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Sense and sensibility: the dynamics of joint commissioning in
English health and social care
Jon Glasby, 1 Helen Dickinson, 1 Helen Sullivan 2,
Stephen Jeffares3 , Alyson Nicholds 1 and Suzanne Robinson 1
1
Health Services Management Centre, University of Birmingham
Centre for Public Policy, University of Melbourne
3
Institute of Local Government Studies, University of Birmingham
2
Address for correspondence:
Jon Glasby
Professor of Health and Social Care
Director, Health Services Management Centre
University of Birmingham
Park House
40 Edgbaston Park Road
Birmingham
B15 2RT
0121 414 7068
[email protected]
HS&DR Funding Acknowledgement
This project was funded by the NIHR Health Services and Delivery Research programme
(project number 08/1806/260).
Department of Health Disclaimer
The views and opinions expressed therein are those of the authors and do not necessarily
reflect those of the NIHR HS&DR programme, NIHR, NHS or the Department of Health.
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Sense and sensibility: the dynamics of joint commissioning in
English health and social care
Abstract
Joint commissioning is an important focus of English health and social care policy, despite
there being little robust evidence underpinning this agenda. This study seeks to provide a
theoretically and empirically robust understanding of the dynamic relationship between
joint commissioning, services and outcomes drawing on data from a large scale, mixed
methods, multi-site research project involving staff and service users engaged in the delivery
of jointly commissioned services across England. We find that joint commissioning is a
useful but not necessarily unique policy tool that is closely linked to other forms of
collaboration. We suggest that its utility is expressed through its capacity to fulfill meaningmaking as well as material functions. We argue that too often questions about ‘what works
in joint commissioning’ focus on the material at the expense of meaning-making, generating
inadequate understandings of the dynamics of joint commissioning. By asking different
questions about what and how joint commissioning means to different actors in the context
of collaboration, we create space for improving our understanding of the contribution of
agency and ideas to the potential and limits of joint commissioning in relation to both
processes and outcomes.
Key words:





Joint commissioning
Health care
Social care
Joint working
Partnerships
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Background
In the UK, as in a number of other developed countries, the delivery of more integrated care
is a crucial – but elusive – goal of health and social care policy (see, for example, Author A
and B, 2009; Allen et al., 2011; Rand Europe and Ernst & Young, 2012). Although service
structures vary from country to country, many systems separate the provision of health care
from the practical assistance they offer with tasks of daily living to disabled and frail older
people (referred to as ‘adult social care’ or as ‘care and support’ in a UK context). Over time,
a growing older population and an increase in the number of people of all ages with multiple
chronic diseases or long-term conditions have arguably made this division both impractical
and unsustainable (see, for example, Author A and B, 2008, 2009 for a review of these
issues). Integration is currently viewed by policy makers as a way of responding to these
challenges, by making better use of scarce resources and offering improved services to users
with complex needs (see, for example, NHS Future Forum, 2012). While many aspects of the
English reform process has been on creating more integrated service provision, a related aim
is to create more joint commissioning (where health and social care agencies come together
to jointly assess the needs of the local population, decide what services are needed, secure
these from a range of providers and monitor the outcome). This reflects the legacy of New
Public Management reforms, which separated health and social care provision from
commissioning and placed greater emphasis on greater choice, competition and quasimarkets (Author A, 2012). Thus, if both commissioning and joint working are increasing
priorities in both health and social care, it is not difficult to see how a commitment to joint
commissioning might be the end result.
Yet, policy aspirations for greater joint commissioning appear to outstrip developments at
practice level - despite the fact that aspirations for effective joint commissioning date back
many years (see, for example, Department of Health, 1995). Research into joint
commissioning remains limited with very few high quality empirical studies and a tendency
to rely mainly on case study material from policy documents and the trade press (see
Authors, forthcoming). By contrast, research into inter-agency collaboration is extensive,
but is limited by a tendency to focus on the process of joint working (how well are we
working together?) and not the outcomes (does it make any difference to people using
services?) As Author B (2008) has argued, this seems to be because partnership is
interpreted as inherently a ‘good thing.’ Thus, if it can be demonstrated that partners trust
each other and feel they have a good relationship, then it can often be assumed that such
partnerships are ‘effective’ (see also Dowling et al., 2004; Cameron and Lart, 2003, 2012;
Perkins et al., 2010). Against this background, this paper makes a new contribution to the
debate by suggesting that too often existing research about ‘what works in joint
commissioning’ focuses on the material at the expense of meaning-making, generating
inadequate understandings of the dynamics of joint commissioning. We argue that instead
of searching for a single truth in the form of ‘what works’ we would be better placed to ask
‘what and how collaboration means’ to the wide range of actors involved in the delivery of
joint commissioning. The paper reports findings from a national study into the processes
and outcomes of joint commissioning in English health and social care providing a
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theoretically and empirically robust understanding of the dynamic relationship between
joint commissioning, services and outcomes by addressing three main research questions:
1. How can the relationships between joint commissioning arrangements, services and
outcomes be conceptualised?
