Research Policy and Planning: The journal of the Social Services Research Group – Vol 17 (2) 1999
More than just a quick fix? The potential of joint commissioning in services for people with learning disabilities
Paul Cambridge, Senior Lecturer in Learning Disability/Service Development Consultant, Tizard Centre, University of Kent
Joint working between health and social services has a long record of fragmentation and under-performance in community services for people with learning disabilities. Joint community teams have helped bring agencies together at the operational level and care management has facilitated service co-ordination for individual service users, but comprehensive service strategies in learning disability are also required. Joint commissioning was offered in the early 1990s as an advance on joint planning, but its implementation was piecemeal and there were legal constraints. This paper examines the renewed potential for joint commissioning in the context of the Government’s emerging social care policy agenda, including its commitment to partnerships and performance management. Drawing on case evidence from learning disability and the wider academic literature, it identifies pointers for the development of joint commissioning in learning disability and argues for the monitoring and evaluation of emerging models.
New approaches to joint purchasing between health and social services emerged in the 1990s: in part a response to the management demands of developing social care markets and part the logical evolution of established joint planning and joint finance initiatives. No single model predominated, and with very different management, budgetary and operational arrangements between health and social services, such joint purchasing was described as collaborative purchasing or purchasing in tandem (Wertheimer and Greig, 1993). Observers also pointed to the lack of agreed definitions for joint commissioning (Hudson, 1995), the weak understanding of function, process and outcome (Poxton, 1994) and the imperative of collaboration where purchasing authorities were too small to develop integrated strategies or lacked the required purchasing skills (Ham, 1992).
Knapp and Wistow (1992) focused on the commissioning process within a model of service development and review, with micro or tactical purchasing also taking place by care managers. This overall process for joint commissioning was later mirrored in the cycle promoted by the Department of Health (1995). Joint commissioning was also defined at this point as:
The process in which two or more commissioning agencies act together to coordinate their commissioning, taking joint responsibility for translating strategy into action (Department of Health, 1995:3).
Two main observations are evident on scrutinising this report. It was explicitly acknowledged that there were legal constraints to full joint commissioning. These concerned the pooling of budgets and devolution of powers of assessment from social services. Implicitly, it was evident that joint commissioning tended to concern small projects rather than wider service strategies. The new Labour administration quickly identified the imperative for joint working, through its commitment to remove the legal blocks to pooled budgets and to promote lead commissioning by a variety of agencies in order to achieve more integrated local provision (Department of Health, 1998a).
The wider potential of joint commissioning as a policy and political instrument should also be recognised. It could be used to help meet some of the Government’s wider social care policy objectives (Department of Health, 1997; 1998b; NHS Executive, 1998), such as equity, social inclusion and managed competition. Of more central significance, it offers a process for informing Best Value in learning disability, translating the information generated by performance management systems, including fundamental service reviews and inspection (Department of Health, 1998a and 1999; Cambridge, in press), into purchasing decisions.
Political expectations of the performance of joint commissioning are similarly high. It offers a system for reversing the fragmentation and fractured accountability in learning disability services generated by the social care contract (Cambridge and Brown, 1997), it could help reduce the imperfections and distortions occurring in social care markets (Wistow et al., 1993), it has the capacity to develop comprehensive service strategies in learning disability and challenging behaviour (Mansell, 1993), and it could provide the framework for producing comprehensive and comparable information on service costs and user outcomes needed for promoting cost effectiveness (Cambridge and Knapp, 1997).
The changed political environment therefore increases the challenges for joint commissioning. The conceptual shift from the periphery to the centre in performance and standards will need to be resolved in relation to the counter-shift towards individualised funding (Nuffield Centre, 1998). There is an increasing likelihood that some social care resources will bypass agencies, managers and professionals (Holman and Collins, 1997). Similarly, the relationship between joint commissioning and tactical purchasing within care management will need to be addressed, particularly considering the organisational and operational variability of care management itself (Cambridge, 1992: 1999a). Parallel considerations are evident for the function and operation of joint commissioning in relation to primary care group purchasing (Department of Health, 1997 and 1998a) and in relation to service development, the links with community care planning.
