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

Factors influencing the commissioning and implementation of health and social care interventions for people with dementia: commissioner and stakeholder perspectives

BACKGROUND

Despite several interventions demonstrating benefit to people living with dementia and their caregivers, few have been translated and implemented in routine clinical practice. There is limited evidence of the barriers and facilitators for commissioning and implementing health and social care interventions for people living with dementia. The aim of the current study was to explore the barriers and facilitators to commissioning and implementing health and social care interventions for people with dementia, using a dementia friendly exercise and physical activity-based intervention (PrAISED [Promoting Activity, Stability and Independence in Early Dementia and Mild Cognitive Impairment]) as a case study.

METHODS

Qualitative semi-structured interviews were conducted with stakeholders from a range of backgrounds including individuals from health and social care, local government, the voluntary and community sector, universities, and research centres in England. The Consolidated Framework for Intervention Research (CFIR) was used to guide the design and analysis.

RESULTS

Fourteen participants took part, including commissioning managers, service managers, partnership managers, charity representatives, commercial research specialists, academics/researchers, and healthcare professionals. Data were represented in 33 constructs across the five CFIR domains. Participants identified a need for greater support for people diagnosed with dementia and their caregivers immediately post dementia diagnosis. Key barriers included cost/financing, the culture of commissioning, and available resources. Key facilitators included the adaptability of the intervention, cosmopolitanism/partnerships and connections, external policy and incentives, and the use of already existing (and untapped) workforces.

CONCLUSION

Several barriers and facilitators for commissioning and implementing health and social care interventions for people with dementia were identified which need to be addressed. Recommended actions to facilitate the commissioning and implementation of dementia friendly services are: 1) map out local needs, 2) evidence the intervention including effectiveness and cost-effectiveness, 3) create/utilise networks with stakeholders, and 4) plan required resources.

The commissioning of infant mental health services in the United Kingdom: A study of stakeholder views

CONTEXT

Infant regulatory disturbances are common and stable over time and can compromise infant outcomes across a range of developmental domains. Many such problems have their origins within the parent-infant relationship and specialized parent-infant relationship teams provide support and intervention that is explicitly aimed at addressing such relationship difficulties. However, there are currently only around 27 such teams across the United Kingdom, and just under half of CAMHS do not accept referrals of children under 2 years of age.

AIM

The current research aimed to examine the views of commissioners of children's services regarding the reasons for commissioning (or not) infant mental health services.

METHOD

Fourteen in-depth interviews were conducted with a range of stakeholders involved in commissioning children's services across 14 areas of England, half of which were commissioning specialized infant mental health services. A thematic analysis was undertaken.

RESULTS

A total of five themes emerged from the data as being key factors in the commissioning of infant mental health services: pressure from local practitioners, policy transfer through policy networks, opportunity for long-term cost reduction, potential to embed the service model within existing services and perinatal mental health funding.

CONCLUSION

As with commissioning more widely, the commissioning of infant mental health services is a complex process, with a range of factors influencing whether such services are commissioned or not, and data to suggest that the process is currently driven by informal and contingent factors, as much as by the evidence regarding what works.

Rethinking Integrated Care: A Systematic Hermeneutic Review of the Literature on Integrated Care Strategies and Concepts

Policy Points Integrated care is best understood as an emergent set of practices intrinsically shaped by contextual factors, and not as a single intervention to achieve predetermined outcomes. Policies to integrate care that facilitate person-centered, relationship-based care can potentially contribute to (but not determine) improved patient experiences. There can be an association between improved patient experiences and system benefits, but these outcomes of integrated care are of different orders and do not necessarily align. Policymakers should critically evaluate integrated care programs to identify and manage conflicts and tensions between a program's aims and the context in which it is being introduced.

CONTEXT

Integrated care is a broad concept, used to describe a connected set of clinical, organizational, and policy changes aimed at improving service efficiency, patient experience, and outcomes. Despite examples of successful integrated care systems, evidence for consistent and reproducible benefits remains elusive. We sought to inform policy and practice by conducting a systematic hermeneutic review of literature covering integrated care strategies and concepts.

METHODS

We used an emergent search strategy to identify 71 sources that considered what integrated care means and/or tested models of integrated care. Our analysis entailed (1) comparison of strategies and concepts of integrated care, (2) tracing common story lines across multiple sources, (3) developing a taxonomy of literature, and (4) generating a novel interpretation of the heterogeneous strategies and concepts of integrated care.

