BUSINESS CASE FOR INTEGRATING CARE...1.5 DELIVERING ON NATIONAL, REGIONAL AND LOCAL INTEGRATED CARE...

BUSINESS CASE FOR INTEGRATING CARE

NHS HOUNSLOW CCG

11 SEPTEMBER 2018

BUSINESS CASE FOR INTEGRATING CARE 11 September 2018

Commercial in confidence - not for onward sharing © PA Knowledge Limited 2

CONTENTS

1 STRATEGIC CASE 5

1.1 OVERVIEW OF HOUNSLOW POPULATION NEEDS 5

1.1.1 Features of the local population 5

1.1.2 Local health needs 7

1.2 OVERVIEW OF THE CURRENT HEALTH AND CARE SYSTEM 8

1.2.1 Primary care 9

1.2.2 Community care 9

1.2.3 Mental health care services 9

1.2.4 Acute care 10

1.2.5 Local authority services 10

1.2.6 Voluntary and community sector services 10

1.3 EMERGING CHALLENGES FROM THE CURRENT WAY OF COMMISSIONING 10

1.4 THE SYSTEM FINANCIAL POSITION 11

1.5 DELIVERING ON NATIONAL, REGIONAL AND LOCAL INTEGRATED CARE PRIORITIES 12

1.5.1 The national picture 13

1.5.2 The regional picture 14

1.5.3 The local picture 15

1.5.4 “At scale” primary care working 16

1.5.5 Integrated out-of-hospital hubs 17

1.6 PROGRESS TO DATE IN DELIVERING INTEGRATED CARE IN HOUNSLOW 18

1.6.1 “At-scale” primary care 18

1.6.2 The enhanced primary care contract 19

1.6.3 Community-based initiatives 19

1.6.4 Local authority partnership 20

1.6.5 The development of the STP Implementation Group 20

1.7 THE BENEFITS FOR RESIDENTS, THE WORKFORCE AND THE SYSTEM OVERALL 20

1.7.1 Residents 21

1.7.2 Workforce 21

1.7.3 System 21

1.8 CONCLUSION 22

2 ECONOMIC CASE 23

2.1 PROCESS TO DETERMINE THE BEST APPROACH 23



2.2 COMPARISON OF OPTIONS FOR COMMISSIONING APPROACH 24

2.2.1 Commissioning approach options 24

2.2.2 Conclusion to first stage of evaluation 29

2.3 EVALUATION OF INTEGRATED CARE SYSTEM DESIGN FEATURES 29

2.4 CONFIRMATION OF PREFERRED OPTION 47

2.5 CONCLUSION 48

3 COMMERCIAL CASE 49

3.1 THE CURRENT MODEL OF CARE – STRENGTHS AND ISSUES 49

3.2 FEATURES OF THE HOUNSLOW MODEL OF INTEGRATED CARE 52

3.3 ICS SERVICE SCOPE 55

3.4 COMMERCIAL STRATEGY 57

3.4.1 Procurement strategy 57

3.4.2 Contractual approach 61

3.4.3 Payments 61

3.4.4 Market engagement 62

3.5 ADDITIONAL COMMERCIAL CONSIDERATIONS 62

3.6 CONCLUSION 63

4 FINANCIAL CASE 64

4.1 COST TO COMMISSION SERVICES IN-SCOPE 64

4.2 MODELLING OVERALL CCG FINANCES 64

4.2.1 Building a long-term CCG financial model 64

4.2.2 Scenarios testing and outputs 65

4.2.3 Scenario 1: low acute growth 65

4.2.4 Scenario 2: medium acute growth 66

4.2.5 Scenario 3: high acute growth 67

4.2.6 Scenario 4: acute growth back-solved 68

4.2.7 Commentary on the scenarios tested 69

4.3 ESTIMATING AN INTEGRATED CARE SYSTEM COST ENVELOPE 69

4.3.1 Commentary on the cost profiles illustrated 70

4.4 CONCLUSION 71

5 MANAGEMENT CASE 72

5.1 PHASES OF CHANGE 74

5.2 PHASE 1: CONFIRMING THE APPROACH FOR INTEGRATED CARE 75



5.3 PHASE 2: IMPLEMENTING THE CHANGE 77

5.4 PHASE 3: MANAGING AND IMPROVING THE NEW SYSTEM 79

5.5 GOVERNANCE 80

5.6 CAPABILITY AND CAPACITY REQUIREMENTS 82

5.7 COMMUNICATIONS AND ENGAGEMENT PLANNING 84

5.8 RISK REGISTER 84

5.9 CONCLUSION 89

A. DICTIONARY OF ABBREVIATIONS USED 90

B. NORTH WEST LONDON SINGLE OUTCOMES FRAMEWORK 92

C. HOUNSLOW “I” STATEMENTS 93

BUSINESS CASE FOR INTEGRATING CARE 11 September 2018 Commercial in confidence - not for onward sharing © PA Knowledge Limited 5

1 STRATEGIC CASE

The strategic case sets out the case for change for greater integration of care in Hounslow through the development of a single contract. It describes the strategic context, alignment with national policy and regional and local plans, and the potential benefits for residents, the workforce, providers and the system overall. The strategic case describes the opportunity to move to a more integrated model of care providing deliver better, more efficient and financially sustainable health and care services in Hounslow.

1.1 OVERVIEW OF HOUNSLOW POPULATION NEEDS

1.1.1 Features of the local population

Hounslow Clinical Commissioning Group (CCG) is co-terminus with the London Borough of Hounslow, a diverse Borough stretching from near central London to the border with Surrey on the outer boundary of Greater London. Its constituent wards differ greatly in character and show a range of demographic and socioeconomic variation – from areas of wealth through to pockets of deprivation.

It is home to a population of around 275,000 people. The CCG commissions healthcare services for a registered patient population of 305,000. This includes a significant number of people who are registered with a Hounslow GP general practice (GP) who do not live in the borough – placing additional pressure on local resources and the population health budget.

The borough has the following features:

Hounslow is the 9th largest London borough by area and is the 18

th largest London borough by population.

Between 2001 and 2011 the population increased by 20%. This compares to a mean national increase of 8% over the same period. As shown in figure 1.1 below, the population is anticipated to grow over future years in line with the rest of England, though below the levels projected for London overall

1. The CCG

must plan adequately to ensure sufficient capacity is available in the local system to support timely access to the right range of services:

Figure 1.1: Forecast population growth in Hounslow (source: Office of National Statistics (ONS), 2016 base year)

Hounslow has the fourth-highest general fertility rate (GFR) in London. In 2015 there were 4,455 live births to mothers living in Hounslow - equating to a GFR of 73.9 lives per 1,000 women aged 15-44. This level is well above the London and England mean. The CCG must continue to provide appropriate maternity (including perinatal) and children’s services to support this population cohort.

The borough experiences an annual population change of around 43,000 (1 in 6) people. This comprises the number of births exceeding the number of deaths (by nearly 3,000 residents), inflow to Hounslow from abroad

1 Other analyses project a greater increase in the population and the potential impact of this growth should be

considered through future scenario modelling and action planning.


(around 6,300 people in 2015), outflow from Hounslow to abroad (around 1,900 people in 2015), inflow to Hounslow from other parts of the UK (around 15,700 people in 2015) and outflow from Hounslow to other parts of the UK (around 19,700 people in 2015). This is a comparatively high turnover rate. In response, the CCG must establish the aspects of health and care provision that are most impacted (by the changing patient and workforce base), and ensure these are managed appropriately.

Hounslow has a significantly larger population of children and young people (aged 0-15) than the London and England mean. While this is expected to reduce relative to the total population over coming years, it will remain above the England mean. This means that the CCG needs to be particularly aware of the needs and expectations of this age group, especially in terms of access and technology.

The population of older people (aged 65 and over) is in line with other London Boroughs but is significantly below the England mean. Over the coming years, this population is forecast to grow by 80% (an additional 25,000 older people) by 2041. This includes a doubling of the population of people aged 85 and over. As shown in figure 1.2, older people will become a proportionately much larger segment of the population. This cohort has a variety of needs relating to frailty, dementia, and long-term conditions – requiring intensive health and care inputs and co-ordination across many different teams. The CCG must plan effectively to manage the needs these people in a sustainable way.

Figure 1.2: Forecast change in population composition by age group in Hounslow (source: ONS, 2016 base year)

The borough has one of the most ethnically diverse populations in the UK. In 2016 it was estimated that 51.6% of residents identify as a member of a black and minority ethnic group. This is projected to rise further in the future. Assessment in 2015 showed that 46.3% of residents were born abroad. 50.6% of school pupils do not speak English as their first language – nearly double the London mean and treble the England mean. The three most common ethnicities identified in Hounslow are white British, Indian and Pakistani. Hounslow also has a number of new communities including Afghan, Bulgarian, and Nepalese communities. Ethnicity is a key factor in epidemiology and healthcare needs. It is also underpins cultural behaviours and attitudes towards health, wellbeing and service use. As such the CCG will need to continue to ensure the right services are provided in an appropriate way.

Reflecting its geographical spread between near central London and outer London, Hounslow has a population density of 49.0 people per hectare (positioned midway between the Outer London mean of 42.3 and the London mean of 56.2). As set out in the Hounslow Future Borough Strategy, to accommodate future population increases over 26,000 new homes are forecast to be built. This development – combined with local land restrictions – implies higher population density in the future and a shift from more suburban to urban living environments. The CCG will need to plan for this growth to ensure that services have sufficient capacity relative to their local areas, while also taking into account constraints on infrastructure (including estate for service provision, and travel times).

0%

20%

40%

60%

80%

100%

0-19 20-64 65-84 85+

2016 2021 2026 2031 2036 2041


The overall level of deprivation in the borough is close to the England mean. In the 2015 Index of Multiple Deprivation Hounslow was ranked 151

st out of 326 England Local Authorities, with 16 lower super output

areas (LSOA) 2 in the most deprived 20% nationally. However, comparison with the 2010 Index suggests a

trend of increasing relative deprivation – when the borough was ranked 156th out of 326 Local Authorities

nationally, with twelve LSOA in the most deprived 20% nationally. Work including the Marmot Review 3

highlights the interlinked relationship between deprivation and health inequality. The CCG must continue to focus on addressing these inequalities, and work with partners – including London Borough of Hounslow – to improve the wider determinants of health.