Closing the implementation gap
Agency roles and responsibilities shifted radically during the two decades following Better Services for the Mentally Handicapped (DHSS, 1971), with early moves towards shared views of services evident in the 1974 NHS Reorganisation Act, which established joint consultative committees and the 1983 Care in the Community Circular (DHSS, 1983) which introduced financial transfers for individuals moving between agencies and out of institutions. Clarity of funding similarly proved important for the new mixed economy of provision in &-institutionalisation (Renshaw et al., 1988: Knapp et al., 1992). The limited impact of existing joint planning and joint finance on the pattern and balance of services for people with learning disabilities was also recognised (Wistow, 1982, 1983 and 1990), with finance time limited and tapering, creating disincentives for local authority involvement (Wistow and Hardy, 1986).
The 1990 community care reforms (NHS and Community Care Act) redefined the responsibilities and functions of the public sector agencies and, although some clarity was established by making social services departments lead agencies for community care planning and care management, there was no device specifically to help integrate frequently diverging purchasing strategies between health and social services locally. These generated acute implementation gaps (Lewis et al., 1995) and increasing inequities between authorities (Cambridge et al., 1994). The emerging care market was also challenging the capacity of the public sector agencies to manage change and deliver integrated and comprehensive community care (Forder et al, 1996), with the contract tending to perpetuate user exclusion (Cambridge and Brown, 1997). Devolved budgets and accountability, with purchasing by care managers, was also generating tensions between tactical and needs-led purchasing and strategic direction (Knapp and Wistow, 1992). Moreover, the policy rationale for joint commissioning had already been widely rehearsed (Box 1).
Box 1. Established policy rationale for joint commissioning [missing]
The Audit Commission (1986) had recommended that local authorities should be made responsible for the long-term care of ‘mentally and physically handicapped people in the community’ and that ‘the resources necessary to do this should be transferred from the NHS’ (para. 174. 1), thus recognising the imperative to develop unambiguous lead agency and funding responsibilities. The Audit Commission also recognised that the needs of people with learning disabilities were rapidly changing as a consequence of deinstitutionalisation and new service principles such as normalisation (Wolfensberger, 1980; 1984) and it was observed that ‘Unless local authorities work with health authorities quickly to ensure a needs based allocation of available resources, the totality of services may contract unacceptably’ (Audit Commission, 1987: 1).
Community Care: Agenda for Action (DHSS, 1988) added weight to the argument for integrated purchasing and service development, stating ‘there must be a clear framework within which local authorities and health authorities are working out their own process of co-ordination. The programme should be matched by parallel approval of those parts of the health service plans allocated and ring-fenced for community care’ para.23). In 1989 the Audit Commission took this concept a step further by suggesting joint management of services by health and local authorities with ‘a joint manager…. responsible for a jointly funded budget’ (Audit Commission, 989:para.66), in other words, local joint commissioning.
The 1990 community care reforms Caring for People (Department of Health, 1989) made little progress in removing the organisational and financial disincentives to joint working. The Audit Commission re-focused attention on funding by observing that ‘Even if clarity of responsibility can be agreed, it must be complemented by ways to adjust finance on a continuing basis’ (1992:paras.20-2 1).
The need for robust financial strategies was further demonstrated by the Care in the Community Initiative (Knapp et al., 1992: Cambridge et al., 1994) and the variety of macro-organisational models emerged. Joint and lead agency services were more strategically driven, better managed, more comprehensively designed and better integrated and implemented, than single agency or independent models. Collaborative culture was seen to achieve a range of benefits: clear mission and coordination; familiarity with service models; fewer developmental risks; common development goals; multidisciplinary working and shared accountability and management responsibility.
The slow and uneven development of community care stems in part from fragmentation of responsibility and accountability, horizontally across agencies and vertically between tiers of government. Not surprisingly, the suggested reforms of many commentators, including the Audit Commission, (1986) and Griffiths (1988), included single agency responsibility for client groups, combined with unambiguous funding channels (Knapp et al., 1992:237).
A longer term follow up of 12 learning disability services through the implementation of the 1990 reforms (Cambridge et al., 1994), identified major difficulties working the mixed economy of provision, particularly where local service strategies did not exist and agency roles and responsibilities were loosely defined in relation to service development. Deficits included inadequate performance monitoring of providers, poorly coordinated community care planning, confused responsibility for the performance of care management tasks and fractures in accountability. In a few localities this impacted negatively on care providers, with some service users returning to institutions (see Camden case study Cambridge et al., 1994).
