You can’t buy me love but can you buy me integration? The example of English Mental Health Services

Introduction: Integration is a recognised as a key element in providing patient-centred care for people with mental health problems. This includes vertical integration between secondary and primary care, horizontal integration between public sector bodies responsible for health, housing and social care, and broader integration with community employment, advocacy and leisure services. In England primary responsibility for overseeing the local mental health system now lies with public sector commissioners, who are expected to use their power as purchasers to shape the local market and ensure that it delivers more integrated care. Commissioning cycles vary between different public sector areas, but all have the similar elements of understanding need, prioritising spend, developing models and using competition and user choice to improve efficiency and quality. Aims: To explore the implementation of commissioning within adult mental health and the extent to which it has been able to provide a new approach to the planning and delivery of mental health services. Theory and methods: This study was based in three local authority areas in England and drew on the experiences of third sector organisations (TSOs) regarding public sector commissioning. The expectation of mental health and general commissioning policies is that TSOs will be involved throughout the commissioning cycle –as consultees on current and future need, as experts on innovative models of integrated care, and as providers from whom services can be purchased. TSOs are therefore well-placed to comment on the operation of commissioning in practice. Furthermore due to the long term presence of many TSOs (and the people who lead them) in local areas they should also be able to provide a comparison with the planning and implementation of integration before commissioning was introduced. A survey was sent to all TSOs within the case study areas who described themselves as having a particular focus on responding to the needs of people with mental health problems. To explore the findings of the survey in more depth semistructured interviews were then completed with a purposive sample of the TSOs. Interviews were also carried out the public sector commissioners with responsibility for mental health services in the case study areas. Framework analysis was used to analysis the interviews and survey data with both deductive and inductive themes being considered. 14th International Conference on Integrated Care, Brussels, April 2-4 2014 International Journal of Integrated Care – Volume 14, 01 October – URN:NBN:NL:UI:10-1-116182– http://www.ijic. org/ Results: From this research it appears that the ‘ideal’ commissioning cycle envisaged in mental health policy is yet to be fully established in the case study areas. Commissioners recognised that they were not yet able to achieve all of the commissioning cycle, but did report progress in relation to the initial stages of joining up of social and health needs analyses. From the perspectives of the TSOs, the main change under commissioning was a shift from grant based funding mechanisms in which they were allocated a block amount of money with relatively few conditions to more contractual processes in which the service model and/or outcomes were more specified. The more contractual system more commonly (although not exclusively) involved competitive tendering processes, and whilst this did result in anxiety over continuation of existing funding most TSOs welcomed the opportunity to bid for new resources. Commissioners’ ability to use their purchasing power to influence better integration was limited through the market dominance of the public sector health care providers, and their insufficient capacity to focus on smaller scale opportunities for integration. Commissioning structures and processes were not seen as being integrated, with evidence of silo working between public sector bodies and indeed by different service areas within the same organisation. The skills, expectations and commitment of individual commissioners were seen as more important than national policy directives. The frequent restructurings within the public sector were disruptive to existing relationships between commissioners and with TSOs, and this resulted in a loss of trust and so flexibility in what could be delivered. Performance based payment systems were welcomes in principle as the TSOs were confident that they would be better placed than public and private sector providers to deliver holistic care that integrated people into their local communities. Discussion & Conclusion: This research highlights the complexity involved in attempting to use market forms of governance as a means to drive more integrated care. Reflecting broader procurement theory, the success of the process is influenced by the transaction costs of managing a supply chain, perceptions of what constitutes ‘value for money’ and the degree of trust or opportunism within the provider – purchaser relationship. That said, if there is sufficient procurement capacity and expertise, and a collaborative process in which parties accept their individual risk on the basis that ultimately patients / service users benefit then it appears that there is scope to use the purchasing power of public funds to encourage innovative approaches to integration.