Chapter 7 - What are the joint governance options?

WHAT IS IT AND HOW WOULD IT WORK?

Commissioners draw up complementary contracts with a single provider network. In advance of contracting, commissioners agree the shared outcomes they want the provider network to achieve for the target populations. The commissioning contracts then set out the separate funding arrangements towards achieving these shared outcomes.

HOW DOES IT AFFECT INDIVIDUALS?

Individuals still receive most of their services separately from social-care and health care, but with more coordination because the two groups have a joint working relationship. For example, commissioners might commission in partnership one home care network to support individuals’ health- and social-care needs.

Pros

• Provider networks contracted for shared set of outcomes
• Relatively easy to establish as does not require transferring funds or delegating responsibility between commissioners.

Cons

• Budgets are not truly pooled as commissioners still contract separately. This reduces the flexibility in the reimbursement models
• Less flexibility for how provider network can allocate funds to support responsive and personalised models of care
• Performance management is complicated with provider network having to respond to many commissioners, although this could be mitigated by commissioners agreeing a joint performance management function.

WHAT IS IT AND HOW DOES IT WORK?

Funds and functions can be delegated between health- and social-care through Section 75 agreements. Funds can be transferred using Section 256 transfers. The agreements delegate responsibilities from one or more commissioners or providers on cross-cutting concerns to another in order to purchase one integrated care service.

Both commissioners and providers would need to establish a partnership body to jointly agree the outcomes of the integrated service. This partnership would have agreed rules on how decisions are made together, such as the outcomes for the population, and how to hold to account the lead commissioner to whom responsibility is delegated for managing the provider network.

HOW DOES IT AFFECT INDIVIDUALS?

Individuals still receive some services separately from social-care and health, but the pooled budget allows some services to be jointly administered. For example, as a result of a joint pool for elderly individuals with mental illness, individuals might find themselves looked after by a single organisation with health- and social-care capabilities, which makes the provision of physical and mental-health care better integrated with social-care.

Pros

• Funds can be pooled. The funds then lose their identity as ‘health’ or ‘social-care’ money and can support capitated models to reimburse a provider network
• Section 75 contracting arrangements are already common across North West London and offer significant flexibility in approach

Cons

• Some services cannot be commissioned via a Section 75 agreement (e.g., surgery and emergency ambulance services. See Supporting Material G: Legal Issues Compendium for full summary)
• Commissioners retain responsibility for their statutory functions even after they have delegated the management of these functions to another commissioner.

CASE STUDY/EXAMPLE

North West London already has £144m of services commissioned using Section 75 agreements. Research on the different agreements is available in the Supporting Material I: Research on Existing Joint Commissioning Arrangements

WORKING GROUP OPINION

All the options allow for service user representation in the governance and decision-making. This could be at board level or by funding commissioning teams to work with service users to co-design new approaches.

The working group were most enthusiastic about options that went beyond cooperating more closely to having fully integrated commissioning teams. These teams would ideally be in completely new organisations, with common management and resources to support new cultures and behaviours being developed.

The working group recognised local areas were likely to start with incremental and/or transitional changes such as Section 75 agreements as new relationships, trust and experience is built up.

However, in the longer term, the working group believed that we should aspire for fully integrated commissioning such as a care trust across health- and social-care.

WHAT IS IT AND HOW DOES IT WORK?

A new organisation is set up to manage integrated commissioning arrangements. Health- and social-care commissioners delegate management of transactional commissioning functions to this organisation but retain decision-making responsibility.

HOW DOES IT AFFECT INDIVIDUALS?

The individual experiences are similar to the delegation of funds/functions except that now the organisation managing the commissioning is jointly health- and social-care. This might change the culture around commissioning.

Pros

• Allows for pooled budget and an integrated commissioning team
• Single reporting requirements from provider network to new commissioning organisation
• Commissioning management organisation could be a lead provider who then sub-contracts and organises other supporting services.

 Cons

• Commissioners would only have indirect capabilities to manage provider networks contracts
• Commissioners would be reliant on the capabilities and capacity of the commissioning management organisations.

WHAT IS IT AND HOW DOES IT WORK?

Care trusts are special commissioning organisations that can take sole control of health functions and manage social-care services to commission integrated services. Governance is controlled by the health body and the local authority loses its control over health functions. The care trust can be party to further Section 75 agreements to manage delegated social-care services.

HOW DOES IT AFFECT INDIVIDUALS?

As a single organisation, the commissioner still has a degree of choice about which services are carried out by a single provider and which are separated into specialised health or social-care providers. In one case, an individual with a history of substance misuse might have a social worker specialised in substance misuse, while in another workers with both social work and health backgrounds might visit them additionally.

Pros

• Strongest organisational form of integrated commissioning with joint governance, pooled budget, joint commissioning teams and single reporting structure
• One organisation responsible for purchasing "health- and social-care” together rather than separately.