As the population of the borough grows and people live longer, the challenge of balancing available resources and local needs continues to grow. At the same time, the unique and evolving Hounslow demographic profile and its constituent population cohorts will require – and drive – differential health and care needs. As such the CCG must continue to work to understand demographic variation and change in order to ensure the right services are commissioned to meet the needs of the population.

1.1.2 Local health needs

Hounslow residents have a broad range of health and care needs. These needs are changing over time in different ways and at different paces.

Hounslow’s population is ageing with consequent increasing needs for health and social care. People are living longer with more – and more complex – long term conditions which the National Health Service (NHS) medical model is ineffective at tackling single-handed. The population with these conditions is expected to grow at a faster rate than the overall population over the next five years; and costs are also anticipated to accelerate.

A number of people with complex conditions (including those with severe physical disability, severe and enduring mental illness, learning disability, cancer, dementia, long term conditions) have more intensive needs requiring support taking up a proportionately larger portion of the local budget. In 2015, 27,000 people in Hounslow (9% of the population) with any of these six conditions needed support costing over 80% of Hounslow’s overall budget. The 2% of people with the most complex conditions required support costing over 17% of the CCG’s budget.

Analysis points to significant observable inequality and variation in the way that health and care services are accessed and provided. This means that some people in Hounslow find it harder to access the support they need, do not receive the breadth of support they require, or receive poorer quality care than people in other parts of the Borough, across London, or England overall. A snapshot of the degree of variation that exists at ward level is set out in figure 1.3:

2 Lower super output areas are geographical units (comprising a mean of around 1,500 residents) used for

statistical analysis

3 Marmot, M. Fair society, healthy lives: the Marmot Review: strategic review of health inequalities in England post-

2010


Figure 1.3: Comparison of health and wellbeing indicators across three wards in Hounslow

While progress has been made on many of these priorities, there are also indicators of poor system performance that must be addressed. A selection of these metrics is shown in figure 1.4:

Figure 1.4: Dashboard of priority Hounslow health and wellbeing indicators

Several of these indicators are outside of Hounslow CCG’s role (and position) to tackle directly, they point to a need for a coordinated, multi-agency response. Additionally, performance against many of these indicators has been consistent – or has deteriorated – over recent years. More concerted effort is needed to build on the incremental or inequitable improvements of past years.

Hounslow’s changing local health needs require a considered response. In previous years, the traditional model of commissioning has worked by delivering year-on-year improvements in health outputs (i.e. measures of process). However, the scale of variance and inequality presents a more substantial challenge. Tackling this will require a coordinated, multi-agency approach with responsibility for driving improvements shared between both the CCG and system partners. As well as a new approach to commissioning, a new integrated care model is needed to improve population health outcomes, based on:

effective care planning and the full engagement of carers and other family members;

health and care services working together;

a renewed focus on preventative and self-care to constrain the growth in prevalence of long term conditions (e.g. diabetes, COPD) that often result from lifestyle choices;

investment in – and better coordination of – services to improve the health and wellbeing of children to minimise the need for more intensive and continuous services throughout adulthood;

the proper integration of mental and physical health services;

identifying local good practice, sharing this and supporting its consistent implementation; and

recognising poor practice and shortfalls against benchmarks, and support health and care services to work together to improve.

The various and changing needs of the population overall drive the CCG’s strategic direction and commissioning decisions - and will determine the nature of the integrated care provided by the local health and care system in the future. A core requirement of this system is that it understands the specific needs of the Hounslow population, as well as its individual communities, and designs its services to meet these needs.

1.2 OVERVIEW OF THE CURRENT HEALTH AND CARE SYSTEM

Hounslow CCG commissions services from – and works in partnership with – a range of providers to improve the health and wellbeing of Hounslow residents through appropriate and effective out of hospital services. The CCG commissions a range of services: primary care, community services, mental health services, elective and

Life expectancy is 5.3 years

lower for men and 4.6 years

lower for women in the most

deprived areas of Hounslow

than in the least deprived

areas

Air quality causes 200

premature deaths a year and

noise affects 60,000 residents

Decayed, missing or filled

teeth hospital admission rate

in Hounslow is 549 per 100,000

children, against a London

average of 368 admissions per

100,000 children

Estimated prevalence for long

term conditions including

hypertension, diabetes,

asthma and coronary heart

disease is higher than QOF

reporting indicates implying

significant under-diagnosis

At least 31,000 people that

should have been screened for

cancer but were not. Cervical

cancer screening figures for

2015/16 show only 63.9% of

85,500 eligible women received

a screen

At Year 6, 24.1% of children are

classified as obese –

significantly higher than the

England average of 20%

Rate of 2,887 hospital

admissions per 100,000 people

aged 65 and over for falls

against a London average of

2,253 admissions per 100,000

people

Incidence of tuberculosis

(which is closely associated

with levels of deprivation)

is 53.7 cases per 100,000

people – significantly higher

than the England average of 12

cases per 100,000 people

Key to sources:

56.8% of adults (aged 18 and

over) are physically active –

lower than the England

average of 66%

Observable variation between

GP practices in diagnosis and

treatment of people with long

term conditions

About 21% (11,500) of children

live in low income families

Rate of 390 hospital

admissions per 100,000 young

people (aged 10 – 24) in

Hounslow against a London

average of 209 admissions per

100,000 young people

Public Health England, London Borough of Hounslow Health Profile

London Borough of Hounslow Joint Strategic Needs Assessment, 2017


emergency hospital care. A list of existing services in scope is provided in section 3.3. A brief summary of these services is outlined below.

1.2.1 Primary care

Following the introduction of delegated commissioning in April 2018, Hounslow CCG is responsible for commissioning primary care services to meet the needs of around 305,000 registered patients (residing in Hounslow and neighbouring boroughs). Primary care services are commissioned from 47 practices that are geographically split into five localities (Brentford & Isleworth, Chiswick, Feltham, Great West Road and Hounslow Heath). Localities are responsible for coordinating primary care in a more integrated way locally. Their geographical distribution is shown in figure 1.5:

Figure 1.5: Overview of Hounslow’s five GP localities

Practices in these localities have come together formally as established GP federations as platforms for greater collaboration, data-sharing and holding contracts in common. In addition, there is a single overarching federation – the Hounslow Consortium – that is the representative body for all primary care providers within Hounslow. Since April 2018 it has been the contract holder for the borough-wide enhanced primary care contract. As such it is responsible for delivering an enhanced range of out of hospital services from GP practices focussed primarily on improving the health of patients with complex needs and long-term conditions but also including other aspects of care (e.g. patient experience, access, cancer screening).

1.2.2 Community care

Hounslow CCG commissions Hounslow and Richmond Community Healthcare NHS Trust (HRCH) to provide a range of community health services for adults and children. These services include community nursing, rehabilitation and therapies (including physiotherapy, occupational therapy, and speech & language therapy), urgent care, health visiting, nutrition and dietetics, health promotion and stop smoking services. HRCH also provides the community recovery services (CRS - providing integrated health and social care support for adults with complex needs), and the integrated community response service (ICRS - which provides rapid, multi-disciplinary support to help people remain at home).

While HRCH provides many of these services independently, it also works in partnership with other organisations including London Borough of Hounslow. Services are provided within a range of setting across the borough including GP practices, community clinics, West Middlesex hospital, residential and nursing homes, schools, and in peoples’ own homes.

1.2.3 Mental health care services

West London Mental Health Trust (WLMHT) is commissioned to provide a range of community and inpatient mental health services for adults and children. These services include children and adolescent mental health, eating disorders, inpatient assessment, liaison psychiatry, community mental health teams, IAPT (improving access to psychological therapies), perinatal mental health, psychology and psychotherapy. It also coordinates a single point of access for its services.


Services are provided within a range of setting across the borough including GP practices, community clinics, hospitals, inpatient assessment units, residential and nursing homes, schools, and in peoples’ own homes.

1.2.4 Acute care

The commissioning of acute services is now primarily the responsibility of the North West London Collaboration of CCGs (NWL). In Hounslow, around 70% of acute care is provided by Chelsea and Westminster Hospital NHS Foundation Trust (CWHFT) from the West Middlesex hospital site. This is towards the southern border of the east of the borough with good access for residents in the Brentford & Isleworth, Chiswick and Hounslow Heath localities. The site catchment area also covers the northern end of the London Borough of Richmond upon Thames, providing acute services for a significant out-of-borough population. The hospital provides a range of emergency and elective care, including a 24-hour accident and emergency (A&E) service.

Most remaining acute care activity for Hounslow residents is provided by Ashford and St. Peter's Hospitals NHS Foundation Trust. The Trust provides primarily emergency care from the St. Peter’s Hospital site in Chertsey, and elective (non-emergency) care from the Ashford hospital in Stanwell.

1.2.5 Local authority services

Many of the services in scope are commissioned by the London Borough of Hounslow. These services include domiciliary care (i.e. personal care provided in peoples’ own homes), health visiting, school nursing, the family nurse partnership, and sexual health services.

The local authority is also a provider of services that are either within scope – or are closely involved as acting on the wider determinants of health and wellbeing. These include Public Health functions (including smoking cessation, substance misuse, and obesity), child protection, adult safeguarding, care home services, housing, benefits support and environmental services.

1.2.6 Voluntary and community sector services

Hounslow CCG also commissions a range of non-statutory, voluntary sector services in partnership with the local authority, to provide support to patients in the community. These services complement statutory requirements.