2. What does primary and secondary empirical data tell us about the veracity of the
hypothesised relationships between joint commissioning, services and outcomes?
3. What are the implications of this analysis for policy and practice in health and social
care partnerships?
Approach and methods
Evaluating joint working is extremely difficult (for an overview of some of these complexities
see Author B, 2008; Glendinning, 2002). Developments in evaluation include refinements to
method-led approaches and current thinking promotes the virtues of mixed method
approaches over the development of a single ‘right’ technique, with El Ansari and Weiss
(2006) suggesting that "a simultaneous multilevel multi-method (quantitative and
qualitative) approach to research on partnerships is optimal, thus drawing on differing
frameworks and seeking to embrace the perspective of all stakeholders and the complexity
of the phenomena under study” (p.178).
Another important development in the evaluation of joint working is the adoption of theoryled approaches. Rather than inferring causation from the input and outputs of a project,
theory-led evaluation aims to map out the entire process, focusing more on ‘what works, for
whom and under what circumstances’ (Pawson and Tilley, 1997) and offering insights about
causality and attribution. As Weiss (1999) and Patton (1997) point out, the sorts of projects
which today's evaluators are asked to work on tend to be multi-faceted, multi-level and with
multiple potential impacts and theory-led approaches are amenable to these projects.
Recent high profile examples include approaches such as ‘realistic evaluation’ and ‘theories
of change’, and aspects of these approaches have been applied in national partnership
evaluations (for example, of Health Action Zones, Local Strategic Partnerships and the
Children's Fund - see Barnes et al., 2005; Office of the Deputy Prime Minister, 2005, 2006;
Sullivan et al., 2006; Edwards et al., 2006). Joint commissioning is clearly situated in this
context, involving a variety of often complicated interventions occurring within a complex
system or environment. We therefore designed our study within a theory-led framework.
Three other factors shaped the choice of methods used in the research:
1. The apparent ‘gap’ between the policy dominance of joint commissioning and local
practice, led us to undertake a literature review to explore the range and depth of
evidence about joint commissioning to try and improve our understanding of what
was informing policy in this area. This review informed the questions we asked in our
empirical research.
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2. The lack of data on the relationship between ideas, processes and outcomes led us
to focus our attention on local practices in different local contexts. We selected five
case study sites in which we would map out the processes, practices and outcomes of
joint commissioning and then test the many different programme theories and
assumptions that might be at work within these contexts. The five case study sites
included in this study were each selected because of recognised good practice in
joint commissioning (see Appendix A for a brief overview) as we felt that these would
offer us the best possible chance of making links between the practices, processes
and outcomes of joint commissioning.
3. The absence of any clear single model of ‘joint commissioning’ shaping practice led
us to adopt an interpretive stance in our research. In practice this meant that rather
than treating joint commissioning as a simple means-ends tool that seeks to deliver
particular aims which can then be judged successful (or not), we sought to unpack
the meaning that joint commissioning provides to individuals in localities, how it
might provide symbolism in collaborative endeavours, support aspects of individual
and group identity and give meaning to the actions of professionals. In support of this
interpretive stance we used the first phase of our research to work with local policy
makers and practitioners to elicit their interpretations of joint commissioning and
what it should achieve.
POETQ is an online tool used to elicit understanding around outcomes of joint
commissioning from those working within these arrangements (see Authors, forthcoming for
a review). POETQ incorporates Q methodology, where statistical comparison of how
respondents rank order a representative set of statements reveals shared viewpoints on a
research topic (Brown 1980). Using data from previous research refined through a pilot
process we arrived at a set of 40 statements relating to the purpose of joint commissioning.
The POETQ survey asks individuals to sort these statements in terms of the degree to which
they agree or disagree with these statements. Factor analysis is conducted on the “sorts”
that are generated from this process and are used to explore if there is a structure operating
within a group of people (i.e. person A’s view compared with person B, C etc) rather than if
there is latent structure operating across a set of traits (such as relationship between shoe
sizes, height, gender, length of forearm). The potential of Q to reveal the subjective
structure of debate surrounding a policy issue or initiative makes it well suited to policy and
programme evaluation (Van Exel et al., 2007; Ockwell, 2008; Brewer et al., 2000) and
importantly to conceptualise aspects of collaborative working such as questions of
democracy (Author D and colleague, 2011) or leadership (Author C et al., 2011). Such an
approach allows researchers to go beyond the orthodox perspectives of joint commissioning
and gain insight from those involved in this at an organisational level about what they
believe it is aiming to achieve in practice.
