Accountable Care Partnerships (ACP)

Programme

Programme Initiation Document (PID)

Executive Summary

DRAFT

INTRODCUTION 2

Context Across NW London we have agreed that Accountable Care Partnerships (ACPs) need to be

developed to play in enabling and supporting sustainable service transformation. Over the last few years our CWHHE CCG teams have worked hard and made significant

progress in in integrating service design and delivery and the successes demonstrate the benefits that can be realised from the health and care system taking a fully joined up approach.

We want to capitalise on this progress and build truly sustainable services and health and care systems. We believe the best way to do this is to develop and implement ACPs.

The Programme Initiation Document (PID) We have developed a thorough and comprehensive PID to reflect the size and complexity

of the change programme we are undertaking. A PID is a critical part of any programme, providing a vital source of information and assurance about what the programme is aiming to achieve and how it aims to achieve it.

This pack has been developed as executive summary of the current draft of the ACP PID, with a view to introducing the core ambtions for the programme and main programme strategies, plans and structures that have been developed.

Further detail can be found in the full PID document or by contact ACPPMO@nw.london.nhs.uk

CONTENTS PAGE 3

1. Why ACPs, our approach & ambitions

2. Programme delivery principles

3. ACP scope & programme delivery strategy

4. Phase 2: the critical path

5. Governance arrangements

6. Resourcing strategy

7. Next steps

DRAFT FOR DISCUSSION

1. Why ACPs, our approach & ambitions

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1a. Why accountable care? 5

Accountable care models around the globe have been shown to be particularly powerful in addressing system-wide challenges of meeting increasing demand and acuity in the context of diminishing funding.

In accountable care models, providers work under a single contract, with a single pooled budget to take joint responsibility for delivering services that improve health and care outcomes for a defined patient or resident population. The partners are incentivised to continuously improve outcomes through outcomes-based incentive payments and, through multi-year contracts, are given greater financial security in order to plan and transform care over the long-term:

Across NWL we have agreed that ACPs have a key role to play in enabling and supporting sustainable service transformation.

Building on progress and our shared ambition Our ambition ACP ambition is firmly rooted in the work completed as part of the WSIC

programme. As part of this work, over 200 individuals from providers, partners, commissioners, patients, carers and the public participated in a series of workshops and events to co-produce a set of principles and tools designed to support organisations to deliver fully integrated care across NW London.

As well as ideas and options for care delivery, it was agreed that Accountable Care Partnerships needed to be developed to enable the wider programme of service transformation.

1b. Adopting international best practices 6

International experiences points to several common factors that feature in all successful accountable care systems – we are adopting these in CWHHE:

Built around the registered population

Outcomes Based Commissioning

Whole population budgets for a defined population and/or geography

Commissioned to deliver outcomes with contracts of at least 10 years in length

Inclusive of the functions most necessary to deliver those outcomes

Accountable for end-to-end care of the population

Functioning at a large scale, sufficient to hold clinical and financial accountability for a population

Making decisions on resource allocation and performance within the organisation/partnership

Embedding service users in decision-making and governance

1c. What are the problems ACPs are trying to solve? 7

Fragmentation: People seeking care frequently require support from a range of different providers, such as – hospitals, intermediate care, primary care, mental health clinics, nursing’s homes. The current fragmented commissioning & delivery system offers uneven quality of care, missed opportunities for the right care in the right place at the right time, and ultimately poor outcomes

Misaligned incentives: Too often our organisations face a different set of constraints and incentives, and consequently each part works to optimise its own performance without fully understanding or assessing the impact on patients or other parts in the care delivery system

Duplication of Efforts: Without understanding the total patient story, providers duplicate efforts and over consume health resources

Unclear Access: With numerous entry points into the system, patients and clinicians are often unclear on how to access the best care available and how to coordinate care to maximize their health outcomes

Workforce: With fragmentation, duplication and operational constraints comes a workforce challenge – we cannot staff or resource all the services we need to provide, leading to gaps in provision or unsustainable staffing costs

Long Term System Sustainability: All of the above drive health care expenditure and contribute to the long term unsustainability of the NHS

1d. ACPs offer a Business Solution to our Care Problems 8

Business Transformation (BT)