1.3 EMERGING CHALLENGES FROM THE CURRENT WAY OF COMMISSIONING

Hounslow CCG’s – and the wider NHS’ - historical approach to commissioning care has developed incrementally over many years, under a wide range of influences:

National policy as set out in prevailing legislation – advocating competition as the means to improve quality of choice, rather than increasing system collaboration, and driving the formal purchaser / provider split. At the same time fostering the creation of powerful and influential foundation trusts, as well as a fragmented regulatory system

National standards – driving a narrow focus on those targets that can be easily measured, rather than on more meaningful outcomes and/or those that multiple providers contribute towards

Regional strategies and plans (including financial control totals) – incentivising behaviours and actions that can have detrimental and/or contradictory local impacts

The consequence of this is a contemporary commissioning system which does not encourage providers to focus on coordinated care delivering the best possible outcomes for patients. This has driven the development of a fragmented health and care system – with over 45 community-based services commissioned from over 20 main providers (with many more delivering support through frameworks including Any Qualified Provider and Personal Care Framework for domiciliary care). The majority of this service provision is commissioned on an activity and outputs basis rather than an outcomes basis.

This fragmented system drives consequences including:

gaps between teams, services and organisations that people can fall between, or that do not provide the comprehensive wraparound care required for complex conditions;

delays in providing the care patients need where decision-making requires the involvement and agreement of more than one commissioner or provider;

inefficiencies arising through duplication (e.g. care provided in peoples’ homes funded separately by the CCG and local authority), or missed opportunities to make better use of system resources (e.g. domiciliary visits by staff undertaking broadly similarly activities)

access points and pathways patients and staff find challenging to identify and navigate (which can result in people defaulting to acute services including A&E where access is assured);


contradictory and/or misaligned incentives driving behaviour that is to the detriment of the Hounslow population and the overall system, while constraining opportunities for provider collaboration and innovation; and

no clear plan for ensuring financial sustainability (particularly constraining demand for acute services which arises through fragmented, hard-to-access community-based provision).

This model is overly reliant on the assumption that it is possible to exactly specify the type of services people need. No two individuals are the same - yet people are often provided support as if they were. And often this support is “delivered to” – not “delivered with” – positioning patients as passive recipients of care rather than recognising peoples’ individual objectives, expectations and preferences.

1.4 THE SYSTEM FINANCIAL POSITION

The historic model will not be financially sustainable in the future. Though the money available for Hounslow CCG to spend on services for the local population (the “allocation”) is expected to increase over the coming years, this will likely be outstripped by increasing population growth and unconstrained demand (particularly non-elective services). And while CCG allocations flex in line with population size and relative need, funding increases typically lag population changes by several years. This will contribute to further strain on local budgets and resources.

Hounslow CCG’s forecast financial position (based on the regional North West London 3-year plan) identifies a 3.5% per annum increase in the allocation for commissioning. However, up to 4.5% of this is anticipated to be absorbed by growth in spending in acute care, with prescribing (5%), continuing healthcare (4%) and other programmes (2%) taking up much of the remaining growth. To balance this, the plan assumes that growth in community, mental health and primary care (i.e. the services in scope of this work) to be less than 1%. This real term funding decrease requires radical thinking about how to expand the out-of-hospital services available to Hounslow residents for a reducing overall budget - delivering more for less.

The financial case describes a series of local scenarios modelled to show the impact of non-elective growth on affordability. The difference between a best-case scenario (i.e. low acute growth) and a worst case scenario (high acute growth) is a £9m per annum impact on the financial envelope available for the services in scope. It should be noted that these scenarios are sensitive to relatively small percentage changes in acute growth and the corresponding Quality, Improvement, Innovation and Productivity (QIPP) schemes provided to deliver a system breakeven position.

As set out in figure 1.6, Hounslow CCG spends significantly more money on community care and enhanced primary care than the regional (North West London) mean.

Budget area Spend per head (17/18)

Regional mean spend per head (17/18)

Variance

Community £168 £118 42%

Primary care other services £166 £148 12%

Acute £730 £771 -5%

Mental health £136 £162 -16%

Continuing care £55 £71 -22%

Figure 1.6: Comparison of spend per head across service categories in Hounslow and wider North West London

To maintain this investment, efforts have been made to carefully manage costs in other health services (specifically acute care). However over recent years non-elective demand has continued to grow steadily. Hounslow now has North West London’s highest emergency admission rate per 1,000 people.

Without taking action there is a risk that spend on non-elective, hospital-based care take up a greater proportion of the CCG’s overall budget. In the future difficult choices may need to be made about the volume and/or quality of out-of-hospital services commissioned. This would directly contradict national, regional ad local ambitions to manage more care outside of hospital.

In response, there is a need for – and an opportunity to design - a new commissioning and care delivery model blending cultural change, novel approaches and new technology. This new model should be defined by:

setting out a clear strategic vision describing “how” and not “what” care should be delivered – giving providers scope and flexibility to innovate a bottom up response;

commissioning care for populations – buying the care needed to deliver the outcomes demanded by the population, with a focus on investing in prevention and more proactive delivery of health and care;


evolving the relationship with the people of Hounslow in line with the operational and commissioning changes, recognising patients, residents, families and carers as service partners

extending contract terms – letting longer contracts to give providers the necessary time to transform care, while providing scope for continuous change;

facilitating a culture of collaboration – investing in the development of trusting relationships between the CCG and providers, and between providers;

introducing appropriate payment methods and incentives – to drive the right system behaviours;

empowering local community groups, employers and the voluntary sector to build community resilience (incorporating learning from the “Stronger Together Cranford” programme in promoting wellness);

sharing responsibility for leading the system – by agreeing risk and reward measures with providers that balance autonomy with accountability; and

driving financially sustainable – directing the necessary transformation (i.e. realising savings opportunities through shifting care and resources into the most appropriate setting) to underpin high quality, accessible and effective services available to all Hounslow residents now and into the future.

This commissioning approach will support alignment with the national vision for greater integration of services, reduced demand on the acute sector and improved out of hospital care. At the same time focussing on delivering more integrated services will help to address the current gaps in care and challenges around care co-ordination that lead to adverse impacts on patient experience and outcomes.

In particular, a more holistic and less disease-based approach will help the cohorts of frail older people, those living with long-term chronic illnesses and mental health disorders and people with medically complex needs, for whom effective community services are vital.

1.5 DELIVERING ON NATIONAL, REGIONAL AND LOCAL INTEGRATED CARE PRIORITIES

The challenges affecting the Hounslow health and care system are shared across much of the NHS. In response, national, regional and local strategies and plans have been developed setting out a consistent, and ambitious, direction of travel towards integrated care.

While the evidence base continues to develop, integrated care has been shown to improve outcomes and to achieve the Berwick “triple aim” (improving care, improving health, while reducing costs). A selection of case studies is provided in figure 1.7:

Figure 1.7: International examples of the impact of integrated care


1.5.1 The national picture

NHS England’s (NHSE) Five Year Forward View 4 (FYFV), published in October 2014, sets out objectives for

sustaining and improving the NHS by addressing three gaps:

health and wellbeing;

care and quality; and

finance and efficiency.

The FYFV presents recommendations to close these gaps by improving the quality of services, reducing fragmentation, and accelerating integration. It describes new models of care to drive deeper – and faster - integration of services, with a particular focus on the delivery of out-of-hospital care. This includes:

A drive towards outcomes-based commissioning: “personalised care will only happen when statutory services recognise that patients’ own life goals are what count; that services need to support families, carers and communities; that promoting wellbeing and independence need to be key outcomes of care; and that patients, families and carers are often “experts by experience”

Taking decisive steps to break down the barriers in how care is provided between services, including health and social care, and to develop radical new care delivery options. This includes permitting groups of GP practices to combine with community nurses, other community health services and hospitals to create integrated out-of-hospital care.

A “new deal” 5 for GPs, investing more in primary care, while stabilising core funding for general practice

nationally over the next two years, and a shift in investment from acute to primary and community services.

Transforming policy into action, since 2015 new models of integrated care have been trialled at 50 national vanguard sites (including Dudley, Stockport and Northamptonshire). These pilots demonstrate a wide range of approaches to integrating care, showing how the framework of the FYFV can be tailored to meet specific local needs. At the same time the evaluation of the pilots described in the Next Steps on the Five Year Forward View shows the positive clinical and operational impacts integrated care can support

6. A summary of impacts is provided

in figure 1.8:

Figure 1.8: UK examples of the impact of integrated care

More recently, transformation towards integrating care at scale has been driven forward by England’s 44 sustainability and transformation partnerships (STP). In some areas, these have evolved into integrated care

4 NHS England, Five Year Forward View, 2014

5 Detail on this new deal has subsequently been described through NHS England’s General Practice Forward View

6 As assessed against 2014/15 activity baselines, vanguard areas piloting two forms of integrated care (the primary

and acute care systems (PACS) and the multi-specialty community provider (MCP)) saw lower growth in emergency hospital admissions and emergency inpatient bed days than the rest of England. On average, per capita emergency admission rates grew by 3.2% in the rest of England, compared to 1.1% in PACS, and 1.9% in MCP vanguards.

In Nottinghamshire a large reduction in A&E

attendances and hospital admissions has

been observed through enhanced primary

care in care homes

As assessed against 2014/15 activity

baselines, vanguard areas piloting two forms

of integrated care (the primary and acute

care systems (PACS) and the multi-specialty

community provider (MCP)) saw lower

growth in emergency hospital admissions

and emergency inpatient bed days than the

rest of England. On average, per capita

emergency admission rates grew by 3.2% in

the rest of England, compared to 1.1% in

PACS, and 1.9% in MCP vanguards

The Fylde Coast Health Economy vanguard

is piloting an extensive care model

comprising a geriatrician extensivist (a GP

with specialised skills), care co-ordinators,

and outreach workers. This is driving more

appropriate and effective care at lower cost

In Dudley multi-disciplinary team working in

primary care is impacting on hospital length

of stays (but not admissions) and voluntary

sector input has reduced primary care usage

https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf

https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf


systems (ICS) with greater responsibility and flexibility to deliver improved population health through collaboration. These 14 areas (as of May 2018) are incorporating learning and good practice from the vanguard sites to develop and deliver new models of care for their local populations.

The evidence base developed through the work of the vanguards and the ICS supported – and continues to support - the case for greater collaboration at a system level to improve population health. At the same time the success of multiple approaches undertaken across England demonstrates the validity of a localising responses to deliver national policy.