In parallel, other observers commented on the patchy experience withjoint commissioning (Waddington, 1995) and the Social Services Inspectorate (1998) highlighted the importance of partnership approaches for creating a single service for people with learning disabilities:
…responsibilities were diffused, even within the SSD alone, the lack of strategic and coordinating lead was apparent (Para. 8.6:57).
Organisations seemed most effective with a single manager leading on learning disabilities strategy and commissioning (Para. 8.7:57).
Field experience therefore suggests that joint commissioning is unlikely to provide benefits outside those localities and places where other approaches to joint working have proven productive, raising the question as to whether it is the joint commissioning model per se which facilitates locally integrated services or the added value of particular local players or organisational conditions. A comparison of experience in Lewisham and Somerset provides a part answer. Lewisham developed an explicit joint commissioning agency while in Somerset joint commissioning evolved from the commitment of key managers in health and social services.
Lewisham Partnership was originally envisaged as semi-independent joint commissioning agency (Wertheimer and Greig, 1993), but now functions as a local purchasing arm of Lambeth, Southwark and Lewisham Health Authority and Lewisham Social Services (without a single budget). Its operational capacity was restricted by the local auditors due to legal constraints to delegated statutory responsibility for assessment and spending (see case study below). Although the legal framework has now been clarified (Department of Health, 1995) and the intention to remove such barriers made explicit (Department of Health, 1998a), such restrictions have undermined the potential of joint budgetary management, resource allocation and devolved assessment for at least 10 years. Ironically, the original Lewisham Partnership model would now be an option for the Department:
Pooled Budgets – health (Health Authorities or Primary Care Trusts) and social services to bring their resources together into a joint budget accessible to both commission and provide services. This will make it easier for staff in either agency to pull together a comprehensive integrated package of care for users (Department of Health, 1998b, para. 2.18).
It is from creative inter-agency collaboration in the past that productive lessons for future joint commissioning can be found. The account provided of lead agency arrangements for community learning disability services in Somerset (Cambridge et al., 1994) Five Years On, provides powerful support for this hypothesis. There was initial agreement on a joint strategy between Somerset Health Authority and Somerset Social Services Department, with lead agency responsibility for management and operation passed to social services through local consensus and a joint county strategy (Knapp el al., 1992).
As people with learning disabilities moved from the old hospitals into new community services, the health authority was billed by social services, with funds progressively transferred. This necessitated information systems on individual service utilisation and costs and planning for change demanded similar systems on needs and outcomes. Thus Somerset developed in the late 1980s the sorts of management information systems the Audit Commission was promoting in the early 1990s and, by default, a model of joint commissioning close to that now being promoted:
Lead commissioners – one authority (Health Authority, Primary Care Trust or Social Services Authority) to transfer funds and delegate functions to the other to take responsibility for commissioning both health and social care. This will put the needs of patients and users at the heart of commissioning and eliminate wasteful overlaps and gaps (Department of Health, 1998a, Para. 2.18).
With care management from within social services, this approach began to link strategy and tactics, seen as an essential element of joint commissioning (Knapp and Wistow, 1992), helping avoid the emergence of two tier services. It is evident from the Ten Years On research currently being conducted that Somerset is encountering new demands for performance management, accumulating resource constraints, an increasingly mixed but managed economy of provision and progressive divergence in service patterns and standards between divisional structures and budgets in learning disability. The intention is now to move towards a more explicit joint commissioning framework (Somerset Social Services, 1998). A small joint commissioning team will develop strategy from community care planning, incorporating the interests of primary care groups and the local NHS provider trust. This tighter central steer will be balanced by more comprehensive care management through joint multi-disciplinary learning disability teams.
Partnership in Action (Department of Health, 1998a), signalled the Government’s intentions to remove the legal barriers to joint working in order to enable three main commissioning models, viz:
pooled budgets between health authorities or primary care trusts/groups (PCT/G) and social services departments, with the joint budget accessible to both commission and provide services;
lead commissioners – health authority, PCT/G or social services department – with funds transferred and functions delegated for the commissioning of health and social care;
integrated provision, with an NHS trust or PCT/G to provide social care services or a social services department to provide a limited range of community health services.