FINDINGS

We identified four perspectives on integrated care: patients' perspectives, organizational strategies and policies, conceptual models, and theoretical and critical analysis. We subdivided the strategies into four framings of how integrated care manifests and is understood to effect change. Common across empirical and conceptual work was a concern with unity in the face of fragmentation as well as the development and application of similar methods to achieve this unity. However, integrated care programs did not necessarily lead to the changes intended in experiences and outcomes. We attribute this gap between expectations and results, in part, to significant misalignment between the aspiration for unity underpinning conceptual models on the one hand and the multiplicity of practical application of strategies to integrate care on the other.

CONCLUSIONS

Those looking for universal answers to narrow questions about whether integrated care "works" are likely to remain disappointed. Models of integrated care need to be valued for their heuristic rather than predictive powers, and integration understood as emerging from particular as well as common contexts.

The international knowledge base for new care models relevant to primary care-led integrated models: a realist synthesis

Background

The Multispecialty Community Provider (MCP) model was introduced to the NHS as a primary care-led, community-based integrated care model to provide better quality, experience and value for local populations.

Objectives

The three main objectives were to (1) articulate the underlying programme theories for the MCP model of care; (2) identify sources of theoretical, empirical and practice evidence to test the programme theories; and (3) explain how mechanisms used in different contexts contribute to outcomes and process variables.

Design

There were three main phases: (1) identification of programme theories from logic models of MCP vanguards, prioritising key theories for investigation; (2) appraisal, extraction and analysis of evidence against a best-fit framework; and (3) realist reviews of prioritised theory components and maps of remaining theory components.

Main outcome measures

The quadruple aim outcomes addressed population health, cost-effectiveness, patient experience and staff experience.

Data sources

Searches of electronic databases with forward- and backward-citation tracking, identifying research-based evidence and practice-derived evidence.

Review methods

A realist synthesis was used to identify, test and refine the following programme theory components: (1) community-based, co-ordinated care is more accessible; (2) place-based contracting and payment systems incentivise shared accountability; and (3) fostering relational behaviours builds resilience within communities.

Results

Delivery of a MCP model requires professional and service user engagement, which is dependent on building trust and empowerment. These are generated if values and incentives for new ways of working are aligned and there are opportunities for training and development. Together, these can facilitate accountability at the individual, community and system levels. The evidence base relating to these theory components was, for the most part, limited by initiatives that are relatively new or not formally evaluated. Support for the programme theory components varies, with moderate support for enhanced primary care and community involvement in care, and relatively weak support for new contracting models.

Strengths and limitations

The project benefited from a close relationship with national and local MCP leads, reflecting the value of the proximity of the research team to decision-makers. Our use of logic models to identify theories of change could present a relatively static position for what is a dynamic programme of change.

Conclusions

Multispecialty Community Providers can be described as complex adaptive systems (CASs) and, as such, connectivity, feedback loops, system learning and adaptation of CASs play a critical role in their design. Implementation can be further reinforced by paying attention to contextual factors that influence behaviour change, in order to support more integrated working.

Future work

A set of evidence-derived ‘key ingredients’ has been compiled to inform the design and delivery of future iterations of population health-based models of care. Suggested priorities for future research include the impact of enhanced primary care on the workforce, the effects of longer-term contracts on sustainability and capacity, the conditions needed for successful continuous improvement and learning, the role of carers in patient empowerment and how community participation might contribute to community resilience.

Study registration

This study is registered as PROSPERO CRD42016039552.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

One Ilfracombe

Purpose

The purpose of this paper is to report the findings of a horizontal integration programme in the South West of England. The programme was unusual insofar as it included the full range of public services being provided in a single town. It was a place-based system framed by the concept that a person’s wellbeing includes their health, economic status and living environment and that they are inextricably linked. As well as aiming for broader system integration, the programme utilised a person-centred approach using service-user perceptions to influence design. It was implemented through a local governance structure using a set of collaborative principles.

Design/methodology/approach

The paper presents personal reflections of the programme manager about the efficacy of the model, its sustainability and the problems encountered. It sets out the principles defining the model and the extent to which the principles were followed in practice.

Findings

Creating a holistic public service based on integration to tackle deep seated problems within a population requires reducing complexity at the interface between citizens and services. A local system model that includes all public services allows for collective responsibility for meeting the service needs of the population augmenting the connections and bridging the gaps between services. There was a recognition amongst participants that service redesign does not require wholesale organisational restructuring but does require creating shared aims and objectives and the participation of leaders with the ability to implement change within their services. A user-led, bottom-up approach provides deeper understanding and traction on the ground but should be combined with top-down strategic support to provide structural sustainability and the ability to scale out.

