with reference to our framework.ResultsThe review included 38 schemes from eight countries. Most of the randomized evidence came from Australia, with nonrandomized comparative evidence available from Australia, Canada, England, Sweden and the US. None of the comparative evidence isolated the effect of integrated funding; instead, studies assessed the effects of ‘integrated financing plus integrated care’ (i.e. ‘integration’) relative to usual care. Most schemes (24/38) assessed health outcomes, of which over half found no significant impact on health. The impact of integration on secondary care costs or use was assessed in 34 schemes. In 11 schemes, integration had no significant effect on secondary care costs or utilisation. Only three schemes reported significantly lower secondary care use compared with usual care. In the remaining 19 schemes, the evidence was mixed or unclear. Some schemes achieved short-term reductions in delayed discharges, but there was anecdotal evidence of unintended consequences such as premature hospital discharge and heightened risk of readmission. No scheme achieved a sustained reduction in hospital use. The primary barrier was the difficulty of implementing financial integration, despite the existence of statutory and regulatory support. Even where funds were successfully pooled, budget holders’ control over access to services remained limited. Barriers in the form of differences in performance frameworks, priorities and governance were prominent amongst the UK schemes, whereas difficulties in linking different information systems were more widespread. Despite these barriers, many schemes – including those that failed to improve health or reduce costs – reported that access to care had improved. Some of these schemes revealed substantial levels of unmet need and so total costs increased.ConclusionsIt is often assumed in policy that integrating funding will promote integrated care, and lead to better health outcomes and lower costs. Both our agency theory-based framework and the evidence indicate that the link is like...

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Note : PACE, Program of All-Inclusive Care for the Elderly; PRISMA, Programme of Research to Integrate Services for the Maintenance of Autonomy; POPP, Partnerships for Older People Projects.

Some schemes used more than one financial integration mechanism.

Typology adapted from: Audit Commission (2009), 19 Carson (2010), 20 Department of Health (2013), 5 Dickinson (2013). 21

…”

Section: Resultsmentioning

confidence: 99%

Integrating funds for health and social care: an evidence review

Mason

Goddard

Weatherly

et al. 2015

J Health Serv Res Policy

150

View full text Add to dashboard Cite

show abstract

“…Worth over £20M with [40][41][42][43][44][45][46][47][48][49][50] Swallow staff involved, this contract was one of the largest ever negotiated between commercial providers and NHS commissioners. With the contract covering an entire region, the aim was to deploy the suite of software tools to the analytics units of local commissioning organisations, train NHS analysts in using the tools and supply 'wrap around' support from consultants with commissioning expertise to help commissioners translate output from the tools into commissioning decisions.…”

Section: Recruitment and Data Collection Via The First Commercial Promentioning

confidence: 99%

“…it's two silos with a lot of aggro', which was mirrored from government level to the local system (Percy, former PCT chief executive officer and Department of Health senior manager, now freelance consultant). Moreover, a recent study found that despite widespread perceptions of the benefits for patients, there was limited evidence that joint commissioning improved outcomes, 41 although a former King's Fund fellow argued that such evidence was difficult to generate, partly because other initiatives might also have had an impact on outcomes. 42 …”

Section: Definitions and Challengesmentioning

confidence: 99%

Knowledge exchange in health-care commissioning: case studies of the use of commercial, not-for-profit and public sector agencies, 2011–14

Wye

Brangan

Cameron

et al. 2015

Health Services and Delivery Research

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BackgroundEnglish health-care commissioners from the NHS need information to commission effectively. In the light of new legislation in 2012, new ‘external’ organisations were created such as commissioning support units (CSUs), public health departments moved into local authorities and ‘external’ provider organisations such as commercial and not-for-profit agencies and freelance consultants were encouraged. The aim of this research from 2011 to 2014 was to study knowledge exchange between these external providers and health-care commissioners to learn about knowledge acquisition and transformation, the role of external providers and the benefits of contracts between external providers and health-care commissioners.MethodsUsing a case study design, we collected data from eight cases, where commercial and not-for-profit organisations were contracted. We conducted 92 interviews with external providers (n = 36), their clients (n = 47) and others (n = 9), observed 25 training events and meetings and collected various documentation including meeting minutes, reports and websites. Using constant comparison, data were analysed thematically using a coding framework and summaries of cases.ResultsIn juggling competing agendas, commissioners pragmatically accessed and used information to build a cohesive, persuasive case to plot a course of action, convince others and justify decisions. Local data often trumped national or research-based information. Conversations and stories were fast, flexible and suited to the continually changing commissioning environment. Academic research evidence was occasionally explicitly sought, but usually came predigested via National Institute of Health and Care Excellence guidance, software tools and general practitioner clinical knowledge. Negative research evidence did not trigger discussions of disinvestment opportunities. Every commissioning organisation studied had its own unique blend of three types of commissioning models: clinical commissioning, integrated health and social care and commercial provider. Different types of information were privileged in each model. Commissioners regularly accessed information through five main conduits: (1) interpersonal relationships; (2) people placement (embedded staff); (3) governance (e.g. Department of Health directives); (4) ‘copy, adapt and paste’ (e.g. best practice elsewhere); and (5) product deployment (e.g. software tools). Interpersonal relationships appeared most crucial in influencing commissioning decisions. In transforming knowledge, commissioners undertook repeated, iterative processes ofcontextualisationusing a local lens andengagementto refine the knowledge and ensure that the ‘right people’ were on board. Knowledge became transformed, reshaped and repackaged in the act of acquisition and through these processes as commissioners manoeuvred knowledge through the system. External providers were contracted for their skills and expertise in project management, forecast modelling, event management, pathway development and software tool development. Trust and usability influenced clients’ views on the usefulness of external providers, for example the motivations of Public Health and CSUs were more trusted, but the usefulness of their output was variable. Among the commercial and not-for-profit agencies in this study, one was not very successful, as the NHS clients thought that the external provider added little of extra value. With another, the benefits were largely still notional and with a third views were largely positive, with some concerns about expense. Analysts often benefited more than those making commissioning decisions.ConclusionsExternal providers who maximised their use of the different conduits and produced something of value beyond what was locally available appeared more successful. The long-standing schism between analysts and commissioners blunted the impact of some contracts on commissioners’ decision-making. To capitalise on the expertise of external providers, wherever possible, contracts should include explicit skills development and knowledge transfer components.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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“…Three decades after the need for better integration of health and social care was recognized, policymakers are still grappling with what joint commissioning means in principle, and there is even greater uncertainty about what it means in practice (Dickinson et al 2013).…”

Section: Joint Commissioningmentioning

confidence: 99%

Public service commissioning: origins, influences, and characteristics

Sturgess

2018

Policy Design and Practice

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Making sense of joint commissioning: three discourses of prevention, empowerment and efficiency

Cited by 18 publications

References 47 publications

Integrating funds for health and social care: an evidence review

Integrating funds for health and social care: an evidence review

Knowledge exchange in health-care commissioning: case studies of the use of commercial, not-for-profit and public sector agencies, 2011–14

Public service commissioning: origins, influences, and characteristics

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