The future organisational framework for pooled budgets was outlined and tested in the Lewisham Partnership model in the early 1990s in South East London:
The aim of establishing the Lewisham Partnership was that it would act as an intermediary body. It would be a separate organisation…. but part of health and the local authority, linked to each other by a management committee and system of contracts. Control… would be split… between the two statutory agencies, the agenda would be set by the management committee and ultimate control exercised through contracts. (Wertheimer and Greig, 1993:36)
The rationale was that Lewisham Partnership could help manage the local community care market and close the gaps between authority level funding and the development of individual, needs led services on the one hand and the health and social care components of service packages for people with learning disabilities on the other. The mechanisms of a pooled budget, devolved purchasing to care managers, individual service specifications and the break up of large ex-public sector providers into smaller, competing, not-for-profit organisations, were used to close these gaps.
Despite the legal difficulties reported above, the original Lewisham Partnership model represents one of the purest attempts to develop integrated joint purchasing (Greig, 1996: Cambridge, 1996) and is close to the pooled budget model identified by the Department of Health (1998a). It can also be developed to take account of PCT/G purchasing and wider partnership working (Figure 1).
There is less evidence on how the lead and integrated provision models are likely to work in practice, although in localities like Somerset (described above), variants of the lead and integrated provision models have already emerged, with social services successfully leading learning disability services in response to the 1990 community care reforms (Department of Health, 1989). Such approaches also offer the advantage of a direct line to community care planning and care management intelligence on needs assessment and provider performance, less available to health authorities or PCT/Gs. Indeed, the government has referenced the importance of joint working in the three areas of strategic planning, service commissioning and service provision (Department of Health, 1998a), suggesting a clear rationale for a social services lead. Moreover, social services departments are more directly and democratically accountable through local government.
Figure 1: A Future Model for Joint Commissioning [image not available]
Some of the fundamental non-legal barriers to joint working, particularly the potential for territorial discontinuity and disconnection between agencies, have not been addressed by the Government. In many localities, joint commissioning would be a virtual logistical and organisational impossibility, due to non-coterminous public sector agency boundaries and area divisions. This raises the possibility of special learning disability commissioning agencies for defined territories, with learning disability budgets ring fenced and transferred and management accountability constructed through representation from the different agencies involved – potentially more than one health authority, NHS trust, PCT/G or even social services department.
Critical considerations for implementation and review
As new approaches to joint commissioning begin to emerge, there is a pressing need to evaluate and review their relative effectiveness in relation to process outcomes, intermediate service outcomes and final outcomes for service users. Despite a huge array of intervening variables, it will remain critical to have such information in order to inform the implementation and review of joint commissioning. In brutal terms, joint commissioning has the potential to help develop integrated and comprehensive services for people with learning disabilities within shared local values or to further exclude service users from decision-making and put managerial interests before those of best practice or public accountability.
The Government have recognised the need to close the policy/practice implementation gap (Department of Health, 1998a), identifying possible new measures for monitoring and review. However, these largely concern process outcomes, such as national guidance, performance management, joint review arrangements and inspection. Intermediate outcomes also need to be tracked, such as the development of integrated service strategies or innovative advocacy or employment services for people with learning disabilities. Final user outcomes, such as service appropriateness, quality or user choice, also need to be available.
It would be naive to assume that joint commissioning will automatically bring gains in efficiency or productivity in services for people with learning disabilities, as it also brings transactional, management and administrative costs. Efficient strategic joint commissioning will need to be informed by and integrated with wider management information systems, otherwise its costs could well outweigh the efficiency savings it could bring to authorities through’ single structures, the delivery of improved user outcomes or reduced service costs.
The emphasis for reviewing joint commissioning therefore needs to be shifted to evaluation as well as monitoring, making it important to include a number of key outcome domains.
Intermediate and final outcomes
Organisational solutions to the failings of community care are often more to do with political and management expediency (Social Services Inspectorate, 1990) than to a concerted effort to improve the quality and outcomes of services for people with learning disabilities. Nocon and Qureshi (1996) noticed a gap between strategic objectives, priorities and plans and ways to measure performance, including outcomes. Jointly commissioned services will not automatically be more sensitive to user or carer needs, or to considerations of gender, race, culture or sexuality than previous arrangements, making values important.