1.5.2 The regional picture

The eight CCGs in North West London – Central London, West London, Hammersmith and Fulham, Hounslow, Ealing, Brent, Harrow, and Hillingdon – have a track record of improving the quality of health services through working together. The CCGs now share an accountable officer (AO), chief finance officer, director of performance, and director of quality and nursing, with a range of functions – including acute commissioning, strategy & transformation - managed collaboratively.

Together the CCGs have led significant transformation of their local care systems, including the reconfiguration of acute services (Shaping a Healthier Future - SaHF), the Integrated Care Pioneer programme (Whole Systems Integrated Care - WSIC), and seven-day services. These plans acknowledge the need for the NHS and local government to find ways of providing care for an ageing population and managing increasing demand with fewer resources. The STP Health and Care Transformation board has recently commissioned work to understand how integrated care development is progressing across all CCGs and providers in NWL and how the integrated care agenda should be progressed.

The NWL STP deepens this collaboration by building upon these programmes. Submitted to NHS England in Autumn 2016 in response to the challenges and opportunities described in the FYFV, the STP articulates a vision for an integrated model of care co-produced with residents, health and care commissioners, and providers. Plans to achieve this are described in figure 1.9:

Figure 1.9: Summary of priorities and plans from the NWL STP

This model is based on the localisation of care delivery where possible – shifting the balance of activity away from hospitals and towards the community and peoples’ own homes. At the same time this model describes the delivery of more proactive care – intervening before peoples’ health and wellbeing deteriorates and not only responding after this deterioration takes place. This will also allow more services to be delivered outside of hospital settings.

Community hubs are a key component - providing a setting where primary, community, mental health, social and acute care providers can come together to deliver integrated, patient-centred services

7. This will underpin the

delivery of more convenient and accessible care with additional capacity outside of hospital.

7 North West London’s Strategic Outline Case part 1 sets out the business case for a £513m investment in

transforming NHS services and care across the region. This includes £69m to improve GP surgeries, and around £300m to make the local hospital facilities safer and more efficient. Locally, this investment would be used to


Local plans must continue to reflect these principles and embed transformation that demonstrably delivers the North West London and national direction of travel. Consideration should also be given to the regional implications of changes to health and care services in Hounslow. This includes the potential effects on the:

Around 30% of acute service activity for Hounslow residents is provided outside the borough (primarily Ashford and St. Peters hospitals);

Significant numbers of people living in north Richmond use West Middlesex hospital for their acute care needs;

Users of HRCH community services recognising that the provider is equitably present across Hounslow and Richmond; and

35,000 people living outside of the borough registered with a Hounslow GP practice.

As a result, commissioners’ and providers’ approaches to integrating care in Surrey Heartlands and South West London in particular are relevant to local plans. More broadly, as the CCG progresses preparations to develop an ICS, it will need to think beyond artificial borders within and between health and care systems.

1.5.3 The local picture

In response to national and regional directions of travel, Hounslow CCG published Future-proofing Health in Hounslow in summer 2017. This document sets out a vision (summarised in figure 1.10) for a future, financially sustainable model of care that improves patient outcomes by embedding the principles of integration, prevention, proactivity and localism. The stated ambition is to do this by working even more closely with system partners.

Figure 1.10: The vision of the future Hounslow health and care system (source: Futureproofing health in Hounslow)

Key to making this model a reality is developing enhanced out-of-hospital care delivered between organisations working as part of an ICS.

It is intended that this care is secured through a single contract that binds partners together to take responsibility for overseeing, managing and delivering care for the whole population. Success will be understood through the use of a consistent set of health outcomes. The budget for this care should be pooled with appropriate incentives (including gain share) built in. This approach will support providers to deliver collaboratively towards a common set of goals including:

provide greater bed capacity at West Middlesex Hospital and other improvements. £140m is earmarked to develop the proposed out-of-hospital hubs at Heston Health Centre, Heart of Hounslow Centre for Health, Brentford Health Centre, Chiswick Health Centre, The Meadows Health Centre, and Feltham Health Centre.


Improving health and wellbeing outcomes.

Taking on greater responsibility for delivering targeted, accessible and appropriate population-based health with patients at the heart of care.

Improving efficiency and local use of resources.

It is expected that the single contract will necessarily build on existing provider relationships and service delivery. This will provide system continuity, as well as providing the foundation for trust which is key to collaboration driving innovation and continuous improvement in Hounslow.

The CCG intends that the single contract brings together the services identified in the scope. The way these services are coordinated and integrated to tackle fragmentation is the essence of the model of care. The commercial case describes the scope and the system model of care in detail. A summary of the key features of the new model of care is set out below:

Integrated primary, community and mental health care functions – with local authority commissioned services including social work and domiciliary care to be included in due course.

Fully interoperable shared care records accessible by system partners (wherever consent is provided).

A 24/7 single point of access to contact primary and community services.

Providers organised and incentivised to support people to be healthy – and not only responding at times of illness and crisis.

Opportunities for staff to train across providers – extending the capacity and skills of the system workforce.

A coherent, shared plan to meet recognised workforce gaps.

Investment in community schemes providing appropriate health and care support closer to home.

Digital access (including apps and 111) to primary care services.

Wearable technology available to monitor and feedback on long term conditions,

To make this model work two key enablers are identified:

the development of “at scale” primary care with the aim of strengthening and make sustainable primary care; and

implementing integrated out-of-hospital community hubs, to ensure that where new or refurbished estate is necessary, it reflects the needs of patients and the strategies of the CCG.

1.5.4 “At scale” primary care working

The new model of care is predicated on providers working in concert to deliver patient-centred care, as close to peoples’ own homes as possible.

Practically, the initial focus of efforts to integrate care will take place in general practice and wider primary care. This is where the majority of patient care is provided (around 90% of total health contacts). GPs are frequently cited as the healthcare professionals most trusted by patients, and typically have the most comprehensive knowledge of patients’ health and care needs, as well as their broader living circumstances. As such GPs are the professionals best placed to coordinate out-of-hospital care.

However, in common with England nationally, primary care in Hounslow is under pressure. Access to practices and continuity of care is becoming variable, while gaps are emerging in the GP workforce.

In response, the CCG continues to coordinate a programme supporting primary care to come together to work “at scale”. This aims to make Hounslow GP practices increasingly resilient (by making best use of local system resources including the workforce and estate) and sustainable (by releasing economies of scale). This work should simultaneously position primary care to play a full role in the future ICS through a unified voice. Progress to date and the direction of travel is set out in figure 1.11:


Figure 1.11: Steps towards developing “at scale” primary care across Hounslow

Over past years the CCG has invested in – and continues to support – locality-based development. This has facilitated the creation of five localities, covering the full borough geographically and comprising all Hounslow GP practices. These are registered companies with the ability to hold contracts and to take decisions collectively. The localities have established leadership teams responsible for coordinating primary care in their communities.

In the future, the CCG is supporting the localities to develop further as primary care networks offering opportunities for joint working between GPs (e.g. by ensuring a shared care record is accessible by the GP locality team where consent is provided) as well as enhancing the capacity of primary care to deliver of out hospital services for the local population.

The localities will provide a platform for greater integration – initially of community services, then of acute, community mental health, local authority and voluntary services. While it is envisaged that the best outcomes for residents will be driven by borough-wide planning and coordination, the operational management of care delivery will take place at practice, locality and borough levels.

1.5.5 Integrated out-of-hospital hubs

Integrated care will need to be supported by development of estates. To realise the benefits of NWL’s SaHF programme, a shift in the activity provided in different care settings is needed. This will see community settings taking on more services from acute sites. Locally, this would alleviate increasing pressure at the West Middlesex site, while also providing the opportunity to improve local estate with variable accessibility and environmental quality.

To do this NWL CCGs are progressing with a plan to develop integrated out-of-hospital hubs across the region. This estate will bring together services – including primary, community, mental health and local authority care – under a single roof. They will provide a setting for a further range of services accessible by the whole population, including outpatient appointments, diagnostics, social care and therapies.

Hubs will provide an environment for integration to take place by fostering collaboration and innovation through co-locating teams and services. The services they provide will be in scope of the integrated model of care. They are also enablers as settings where health and care can be more effectively joined up to benefit patients.

Locally, capital has been set aside to develop a minimum of one integrated out of hospital hub in each of the five localities. This will involve the construction of new estates and changes to some of the existing ones. The proposed hubs in Hounslow and the latest position on their planning and delivery is set out in figure 1.12:

Locality Hub location and overview Latest position on planning and delivery

Brentford and Isleworth West Middlesex Hospital

Development of a hub on the acute hospital site to complement the Brentford Health Centre already within the locality.

Scheme currently under review prior to detailed planning commencing.

GP practices working independently

GP practices working together informally

GP practices working together as locality teams covering a defined population

GP practices working together to provide borough-wide services integrated with community services

GP practices working with a full range of health, care and local authority partners providing integrated care for the full Hounslow population

GP practices working

independently to provide core

primary care services to their

registered patients only.

GP practices collaborating to

extend the primary care services

they can provide to patients.

Exploration of opportunities to

share clinical expertise, patient

referrals and resources.

Practices working together to

coordinate primary care across a

geographical locality. Coordination

requires oversight of a lead GP

supported by a locality leadership

team. Locality-based model of care

to deliver enhanced primary care

services creates opportunities for

specialisation, patient referral and

sharing resources.

Effective locality working acts as a

foundation for planning and

coordinating the delivery of

services at a greater scale i.e.

across the whole Hounslow

population.

Core and enhanced primary care

integrated with community services

to wraparound patients.

Acute, community mental health,

Local Authority and voluntary

sector services integrated into the

integrated model of care.

Services are aligned to a common

set of patient outcomes, a single

contract and budget underpinning

comprehensive and consistent out-

of-hospital services for all

Hounslow residents.

This transition is the current

focus of the CCG’s primary

care development activities


Locality Hub location and overview Latest position on planning and delivery

Brentford Health Centre

Repurposing the site currently occupied by three GP practices as an integrated hub.

Options appraisal approved by CCG and endorsed by NHSE Project Appraisal Unit (PAU) and the London Capital Committee. To agree heads of terms with NHS Property Services (NHSPS) to commence detailed design work.