In phase 2 we explored the outcomes that people felt joint commissioning was designed to
achieve through a series of feedback workshops with staff, as well as interviews and focus
groups with front-line practitioners, local managers, service users and carers (see table 1 for
practical details). These were designed to provide initial feedback to staff who had
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completed the POETQ process, to explore what local processes were in existence, to
understand what practices local sites feel constitute joint commissioning and to capture
examples where joint commissioning was felt to have resulted in specific impacts for service
users or for local organisations. Data collection took place during a series of two- three day
site visits at each of the five sites with the aim of immersing the research team in the field.
Where appropriate, visits were also arranged to observe the various jointly commissioned
services in operation, in an attempt to observe how they worked in practice, for instance
where two or more services had been co-located, or a partnership of organisations had been
involved in building new integrated provision. All interviews and focus groups were
recorded with a digital audio recorder, professionally transcribed and electronically coded
using NVIVO 9. In order to ensure consistency in coding across the research team we
developed a codebook (MacQueen et al., 1998). To produce this we inductively coded data
developing a series of freecodes. As a research group we met and discussed the freecodes
and how these aligned with our overall research questions. We then used the research
questions to introduce five topline codes and a series of subcodes, based on our analysis of
the text within the data.
Table 1 Main methods of data collection in each case study site
Mode of data collection
A
B
C
D
E
Feedback workshop
11
7
0
3
3
Focus group (staff)
6
7
0
0
3
Focus group (service user/carer)
11
14
14
0
0
Individual interview (staff)
4
0
6
11
3
Individual interview (service user/
carer)
TOTAL
2
0
0
0
0
34
28
20
14
9
Findings
Five key ‘viewpoints’
In total just under 100 individuals across the five sites completed the POETQ survey including
individuals from a range of different backgrounds including joint commissioning managers,
senior leaders and clinicians. Due to the size and scope of joint commissioning
arrangements the number of respondents varies between sites. Respondents spent nearly
52 hours in total completing these sorts, and the average lengths of time that respondents
spent completing the survey was somewhere between 32 and 37 minutes. From this data
five distinct and shared ‘viewpoints’ of joint commissioning emerged. These spanned both
the different sites and professional groups. Crucially, none of these are necessarily ‘right’ or
‘wrong’ – but are simply different ways in which people think and talk about joint
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commissioning (each of which implies a different sense of what success might look like – see
Table 2 for a summary):

‘Ideal world commissioning’: sees joint commissioning as a “no-brainer” – it’s a
natural way of working that can improve outcomes for service users, improve joint
working and deliver better value for money all at the same time.
 ‘Efficient commissioning’: rather than improving outcomes for service users, this
view is about delivering the same for less and is more about benefits to local
organisations/delivering within scarce resources than it is about improving people’s
lives.
 ‘Pluralist commissioning’: this view is more concerned with joint commissioning as a
means of achieving fairer access, inclusion and respect for service users. It is more
about involving and engaging service users to respond more creatively to need – and
sees current professional divisions as creating a culture of ‘us and them’ between
workers and people using services.
 ‘Personalised commissioning’: suggests that the primary focus of joint commissioning
should be about offering the highest quality service and a seamless service to users.
However, the way this viewpoint differs to the others is that it is more skeptical
about the mechanism of joint commissioning, believing that it can sometimes be
cumbersome and costly.
 ‘Pragmatic commissioning’: this view sees joint commissioning as good in theory, but
difficult to achieve in practice (and also comes at a price). While it might be able to
improve outcomes, it takes a lot of time and effort and can also increase costs as well
as lead to savings.
These data provide the first empirical evidence about the different interpretations that are
linked to the idea of joint commissioning. The content of the various interpretations
illustrates variation not just in what joint commissioning is aiming to achieve, but also how it
will go about accomplishing its goals. In some cases this variation may be complementary,
meaning that different interpretations of joint commissioning can operate alongside each
other in a productive way. In other cases however, the variation between interpretations
may inhibit productive action as different groups vie to achieve dominance over the meaning
of joint commissioning. More likely though is simply an absence of appreciation about the
range of interpretations in operation as insufficient attention is paid to exploring the
multiple understandings of joint commissioning that may be at work in any locality.