• Organisational design • Commissioning • Financial Incentives • Risk/Reward

Care Transformation (CT)

• Clinical pathways • Model of care • Patient experience and access

(being addressed through, for example, the STP, BCF, Local Services Transformation, LikeMinded, Primary Care SCF)

Business problems (BP)

1. Fragmentation of services 2. Misaligned incentives 3. Duplication of effort 4. Unclear Access Points 5. Long term sustainability

Care Problems (CP)

1. Social isolation 2. Inconsistency of quality care 3. Inappropriate care settings 4. Lack of self care and well being

BT addresses BP

CT addresses CP

Enabling

ACP

Enabling Causing

1e. ACPs in a nutshell…. 9

“[In our accountable care system] what we have tried to do is not focus on the marginal edge of money that we have not got and not worry about the million we are short.

“Rather, we have tried to say ‘we have $1.4bn here and how we use it is what matters’.”

Dr. Nigel Millar, Chief Medical Officer

District Health Board for Canterbury, NZ

1f. Our ACP ambition & approach 10

DRAFT FOR DISCUSSION

Our STP vision is as follows:

“Enabling people in NWL to be well and live well”

The Accountable Care Partnerships programme in CWHHE will assist in achieving this long term vision through the following approach:

One System, One Budget, Better Outcomes

What we mean:

One system = a one team and one system culture designed to deliver fully integrated care with no organisational or service boundaries

One budget = we have only one health budget available – our organisations will be working under a single capitated budget for the benefit of our population

Better outcomes = a one system, one budget approach will deliver better outcomes for our patients and residents and for long-term system sustainability

1g. ACP goals & objectives 11

CWHHE Aspirations for Accountable Care are…

CWHHE will meet these aspirations by April 2018 by…

Objective #3: Enabling the employment of advanced health information technology that continuously collects, connects and shares

patient information and clinical decision support among the network(s) of providers

Objective #2: Establishing contractual risk/gain sharing mechanisms that foster incentives to

enhance care coordination and provider integration, reduce system inefficiencies, and

improve overall quality of care

Goal #2: Enhance patient navigation and care coordination throughout the care continuum

Goal #5: Eliminate systemic waste and duplication of efforts

Goal #6: Improve long term sustainability of the health care

system

Goal #3: Increase innovation and information sharing among

providers

Goal #4: Eliminate patient visible organisational boundaries

Goal #1: Improve patient and citizen health and well being

outcomes

Objective #4: Implementing accountable care provider partnerships that are viable, sustainable,

and value adding for the future

Objective #1: Commissioning a network(s) of providers to deliver health and well being

outcomes (rather than services and/or processes), under one contract and capitated

budget for a given population

CWHHE’s Vision for Accountable Care is…

Better outcomes: person-centred individualised care; right services at the right time in the right place to deliver better outcomes for patients and system sustainability

One System: system designed to enable fully integrated services - no patient visible organisational boundaries

One Budget: health organisations work together to deliver outcomes under one capitated budget

2. Programme delivery principles

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2a. ACP Programme guiding principles 13

Whilst recognised as an essential part of our service and system transformational work, the journey towards the implementation of ACPs is going to be challenging – we are breaking new ground with only limited experience in the UK to draw upon.

It is essential therefore that as a system we commit to a fully joined up and pragmatic approach to solving problems as we encounter them – this will help ensure we grow and develop together and that we have shared ownership of the outcomes.

To support this, we have established a set of guiding principles for all participants and to underpin all action plans. These principles are intended to help ensure our staff, partners and stakeholders recognise our shared rights and responsibilities as we progress through the programme.