Originality/value

The paper demonstrates that horizontal service integration based on the concept of wellbeing is possible but faces significant challenges. The benefits and complexities of inter-agency collaboration multiply when enhancing the outcome focus from improving population health to general wellbeing. New theories of implementation and transformation are needed that relate to this important emerging service theme.

An exemplar of GP commissioning and child and adolescent mental health service partnership

Purpose

– The purpose of this paper is to draw attention to commissioning and service structures enabling implementation of evidence-based cost-effective care as illustrated by the “1419” young people’s service treating mild to moderate severity mental health difficulties in teenagers old 14 to 19 years. The authors describe relevant local contextual factors: “relational commissioning”, demand capacity planning and a receptive and safe clinical context.

Design/methodology/approach

– The authors used a participant observer qualitative research design to describe commissioning and service design. Treatment outcomes were analysed using a quantitative design and found significant improvement in service user mental health and daily function. These results will be reported elsewhere.

Findings

– The dynamics and structures described here enabled clear shared goals between service user, service purchaser, service provider and service partners. The goals and design of the service were not static and were subject to ongoing development using routine outcome measures and conversations between referrers, commissioners, service users and within the team about what was and was not working.

Research limitations/implications

– The methods are limited by the lack of a prospective systematic evaluation of the implementation process and by the time limitations of the service.

Practical implications

– Implementation of whole system change such as that envisioned by Children and Young People’s Improving Access to Psychological Therapies requires consideration of local context and process of implementation. The authors suggest key factors: consideration of “relational commissioning” with purchasers, providers and service users designing services together; case-level collaboration between services and partner agencies; smaller child and adolescent mental health teams eliminating competing task demands, permitting speed of action, providing psychological safety for staff, promoting shared goals and innovation; rigorous demand/capacity planning to inform funding.

Social implications

– The failings of child and adolescent mental health services (CAMHS) are detailed in the Department of Health report “Future in mind: promoting, protecting and improving our children and young people’s mental health and wellbeing” (2015). The aims of the report are contingent on the ability of local health providers to implement its recommendations. The authors provide a theoretical approach to enable this implementation.

Originality/value

– To date there are no published papers addressing the key characteristics enabling implementation of evidence-based practice within CAMHS. The unique experience in forming the“1419” service has important implications nationally and brings together evidence of an effective service within a theoretical underpinned context.

A rapid review of the impact of commissioning on service use, quality, outcomes and value for money: implications for Australian policy

The aim of this systematic review was to assess evidence of the impact of commissioning on health service use, quality, outcomes and value for money and to consider findings in the Australian context. Systematic searches of the literature identified 444 papers and, after exclusions, 36 were subject to full review. The commissioning cycle (planning, contracting, monitoring) formed a framework for analysis and impacts were assessed at individual, subpopulation and population levels. Little evidence of the effectiveness of commissioning at any level was available and observed impacts were highly context-dependent. There was insufficient evidence to identify a preferred model. Lack of skills and capacity were cited as major barriers to the implementation of commissioning. Successful commissioning requires a clear policy framework of national and regional priorities that define agreed targets for commissioning agencies. Engagement of consumers and providers, especially physicians, was considered to be critically important but is time consuming and has proven difficult to sustain. Adequate information on the cost, volume and quality of healthcare services is critically important for setting priorities, and for contracting and monitoring performance. Lack of information resulted in serious problems. High-quality nationally standardised performance measures and data requirements need to be built into contracts and ongoing monitoring and evaluation. In Australia, there is significant work to be done in areas of policy and governance, funding systems and incentives, patient enrolment or registration, information systems, individual and organisational capacity, community engagement and experience in commissioning.

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

Background

English 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.

Methods

Using 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.

Results

In 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.

Conclusions

External 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.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Integrating funds for health and social care: an evidence review

OBJECTIVES

Integrated 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.

METHODS

We 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.

RESULTS

The 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.

CONCLUSIONS

It 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 likely to be weak. Integrated care may uncover unmet need. Resolving this can benefit both individuals and society, but total care costs are likely to rise. Provided that integration delivers improvements in quality of life, even with additional costs, it may, nonetheless, offer value for money.