Chiswick Chiswick Health Centre

A scheme to improve the current configuration and increase the number of clinical spaces

Options appraisal approved by CCG and endorsed by NHSE PAU and the London Capital Committee. To agree heads of terms with NHSPS to commence detailed design work.

Feltham Health Centre on Feltham High Street

Acquired on a long lease in 2008 together with a new proposed independent Living Scheme in Feltham.

Site utilisation and feasibility study underway.

Great West Road Heston Health Centre

A scheme has been developed for a new build facility on the Heston Health Centre & Berkley Centre site to replace two out-dated small buildings providing a new Health Centre accommodating 5 GP practices (including 3 already on site) together with additional clinical and administrative space.

The Stage One Business Case was approved by the CCG in March 2018 and the London Capital Committee in July 2018. Approval allows the estates provider to progress to full planning permission and procurement of a build contractor.

Hounslow Heath The Heart of Hounslow Centre for Health

This building was procured through the LIFTCo in 2009. Subsequent underutilisation points to capacity available for additional out-of-hospital service

On-going review to identify opportunities to address underutilisation of space. A detailed site utilisation and feasibility study will be undertaken in 2018/19.

Figure 1.12: Overview of current delivery pipeline for out-of-hospital hub schemes in Hounslow

1.6 PROGRESS TO DATE IN DELIVERING INTEGRATED CARE IN HOUNSLOW

Hounslow CCG has achieved a great deal working with system partners to deepen collaboration and deliver a better, more integrated service model.

1.6.1 “At-scale” primary care

Historically, Hounslow GP practices have operated as independent contractors within the broader system. This means that local residents have experienced varying access to primary care services depending on the practice they are registered with. Similarly, this care has been of variable quality and impact. Additionally, where some practices have been of sufficient size to offer a range of additional primary care services, many have been limited to providing core primary care services.

Hounslow CCG has worked since its inception on tackling this variation and addressing the impacts on patients. The key approach has been to focus on developing the locality model. This has supported GP practices to come together as five localities – comprising all 47 GP practices and covering the whole population of Hounslow.

The locality model provides a platform for greater collaboration and coordination of primary care. Each locality is led by a local GP with an established supporting leadership ensuring practices are directly involved in planning, monitoring and improving services for patients.


The locality model provides a scale for taking decisions and driving actions which extend benefits across the whole locality population. Working in this way provides individual practices with the opportunity to benefit from shared experiences, knowledge and clinical expertise. Together, this model supports practices in breaking down the variation and inconsistency of the historic model.

This model gives primary care a stronger, more unified voice in broader change initiatives in Hounslow. Practically, steps towards data sharing, multi-disciplinary team working, and sharing learning and clinical expertise has improved the coordination and quality of care provided.

Over the past 2 years, locality working has underpinned successful delivery of out-of-hospital contracts through sharing resources (e.g. workforce, estates, processes). The model has driven improvements in services for patients, including increased performance of diabetes management, and improving access through extended access hubs.

To drive the development of general practice as well as to hold and manage contracts, the CCG has also worked with providers to establish the Hounslow Consortium as a single overarching federation representing all primary care providers in Hounslow.

The Consortium was formed in February 2018 with the vision that general practice is at the heart of delivering comprehensive patient care and reduce variation. The resilience and sustainability of local general practice is key to delivering this vision. The Hounslow Consortium aims to build on the strong link between practices within the five localities (underpinned by a signed memorandum of understanding) to deliver services for the benefit of their local patient population.

As a member of the developing provider alliance, the Consortium has an increasingly important role in designing the transformation towards deeper integration, as well as practically managing and coordinating care on the ground to drive the benefits sought.

1.6.2 The enhanced primary care contract

To be sustainable, “at scale” primary care providers need a purpose and source of income. In Hounslow, the CCG has committed to primary care development by commissioning the enhanced borough-wide primary care contract from the Hounslow Consortium. This contract brings together 26 individual out-of-hospital services that were previously provided under separate contracts with individual practices. Services commenced in April 2018.

It is mandated that over time all Hounslow residents will have access to the full range of services. As such the Consortium is responsible for coordinating contract delivery from practices ensuring that all patients can benefit. Practically, this means establishing pathways for referrals between practices so as to make best use of workforce specialties and capacity, as well as limited local estate.

This process has standardised the care to be provided (i.e. improving quality to a consistent level). There is emerging evidence of success in terms of improved patient outcomes. Practices are incentivised to deliver care in the most efficiency way. At the same time the commissioning and contract management process has been simplified. Most importantly, by shaping the way care is delivered the contract has started to drive reductions in some key acute activity.

The Consortium now has a significant revenue stream combined with a responsibility for managing operations. As such it is expected to drive on-going provider development. The contract itself will aid broader system transformation, by providing more – and more specialist – activity in general practice (including a more preventative approach), reducing activity provided in hospital.

1.6.3 Community-based initiatives

Hounslow system partners have a track record of working together to deliver tangible improvements in services for local residents. For example:

ICRS – HRCH coordinates this service which works to prevent people from being admitted to hospital where possible by providing rapid, comprehensive health and care support at home. This support is provided by a multi-disciplinary team comprising a GP, nurses, therapists, social workers, pharmacists and a handyman. These staff work for different originations and work together to provide the right care in the right place at the right time. The impact of this service has been recognised through shortlisting for the Health Service Journal’s awards in the categories of “Value and improvement in specialist services” and “Value and Improvement in community health design”.

Hounslow CRS – HRCH coordinates this service for people with complex conditions (including acquired and long-term neurological conditions) who have lost their independence. It supports people to build confidence, regain skills, and self-manage their health needs. Provided by an integrated health and social care team, it offers effective and accessible that wraps around people at times of need.


Primary care practice coordinators (PCPC) – commissioned in 2017, this service functions as the interface between primary, community, mental health and social care. Primary care officers embedded in each GP practice work to improve patient care by supporting it to be more co-ordinated, proactive and planned. Practically, this means helping patients through service signposting, navigation, promoting independence through the patient activation measure tool, and providing self-care advice. The service also contribute towards effective locality working by supporting practice data collection and information sharing. Further work is taking place to redesign the service to align even more closely with locality working and HRCH’s community nursing transformation project.

Tackling variation in Feltham – the CCG has worked with partners including HRCH, WLMHT, the local authority and the voluntary sector to tackle historical variation in service quality and value for money in the Feltham locality. A key focus has been on developing community resilience by repurposing the Feltham Centre for Health for use by the community to provide classes, cafes and drop-in sessions. This is the foundation for proposed future work to develop a more proactive “front end” of A&E to ensure people receive the care they need in the right place. This will see greater GP input to A&E triage and ambulance conveyancing to identify patients who can be better supported at home, in primary care, or in out-of-hospital hubs.

1.6.4 Local authority partnership

Uniquely in North West London, Hounslow CCG and the London Borough of Hounslow have worked together over many years in commissioning, delivering and managing care. This relationship is key to success of the future ICS.

The organisations share significant aspects of their commissioning functions through a joint commissioning team under a Section 75 Agreement. This team covers all community mental health, as well as nursing and residential care. This approach is cost effective, and also provides an environment for collaboration and integration to flourish.

Collaboration has also taken place through the Better Care Fund (BCF). This national programme is aimed at joining-up health and care services through sharing resources and joint planning. In Hounslow, the original BCF programme focussed on jointly coordinating activities including personal care provided in people’s own homes. More recently, the follow-up integrated Better Care Fund (iBCF) resulted in the CCG allocating its share of funding to the local authority to invest, recognising the value of local authority-commissioned services in improving the health and wellbeing of residents.

1.6.5 The development of the STP Implementation Group

Following the approval of the NWL STP, representatives of Hounslow providers (covering the most significant aspects of local care delivery) have been meeting monthly as the STP Implementation Group. The membership includes the Hounslow Consortium, HRCH, WLMHT, London Borough of Hounslow, and the voluntary and community sector.

The group is focussed on making local progress in line with the transformation vision and supporting plans set out in the NWL STP. Increasingly, members are also using this forum to explore other opportunities for improving and integrating care locally.

It is envisaged that this group will evolve to become the foundation of a provider alliance that can work to co-produce an integrated model of care to implement across Hounslow, as well as to begin to implement the necessary enablers that will be the foundation for integrated out-of-hospital care in Hounslow in the future.

1.7 THE BENEFITS FOR RESIDENTS, THE WORKFORCE AND THE SYSTEM OVERALL

The benefits of partnership working in Hounslow have already – and continue to be experienced – by local residents. A coordinated effort is now required to accelerate this progress, and to ensure that all residents can experience the full range of benefits of closer integration.

The single contract and model of care to be co-produced, managed and delivered by providers will be defined by:

services of consistent quality and impact that are equally accessible by all residents across the borough;

comprehensive services that address peoples’ broadest health and wellbeing needs in a joined-up way;

effective coordination of the system overall (with clear accountability and responsibility for making decisions about people’s care) and frontline care (with clear access points and navigable care pathways);

providers working together in the best interests of Hounslow residents and the system overall;

making best use of the resources (workforce, estates, equipment and technology) within the system;

a culture of collaboration, innovation and continuous improvement based on sharing data, clinical expertise and patient experience; and


demonstrable financial sustainability based on providing the right care in the right setting at the right time.

The success of this will be assessed through two sets of measures:

NWL single outcomes framework

The integrated model of care will deliver the single outcomes framework (provided in Annex A), which has been developed through extensive engagement with people across North West London over many years. Implementing this locally would give providers a set of clear, common goals work towards which the CCG has been told are important. Aspects of the framework could be incentivised to drive the outcomes that matter most to local people and the health of the public.

Hounslow “I” statements

Through Future-proofing health in Hounslow, the CCG described a range of patient outcomes expressed as “I” statements provided in Annex B. These provide a guiding principle for designing and improving care to achieve these. Underpinning the statements are metrics which will be central to performance monitoring in the future.

Taken together, these measures will be used as tools to measure, influence and drive a more integrated approach of delivering care which is anticipated to achieve a significant range of benefits. These are described below in terms of their impact on patients of all ages and their carers, the workforce, and the wider system:

1.7.1 Residents

It is anticipated that residents will experience the following benefits:

Improving and making consistent health and wellbeing outcomes, delivering better quality of life and independence.