The Department of Health (1996) recognised the requirement for good practice in commissioning to reflect the diversity of minority ethnic health needs. Others stress the requirement for commissioning and contracting to involve rather than exclude service users and carers and address often invisible needs relating to sexuality and adult protection (Cambridge and Brown, 1997; Cambridge, 1999b; Brown, Stein and Turk, 1995). Such issues are central to joint commissioning, which has the potential to set permissive standards for management and staff behaviour, as well as incorporate standard performance and cost indicators (Department of Health, 1999).
User centred approaches to developing information on quality and outcomes could include user focus groups, involving individuals in care and service planning or including advocates in service audit. Broadening stakeholder involvement is part of a balanced approach to joint commissioning and Best Value, although it is essential to acknowledge that many people with learning disabilities will remain disadvantaged due to their lack of understanding and use of language.
Responding to challenging needs
Challenging needs is an example of the potential for joint commissioning to respond to a critical policy and practice theme and an important area of generally unmet need. A variety of complex definitions of challenging behaviour have emerged, but the influential King’s Fund’s report Facing the Challenge (1987) used an operational definition developed from the work of the Special Development Team at the University of Kent:
Severely challenging behaviour refers to behaviour of such intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit or delay access to and frequent use of ordinary community facilities. (Special Development Team, 1987:8)
Specialist providers and professionals from health have generally retained responsibility for those people with learning disabilities who challenge services, particularly those moving from institutional care. Community support teams for people with learning disabilities and challenging behaviours are usually health funded and led by psychology services (Emerson et al, 1996).
Service co-ordination, placement development, the prevention of placement breakdown and the development of appropriate provisions for people with challenging behaviour have usually been the remit of community support teams outside a commissioning framework (Forrest et al., 1995). This is despite the central policy recommendation that commissioners take a strategic view of challenging behaviour and purchase services based on individual needs (Mansell, 1993).
A challenging behaviour strategy requires pro-active purchasing which shifts the emphasis from ‘removing’ challenging behaviour by using out of authority placements or ‘containing’challenging behaviour in low cost, poor quality services to ‘developing’ local competence through investing in management and staff training. Mansell (1993) envisaged commitment, individualised services, effective models of support, good management and investing in relationships as prerequisites for reaching the ‘developing’ stage.
The intelligence needed for joint commissioners to develop a comprehensive range of local services for people with learning disabilities and challenging behaviours already-exists..(Mansell -et al., 1994: Greig et al., 1996). Such a strategy would comprise the key components of prevention (aiming to reduce the incidence of challenging behaviour), early intervention (from an awareness of the information required to identify the emergence of challenging behaviour), the provision of technical and practical support (of sufficient intensity to bring about changes in behaviour), and placement development (to reflect people’s special needs). Such intermediate outcomes are difficult for health authorities or social services departments to develop in isolation, but this frequently remains the practice in relation to challenging behaviour:
The community care reforms may have led some people in health authorities to believe that they would have no continuing responsibility for services for people with learning disabilities….
Nevertheless the actual boundary of responsibility remains for local agencies to decide (and there are clear perverse incentives for neither to take the lead) (Mansell, 1993:15).
Aligning strategy with tactical behaviours
The extent to which joint commissioning becomes responsive to individual needs partly hinges on relationships with providers and the type of contracting (Flynn and Common, 1990: Churchill, 1992: Flynn et al., 1995), and partly on the extent to which purchasing is devolved to care managers. The latter may be on joint agency teams or quasi-independent service brokers (Brandon and Towe, 1989: Dowson, 1995: Dook et al., 1997). If devolved purchasing is to be viable within joint commissioning systems, particularly in relation to direct payments (Holman and Collins, 1997), accountability will need to be defined, safeguards put in place and minimum standards set.
Individualised information systems on needs, costs and service utilisation will consequently be essential for such approaches (Cambridge, 1996). Devolving responsibility for assessment to professionals on joint teams, with an annual review cycle, would help ensure a fit between care management, individualised purchasing and joint commissioning (Greig, 1996: Greig et al., 1996). Individualised costs will therefore need to be constructed by commissioners according to the principles of comparability and comprehensiveness (Knapp and Cambridge, 1996). Ibis will be required if they are to reflect the reasons for cost variability between individuals and services (Knapp and Beecham, 1990), demanding a significant investment in information technology (Browning, 1992). Joint community learning disability teams, with care management responsibility, represent the idealised operational mechanism, although ad hoc arrangements, such as forums between care managers, primary care groups, self advocacy groups and joint commissioners, could also be established to negotiate shared priorities. Any such tactical purchasing will need agreed access to individual information systems.
