The joint commissioning challenge ahead – the Glasby view

Joint commissioning between social care and health is the glue that will hold our developing system of care together, argues Jon Glasby

In recent years, commissioners have found themselves increasingly responsible for tackling a series of longstanding difficulties in health and social care. From engaging the public in debates about the role of the state to delivering personalised services, and from developing a preventive approach to resolving significant financial tensions, it is commissioners who are in the spotlight.

In an era of new public management, the role of government and local health and social care is increasingly seen as “steering” rather than “rowing” (that is, assessing the needs of the population and of individuals, and ensuring that the right kind of support is available – irrespective of who provides it). Of course, for social care this is nothing new, and many senior social services managers have more than a decade of experience in trying to develop and manage a mixed economy of care. For the NHS, this is still relatively uncharted territory, and there is clear scope to learn lessons across the health and social care divide.

Although commissioning is so central to current aspirations, it remains under-developed in many areas of the country. In the NHS, there has been a tendency to reorganise health care commissioners at regular intervals, leaving provider services largely intact (and indeed sometimes even granting provider services greater powers and freedoms). While this is done with the aim of boosting commissioning, the evidence suggests that such repeated reorganisation can actually damage commissioning as a result of the staff turnover and organisational upheaval it creates.

If commissioning really is to drive the new system, then we should surely be creating foundation commissioning trusts rather than foundation hospitals? However, leaving aside these aspects of NHS policy, commissioning remains in need of support and development. Where, for example, is the Royal Society of Health and Social Care Commissioners, or the commissioning-focused MBAs? Without this sort of infrastructure, it is hard to see how commissioning can become embedded as the career of choice for current and future managers.

Of course, all this applies to commissioning in either health or social care. When it comes to joint commissioning, the task is even more fundamental. Commissioning – as we are often reminded – is not the same as contracting, and is much more about understanding and agreeing the needs of a population, securing the right kind of services and monitoring and measuring their impact. This is sometimes described as not just being the “brain” of the health and social care system, but also trying to be its “conscience” and its “eyes and ears” as well. Doing this in an inter-agency setting remains extremely difficult, not least because of the various legal and financial barriers that prevent more effective partnership working. More fundamental still is the need to develop a shared vision of what life should be like for local people – a task which health and social care will continue to find hard given their very different value bases, approaches and histories.

Essentially, therefore, successful joint commissioning involves resolving the difficulties inherent in developing the capacity of the commissioning function, while also tackling the problematic nature of the health and social care divide. In the past, many areas have tried to do this via individual joint commissioners, and the task has often been a difficult and sometimes thankless one. Now, however, policy is clear that such joint commissioning is to be the core business of both health and social care – the glue that holds the system together and the mechanism that drives change forward.

While this focus and national commitment is to be applauded, the challenge ahead is both exciting and daunting. With so much aspiration resting on their shoulders, individual commissioners and the health and social care communities are going to need all the support they can get.

Jon Glasby is professor of health and social care at the Health Services Management Centre, University of Birmingham

This article appeared in the 11 October issue under the headline “We’ve got to make this stick”

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