Commissioning [Integrated] Care in England: An Analysis of the Current Decision Context

Abstract

Background: The emergence of Integrated Care Systems (ICSs) across England poses an additional challenge and responsibility for local commissioners to accelerate the implementation of integrated care programmes and improve the overall efficiency across the system. To do this, ICS healthcare commissioners could learn from the experience of the former local commissioning structures and identify areas of improvement in the commissioning process. 
 Aim & Audience: This study describes the investment decision process in integrated care amid the transition toward ICSs, highlights challenges, and provides recommendations to inform ICSs in their healthcare commissioning role. It is expected that this study encourages an open discussion within the emerging ICSs on the barriers and enablers of the local commissioning of integrated care. We also believe that findings of this study are likely to be of international interest as countries are gradually moving towards integrated care, and local purchasers of healthcare from high-income economies are likely to encounter similar challenges as the ones faced by local commissioners in England.
 Methods: We conducted twenty-six semi-structured interviews with local commissioners and other relevant stakeholders in South East England in 2021. Interviews were supplemented with existing evidence from the literature.
 Results: England’s local healthcare commissioning has made the transition towards a new organisational architecture, with some integrated care programmes running, and a dual top-down and bottom-up prioritisation process in place. The commissioning and consequent development of integrated care programmes have been hindered by various barriers, including difficulties in accessing and using information, operational challenges, and resource constraints. Investment decisions have mainly been driven by national directives and budget considerations, with a mixture of subjective and objective approaches. This contrasts with what seems to be a set of desirable prioritisation criteria, with the triple aim framework at the front. A systematic and data-driven framework could replace this ad-hoc prioritisation of integrated care and contribute to a more rational and transparent commissioning process. To develop such a framework, a good reference point could be the health technology assessment framework established at national level to guide priority-setting decisions. 
 Conclusion & next-steps: The local healthcare commissioning structures in England are complex, the evidence available is rich, and integrated care is undoubtedly the goal to achieve. However, the multiple barriers that commissioners face hinder the development of integrated care programmes and limit the local use of evidence in healthcare decision-making. The emerging ICSs seem to open an opportunity for local commissioners to strengthen the commissioning process of integrated care with evidence-based priority-setting approaches similar to the well-established health technology assessment framework at the national level. To support this, we are developing a data-driven framework to monitor and assess ‘integrated care programmes’.