Integration with Best Value
If Best Value is to effect improvements in the value of services and/or reduce costs – which may itself be na7fve given what we know about the relationships between improvements in quality and outcomes and increased costs (Cambridge et al., 1994) – joint commissioners will need to act on the Best Value information collected by fundamental performance reviews within social services departments and service reviews within learning disability. Achieving a shift towards value will require that poor quality or abusive services are decommissioned, and also that relatively expensive services are examined for their productivity. Hard work will also be needed with providers to achieve the desired shifts without generating gaps or discontinuities in provision. At its simplest a process which compares service costs to quality might consist of:
- identifying Best Value or quality criteria;
- comparing these to costs, and ;
- making judgements about their relative worth.
Table 1 provides a basic framework for applying rules to this process.
A first step to resolving some of the conflicts which will surface between Best Value and costs will be for commissioners to be explicit with providers about Best Value criteria and to reference these in contracts and individual service specifications. At the same time commissioners need to continue the push from block to individual contracts because it is only at the individual level that things important to service users and individual outcomes can be sensibly referenced.
Table 1. The basic rules for gauging Best Value.
|Intervention or service||Higher cost/more expensive||Same cost/equally expensive||Lower cost/less expensive|
|More effective or higher quality||Judgement required on non financial costs/benefits||Best Value||Best Value|
|Equally effective or same quality||Not best value||No discernible gain or losses||Best Value|
|Less effective of low quality||Not best value||Not best value||Judgement required on non financial costs/benefits|
Commissioners will need to be able meaningfully to compare purchasers on price as well as value. Best costing practice is based on the key considerations of comprehensiveness, individualisation, comparability and productivity, which can be translated into key principles (Cambridge and Knapp, 1997):
- ensuring comprehensiveness – including all relevant services in care programmes, service packages and accommodation;
- taking account of individual variations – costs are usually linked to differences in service user characteristics, needs and outcomes;
- making like for like comparisons – recognising differences between users or populations of service users in interpreting differences and similarities in costs;
- linking costs to outcomes – taking account of the outcome and quality of life gains for service users when comparing costs.
The outcomes of services have complex relationships with costs, in that variations in costs are rarely explained by single variables, but we know the main determinants to costs, such as the size of group homes, and that these also help determine outcomes, and commissioners will need to use such intelligence.
Policy and practice evidence suggests that joint commissioning was introduced as a quick fix for fragmenting social care following the 1990 community care reforms, primarily as an attempt to avoid a major reorganisation of health and social care. What can be done to help make joint commissioning in services for people with learning disabilities work well as a pro-active and productive instrument for service development?
Development and review priorities
Authorities should give priority to constructing new joint Commissioning arrangements in project and service development areas with a proven track record of successful joint working, and priority areas such as challenging behaviour and adult protection, where the imperative for a joint approach is strongest. The experience accumulated and lessons learned could then be transferred to inform joint commissioning in services for people with learning disabilities.
A starting point for monitoring progress with joint commissioning is to review the pattern of services being jointly developed and purchased in relation to identified needs and priorities. At a conference in 1996 at the University of Kent, organised by the PSSRU and the Tizard Centre, and designed to facilitate joint commissioning between a local authority social services department and health authority, delegates from different divisions and NHS trusts were asked to produce such lists. A wide range of services and resources was seen to have the potential to be included in joint commissioning, viz: community learning disability teams, community support teams for challenging behaviour, locality forums, shared information bases, new styles of joint planning team and pilot services for independent living, respite and enhanced care, supported living and employment.
This suggests that a bottom up development approach to joint commissioning has the potential to help build consensus between agencies and professionals, providing a sound basis for replicating or extending successful initiatives.
Establishing a common value base
A shared commitment to de-institutionalisation, desegregation and individualisation is required for best practice in services for people with learning disabilities. This is needed to ensure progress and avoid disputes over service models, such as the scale of residential provision or approaches to day support and employment. Developments grounded in normalisation and social role valorisation (Wolfensberger, 1980 and 1984) and an ‘Ordinary Life’ model (King’s Fund, 1980), provide such principles. However, thought will also need to be given to the failure of normalisation to include those on the margins by virtue of culture, gender or sexuality (Brown and Smith, 1992).