2b. Programme delivery principles 14

DRAFT FOR DISCUSSION

Principle The Programme will…

1. COLLABORATION Gain commitment from providers and commissioners to work together for the improvement of CWHHE health and well-being outcomes

2. LOCAL VARIATION Apply a common approach to ACPs in CWHHE only where appropriate thus allowing localities to progress according to local needs and readiness

3. CO-PRODUCTION Co-produce solutions between CCGs, providers, local authorities, patients/citizens, and NHS England

4. DELIVERABILITY Be driven to deliver pragmatic and tangible change

5. TRAILBLAZERS Harness great work already underway to help as pathfinders and trailblazers

6. CLINICAL AND MANAGERIAL LEADERSHIP

Be clinically lead through clinical GP CCG leadership coupled with strong managerial leadership and expertise

7. FOLLOW-THE-DATA Be compelled by data, rather than by intuition or personal experience

8. TRANSPARENCY Incorporate a robust and transparent process – sharing of data where this does not represent commercial conflict

9. ACCOUNTABILITY Through collaboration, clear roles and responsibilities of delivery, holding each other to account for delivery of transformation

10. ADAPTABILITY Dynamically evolve and adapt to a changing external environment

11.SUSTAINABILITY Be forward looking to drive long term sustainable change

3. ACP scope & programme delivery strategy

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3a. ACP Scope & the Definition Framework 16

What is the scope of the ACPs we need to deliver? The definition of ACPs and the scope of delivery for implementation by April 2018 (including

detailed definition of scope of services, geographies, patient populations,) will be defined throughout Phase 2 of the programme which will be enacted between July 2016 and January 2017.

Further information on the approach, milestones and timelines can be found in section5.4 of the PID.

Developing the ACP Definition Framework A key part of the programme will be the development of the ACP Definition Framework. This

will be the key tool that will confirm our system-wide needs, ambitions for health and care delivery and our expectations for the development and implementation of an accountable care system.

The table below captures the main headings and information to be included in the definition framework and thus offers a good framework for the scope of the ACP programme:

A draft ACP Definition Framework will be completed for discussion with stakeholders and the provider market by November 2016. This is part of the iterative process for the framework and will support the completion of the final document during phase 2.

3b. The ACP Definition Framework – what it will include 17

DRAFT FOR DISCUSSION

No. Framework Requirement / Expectation Things this will include / consider

1. Our overriding principles that must be addressed by the ACP(s)

WSIC vision: • Empowered patients: self-care, choice, independence • GPs at the centre: leading, co-ordinating, requesting care in best setting • Integration enabled: finances, contracts, shared ownership Quality, equity, sustainability

2. Define priority health need(s) we want to address

Right Care priorities; services with biggest demand/spend/inequities; data analysis

3. Define priorities within these areas Targeting higher usage in certain groups; segmentation of people; data analysis

4. Define the outcomes we want Co-designed with clinicians, patients, carers, residents

5. Define the services / interventions that will deliver these outcomes

Currently provided-v-could be provided; Commissioner view on best practice, best value; clinician view on best practice; patient view on what works for them; innovation

6. Identify the providers and types of providers needed to deliver these services

Must include GP primary care; urgent care/OOH; community/out of hospital provision; acute; MH; social care; third sector

7. ACP scope Footprints – range from500,000 – 1m; with locally sensitive delivery

8. Budgets needed / affordability Current spend on population; on the services in scope; by CCG and in aggregate; will use capitated budgets and whole population approach

9. Contract / Business model to deliver 1-8 above

Provider-led response; to consider ACO, ACP, Joint Venture, Alliances, LHP etc etc

10. Risk / Gain share / performance management arrangements

Commissioner risk share with ACP; phasing out risk ‘held’ by CCGs; arrangements within partners of the ACPs

11. Provider / partnership capabilities Will be tested; gateways ACPs must pass through (pass or fail); framework of competencies we are expecting; defined commissioner levels of assurance sought

3c. Summary of the programme structure 18

As with any complex change programme there are several strands of work that need to be carried out simultaneously and in a sequential and incremental order (the ‘critical path’) to enable the full achievement of programme objectives.

The development and implementation of ACPs across the five boroughs of CWHHE represents a challenging and complex programme and as a consequence, a carefully crafted and well developed delivery strategy is a critical step on our journey.

The diagram in the next slide provides an overview of the programme approach and timelines, demonstrating the key phases we are working through and the timeframes within which they need to be delivered.

Each phases is ‘gated’ which means the objectives of each phase must be completed before progress can be made into the stage. This approach is a critical factor in helping ensure a robust approach to development and delivery of key milestones.

The full PID document provides further detail on the assumptions, strategy, milestones, and critical path that underpin this approach.