Improving patient experience through greater care continuity and coordination, as well as data-sharing ensuring patients only need to tell their story once (rather than having to explain their needs multiple times to different professionals)

Reducing clinical risk through standardised practice, the removal of artificial barriers through the development of a single team, and with a clear framework of integrated accountability for patient wellbeing

Providing for earlier intervention and anticipatory care to mitigate the risk of more intensive care (typically provided in hospital) following deterioration or crisis, while reducing the need to attend hospital by offering more flexibility to remain at home with comprehensive, wrap-around support

Improving and making consistent access to out-of-hospital services in a timely way, with signposting and navigating support provided along the way

Greater personal control of care, with more choice, power and control over the care received

Care planning and delivery that involves carers as partners, with better data sharing identifying carers and appropriately responding to their needs

Empowering local people to improve care by developing the role of the community and channels where patients’ voices can be heard.

1.7.2 Workforce

It is anticipated that workforce (clinicians and non-clinicians alike) will experience the following benefits:

Improving workforce morale by tackling the challenges that make frontline care delivery frustrating currently

Increasing workforce capacity through making better use of collective resources, addressing gaps and reducing workloads

Supporting clinicians and specialists to operate at the top of their licence through better skill-mixing

Opportunities for professional development including placements across settings (acute, community, primary care), expanded and shared learning and development, and new routes for career progression

Expanding the use of technology to improve care decision-making, the flexibility of work as well as improving efficiency

1.7.3 System

It is anticipated that the system will experience the following benefits:


Resources directed to where they are most needed (initial work undertaken by the local authority identifies that significant numbers of hospital admissions could be avoided by through referral into – and earlier intervention from - adult social care)

Improving productivity through better use of the workforce and new technology

Reducing inefficiencies and duplication

Improving community resilience by identifying and investing in local assets

Fostering innovation by moving away from short-term contracts focussed on delivering activity that are intensively performance-managed.

1.8 CONCLUSION

Hounslow CCG has had many notable successes working with system partners to improve services for residents. However, many of these improvements have been incremental in nature, taking place over extended time. The challenges facing the system – driven by demographic change, as well as changing resident behaviours and expectations – cannot now be tackled by continuing to identify and implement small-scale changes.

In response to these challenges, and in line with national, regional and local strategic drivers, the system is embarking upon a fundamental transformation of the way that health and care services are commissioned and provided outside of hospital.

The objective is the establishment of an ICS that will tackle fragmentation wherever possible, underpinned by a contractual approach that unites partners by a common set of outcomes, aims and incentives. This will improve health and wellbeing outcomes, patient experience and workforce morale, while at the same time driving efficiency and hence financial sustainability.

This will be achieved through a new model of care that is patient-centred, coordinated and delivered at the right scale. This model will drive benefits including:

Improved quality of life and health outcomes for residents

Improved quality of care and experience of care by patients

A financially sustainable health and care system

A motivated workforce with enthusiasm to develop and drive service improvement

This is an ambitious response, proportionate to the scale of the challenge facing the Hounslow system. The subsequent chapters of this business case consider and build the detail underpinning this approach to progress towards making this reality.


2 ECONOMIC CASE

The economic case evaluates the options responding to the case for change. Evaluation is based on critical success factors and criteria designed to test the delivery of the benefits sought. The economic case proceeds through two key steps. First, it evaluates options for the commissioning approach to determine the preferred approach. It then individually evaluates a range of design (across scope, service solutions and transformation options) to determine the preferred option.

The strategic case sets out the case for change in Hounslow, as well as recognition of the local appetite for a more collaborative approach to integrate care. This reiterates the vision described through Future-proofing Health in Hounslow and is supportive of the direction of travel identified in national policy (in the FYFV) and regional plans (the NWL STP).

This will be a bold and ambitious shift to a new way of working between commissioners and providers. It will drive changes in system accountability and responsibility, the way that money flows, and how the right behaviours are incentivised. This transformation requires careful consideration across a broad range of options to objectively determine the best fit to Hounslow.

2.1 PROCESS TO DETERMINE THE BEST APPROACH

Many NHS organisations are exploring new ways of working to respond to on-going pressures and challenges in the health system.

These innovative models of care – including the primary and acute care system, the multi-specialty community provider, urgent and emergency care networks, and acute care collaborations – provide a blueprint for joining up the way services are provided. These models have been implemented in different forms across many national pilot sites, recognising the need for care that is planned and delivered in a way that is tailored to the local population, its needs, geography and existing relationships.

In addition to the way that care is provided, innovation is also underway in how services are commissioned. This recognises that the historic way of commissioning services has promoted reductions in waiting times and achievement of targets by individual organisations but led to the fragmentation in service delivery. Increasingly commissioners are considering options for working more collaboratively with system partners to share responsibility, risk and benefits – as well as creating an environment for innovation and transformation.

Integrated care can take on multiple forms and the form that will best meet local needs in Hounslow must be determined through a robust evaluation. To do this a range of design features will be considered to understand what will most likely drive the benefits sought in Hounslow. These are listed below:

Service solution options:

Route to market

Delivery model

Contract structure – form

Contract structure – length

Contract structure – flexibility

Payment approach – core payment

Payment approach – incentive payment

Risk sharing

Transformation options:

Transformation phasing

The approach to the evaluation is described in figure 2.1:


Figure 2.1: Economic case methodology

As identified above, this economic case takes a two-step approach to evaluation. First, high-level options for the overall commissioning approach to the case for change are evaluated in section 2.2. The purpose of this is to test the hypothesis that the deeper integration of integrated care will best achieve the benefits Hounslow CCG is seeking.

Once the best option for the commissioning approach has been determined been established, the detailed design features for an ICS are evaluated in section 2.3. The purpose of this is to determine a preferred option that will serve as the blueprint for Hounslow’s future ICS.

2.2 COMPARISON OF OPTIONS FOR COMMISSIONING APPROACH

The change described in this business case presents a transformation in the way that care is provided, as well as in the way that it is commissioned. In terms of sequencing, the right commissioning approach must be agreed and put in place to enable the implementation of the ICS model of care.

This section sense-checks the CCG’s stated ambition of commissioning an ICS, and working in partnership with a local provider alliance to co-design this system. This is done by comparing this proposed approach with a set of other commissioning options to achieving integrated care (rather than a full assessment of all strategic options).

2.2.1 Commissioning approach options

Potential options for the commissioning approach are shown in figure 2.2, and are described in more detail underneath:

Figure 2.2: Overview of potential options for a new commissioning approach

Confirm proposed

commissioning approach

Consider high-level options

for commissioning approach

Review objectives and

critical success factors

Assess different

design features

Preferred

option

Confirm ICS as preferred commissioning approach and confirm

preferred features of ICS design to consider commercial

viability, affordability and deliverability through the remaining

business case

Assess different choices in design features to

determine proposed approach to ICS design

Against objectives and critical success

factors, consider design features where

choices remain

Against imperatives to improve care,

reduce inequalities and ensure future

sustainability, confirm approach

Test commissioning approach

against other options

TASK OUTPUT PROCESS

Evaluation 1:

Test preferred

approach to

commissioning

integrated care

Evaluation 2:

Assess ICS design

features and confirm

preferred option

Sco

pe

of

inte

gra

tio

n

Pace of delivering change1

2

3 4

Increasing ambition,

wider impact and

potential benefits,

corresponding with

increased delivery risk

Option 1: the status quo – no change

Option 2: iterative steps towards a narrower

scope

Option 3: proposed approach of iterative

steps towards a broader scope

Option 4: transformational steps towards a

broader scope


Option 1 – the status quo, as described in the strategic case.

Option 2 – iterative steps towards a narrower scope than proposed. This may comprise a narrower range of services (e.g. focussing only on primary and community services for example), impacting specific cohorts of the population (e.g. children or older people), or at an incremental pace of delivery. It could also describe a narrower scope for the commercial approach – for example, a shorter contract duration.

Option 3 – the proposed approach of iterative steps towards an ICS with a broad scope including primary, community, mental health, local authority and acute-based services, available to the whole population. It could also describe a wider scope for the commercial approach, with flexibility to work with the provider alliance towards ambitious design features (e.g. pay-by-outcomes) gradually and/or in a phased way.

Option 4 – transformational steps to a wider scope. This may comprise a wider range of services (e.g. including all acute services as in a vertically integrated PACS model), impacting upon the whole population and through a “big bang” implementation. It could also describe a wider scope for the commercial approach, for example a longer contract duration, or launching on the basis of an innovative contracting and/or payment mechanism (e.g. capitation for the core payment, with pay-by-outcomes for incentives alongside a risk-sharing mechanism with all system partners).

Key to this evaluation process is the development of robust criteria to objectively score options and design features for Governing Body approval. These reflect the objectives and benefits essential to tackle the case for change described in the strategic case. To do this, proposed criteria (organised by critical success factor) were developed and presented at an internal working group and a Governing Body seminar. These are set out in figure 2.3:

Critical success factor Evaluation criteria

Strategic fit 1. Options must satisfy existing and future system needs, while delivering towards national, regional and local strategies:

a. National (FYFV)

b. Regional (NWL STP)

c. Local (Hounslow CCG)

Delivering benefits 2. Options must enable and incentivise providers to deliver services:

a. improving outcomes and experience

b. balancing potential benefits against the risk of delivery failure

System partner capacity, capability and sustainability

3. For each incorporated design feature:

a. the readiness of system partners to respond and deliver the new ICS requirement within the timescales available

b. the attractiveness of this to the CCG and to system partners

c. the likely sustainability of system partners to deliver this

Affordability 4. Options are financially sustainable within the anticipated future finances of Hounslow’s system

Achievability 5. Options are likely to be:

a. deliverable by providers (in terms of the level of change required and risk implied)

b. manageable by the CCG (in terms of the skills and resources required to deliver)

c. attractive to Hounslow residents and the workforce

Figure 2.3: Critical success criteria for evaluating options

This is not a financial evaluation because the financial envelope available (i.e. the CCG’s allocation) does not vary across options, so it does not consider varying levels of spend to achieve different outcomes.