Common aims and objectives and agreed routes to achieve them are similarly needed for joint commissioning. Conflicts between agencies and professionals are likely to emerge without agreement on goals, for example the ‘five accomplishments’ method (O’Brien, 1987), which help focus attention on outcomes and process at the care level. At the same time, effort should also focus on closing the gap between what professionals and providers want and what users say they need (Nocon and Qureshi, 1996).
The national service objectives identified to date (Department of Health, 1999), suggest the need to develop meaningful criteria for measuring performance, quality and change. Those objectives relating to adult services include respect for dignity and furthering social and economic participation. These are difficult to measure and represent intermediate service_ outcomes more than final user outcomes. Those indicators identified which refer directly or tangentially to learning disability (Department of Health, 1999) include the unit costs of residential care, adults helped to live at home, avoidable harm for adults (in the context of learning disability one would need to examine performance in reporting and responding to physical sexual and other forms of abuse) and a small number of generic measures of quality and process (some of which amount to monitoring aspects of care management performance, including needs statements, reviews and carer assessments). Commissioners will need to give urgent consideration to supplementing such measures in the area of user outcomes.
Developing technical expertise
Joint commissioning will need to undertake needs assessment and epidemiological work in order to inform the development of shared entry and eligibility criteria, using targeting methodologies such as the district audit model (Audit Commission, 1993), as well as the development of service strategies. This is not only vital in priority areas like as challenging behaviour (Mansell, 1993), but also a range of other activities such as adult protection (Cambridge, 1999b). Such technical expertise will only be sustainable if it is responsive to the relationships between purchasing and care management, making considerations of equity and target efficiency relevant (Challis and Davies, 1986: Davies et al., 1990).
More widely, communication, advocacy, sex education, supported living and employment services will be required, along with the grounded development of policies and guidelines covering a range of service and staff competencies, including sexuality, HIV, adult protection and sexual abuse, control and restraint and whistle-blowing. There are examples of inter-agency policies in adult protection which were formulated and implemented through consensus between providers, the police, user and carer organisations as well as health and social services (Greenwich Social Services, 1993). Joint commissioners should ensure that general budgets are top-sliced or specialist budgets in development priority areas are ring-fenced to protect or foster such important services and expertise. Pump priming resources will also need to be allocated as needs in the population of people with learning disabilities change or service development priorities shift with the implementation of new policies and procedures.
Commissioners should seek actively to intervene in the market to break up monopoly providers, encourage new providers and co-operate with existing providers (Forder et al., 1996). Awareness of the imperfections of quasimarkets (Le Grand and Bartlett, 1993) will also need to be translated into direct interventions or strategies for sharing expertise or intelligence with other commissioners. Information from service audit and research will be essential for such tasks and will enable commissioners to construct relationships between needs, resources and outcomes (Davies and Challis, 1986) and to link decision-making at the strategic level with tactical purchasing and service planning.
Caution will also be required for managing markets, as the principles underpinning joint commissioning remain predicated on markets and competition. Joint commissioners will need to acknowledge the limits of contracting (Stewart, 1993: Johnstone, 1994: Cambridge and Brown, 1997), the political problems inherent in quasi-markets (Penna and O’Brien, 1996: Cutler and Waine, 1997) and the difficulties of establishing constructive relationships with voluntary providers (Todd and Ware, 1997). Matching the different interests at stake in Best Value will also be a task for commissioners. Related questions include how to pay for and manage voids in residential services, the pump-priming and development costs of new services, renegotiating price with changing needs, developing and funding training strategies and developing and sharing information systems on outcomes and costs across agencies (Cambridge and Knapp, 1997).
One of the reasons joint commissioning has been slow to develop is the sheer enormity of the task and the exceptional challenges for doing it well. Best Value, used constructively and creatively with joint commissioning, with its emphasis on review and performance management, could facilitate joint commissioning. Special attention will, however, need to be given to user involvement and the delivery of final user outcomes, demanding links with care management and the development of new methods of consultation. The different joint commissioning arrangements which will emerge will also need careful evaluation to ascertain their relative effectiveness.
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