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Table 2 Summary of national viewpoints of joint commissioning
Viewpoint
Ideal world
commissioning
Efficient
commissioning
Pluralist
commissioning
Personalised
commissioning
Pragmatic
commissioning
Description
Delivering better services for less
money
Saving money but not necessarily
impacting on users
An opportunity to get beyond the
myths of “us and them” to offer
users greater choice and a fairer
system
Less about choice and more about
giving the user what they want – a
decent service
Acknowledges the difference
between rhetoric and reality whilst
also recognising that successful joint
commissioning is difficult to achieve
and often comes at a price
Main Argument
Let’s be optimistic
Let’s do what we
can
Let’s open this up
Viewed by others
Lacking
perspective
Lacking ambition
Lacking control
Let’s get the job
done
Lacking principles
Let’s be realistic
Lacking pace
What does joint commissioning mean locally?
The viewpoints illustrated above are those that emerged from a national level analysis of all
the local Q sorts undertaken by respondents. We also examined Q sorts at case study level
and found groups of individuals in each of the sites whose views reflected the ‘ideal world’
perspective which suggests that the notion of joint commissioning as being a generally ‘good
thing’ was well embedded in the case study sites. However, we also found some variation to
the national viewpoints. Consequently in phase 2 of the research, we sought to explore in
greater detail the local dynamics of joint commissioning, services and outcomes. We did this
by analysing how people talk about joint commissioning, what organisational processes are
in place to facilitate joint commissioning, what people are doing when they say they are
‘jointly commissioning’ and what impact (if any) joint commissioning has had.
An important finding from the local studies was that many participants did not actually use
the term ‘joint commissioning’ at all. For case study A, the key term was ‘integrated’ rather
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than ‘joint’ commissioning; where the suggestion is that the former is more joined up than
the latter. Sites C and D are fully integrated organisations and what others might see as
‘joint commissioning’, they therefore saw simply as ‘commissioning.’ In case study E,
moreover, the emphasis was very much on more bottom-up community commissioning with
the third sector and with local residents, and so the language was much more about
involvement, engagement, co-production and community. While government policy and
academic research might be interested in the nature and the outcomes of ‘joint
commissioning’, local practitioners, perhaps unsurprisingly, may have more complex and
nuanced perspectives.
In addition, participants repeatedly emphasised the importance of context (time and space)
in determining whether and how they understood joint commissioning at this point in time.
Case Study A was the most established of all the joint commissioning arrangements with
more than a decade of experience. Covering a single, co-terminous local authority (LA) and
Primary Care Trust (PCT), it is a small area surrounded by bigger health and social care
communities. It developed integrated structures locally as a means of achieving economies
of scale and of protecting services that they felt could best respond to local needs in context
of high levels of deprivation. In contrast, Case Study B is a large LA working with multiple
PCTs and with a large pooled budget. After a history of poor relationships, significant
overspends and services that did not meet users’ needs, joint commissioning was felt to be a
way of making a fresh start, bringing the budget under control, starting to get all agencies’
‘house in order’ and beginning to design new services for the future. Case studies C and D
were fully integrated organizations (known as ‘Care Trusts’), one with a strong aspiration to
create more person-centered services in the community and to keep a very large older
population out of hospital. Case Study E was a response to high levels of need on two public
estates and much more focused around the empowerment of local people. From the
interviews and focus groups it was possible to identify different primary and secondary aims
for each case (see Table 3 for a summary).
Table 3 Primary and secondary aims of joint commissioning
Case study
A
Primary aim
Tackle health inequalities
B
Productivity – bang for buck
C
Service user at centre of service
Secondary impacts
Preventative services
Efficiencies
Wider range of services for users
Create one stop shops and easy
access
Empowerment
Efficiencies
Redesign services over larger area
Consistency of services
Streamline services
Early intervention
Seamlessness
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design
D
Kick-start merger process into Care
Trust
E
Empowerment of community
Single contact points
Key-workers
Value for money
Choice
Focus on health inequalities and
preventative services
Economies of scale
Innovative services
More appropriate services
Efficiencies
Reduce waste
Preventative services
The relationship between these aims and the local interpretations of joint commissioning
were not necessarily straightforward. This was not always because of any confusion about
what the localities were doing, but rather because in many cases there had been no explicit
discussion about the range of potential interpretations of joint commissioning and so local
priorities and interventions emerged informed by one dominant viewpoint and were
accommodated (more or less) by others. The structures, processes, practices and impacts of
joint commissioning were shaped by the coincidence of dominant local viewpoints and
identified aims. While we noted some variation that could be explained by the particular
local interpretation of joint commissioning and its associated objectives (e.g. a focus on
particular structural arrangements for localities opting for Care Trusts), overall we found a
great deal of similarity in the mechanisms employed. We explore these in more detail below.