3d. Overview of the programme structure 19

3e. Delivery strategy & approach 20

• The diagram on the next slide provides an overview of what we are seeking to implement from April 2018 and importantly, how we want the ACP model to mature in subsequent years.

• The diagram makes it clear we are not seeking to establish fully functioning, all-encompassing ACPs from day one (ie as illustrated in ‘Future State’) but rather introduce whole population ACPs with a few key areas on which to have a priority focus. This recognises the need to establish ACPs that are system-wide and focussed on addressing the priorities set out in the NW London STP but also that time will be needed to enable ACPs to stabilise and mature.

3e. The delivery strategy 21

DRAFT FOR DISCUSSION

4. Phase 2: the critical path

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4a. The importance of phase 2 in the ACP programme 23

Phase 2, stretching from July to November 2016 represents the single most critical phase at this stage in the development of ACPs.

As set out in the PID, during this phase work will be carried out to scope the shape and detail of the accountable care system we are looking to create, including details around outcome measures, budgets, contract form and size & scope of ACPs.

This work will culminate in the development of the ACP Definition Framework and the initiation of the formal market engagement, in turn marking the beginning of the formal contract award process.

Zooming in Phase 2 part of the programme, the critical path on the next slide outlines key programme activities required to meet the November definition framework and market engagement initiation milestones.

4b. The Phase 2 Critical Path 24

DRAFT FOR DISCUSSION

4c. Phase 2 - the Critical Workstreams 25

DRAFT FOR DISCUSSION

2. ACP Business Operations 1. Programme Delivery

1.4 Patient Engagement

1.2 Communications and Stakeholder Management

1.1 Locality Delivery

2.3 Route to Contract Award

2.4 Finance and Capitation

1.3 Governance and Assurance

2.5 Contracting

2.6 Business Intelligence and IT

2.1 Outcomes and Benefits Realisation

2.2 Culture Change and Provider Development

1.5 Quality

5. Governance arrangements

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5a. Governance arrangements 27

Good governance is essential to the success of any transformational programme and is especially important given the scale, complexity and multi-partner nature of our ACP ambitions.

Plans are in place to ensure the ACP programme is effectively governed to support the development and implementation of ACPs in CWHHE during Phase 2, and also with a view to widening the scope to incorporate BHH CCGs (from Phase 3 onwards) should this be agreed as necessary by all parties.

We additionally recognise that governance of the eventual ACP(s) is of vital importance and thus a separate programme workstream will be initiated to ensure robust arrangements are developed and agreed prior to ACPs going-live in April 2018.

5b. Initial ACP Programme Board – function & objectives 28

Initial ACP Programme Board An Initial CCG Commissioner-led CWHHE ACP Programme Board has been established in Phase 1 to drive

the immediate tasks required to define the scope of the ACP programme, up to and including the draft ACP Definition Framework as well as directing the mobilisation of a formally constituted CWHHE ACP Programme Board and associated governance arrangements.

Responsibilities & objectives of the Initial ACP Programme Board ACPs in CWHHE will require a strong collaborative partnership among CCGs, providers, local authorities,

NHS England, patients, and other stakeholders who could play a role in the success of delivery. The Initial Board is responsible for direction-setting during Phases 1 and 2 of the programme, in

preparation for Phase 3 onwards. The Initial Board shall therefore undertake the following work until the end of Phase 2 of the programme:

Oversee the mobilisation of initial programme resources & the Initial ACP Operations Board. Make recommendations to the CWHHE CCG Governing Bodies on critical aspects of ACP development

as outlined in the programme critical path. Steer the direction and development of the PID and manage the process to obtain Governing Body

approval Assess outstanding governance queries (eg involvement of NHS E) Recommend the establishment of a substantive ACP Programme Board following Phase 2 of the

programme.

5c. Proposed scheme of delegation 29

To ensure efficiency of decision making, Governing Bodies will be asked to delegate authority to act to the ACP Programme Board (both in its initial form and in its fully constituted form) in relation to day-to-day programme operating decisions.

