Commissioning approaches and associated priorities

To engage in any form of commissioning you will need to acquire an understanding of need. This section explores the synergy between the generic priorities of a number of commissioning frameworks and Reading Friends activity, outcomes and evidence.

Understanding the detail is essential preparation for conversations with commissioners and for considering where Reading Friends might make a contribution. So do take time to understand the local structures and framework documents.

If you work in England you might start by referring to:

• Joint Strategic Needs Assessment (JSNA). The directors of public health, adult social care and children’s services have a statutory obligation to produce a JSNA through the Local Government and Public Involvement in Health Act (2007). The JSNA is expected to influence the commissioning process across both health and social care and to underpin the development and implementation of strategic planning across local partnerships. These documents are refreshed and updated at least every three years.
• Joint Health and Wellbeing Strategy (JHWS). Health and wellbeing boards in England are required to produce an annual JHWS for the local area, based on the needs identified by the JSNA. This document sets out the jointly agreed priorities upon which commissioning plans are based.
• Commissioning Intentions.  These documents are sometimes produced by individual service areas such as Adult Social Care, they are based on the needs identified in the JSNA and describe in more detail the priorities, principles and approach that a service will be taking to secure improved outcomes for individuals, communities and places.

You should also refer to the Age UK Loneliness Heat Map, which shows the relative risk of loneliness across neighbourhoods in England based on the Census 2011 figures for the following factors:

• Marital status
• Self-reported health status
• Age
• Household size

These four factors predict around 20% of the loneliness observed amongst older people 65 and over as represented in the English Longitudinal Study of Ageing (ELSA). Each neighbourhood is categorised from very low risk to very high risk of loneliness depending on the quintile it falls into based on the four factors.

If you are based in Scotland:

• The Scottish regional Health Boards each develop joint health improvement plans (JHIPs) for each local authority area based on the needs of the local community.

Northern Ireland:

• The Local Commissioning Groups (LCGs) have responsibility for the commissioning health and social care to meet current and emerging needs and so refer to the findings of these assessed needs.

Wales:

• Local Health Boards are the vehicle through which leaders of local public and third sector organisations come together to develop an integrated plan for each area. Each board must carry out a well-being assessment and publishes an annual local well-being plan. 

Increasingly, commissioners across the UK are looking to draw on existing community assets and the strength of local networks to meet priority needs.

In some areas commissioning professionals are focused on the design of integrated services for individuals, communities and populations. This is in recognition of the value of working with people and communities holistically, and often means that local authorities, health bodies and others can better work together to support people facing complex conditions and multiple challenges.

Whilst the specific outcomes will differ depending on the local population needs, there are a number of shared high level goals that Reading Friends can contribute towards such as:

• Enabling residents to live full and varied lives, where quality of life is important and where people have choice.
• Building strong communities and protecting vulnerable people.
• Ageing well – enabling people to live better as well as live longer.  This often includes tackling social isolation and loneliness.
• Supporting people with dementia and delaying its onset.

The transfer of public health from the NHS to local government and Public Health England (PHE) is one of the most significant extensions of local government powers and duties in a generation. It has provided an opportunity to change the focus from treating sickness to actively promoting health and wellbeing.

There are five domains that are priority areas for local authorities to deliver against;

• Health protection – e.g. ensuring the public is protected from disease and illness through vaccination programmes.
• Health improvement – e.g. smoking cessation, reducing obesity levels, encouraging healthy activity, offering services that have been shown to improve mental health and wellbeing.
• Prevention of ill health – e.g. reducing the numbers of people living with preventable ill health.
• Healthy life expectancy – e.g. preventing people dying prematurely and reducing the life-expectancy gap between communities.
• Wider determinants of health and inequalities – This domain provides recognition that there are a great many factors that will determine whether someone is healthy or not, such as housing, education and employment.

Prevention work has significantly increased and a focus on wellbeing and social isolation is part of this. Some commissioners recognise that investing ‘up stream’ in services provided by the community can help to keep older people out of more costly care scenarios.

Furthermore, the Care Act 2014 brought care and support legislation into a single statute, placing overall wellbeing of individuals at the forefront of their care and support. 

Overall wellbeing includes physical and mental health, and recognises the need for access to employment, education and social opportunities. It requires local authorities to provide comprehensive information about services and providers in localities, including services that help prevent individuals care needs from becoming more serious.  It also requires local authorities to identify any carers or people in their area with needs that are not currently being met to enable the lacking services to be developed or provided.

Within a commissioning context, some of the language of outcomes may be expressed as:

Adult social care

• Keeping people independent: Primary prevention – Keeping people well and out of the care system. Support for older and vulnerable people and an emphasis on those potentially at risk of needing care support.
• Regaining independence: Secondary prevention – reablement of people who have experienced an episode which has temporarily affected their independence – such as a stroke, fall, spell in hospital, bereavement. Re-establishing independence through activities, social contacts, physiotherapy, aids in the home.
• Improvements in terms of all aspects of health and wellbeing: Personalisation – self-directed support via individual plans and personal budgets to enable people to make their own choices for care and daily living. 

Health

• Reduced health inequality and improvement in health overall – promoting healthy lifestyles and preventable ill health and reducing inequality across the social gradient of health.
• Wellbeing – social networks and capital, volunteering, addressing social determinants health.

Clinical Commissioning Groups (CCGs) are responsible for commissioning many local health services and some social services in England.

They are made up of groups of local GPs working alongside a hospital professional and representatives from other local partners. CCGs do not align with local authority boundaries; there will be several CCGs within each local authority, and indeed some that cross county boundaries. CCGs and similar bodies in Scotland, Wales and Northern Ireland are responsible for commissioning services that include:

• Rehabilitation care
• Community health services
• Mental health and learning disability services

The CCG, or similar, determines the kinds of health services it wants in place for the local population through its Commissioning Strategy and may publish these as commissioning intentions.

This is the practice of referring patients to social activities instead of or as complementary to more conventional forms of medicine. Social prescribing reduces the over subscription of drugs, thus saving money for the NHS and can lead to the same or better outcomes for patients.

Social Prescribing is currently being championed by both the Department of Health and NHS England in its Long-Term Plan as part of the commitment to personalised care and in recognition that it can help with the major challenges facing health and social care, such as an aging population, loneliness, mental health and other long term conditions.

Social prescribing schemes rely on link workers to signpost people onto community-based activities that improve health and wellbeing. There are many different names used to describe the role. These include wellbeing advisor, community connector, community navigator, community health worker, community health agent, health advisor, depending on local preference.

Link workers provide a face-to-face conversation with patients during which they can learn about the possibilities and design their own personalised solutions to social, emotional or practical needs, often using services provided by the voluntary and community sector.

Many link workers are attached to general practices and primary care networks, although they may be employed by local social prescribing connector schemes hosted by the voluntary, community and social enterprise (VCSE) sector. 

Social prescribing is still in the early stages of development and schemes have not yet been established in every locality.  You will need to research whether there is a scheme in your area, what it offers and how Reading Friends can get involved.

Once you have familiarised yourself with the language being used by commissioners in your local area you can begin to consider how Reading Friends could contribute to improving priority local outcomes. 

For example Reading Friends is particularly strong on wellbeing (rather than illness prevention) and the programme could contribute towards:

• Tackling loneliness – creating opportunities to make social connections and participate in activities.
• Social isolation – through volunteering, which gets people out of the house and gives them a sense of purpose, providing essential social contact. 
• Supporting people living with and carers during the early stages of dementia. 
• Independence through skills development –  improving literacy through reading.
• Supporting vulnerable people – libraries and other community spaces are perceived to be safe places for people with conditions such as depression.