Commissioning integration: at a glance

  • Consult with all interested parties, get everyone in the same place, establish what you want to achieve and ensure you get the governance right
  • Section 75 agreements (now widened to allow pooling of money for primary medical care provision) still underpin joint and collaborative working with Local Authorities, while devolution powers can facilitate collaboration on a wider scale
  • Accountable Care Organisations (ACOs), partnerships and systems must not cross the line between provider and commissioner functions; the legislation does not permit commissioner functions to be delegated from commissioners to providers

Why this area is important

Integrating care so that services are designed around patient needs rather than around institutions or organisations is a key plank of government health reforms. The aim is to drive up quality and improve efficiency.

The government has not prescribed models for integrated care. It wants innovation and local iterations that best fit local needs; however, there has been no substantive change to primary legislation to facilitate this, so commissioners must use the legal tools currently available to them.

Key issues

While local authority budgets have been slashed, health budgets have had more protection. If no ring-fencing is put in place some observers worry that NHS money could be spent on other council activities.

Commissioners in the NHS or local authorities can use Section 75 of the NHS Act 2006 to pool funds and delegate the exercise of functions when working out a local approach to achieving integration. The onus remains on organisations on the ground to make this happen.

But the 2012 Health and Social Care Act cemented the split between commissioners and providers, and bars providers from taking on certain commissioner functions. Some perceive this as a barrier to achieving ‘the Holy Grail of integration’ – the development of standalone ACOs that carry out both commissioning and provision of services. The idea is that they will hold a capitated budget for the provision of services to a population and bring together primary and secondary care, mental health and social care.CCGs cannot currently delegate their commissioning functions to an ACO, although it could in principle be possible for an ACO to manage some of the CCG’s functions.

Potential solutions

While new legislation to address such concerns about ACOs is unlikely any time soon, NHS and social care leaders want more political support so they can forge ahead in forming new collaborations without fear of legal challenge.

It is not clear, in the wake of Brexit, whether NHS adherence to the European framework of laws on commissioning and procurement will change. Either way, there is domestic legislation which requires CCGs and NHS England to consider and test the market for the most capable providers.

In the meantime, the England-wide network of 44 Sustainability and Transformation Plans (STPs) are intended to bring all significant players together within health and care systems to give shape to local integration. These plans will need to steer a course through the existing procurement and competition regime seeking to encourage local organisations to work more closely together while at the same time ensuring new contract opportunities are opened up to existing markets.