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Accountability must start with genuine co-production

John Richards
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Commissioners need to build trust among their partners, says the chief executive officer of Southampton City CCG

When he opened the integration summit, Lord Adebowale said of the need to integrate: “It is all about people”.  This has an elegant simplicity. We should not over-complicate our approach.

Concerns about the better care fund have centred on the financial risks of a policy that will see a pooled fund in excess of £3.8bn, including the pooling of a hefty slug of clinical commissioning group funding that is currently spent on acute healthcare. Once invested in better care, that money will no longer be available to meet the costs of acute hospital admissions.

Critics worry that this bold policy will place yet more pressure on hard-pressed hospital services or force NHS commissioners into significant deficit as they continue to pay for hospitals according to an activity-based tariff.

Acute activity has continued to rise despite attempts to invest in admission avoidance and out-of-hospital care over at least the past two decades. In Southampton, at last, there are encouraging signs of demand starting to level off, but a healthy dose of scepticism is probably well placed. 

We have already set out ambitious plans to accelerate integrated care, bringing together primary, community and social care into teams serving populations of 30-50,000 people, based on the principles of person-centred care, and using co-production to help build more resilient communities. It is a familiar story, but one difference is that we will have pooled the lion’s share of out-of-hospital funding for health and social care, about 10 times the better care fund requirement.

Here’s the rub. It really is not about the money. Hospitals continue to run with levels of bed occupancy that are too high and extra beds are kept open by paying a premium for agency staff. Not only is this costly, it puts safe care at risk and increases the loss of independence for patients.

Everyone wants to see the better care schemes work at scale and with pace.

A statutory duty to pool a larger proportion of health and social care funding, far from being an unwelcome ‘top-down’ imposition, might be positive. Taking away the arguments about who pays could help to focus local action on doing the right thing for people, managing the risks and making it work.

‘People first, system second, organisations last’ is an easy mantra but there are real problems, not least for providers. We are exploring better ways of locating risk and reward in contracts, but more action is needed nationally to bring the regulatory regime into line, so that the marketplace does not become moribund.

At the summit, we simulated (in caricature) the kinds of exchanges that occur between the various parties involved in supporting health and wellbeing boards in driving forward integration. Clinical commissioning group delegates made the offer to demonstrate collaborative leadership. What did we mean by this?

We found there was widespread misunderstanding of CCGs. We need to provide clearer information to our partners about our governance and funding arrangements. We want to promote mutual understanding and build confidence among our partners, thereby enabling alignment to shared objectives and the willingness to take risks together for the common good.

Tensions around local democratic accountability of councillors and suspicions about CCGs surfaced during the discussions. CCG accountability was described as “labyrinthine”. But the accountable officer of a CCG must demonstrate good stewardship of the public purse and, above all, must safeguard the quality and safety of the services commissioned. As anyone who has experience of getting on the wrong side of this will attest, it doesn’t feel very attenuated in the white heat of public scrutiny.

And yet, real accountability has to go much further: it has to be felt and believed. It has to start with genuine co-production, working with people, service users and carers, families and communities.

The relationship we seek with partners is simple: the CCG has to participate in co-creating the health and wellbeing strategy, and then to offer its own plans as the NHS contribution – to be judged with real understanding and insight, and held to account to play its part.

What do we ask in return? Merely that this offer is reciprocated.

John Richards, chief executive officer, Southampton City Clinical Commissioning Group

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