1. The joint commissioning of specific services: How to commission services between education health & social Care including Therapy Services
Martin Cunnington, Principle Associate

2. Legal framework
S. 25 Children & Families Act 2014: Duty to integrate education & training provision with health & social care provision.
S. 26 Children & Families Act 2014: Joint commissioning duty.
S. 30 Children & Families Act 2014: Duty to create a Local Offer.
Improved outcomes for children and young people with SEND aged 0-25.
S. 31 Children & Families Act 2014: Duty on partners to co-operate with the local authority.
S. 19 Children & Families Act 2014: Principles.
S. 49 Children & Families Act 2014: Provision of Personal Budgets & Direct Payments.
S Children & Families Act 2014: Duty to create person centred EHC plans.
S. 42 Children & Families Act 2014: Duty to secure the health provision within an EHC plan.

3. Improved outcomes for children and young people with SEND aged 0-25.
Legal framework
S. 2 Health and Social Care Act: Duty to improve the quality, effectiveness and experience of health services.
S Health & Social Care Act: Duties to create a Joint Strategic Needs Assessment and Joint Health and Wellbeing Strategy.
Working Together 2015: Taking action to enable all children to have the best outcomes.
Improved outcomes for children and young people with SEND aged 0-25.
NHS Five Year Forward View: Integrated models of care across traditional boundaries.
S. 195 Health & Social Care Act: Duty on the Health and Wellbeing Board to promote the integration of health and social care services and joint commissioning.
NHS Five Year Forward View: Empowerment of patients to take control over their own care & treatment.
S. 3 Care Act 2014: Duty to promote the integration of health and social care services.

4. Joint commissioning cycle from SEND 0-25 Code of Practice

5. A shared approach to improving outcomes
SEND Code of Practice
“Partners must agree how they will work together. They should aim to provide personalised, integrated support that delivers positive outcomes for children and young people, bringing together support from across education, health and social care from early childhood through to adult life and improve planning for transition points”.
Strategic partnerships with robust local governance arrangements

6. A shared approach to improving outcomes
Approval of strategic priorities through CCG, LA, School and College governance arrangements.
Strategic partnerships with robust local governance arrangements
Health and Wellbeing Board
Shared vision
Health & Wellbeing Strategy & JSNA
Champion integrated working & joint commissioning
A shared understanding of the needs and aspirations of CYP with SEND and their families and carers.

7. Evidenced based approach to joint commissioning
Clearly define the population group you will be targeting.
Needs assessment: How good is your data?
Co-production of children, young people and parent carers.

8. Evidenced based approach to joint commissioning
Which services / professional groups are involved in supporting the group of children and families you are targeting?
How effective are the interventions currently being commissioned?
Interventions need to be flexible to respond to individual need that changes over time and not tied to specific tiers.

9. Evidenced based approach to joint commissioning
Children, young people & parent carers have often praised specific professionals for the quality of their support, but have complained about their overall experience of the service.
Current offer of support for children & young people with SEND is fragmented, delivered by multiple providers across health, education and social care.
Providers are incentivised to deliver episodes of care rather than outcomes.

10. Outcomes based approach to commissioning
Traditional approach to commissioning therapy services.
Commissioning Outputs
An increasing number of CCGs and local authorities are working collaboratively to explore new outcome based approaches to commissioning pathways for specific groups or children, rather than commissioning multiple providers to deliver elements of a pathway.
New approach to commissioning a pathway for a defined group of children.
Commissioning outcomes

11. Outcomes based approach to commissioning
Stages in the outcome based commissioning process
Define the population group(s) & then the outcomes for the population group(s).
What data do we have?
How many providers are involved in the pathway?
How will we measure the outcomes?
Define a capitated budget to deliver the pathway.
Identify Outcome based contacting model:
Accountable Lead Provider
Alliance
The stages in the outcome based commissioning process is based on having a shared vision across CCGs and Local Authority for how children’s services will be transformed in the future.

12. Outcomes based approach to commissioning
Defining the responsible commissioners for the new pathway
Must should could exercise as part of a wider provider mapping exercise
Based on the three core responsibilities within section 1 of the Health Act 2006.
Group by age (0-5, 5-18/25).
Must – Statutory duty
Should – NICE guidance / evidence based practice
Could – Contribution towards medium / long term priorities
What data do we have?
How many providers are involved in the pathway?
How will we measure the outcomes?

13. Outcomes based approach to commissioning
Tools from literature for measuring outcomes
Clinical & Social Outcome Measures
National children & young people’s health data set.
Children & young people’s benchmarking Tool.
CAMHS modelling tool.
What data do we have?
How many providers are involved in the pathway?
How will we measure the outcomes?
Patient Reported Outcome Measures (PROMS)
Standardised questionnaires that measure outcomes from the perspective of the child / parent. Examples include:
KIDSCREEN
PedQL
EQ-5DY

14. Outcomes based approach to commissioning
Defining the budget
Outcome based commissioning gives commissioners an opportunity to define the budget to meet a set of specific outcomes that matter most for a defined population group.
Opportunities
Capitated budget (bundled payment) – Year of Care approach.
Commissioning for Quality and Innovation Schemes (CQUINS).
Define a capitated budget to deliver the pathway
Opportunities to align the current finance work linked to the ND project with CAMHS procurement, work with NHS E Specialist commissioning to include tier 3.5 outreach model to reduce Tier 4 admissions and align maternal mental health and perinatal mental health finance to the capitated budget.