Structures and processes for joint commissioning
Formal structures, including fully merged organisations, integrated management structures
and single line management arrangements, are key elements in four of the five case study
sites. The exception to this is site E which had the status of a project and so had no
formalised structures built up around it. This project relied on an informal partnership
between agencies which did not require any formalised agreements in terms of budgets or
administrative systems. 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). Of all the mechanisms in place, pooled budgets were the
most common (in 4 of the 5 sites). As a Director from site A described, pooled budgets:
“offered a much better chance of spending that money in a way that’s going to
achieve the outcome sensibly rather than...three or four...different approaches of
different people...trying to tackle it in a different way”.
Other respondents also saw pooled budgets as a way of trying to get beyond artificial
debates as to the difference between ‘health’ and ‘social care’ need – focusing instead
simply on ‘need.’ Some sites also linked their pooled budget to lead commissioning
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arrangements where one of the partners would take the lead on commissioning particular
services with the support of their other partner(s). Lead commissioning arrangements were
also seen to be a helpful way to identify waste or duplication in particular service areas
where an entire pathway would be examined across a range of partners.
Most sites had some form of co-location of staff from different partner organisations either
within the same office space or else within the same building. One site went beyond just
assigning different teams to the same office space and had a hot-desking policy whereby
professionals from a range of backgrounds could work alongside different colleagues on
different days. This sort of approach was not always favoured by all and staff sometimes felt
that they lacked a natural “home” or had been moved a lot and found this disruptive.
However it was acknowledged to be an effective way of encouraging staff from different
professions and organisations to get to know each other.
Where integrated teams existed, joint commissioners were keen to see the use of integrated
assessments, rather than service users having to be assessed a number of times by different
professionals. These helped coordinate and streamline care pathways. For example, case
study A uses a single assessment process and then streamlines service user enquiries to a
single point of contact known as ‘customer access teams’. These then use a prioritisation
process to categorise requests into need. Those with low level needs are referred to a
generic worker (e.g. occupational therapy assistant or assessor) and specialist staff deal with
more complex cases. Not all sites worked in this way and assessment was generally seen as
a rather tricky issue. At site B for example, although some progress had been made, one
commissioning manager told us:
“Even though we’ve moved towards joint commissioning locally, I’m sure nurses still
assess and I’m sure social workers still do their own assessment and I’m sure housing
do their own assessment.”
Service user involvement formed a significant component of a number of the sites and
fulfilled a range of different functions. Staff at case study A described how the older people’s
forum acted as a conduit and repository of information for members, but also enabled
“expert older people” who have learned to speak up:
“If you want to have integration, you want to have a joint commissioning process
that’s open and transparent and involves people.”
Site C also had processes in place to engage carers on the basis that they have a great deal of
knowledge about the barriers and facilitators of high quality services:
“I think the key is to get the people involved... carers and the families that will be
those people receiving the service, in designing what that might look like in the
future, so they feel part of it.”
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Site E ran a range of different engagement initiatives designed to reach out to the local
community, such as having large scale events and the use of community researchers. The
community researchers were trained by a third sector organisation and would visit places
such as GP waiting rooms and speak to people within the community about their service
priorities. We also found evidence of the creation of hybrid roles that span across the health
and social care divide. Case study D referred to the creation of “hybrid bureaucrats” though
it also acknowledged the challenge these people faced in working two systems but also of
gaining the respect of those in both organisations, particularly if job descriptions were not all
that clear.
Joint commissioning and local practices
Our 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. What they did identify were issues about
relationships and creativity and risk and we reflect on these briefly here.
Despite the attention paid to formal structures a number of respondents were keen to
highlight the significance of relationships between individuals and teams. As one manager at
site B explained:
“I don’t think we’ve concentrated enough on the culture of working together… Where
we’ve made improvements is where we’ve been co-located...we’ve just spoken to
each other and worked though solutions.”
Co-location had facilitated better relationships as it meant that professionals came into
contact with each other more often on an informal basis. As one manager described:
“You can get so much done by these ad hoc conversations, unplanned conversations
most of the time and you’re suddenly, oh wow and we can do this.”
In contrast, some participants argued that co-location could only go so far in helping to bring
people together and that more in-depth work was required to support joint work. In Case
Study A, participants felt that creating a more integrated structure had helped to create a
more creative and innovative approach than might be possible within a single organisational
setting. Staff here talked about taking the “best from both.” This was also true for one
manager in site C, who explained:
“It could be that you end up doing something that you wouldn’t necessarily have
thought about had it just been you working in isolation.”
However, in site B despite organisational changes, it was suggested that often people still
felt like activities were taking place in silos and that there had not yet been much that was
creative or innovative. As one officer explained:
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“I just think that we do things, both politically and strategically, [but] I’m not sure we
do things around a table with one piece of paper satisfying a joint agenda. I still think
we are very much a ‘them and us’ [culture].”
