I was recently asked to give a brief talk on the role of a commissioner in integrated care. Chris Ham, Judith Smith, and Elizabeth Eastmure’s paper on this issue highlights the factors on which commissioners need to focus on to make a success of commissioning integrated care and some of the barriers currently in place.
What struck me coming away from the meeting was a realisation that too often, as commissioners, we seem to put up virtual barriers that don’t really exist. They seem to be driven by a fear of being found doing the wrong thing or of legislation being brought to bear but are more often the result of a culture of feeling the need to constantly seek permission (rather than forgiveness). That is not an excuse for ignoring good process. In fact, if good processes are applied to making changes, my experience is that change is far more likely to be successfully implemented. However, the commissioner’s role in creating integrated care needs to be, in my experience, far more sophisticated than, say, for planned care.
Sometimes the solution being forged is so complicated and fraught with risk that it is not just desirable but essential to work with specific providers to make the transformation happen. We did this in Louth where a massive change in the service model was proposed by the local GPs. They led and participated in designing the new system but we needed to work with community services and the acute trust to make sure implementation could be safely delivered. We were working in uncharted and unspecified territory. It required the total commitment of all involved to be flexible, adaptive, and tenacious (including the commissioner!). The benefits are now being realised, but more needs to be done and will be led, even more strongly, by the Clinical Commissioning Group (CCG).
Another example is the work led by one of my team, Sarah Furley, on commissioning palliative care. As a result of the hard work she and the contracting team have undertaken, we now have two services (a palliative care co-ordination service and rapid response teams) being delivered by third sector providers which are part of an integrated pathway commissioned across the NHS. The benefits of this approach in reversing the numbers of people dying in hospital are starting to appear.
Again and again the major difficulty in forging an integrated approach hasn’t been so much about contracting and procurement but attitudes and relationships. The work being done by the Lincolnshire West CCG focussing on frail older people illustrates the fact that most of what is needed to deliver integrated care already exists – it is about doing it more effectively and joining it up, not reinventing it.
Steve Field chaired the meeting at which I presented and sitting just in front of me was Robert Varnam – both are part of the Future Forum and the latter has a lead role on the integrated services work. Right across the NHS there will be experience that needs to be captured and the Future Forum needs to help construct a framework to support this work. I will be trying to provide constructive feedback and appeal to as many others as possible to do the same. I sense a real opportunity to make a difference.
Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.