How effective is joint commissioning? An exploration of processes, practices and outcomes in five English localities Helen Dickinson, Health Services Management Centre

Joint commissioning is... is concerned with the ways in which relevant organizations might work together and with their communities to make the best use of limited resources in the design and delivery of services and improve outcomes.

Joint commissioning Policy aspirations outstrip developments at practice level (despite aspirations for JC dating back many years). Limited research (often conflated with joint working or commissioning more generally). Research often process, rather than outcome focused.

Research questions How can the relationships between joint commissioning arrangements, services and outcomes be conceptualised? What does primary and secondary empirical data tell us about the veracity of the hypothesised relationships between joint commissioning, services and outcomes? What are the implications of this analysis for policy and practice in health and social care partnerships?

Methodology Interpretive (what and how does joint commissioning mean..) Based on surfacing programme theories in 5 in-depth case studies. 2-phase using POETQ, focus groups, semi- structured interviews, documentary analysis

Viewpoints of joint commissioning Ideal world commissioning: joint commissioning is a no- brainer. Efficient commissioning: delivering the same for less and is more about benefits to local organisations than it is about improving peoples lives. Pragmatic commissioning: good in theory, but difficult to achieve in practice (and also comes at a price). Pluralist commissioning: joint commissioning as a means of achieving fairer access, inclusion and respect for service users Personalised commissioning: joint commissioning should be about offering the highest quality service and a seamless service to users. However, joint commissioning can sometimes be cumbersome and costly.

Case studyPrimary aimSecondary impacts ATackle health inequalitiesPreventative services Efficiencies Wider range of services for users Create one stop shops and easy access Empowerment BProductivity – bang for buckEfficiencies Redesign services over larger area Consistency of services Streamline services Early intervention CService user at centre of service design Seamlessness Single contact points Key-workers Value for money Choice DKick-start merger process into Care Trust Focus on health inequalities and preventative services Economies of scale Innovative services EEmpowerment of communityMore appropriate services Efficiencies Reduce waste Preventative services

Structures, processes and practices of JC Formal structures are time and resource consuming to develop but local respondents valued them as means to cement relationships and make local partnerships less dependent on the contributions of key individuals (who might leave and put previous joint initiatives at risk). Respondents found it difficult to identify particular practices associated with joint commissioning and which are different to other ways of working – be they in terms of more general joint working or commissioning.

Impact of JC Respondents often found it difficult to identify the impacts that joint commissioning had in practice. Whilst there were many examples of positive initiatives, people struggled to link these to joint commissioning per se or to cite formal evidence of impact. I think weve not always been as focused on demonstrating the outcomes that its achieved and some of thats to do with data information systems... not being...robust enough to sort of come up with what we want really.

Impact of JC Joint working better or stronger Efficiencies (although not necessarily a positive) Improving access (although service users not necessarily share this belief) Are efforts put into what service user wants?

Four key themes Is there anything specific about JC? Identifying evidence of impact remains difficult – technically and practically. Sometimes faith in the potential of joint commissioning appeared to run ahead of detailed collective thinking. Several sites talked of ways in which they had been able to make efficiency savings through joint commissioning. However, these often seemed to derive from one-off actions or initial changes and there was little evidence of scope for recurring savings.

What does this tell us about joint commissioning? Range of different interpretations of joint commissioning – demonstrated in an empirical sense (Qdata). JC as a framing concept – value lies in its ambiguity and symbolism and consequent capacity to attach people to it. JC as a boundary object – plastic enough to adapt to local needs but robust enough to maintain common identity (Star and Griesmer, 1989) Ability of practitioners to nimbly adapt to successive policy changes

Conclusions Not able to demonstrate link between best practice joint commissioning and outcomes. Need to ask different questions of JC than those traditionally asked. Value of JC not as a rationalist service improvement intervention

Dickinson, H, Glasby, J, Nicholds, A, Jeffares, S, Robinson, S, Sullivan, H (2013)Joint Commissioning in Health and Social Care: An Exploration of Definitions, Processes, Services and Outcomes This project was funded by the National Institute for Health Research Service Delivery and Organisation programme (project number 08/1808/260). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR SDO programme or the Department of Health