The impact of joint commissioning
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. In site A, staff
believed that joint commissioning ‘works’, but acknowledged that this was hard to
demonstrate:
“I think we’ve not always been as focused on demonstrating the outcomes that it’s
achieved and some of that’s to do with data information systems... not being...robust
enough to sort of come up with what we want really.”
Another commissioner responded:
“If you were designing integrated commissioning now, you’d maybe give much more
thought to some of the support functions that needed to be there, to give some of the
evidence.”
In many ways, this was exacerbated by the local emphasis on developing a more
preventative agenda, with participants acknowledging that “it is very difficult to prove what
you’ve prevented.” Other sites struggled with attributing any changes in outcomes to
specific joint commissioning activity:
“I think joint commissioning, integration, whatever you want to call it... We face
[problems] because we tend to do lots of things at the same time. So we implement
new interventions, commission new services at the same time all with similar benefits
against them that we want to achieve. It is quite difficult to unpick which variable is
impacting on which.”
One of the impacts of joint commissioning identified by many of the sites was that joint
working was now “better” or “stronger” than it had been previously. Site D described that
prior to the establishment of the Care Trust their joint initiatives were mostly through big,
flagship projects (rather than an everyday occurrence). Since the establishment of the Care
Trust joint working had become more part of the normal expected practice:
“Leading up to becoming a Care Trust... [there were] quite a lot of blockages
beforehand. I think once we actually became a Care Trust, I’ve not been so aware of
the blockages. It comes back to the thing of the jointness just becomes what we do
and so it’s not necessarily big projects that people are trying to shoehorn through to
make a big impact, it’s just daily work."
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The achievement of efficiency goals were cited as evidence of impact by some respondents.
In site B, where part of the aim of joint commissioning seems to be to resolve previous
budgetary problems arising from single agency commissioning, the 2010-11 budget was
balanced for the first time in a number of years and joint commissioners made efficiency
savings of £4 million per year. One commissioner also felt that joint approaches had reduced
duplication:
“We found out since coming together...we’ve both commissioned... the same services
with the same providers and haven’t known about it.”
However these efficiency achievements were not seen as positive by all. As one officer
explained,
“A lot of the schemes that you see them going through are taking money out of the
system and not reinvesting.”
Site C also spoke about the efficiency gains that it had made through integration, although
these were often in relation to other initiatives that were not necessarily directly arising
from joint commissioning (such as the use of individual budgets). Site D believed that
bringing commissioners together had probably saved money as it makes it more difficult for
providers to:
“…play off against the other. They can't play any tricks....all the commissioners are
together in one place.”
Interviewees here spoke of “driving a tight deal” but again did not have the data to
demonstrate that this was directly related to joint commissioning. This was a very similar
case to site A who suggested that, although they generally thought that integrated
commissioning had delivered efficiencies, they would find it difficult to evidence this:
“I think we have struggled to necessarily measure that effectiveness in terms of
productivity. It’s not been easy to, if you like, quantify it...I think we’ve felt that we
have to look at proxy measures around it...and we have got a number of areas that
you could identify as being a proxy measure of effectiveness or efficiency, so we have
very low, immensely low delayed discharge rates in [place] and we believe that’s
linked to the fact that our teams are very integrated, so things happen more quickly.”
Many of the potential savings claimed seem to have derived from one-off interventions, and
it was less clear whether sites expected initial savings to be replicated in future or over time.
Most sites also talked about joint commissioning improving access to services. However the
view from users was more equivocal. A number of service users felt that the onus remained
on them having to be savvy in order to access any care they might need and/or dependent
on informal carers for support, transport and advocacy. Other users and carers spoke about
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little changing for them in terms of ease of access, variable quality of communication, a lack
of recognition of the crucial role of families in providing support and mixed experiences of
GPs. There were also concerns from some sites that joint commissioning may not always be
addressing the things that really matter to service users:
“We all put these efforts into these joined up websites and these joined up structures
and I’m not sure we’ve actually asked people if that’s what they want.”
One of the issues raised by service users was that although some services were felt to have
been improved they could not actually reach them due to poor public transport:
“I think one of the major things is, not the actual provision of the services, it’s when
they’re planning, say to move services or integrate them, they don’t look at the
transport consequence.”
To some extent the integration of provision had compounded this situation for some as
there were now fewer entry points for services and some service users found they had
further to travel to access them.
Discussion and conclusions
Despite longstanding policy interest in joint working and in commissioning, the formal
evidence that either leads to better outcomes is often lacking. This study aimed to improve
our understanding of the relationship between the ideas, activities and outcomes of joint
commissioning by adopting a more theoretically-informed approach and an interpretive
stance. Our findings have implications for future research, policy and practice and we
explore some of these here.