The evaluation therefore considers the extent to which each option:

supports the CCG’s overarching quality objectives i.e. improving population health outcomes;


balances the need to improve quality in a financial sustainable way with the need to frame an attractive proposition for system partners; and

can be implemented and managed effectively.

The evaluation of the commissioning options against these criteria has been made using the scoring definitions captured in figure 2.4. Note that the scoring is a relative scale – for example, a minus or double minus does not necessarily mean that the option cannot deliver against this criterion, but that it is less likely to do so relative to other options.

A five-point scale has been used to differentiate between the options, but it should be noted that criteria have not been weighted for this exercise. The purpose is simply to consider whether the CCG’s preferred approach to progress out-of-hospital integration via an ICS remains the most appropriate option available.

Marker Descriptor Definition

– – Double minus The option is significantly less favourable against the criterion

– Minus The option is relatively less favourable against the criterion

0 Neutral The option is neither favourable or unfavourable against the criterion

+ Plus The option is relatively favourable against the criterion

+ + Double plus The option is significantly more favourable against the criterion

Figure 2.4: Scoring definitions for evaluating the commissioning approach

Each commissioning option has been considered against each of the five evaluation criteria. The tables below show the relative scoring of each commissioning approach option against each criterion of the critical success factors. The rationale for this is also provided.

Criterion 1 – strategic fit: options must satisfy existing and future system needs, while delivering towards national, regional and local strategies

Commissioning approach option

Assessment Score

Option 1 – the status quo As set out in the strategic case, this option i.e. the status quo will not integrate services between contracts or across pathways and will not release the benefits sought. As such it will not satisfy national, regional or local strategic intents

- -

Option 2 – iterative steps towards a narrower scope

This option will see the integration of some services (e.g. primary and community) but will not maximise opportunities and/or of benefits available in delivering out-of-hospital care. Alternatively, benefits may be limited to specific population cohorts, which is antithetical to the CCG’s stated ambition of improving whole population health

-

Option 3 – the preferred approach

The preferred option will see the integration of a broad scope of services, maximising opportunities for improving out-of-hospital care, tackling fragmentation and duplication, and achieving efficiencies. While bold, this is blended with a proposed approach to co-design plans in an iterative, phased way with the provider alliance. This significantly reduces the risk of delivery failure

+

Option 4 – transformation steps towards a wider scope

In line with option 3, this approach will maximise opportunities so meeting national, regional and local strategic aims. However, the scope of the commercial model (e.g. innovative route to market, delivery model, contract length, or payment mechanism) represents significant delivery risks. These will be magnified by a “big bang” approach to implementation. As such this option is likely to be unattractive to the CCG and regulators

0

Figure 2.5: Score and rationale for the assessment of commissioning approach options against criterion 1

Criterion 2 – delivering benefits: options must enable and incentivise providers to deliver services that improve outcomes and experiences, while balancing benefits against the risk of delivery failure



Assessment Score

Option 1 – the status quo The status quo will not release the benefits sought in a planned way, at scale, or across the whole population. Care quality and outcomes will not improve, and may in fact deteriorate in light of the factors described in the case for change

- -


This option may see the release of some benefits of integration, though the service scope or population focus means that these are constrained

-


The preferred approach will drive towards integration across most out—of-hospital services (primary, community, mental health, local authority, acute care), and across the whole population. This maximises the benefits achievable, and the population who will experience improvements. This approach represents a step change locally (in both the commissioning and delivery of care) and the risk of delivery failure is reflected in the scoring

+


This option similarly provides scope for the fullest range of benefits across the whole population. A wider scope could include even more services (including acute and specialist services) presenting opportunities for benefits exceeding those in option 3. However, the delivery approach represents an enhanced risk of delivery failure, balancing the assessment

+


Criterion 3 – system partner capability, capacity and sustainability: partners must be able to respond within the time available, the option must be attractive to the CCG and providers, and will be sustainable


Assessment Score

Option 1 – the status quo The status quo presents continuity from existing arrangements and so system partner capability and capacity is assured. No change is required and hence no additional resources are needed. However, as described in the case for change this option is fundamentally unsustainable and without taking steps now, difficult decisions may need to be taken impacting service volume and/or quality

- -


The scale and approach to change means this option is deliverable within existing system capacity. However, local providers have already committed to a bolder scale of integration, so this option would represent a regressive step. It is unlikely that the scope of this integration will close indicative gaps in health outcomes, care quality and financial sustainability and so cannot be considered attractive

-


The members of the provider alliance share the same ambition for transforming care locally and are committed to the journey. This provides the basis for developing detailed plans over the coming months describing how change will be delivered. Taking an iterative approach provides multiple checkpoints to assess progress and to course correct as required. Overall this represents an attractive option to deliver sustainable change

+


The wider scope and scale of this option presents even greater opportunities for innovation, efficiency and system sustainability. But this comes with greater risk and a need for more investment in system capacity and specialist expertise to transact this change. A “big bang” approach will present time pressure to providers. Taken together, these factors mediate the attractiveness to the CCG, providers and regulators

+



Criterion 4 – affordability: options are financially sustainable within Hounslow’s anticipated future finances


Assessment Score

Option 1 – the status quo The financial analyses summarised in the strategic case and described in the financial case show that the status quo is likely to become financially challenging in the future due to increasing strain on resources caused by unconstrained demand

- -


A narrower scope will limit opportunities to tackle fragmentation, and as such will likely constrain innovation, provider-led change, and the identification of potential efficiencies across contracts and between pathways

-


The preferred approach provides a platform for system collaboration which maximises opportunities for tackling duplication and identifying efficiencies. This could be enhanced through broad commercial options (e.g. moving towards a capitated payment, incentivising through pay-by-outcomes)

+


A wider scope could open up further opportunities to improve financial sustainability (e.g. working with CWHFT via an ambitious risk sharing mechanism). This could drive improved system financial sustainability

+


Criterion 5 – achievability: options will be deliverable by partners, manageable by the CCG, and attractive to both Hounslow residents and the local workforce


Assessment Score

Option 1 – the status quo While no change in the status quo requires no additional capacity (either in delivery or commissioner oversight), this option is fundamentally not attractive to Hounslow residents or the workforce. It will not tackle the issues emerging through patient and clinician feedback, which are likely to deteriorate in the future as non-elective demand places increasing strain on the system

- -


The scope and approach for this option are deliverable by partners and manageable by the CCG. As described above this will constrain benefits though, and so this approach is unlikely to be attractive to residents and the workforce

-


While a more ambitious change, system partners have expressed their interest in progressing on this basis. The alliance model would bring together system resources, increasing available capacity and capability to manage change. This approach should support the delivery of a wide range of benefits across the population, and so will be attractive to residents. New workforce development and progression opportunities should emerge, making this attractive to the local workforce

+


The wider scope and boldness of this option could open up even greater opportunities for releasing benefits through integration. This would be attractive to residents and the workforce. However, the scale and nature of the delivery approach would require significant investment in system capacity and capability. Without this there are significant risks of delivery failure and/or timescales slipping.

+


The table below provides an overview of total scores for each criterion against all options:



Critical success factor criterion Total

1 2 3 4 5

Option 1 – the status quo – – – - – – + -5


– 0 0 – 0 -2


+ + + + 0 0 4


0 + + 0 – – 0

Figure 2.10: Aggregate scores for assessment of each commissioning approach option

2.2.2 Conclusion to first stage of evaluation

The CCG has a stated ambition to integrate out-of-hospital care locally. There are a limited number of options to achieve this, particularly given the strategic, operational and financial context locally. All of these options present a level of risk. However evaluation of options points to “doing nothing” (i.e. the status quo) as by far the worst option to realise the benefits sought. Options for a wider scope score better as they deliver benefits for the whole population. And adopting an incremental, evolutionary (and not radical) approach – i.e. the preferred option – scores most highly and so confirms this is the best fit for Hounslow.

2.3 EVALUATION OF INTEGRATED CARE SYSTEM DESIGN FEATURES

Having established the preferred option for the commissioning approach, this next section evaluates the design features of the proposed ICS to determine a preferred option. This process consists of:

Identifying critical success factors that will drive the benefits sought;

identifying core design features – comprising options for scope, the service solution and transformation; and

evaluating options for design features to identify those that represent the best fit for Hounslow.

This evaluation is based on the critical success factors described in section 2.2.

The ICS represents an innovative approach to commissioning and providing care. At the same time this implies a transition from current arrangements to a future based on new ways of working. Together, this represents a step change and opens up a wide range of potential for doing this differently. These include:

Service solution options:

Route to market: covering the commissioning approach to procure the ICS

Delivery model: covering the corporate form required to deliver the ICS

Contract structure – form: covering the type of contract to underpin the ICS

Contract structure – length: covering the length of the contract to underpin the ICS

Contract structure – flexibility: covering the flexibility of the contract to underpin the ICS

Payment approach – core payment: covering the means by which services will be paid for

Payment approach – incentive payment: covering the means by which additional ICS behaviour will be incentivised

Risk sharing: covering how risk will be shared between the commissioner and providers through the implementation of the ICS

Transformation options:

Transformation phasing: covering the steps to achieve integration.

Options for each of these design features are described to illustrate pros and cons to inform decision-making on the form of the ICS. These are identified in figure 2.11:


Figure 2.11: Summary of detailed features for ICS design options

The design features have been summarised and tested through:

an internal working group session;

a Governing Body seminar; and

a dedicated Finance & Performance working group session.