 Cons

• Require public business case to set up, so difficult to establish. Additional time and political will is needed compared to other joint governance arrangements
• Care trust agreements are harder to leave and unpick than other joint governance arrangements.

Once local areas have agreed their vision for Whole Systems Integrated Care, they need to determine the capabilities their joint commissioning arrangements must have to enable the changes to service user outcomes. There may be a difference between the body that signs off the joint commissioning plans (e.g., Health and Well-being Board) and the body that is held accountable (a joint commissioning board). This will depend on factors, including:

• Which population groups commissioners are prioritising: When resources are spent relatively equally across health- and social-care, integrated commissioning structures may make more sense compared to when health care spending predominates.
• Model of care: Depending on the combined services being commissioned, stronger joint governance arrangements may be required.
• Payment model needs: A capitation model where many budgets are pooled will be better supported by more heavily integrated commissioning structures.
• Quality of relationships between commissioning organisations: When a high degree of trust and collaboration already exists, commissioners will find it relatively easier to work together in an integrated way compared to local areas working together for the first time.

Local areas should also be pragmatic when selecting their governance structure. They may choose fully integrated commissioning as the preferred approach. However, the short-term complexities in establishing this may mean that transitional arrangements are needed that support more immediate improvements in care for the population.

The working group defined the principles of good governance to include:

• Putting the service user first: The service user perspective has to drive the operating model.
• Hold providers accountable: Financial risk and delivery risk (e.g., outcomes) must be assessed, distributed and mitigated by the commissioner. Ways to enforce should include financial penalties/incentives and exit clauses in contracts based on outcomes (balanced by increase in length of contract terms to give stability for providers).
• Involve primary care and the third sector: GPs must be incorporated into the provider vehicles to ensure the appropriate referrals are made through the system.
• Work towards a shared set of outcomes: As much as possible, all commissioners should work towards a shared single set of service user outcomes which includes and surpasses meeting the statutory requirements of each commissioner.

Having set up the initial workings of pooled commissioning, shared decision-making bodies should be formed which enable effective and decisive joint commissioning on an ongoing basis. This requires both the tactical capabilities for commissioning and performance management of joint provider networks, as well as the more strategic capabilities to make sure the statutory obligations of both social- and healthcare commissioning groups are met.

Within joint commissioning frameworks which are more deeply integrated, the tactical aspects of joint commissioning can be delegated more easily to share staff with a good understanding of the statutory obligations. In both cases of a care trust and a commissioner with delegated management responsibility, a single commissioning function will be able to manage providers of integrated care to ensure both social- and health-care outcomes meet statutory obligations. In these cases, a shared board, with key representatives from all commissioners as well as lay partners should meet (initially on a frequent basis) to review progress, ensure statutory requirements are being met, and set high-level direction for the shared organisation to follow.

Within joint commissioning frameworks which are less integrated, like a partnership agreement or a delegation of funds/functions, more high-level attention must be paid, at least initially, to the pooled activities. Without shared teams of commissioners working together, a joint board should meet as often as needed to make decisions on tactical pooled commissioning decisions.

In the best case, consensus should be reached on shared decisions. In some cases it may be necessary to resolve a disagreement over the best course of action. Shared decision-making agreements should bear in mind the following principles:

• Where commissioners have vetos there is a risk of deadlock. Where no joint programme goes ahead without agreement on both sides, deadlock can arise. However, because commissioners have statutory obligations, this may end up with independent commissioning to break a deadlock, which would defeat the purpose of shared commissioning.
• Any system of voting must respect statutory obligations. It is not acceptable to have a system of voting in which one party can impose a decision on the joint pool, particularly in situations where this would prevent statutory obligations from being met.
• One option to fairly resolve disagreement is to allow either social-care or health care a veto, reflecting the importance of meeting differing statutory obligations, but allowing a majority in each group to make a decision.

Some options for voting weights between health- and social-care commissioners, where there are multiples, could be:

• Equal weights: Each health-/social-care commissioner receives a single vote.
• Weighted by budget: Each health-/social-care commissioner receives votes proportional to the budget committed to the joint programme. This could be done either at the level of the specific proposal, or of the joint budget pool as a whole. This means that the commissioners with the most on the line have the greatest say in any decisions.

• Which other commissioners are you going to form joint commissioning arrangements with?
• What joint governance arrangements will you form?
• Why have you chosen this option?

To implement Whole Systems approach you will need to plan for and complete the following:

• Meet as commissioners and service users to discuss your vision for integrated care locally
• Decide what functions joint commissioning arrangements will need to enable this vision (more information on the types of functions joint commissioning arrangements could have is available in the reference material)
• Decide which of the four joint governance structural forms best supports these functions (further information on case studies for these structures, their pros and cons and legal implications is available in the reference material)
• Identify overall governance body for arrangements (e.g., Health and Well-being Board) and agree how service users would be represented
• Agree structure, role and location of any joint commissioning team
• Develop and agree business case for any joint commissioning team
• Create and agree legal documents underpinning joint commissioning arrangements