Our Qdata provides, for the first time, empirical evidence about the different interpretations
that are linked to the idea of joint commissioning. They reveal how these interpretations
generate different priorities, processes and activities and highlight our need to understand
more about how local interpretations are arrived at and the extent to which they are
formally elaborated. There are questions here for researchers about the role of
interpretations and how we might improve our understanding of them. One option is to see
joint commissioning as a ‘framing concept’ that supports a range of organisational, structural
and in some cases cultural changes. Viewed from this angle, the value of joint
commissioning lies in its ambiguity and symbolism and its consequent capacity to attach
people to it. This is an important observation and one which has been made elsewhere in
relation to the notion of joint working more generally (Author B, 2008). Another related
option is to understand joint commissioning as a ‘boundary object’:
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“Both plastic enough to adapt to local needs and the constraints of the several parties
employing them, yet robust enough to maintain a common identity across sites...They
have different meanings in different social worlds but their structure is common
enough to more than one world to make them recognizable, a means of translation.
The creation and management of boundary objects is a key process in developing and
maintaining coherence across intersecting social worlds” (Star and Griesemer, 1989,
p.393).
Author C and colleague (forthcoming) explore boundary objects in the context of integration
in health and social care including the role of joint commissioning.
Exploring the different interpretations of joint commissioning is important for policy makers
and practitioners as the co-existence of multiple interpretations may create tension,
instability, and even conflict within localities and between localities and the centre, as
professionals, practitioners and users with different viewpoints encounter each other. At
best the coming together of different viewpoints could result in innovation if opportunities
are provided for actors to explore the different interpretations at work. At worst, there is a
risk that the conflict and tension generated by the co-existence of multiple viewpoints could
stultify developments and lead to some actors withdrawing from the process. It has long
been argued that studies of collaboration have predominantly focused on the process of
how partners work together and not on the outcomes that the collaboration achieves. Here
we are able to theorise why partners might find the collaborative processes of joint working
to be as important as the intended outcomes, and why, in some cases the enactment of a
‘joint’ way of working might become the core concern with outcomes perhaps neglected.
One observation from our study is that little in what localities were doing and certainly in
how they were doing it was new or unique to joint commissioning. The aims of
empowerment, efficiency and service improvement were common as were the mechanisms
- pooled budgets, co-location, single assessment, single line management, joint posts and so
on. This poses an empirical challenge – to what extent is it possible to disentangle the
actions of ‘joint commissioning’ from more general joint working? However it also raises a
different issue which concerns local actors’ ability to adopt new policy language without
making any significant change to their ongoing activities. What we were observing in our
case study areas was local actors creating a narrative about the progression of health and
social care services in their area. This may explain why many of our sites – which had all
been chosen as examples of good practice in terms of their joint commissioning – rejected
this term, and tended to use another phrase to describe what they were doing locally. This
flexibility of interpretation is often associated with national policy initiatives that require
local ownership to be effective, for example the national evaluations of Health Action Zones
and Local Area Agreements both found that local interpretations were important in
determining whether the policy had local traction or not (Barnes et al., 2005; CLG, 2011).
Respondents were often not unduly concerned with these linguistic inconsistencies and the
overlap between concepts which could reflect a wider societal shift in how we understand
time and progress. According to Bauman (2000, p.137-138) “in a life ruled by the precept of
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flexibility, life strategies and plans can be but short term”. One reflection of this is
practitioners’ ability to nimbly adapt to successive policy changes.
The study rehearsed some longstanding arguments about the respective roles of formal
structures and processes versus actors and relationships in enabling joint working (Williams
and Sullivan, 2009). Respondents referred regularly to the importance of formal processes
and structural arrangements, yet at the same time were anxious to emphasise the necessity
of good inter-personal relationships for building joint commissioning and getting it to ‘stick’
locally. We undertook the research at a time when localities were once again in a state of
flux, trying to respond to a radical new agenda that would fundamentally alter organisational
configurations. Respondents’ focus on formal structures may have been a response to this
turbulent policy context, with local areas feeling that they had to make their relationships
more structural in order to protect against future disruption, reorganisation and loss of
organisational memory. This might therefore suggest that there is something that formal
(structural) integration offers as distinct from collaboration more generally: stability, a
degree of protection against change and a symbol of the commitment of local partners. At
the same time budgetary constraints coupled with national reorganisations are reducing the
workforce and disrupting existing relationships, while the advent of clinical commissioning
will introduce new potential partners, and the process of building trusted relationships at
local level will need to begin again.
