Place-based commissioning - Radical thinking required

Place-based commissioning and the creation of Accountable Care Systems (ACSs) are the most recent manifestation of the drive to deliver more integrated health and social care. Despite warnings from Jim Mackey against “trendy new organisational reconfigurations”we can expect the sustainability and transformation agenda to encourage the creation of a significant number of ACSs throughout England.

The need to enable genuine place based commissioning and contracting, shifting the NHS away from current activity focused funding and towards capitation and outcome based payment systems is unquestionable.  However, given that the NHS has been trying, and mostly failing, to achieve integrated, outcomes-focused care for the last four decades there are real questions about what will be different this time.

A spate of recent publications attempt to answer this question. The New Local Government Network call on the NHS to take a fifteen year planning view, and move away from short term political drivers. The King’s Fund’s report on place based commissioning calls for fundamental changes to commissioning and for organisations to surrender some of their autonomy in order to work together for the greater good.

These are important points, but across the NHS there is growing disillusionment and concern that yet another planning round will not deliver meaningful change. We need to tackle the real barriers to delivery of proper change.

Accountable care systems will be complicated to make work. There is significant risk of inadvertently introducing perverse incentives or of the largest player in the system holding all the power and thereby not changing in the way that they need to. Legislative change is required, to enable the creation of genuine Accountable Care Organisations (ACOs); enabling behavioural and structural change as well as relocation of funding. In the design of any business, form should follow function – but the NHS no longer works this way. While the NHS is suffering from significant reorganisation fatigue and further wholesale change is going to be unpopular, the reality is that for integrated care to be truly successful it will be necessary to design the system we want and then create organisations to deliver this.

Behaviour follows form, so in doing so perhaps we can also do more for the beleaguered health and social care workforce. Care can only truly be integrated if front line staff start to think and act differently. Can we design mechanisms that will engage the workforce more effectively? Can we learn from social enterprise models, mutuals or John Lewis style partnerships in empowering staff to improve the service they provide? It is not always obvious how the contribution of an individual in a complex care pathway delivers better outcomes for patients – but this needs to be clear to every member of staff if they are to remain motivated to do the best job they possibly can in the face of mounting difficulties. Furthermore, incentives must be designed to drive the right behaviours.

Lessons from other industries suggest that it takes a number of iterations to get alliances right and the challenge of behaviour change should not be underestimated.  We are still a long way from the step change in approach we need to make truly integrated care a reality. We need to recognise that we cannot provide effective integrated care through good intention alone – we need to address the problem as a whole, designing the whole system and starting on the journey in the right way.