15. Outcomes based approach to commissioning
Defining the budget
“The characteristics of a bundled payment system include:
A single payment for the whole care cycle, with mandatory outcome reporting
Incentivises providers to improve outcomes and lower costs across the full care cycle
Underpinned by shared incentives between providers in achievement of agreed outcomes”
Outcomes Based Healthcare
Define a capitated budget to deliver the pathway

16. Outcomes based approach to commissioning
Accountable Lead Provider
Incentivised to deliver an “integrated programme of care”, involving related pathways and sub-contractors.
Accountable for the achievement of the outcomes and performance managing sub-contractors to deliver a seamless, joined up approach.
Identify Outcome based contacting model:
Accountable Lead Provider
Alliance
Commissioners relate to one provider within a wider supply chain. Lead provider should be incentivised to deliver LEAN approaches to delivery and maximise opportunities for research and development through new partnerships with Universities.

17. Outcomes based approach to commissioning
Accountable Lead Provider
Accountable for delivering personalisation through a new child and family centred approach.
Accountable for delivering integration, workforce training and development and integrated I.T. and information sharing solutions to achieve the outcomes.
Opportunity to promote integration across health, education and social care.
Identify Outcome based contacting model:
Accountable Lead Provider
Alliance
The Accountable Lead Provider needs to be a provider who is delivering at the centre of a wider pathway / programme of care and has the opportunity to use it’s clinical expertise and financial leavers to deliver innovative approaches to integration that deliver the agreed outcomes.
Opportunity to explore how current education and social care services could be part of the integrated programme of care.

18. Outcomes based approach to commissioning
Identify Outcome based contacting model:
Accountable Lead Provider
Alliance
Alliance Agreement
Providers & Commissioners
Bi-lateral Contract with Provider 1
Bi-lateral Contract with Provider 2
Bi-lateral Contract with Provider 3
Bi-lateral Contract with Provider 4
The Alliance contract places a mandatory requirement upon the named providers and commissioners to form a strategic partnership to achieve the outcomes in the Alliance Agreement. CCGs and KCC will need to weigh up which is the preferred outcome based contracting model. A number of the CCGs and Local Authorities who have gone down this road have gone with the Accountable Lead Provider approach. If this is the preferred approach then it would be prudent to require the Lead Provider and its sub-contractors to participate in a transformation board to mitigate the risks of CCG and LA commissioners not engaging directly with the Lead Provider’s sub-contractors.
Reference new NHS Standard contract team guidance on Alliance contracts, bring commissioners and providers together.

19. Outcomes based approach to commissioning
Alliance
Accountability for delivering the identified outcomes and integrated programme of care sits with a strategic partnership made up of multiple providers and commissioners.
Each provider shares the incentives and risks of not achieving the outcomes specified in the contract.
Can deliver many of the benefits of the Accountable Lead Provider in terms of new joined up approach.
Identify Outcome based contacting model:
Accountable Lead Provider
Alliance
The Alliance contract places a mandatory requirement upon the named providers to form a strategic partnership to achieve the outcomes in the contract. CCGs and KCC will need to weigh up which is the preferred outcome based contracting model. A number of the CCGs and Local Authorities who have gone down this road have gone with the Accountable Lead Provider approach. If this is the preferred approach then it would be prudent to require the Lead Provider and its sub-contractors to participate in a transformation board to mitigate the risks of CCG and LA commissioners not engaging directly with the Lead Provider’s sub-contractors.
Reference new NHS Standard contract team guidance on Alliance contracts, bring commissioners and providers together.

20. Outcomes based approach to commissioning
Alliance
Binds together a set of commissioners and providers to work as a single integrated team to deliver the specific integrated service or programme under a contractual framework.
Offers a more collaborative and collegiate approach than traditional commissioning processes.
Providers and commissioners co-operate to seek what is best for the integrated service rather than individual organisations.
Identify Outcome based contacting model:
Accountable Lead Provider
Alliance
Reference new guidance from NHS Standard Contract Team on Alliance contracts, including a new model alliance agreement that can work with current NHS standard contract, social care contracts and primary care contracts.

21. Further reading
M. Gascoigne (2015) Commissioning for Speech Language and Communication Needs. Better Communication Research Programme
Outcomes Based Healthcare & Capsticks (2014) Contracting for Outcomes: A Value Based Approach
Outcomes Based Healthcare (2014) Outcomes myths
The Health Foundation (2015) Need to nurture: Outcome based commissioning in the NHS
Health Foundation - Need To Nurture Outcomes-based commissioning
A. George Using integrated intelligence to drive service change: supporting people with multiple morbidities in Kent
Children and young people’s health services data set (2015)

22. Further reading
P. Corrigan & S. Laitner (2012) The Accountable Lead Provider. Developing a powerful disruptive innovator to create integrated and accountable programmes of care. Right Care Casebook Series
In-Control (2014) Personal Outcomes Evaluation Tool for children and young people with SEND
A. Allard et. al (2015) Key health outcomes for children and young people with neuro-disability: qualitative research with young people and parents. BMJ.com
P. Kumalo & M. Cunnington (2015) Using incentives to improve experience in maternity, children and young people’s services. South East CSU