Despite our research finding substantial support for the idea of ‘ideal world’ commissioning
in practice, many sites struggled to cite specific examples of the impact of joint
commissioning or to evidence their claims, thoughts and hopes. This seems to be the result
of a number of inter-linked issues:
1. Many of the changes which participants described were hard to attribute to joint
commissioning per se – and it is easy to imagine similar benefits being achieved
through other mechanisms. Rather than joint commissioning being a ‘solution’ to the
problems of the health and social care system, therefore, it may be more the case
that local organisations committing to work together on shared issues is more
important than the precise route they choose to move forward.
2. Identifying evidence of impact remains difficult – technically and practically. The
more specific that sites were about what they were trying to achieve and the more
narrow these aims were, the easier they were to evidence. For example, sites A and
C found it difficult in some respects to evidence the preventative, holistic, patientcentred aspects of joint commissioning, whilst it was much easier to find evidence for
site B (who had as a key aim to balance the budget and make savings). As with other
forms of joint working, being clear in advance what success would look like – and
being realistic about what joint working can actually achieve in practice - seems
crucial. To some extent this is the sort of challenge that theory-based approaches
are often confronted with. Whilst they are designed to deal with complexity they
may end up being used to account for simpler things (Barnes et al., 2005; ODPM,
2006).
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3. Sometimes faith in the potential of joint commissioning appeared to run ahead of
and even replace detailed collective thinking at the sites about what their theories of
joint commissioning were. In the absence of such theories evidence of impact will
always be elusive and justifications will remain at the level of ‘faith’.
4. 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 (such as removing longstanding duplication, revisiting
contracts etc), and there was little evidence of scope for recurring savings. Making
efficiencies in itself may also not lead to better user outcomes (although making
savings in a difficult financial context might be a good outcome in its own right).
A key insight from our study is that the value of joint commissioning may not lie in a
rationalist model of service improvement where a particular intervention can be directly
linked to a specific outcome. As we have demonstrated, different people interpret joint
commissioning in a number of different ways, and there seems to be little if anything that is
distinctive about the practices or the impacts of joint commissioning as opposed to other
ways of working.
This suggests that we might need to ask very different questions of joint commissioning than
those that we have traditionally asked. Author C (2011) describes the New Labour
government’s valorisation of evaluation as a search for the “truth” within their evidencebased policy agenda. Author C concludes that “despite the considerable financial and
human investment made in policy evaluation in the UK between 1997 and 2010, the
attachment to the idea of ‘truth’ disconnected ‘evidence’ from ‘argument’, impaired the
exercise of evaluator judgement and fragmented the contribution of evaluation to the policy
process” (p.500). Similarly, we might argue that a huge amount of investment has been
made in joint commissioning and on the basis of the evidence from ‘best practice’ case study
sites we have presented here there does not seem to be a clear link between joint
commissioning and better outcomes. Author C points to the importance of theory-led
approaches to evaluation in understanding the various different rationalities that are at play
within any given context. What Author C is arguing here is that within any situation there
are multiple truths operating and a range of reasons why actors might behave in a particular
way. What is important are the situated realities of individuals and how they experience
joint commissioning within the complex contexts of everyday organisational practice. What
this suggests is that we need to ask different questions of joint commissioning and the actors
involved in it, focusing on what and how collaboration means. Ultimately, this may allow us
to understand the notion of agency in joint commissioning in a different way, beyond just
improving outcomes, and offers us a chance to understand joint commissioning as an
instrument of control and liberation, creativity and conflict.
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Appendix A Key features of case study sit
Case study site
Case Study A
Case Study B
Case Study C
Case Study D
Case Study E
Joint
commissioning
arrangement
Pooled budget
Joint Commissioning Unit
Joint Commissioning Unit
Care Trust (integrated health and
social care organisation)
Care Trust
Single Local Authority (LA) and
Primary Care Trust (PCT) with pooled
budget between health and social
care
Long history of joint working,
integrated management
arrangements and integrated teams;
strong commitment to public
engagement. The focus here was on
older people’s services.
Single LA and multiple PCTs with very large
pooled budget
Integrated commissioning and
provision
Integrated commissioning and
provision
Partnership between urban
Authority and third sector
organisation
None
Integrated commissioning and
service delivery. Formed between
a single LA and PCT. Strong
reputation for its efficient use of
hospital bed days for older people.
Includes integrated approaches
to children’s services and to
public health. Formed
between one LA and one PCT,
alongside an integrated social
enterprise for service
provision.
2009
Joint project to develop more
community commissioning on
two public housing estates.
Also pursuing strategic
collaboration with other
nearby local authorities.
General population – all health and
adult social care
General population
Estate residents
Background
Year established
2002
Joint commissioning for people with mental
health problems and for people with learning
difficulties with one LA and multiple PCTs. Was
formed in the face of significant previous
overspends and a history of difficult
relationships. It has since won national
recognition for its joint working.
March 2010
Client group
served
Older people
Learning disability and mental health
May 2003
2009
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