The Scheme of Delegation (right) outlines the major decisions that will remain with CCG Governing bodies and the areas of work we intend to request to be delegated to the future ACP Programme Board

At the CWHHE CCG governing body meetings in Sept 2016, we will be asking governing bodies to: 1. Approve the direction of travel for

governance set out in the PID, in particular to provide a mandate for the Initial ACP Programme Board to proceed as described

2. Approve the Scheme of Delegation (Authority to Act) and assurance mechanisms outlined in the governance section

5d. Overall governance arrangements – structure diagram 30

5e. Risk escalation pathway 31

DRAFT FOR DISCUSSION

6. Resourcing strategy

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6a. Resourcing Principles 33

DRAFT FOR DISCUSSION

Adaptable and flexible resourcing arrangements: • Resourcing arrangements will be revisited at the beginning of each Phase to ensure they continue to be fit for purpose. Sustainable team for the future • From a commissioner perspective, the programme leadership team will be composed of individuals seconded from CCGs

or redirected to deliver the ACP. This will ensure continuity of knowledge that will evolve over time as well as foster a network of change champions across the system that will prove to be vital in the people change process.

Expert advice • Experts will be contracted in advisory support roles as well as to deliver specific deliverables that require specialist input. • For continuity purpose, the intent is to commission a strategic partner to provide these services for an extended period of

time rather than several disconnected arrangements that end up being delivered in silos with a lack of knowledge transfer. The programme will require NHS-England approval to commission this expert advice.

Commissioners and providers working together as one team • As this is a system wide change, commissioners and providers will both have important roles in the delivery of the

transformation. It will be crucial for commissioners and providers to work together as one team enabling one another to succeed. This represents a culture shift from the traditional siloed ways of working and thus will need to be gradual.

Learning together • This transformation has never been done at such a large scale in the NHS. Therefore resource experience and skills

required may not always be readily available. Therefore, the delivery team will need to learn, grow, and adapt together. Strategies will be put in place that focus on building new capabilities in our system leaders and team members – forcing us to think differently and innovate together.

Team networks • Our team resourcing model will move away from traditional hierarchies to a network model that bring together expertise

and resources from different sectors and communities as and when required

6b. Meeting our resource requirements 34

DRAFT FOR DISCUSSION

ACP Core Team

Outsourced / specialist expertise

Regional / National /

global alliances

Public Sector Strategic partners

Delivery partners Frontline Staff

Citizens and community

partners

Research & Academic Partners

We will seek to secure a mixture of dedicated resource assets including establishing a core team for the life of the programme, securing specialist external support and developing an approach to task & finish requirements. In all cases we will look to draw from internal teams as much (and as responsibly) as possible, offering secondments & fixed term opportunities to all internal staff, as well as staff in partner organisations

Collectively, our resourcing model (below) will move away from traditional hierarchies to a network model that brings together expertise and resources from different sectors and communities as and when required.

6c. Leadership Team & Developing Resource proposals 35

DRAFT FOR DISCUSSION

We have established an initial commissioner team leadership based on meeting the requirements for Phase 2 of the programme. Details of the team and the functions they are covering are set out in the PID.

At this point in time, providers are not able to be a part of the core leadership team as this may inhibit fair competition of contract award with any one provider. Nevertheless, provider co-production will be required throughout this Phase to start to change our ways of working in preparation for a combined delivery team in later phases, once contract has been awarded.

Interim resourcing arrangement have been agreed to help meet the delivery needs in phase 2. A more stable solution is required to support on-going development and implementation of ACPs.

A key deliverable therefore in this phase of the programme is the development of a full resource proposal covering the life of the programme together with, subject to approval, mobilisation of the plans. The proposals will be discussed by the initial ACP Programme Board n September 2016.

7. Next steps

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7a. Next Steps 37

DRAFT FOR DISCUSSION

• Incorporate comments from today – more detailed feedback on the PID document can be sent to ACP.PMO@nw.london.nhs.uk

By the end of phase 2 (to Jan 2017): Proposals for formal governance arrangements including clarification on the role

of Local Authorities, the role of NHS-England and the role of neighbouring boroughs - in particular the role of BHH will be agreed

The draft ACP Definition Framework will have been published for testing with the provider market

Locality delivery strategy will have been developed and implementation will have started

Social care links and agreed approach to joining up ACP development Resourcing plan mobilised Phase 3 plan agreed Recommendations on the preferred route to contract award and the final ACP

Definition Framework will be developed for agreement at January GB meetings.