Each design feature has been assessed against the evaluation criteria using the methodology described in the table below:

Marker Description

The criterion has been assessed favourably which would make this design feature more attractive

- This is neither favourable nor unfavourable, or there is insufficient evidence to assess at this stage

This criterion has been assessed unfavourably which would make this design feature less attractive

This criterion has been assessed unfavourably and the assessment is sufficiently certain that this design feature should be ruled out at this stage

Figure 2.12: Methodology for options appraisal

In the discussion of design features, the final assessment against evaluation criteria is summarised using the RAG rating described in figure 2.13:

Marker Description

Green Preferred: this feature is currently seen as the best choice

Amber This feature is not yet discounted but is not preferred

Red This feature is discounted and will not be considered further

Feature category Complexity increases from left to right

Service

solution

options

Route to market CCG renews or

procures services

on an individual

basis (status quo)

Direct award Open market

procurement with

notice placed in

the EU's Official

Journal

Delivery model Alliance contract Corporate joint

venture

Prime contractor Prime provider

(with sub-

contractors)

Single integrated

provider (fully

integrated MCP)

Contract structure -

form

NHS standard

contract

NHS Integrated

Care contract

Partially bespoke

contract

Fully bespoke

contract


length

2-3 years 5 years 7 years 10 years


flexibility

Provided for in

the original

contracting

documents

Not provided for

in the original

contracting

documents but

significant

economic,

technical or

convenience

barriers to a

different provider

Unforeseen

circumstances,

insubstantial or

low value

changes

New contracting

approach (e.g. via

procurement or

alliance addition)

Payment approach –

core payment

Block Capitation Capacity-based Activity-based


incentive payment

None Pay-for-

performance

Pay-by-outcomes

Risk sharing None Smoothing

transition

Aligning

incentives

Smoothing

transition +

aligning

incentives

Transforma

-tion options

Transformation

phasing

Initial focus on

four priority areas

Initial focus on

whole population


Figure 2.13: RAG assessment for options appraisal

Route to market – options

Figure 2.14: Options for route to market

The route to market determines the commercial strategy the CCG will adopt to make the ICS a reality. This choice is essential in balancing local priorities (i.e. continuing to build relationships with existing system partners who best understand the geography of Hounslow and the needs of its population) with legal requirements and the potential risk of challenge.

Figure 2.15 describes the possible routes to market. These are subsequently evaluated against the critical success factors.

Feature Description 1 2 3 4 5

a b c a b a b c - a b c

CCG reviews or procures services on an individual basis (status quo)

CCG determines the future of each contract in scope on an ad-hoc basis as contract expiry approaches

- - - -

Direct award A single provider is appointed based on evidence that they are the only capable organisation and/or represent the only affordable offer

- -

Notice placed in the EU’s Official Journal (OJEU)

An open market procurement is undertaken with the aim of identifying the most appropriate provider(s) based on responses to procurement documents

- - - - -

Figure 2.15: Summary of evaluation of possible routes to market

Route to market – evaluation

Reviewing or procuring services on an individual basis represents the status quo position. Taking this approach would not tackle fragmentation in and of itself. The development and implementation of an alliance agreement (see evaluation of the delivery model below) could work to drive integration in parallel with existing contractual arrangements. It could also be used to focus providers to deliver the single outcomes framework, with embedded incentives built in to support this objective. Informing the market of the CCG’s preferred approach to work with the alliance would help to manage this risk. As the status quo, this approach is familiar to both the CCG the system partners, so represents continuity in understanding without the need for additional resource. This design feature is taken forward as preferred feature.

A direct award would come about through the CCG awarding a single contract or fewer single contracts for the scope of out-of-hospital services to a single provider or fewer providers. A single contract could work to break down fragmentation arising through contracting arrangements and focus on delivering the single outcomes framework with appropriate incentives embedded. However, a direct award must be to a single organisation or organisations – and not to an alliance. In fact selecting a provider from the existing alliance may in fact magnify the risk of challenge due to the financial value of the contract or contracts. Unless the CCG can prove that there is insufficient credible interest in the opportunity from any other providers in the market then there is a risk of successful challenge against compliance of the Public Contract Regulations 2015. As such this would not be considered attractive to either the CCG or to existing providers, and for this reason this feature will not be taken forward for further consideration.

The CCG could undertake an open market procurement to select a provider for a single contract through a competitive process. A preferred bidder would be selected through an assessment of the most economically advantageous tender. To initiate this a notice would need to be placed in the OJEU and/or Contracts Finder. As


Service

solution

options


procures services

on an individual

basis (status quo)


procurement with

notice placed in

the EU's Official

Journal


with a direct award, an open market procurement (which would be based on a single contract for the services in scope) could tackle contractual fragmentation and better incentivise integration.

However, this approach potentially contradicts the CCG’s stated vision in Future-proofing health in Hounslow of driving local integration through improved collaboration. An open market procurement could be a costly and complex process requiring significant amounts of CCG investment over a period of time likely to be between 18-24 months. Any change of provider may cause service disruption, and a considerable transition period may be needed as the selected provider establishes themselves and their supply chain locally. While it represents many risks, it should be noted that it remains a legitimate option and that which most straightforwardly discharges the CCG’s procurement duties under the law. As such it is taken forward as a possible option and discussed further in the commercial and management cases.

Figure 2.16: Output of evaluation of potential routes to market

Delivery model – options

Figure 2.17: Options for delivery model

The delivery model defines the way the route to market is transacted. It describes the contractual and/or corporate form of the local system supply chain. It is a key enabler to how services are integrated across or along pathways – and explores features ranging from informal collaboration, through to formal integration between organisations.

While it is not advisable for commissioning organisations to define the legal form of the delivery model sought through open market procurement, it is instructive to consider the principles to test that the CCG’s preferred option (i.e. through working with existing providers) represents the best route to better integration.

Figure 2,18 describes the possible delivery models. These are subsequently evaluated against the critical success factors.



Alliance contract A group of providers agrees a legally-binding alliance agreement with the CCG to deliver services, with bilateral contracts updated to reflect the requirements of the alliance agreement


Corporate joint venture Providers remain as separate organisations but establish a new legal entity (the joint venture - JV) through agreed terms and conditions. This organisation would be used to hold the contract, employ the staff, and oversee the delivery of the services


Service

solution

options


procures services

on an individual

basis (status quo)


procurement with

notice placed in

the EU's Official

Journal


Service

solution

options


procures services

on an individual

basis (status quo)


procurement with

notice placed in

the EU's Official

Journal


venture


(with sub-

contractors)

Single integrated

provider (fully

integrated MCP)


Prime contractor A single organisation is contracted, and then sub-contracts individual providers to deliver care

- -

Prime provider (with sub-contractors)

A significant variation on the prime contractor model in which the contracted organisation also delivers care directly as part of the agreement

- - - -

Single integrated provider (fully integrated MCP)

A single organisation assumes all responsibility and leads/provides services for an entire care pathway. This would be achieved by partly or wholly absorbing 2 or more providers

- - - -

Figure 2.18: Summary of evaluation of possible delivery models

Delivery model – evaluation

Using an alliance contract, the CCG would underpin provider collaboration formally through a legally-binding alliance agreement. This should describe the extent, principles and features of the integration sought – as well as the incentives towards these. Bilateral contracts could then be updated to reference the alliance agreement. This is an approach based on trust, and in line with stated plans the CCG has worked extensively with local providers through the STP implementation group to develop relationships, mutual understanding and ways of working. While this approach will not reduce contractual volume or complexity, it could drive the service integration required. Consideration may need to be given about how governance and accountability will work within the alliance, and this should be tested through a robust assurance process. This design feature is taken forward as the preferred feature.

The next four features are based on the development and award of a single contract. This contract would bring together all services in scope; describing what care is to be provided, and the incentives to deliver more integrated care. As such these are a good fit with the national direction and travel and provide a contractual basis for improving outcomes and other benefits through integration.

The corporate joint venture would see the single contract being awarded to and provided by a new entity, formed jointly by two or more providers. Although a good fit strategically, the JV form presents a range of risks. Creating a JV can be time consuming and expensive. JV partners will continue to be responsible for their on-going individual organisational responsibilities, and so the success of the JV is dependent upon the commitment from and investment of its constituent partners. Additionally, it can give rise to complexities in how VAT is applied – increasing the costs of provision and potentially impact the level of care provided. It can also create uncertainty regarding NHS pension benefits. As such it is unlikely to be attractive from the perspective of the workforce, current providers or the CCG and for this reason this feature will not be taken forward for further consideration.

With the prime contractor model, a single organisation assumes full responsibility for service provision and leads integration of the whole pathway. However, services would be delivered through subcontracts with other providers. The prime contractor may be an existing provider; a newly created JV or a new “third party” integrating organisation. With a prime provider, commissioners hold a single contract. In addition to the responsibilities for organising care in the prime contractor model, the prime provider would deliver a significant part of the pathway or service. The prime provider subcontracts or uses an integration agreement for delivery of other parts of the pathway, where needed. These approaches could simplify contractual and governance arrangements and provide for integration across all services in scope. However, these are novel arrangements and as such come attached with delivery risks from a CCG and provider perspective. Assuming a successful procurement, they are dependent upon appropriate, effective and sustainable supply chain managements. In the event of a prime provider, steps should also be considered to minimise the risk of monopolising service delivery. As such, there is a balanced position on these features and so they are carried forward for consideration.

The single, integrated provider (a fully integrated MCP or PACS model) would see the CCG holding a single contract with an organisation responsible for delivering all services in scope. This would be achieved through partly or wholly absorbing the organisation currently responsible for the delivery of that care. While this would be a step change in contractual and organisational integration, this represents significant risks. It is unlikely that this model would be attractive to current providers. A fully integrate model would require general practices to pool their core contracts, and this is highly unlikely across all Hounslow practices. For this reason, this feature will not be taken forward for further consideration.


Figure 2.19: Output of evaluation of potential delivery models

Contract structure, form – options

Figure 2.20: Options for contract structure - form

The form of the contract structure provides the underpinning arrangements for all care delivery. It is necessary to determine the right approach to ensure that local integration has the necessary legal, contractual support – particularly in considering step changes in how care is commissioned and provided.

Figure 2.21 describes the possible contractual forms. These are subsequently evaluated against the critical success factors.



NHS standard contract Continuing to use the NHS standard contract (which is currently used for the majority of services delivered in Hounslow)

NHS Integrated Care contract Using the draft of the new Integrated Care contract

- - - - - -

Partially bespoke contract Using either the NHS standard contract or the Integrated Care contract as a starting point, then seeking to change schedules and clauses that are normally nationally mandated and not for local amendment or completion

- - - -

Fully bespoke contract Essentially creating a new contract through CCG legal advisors

- - -

Figure 2.21: Summary of evaluation of possible contractual forms

Contract structure, form – evaluation

The NHS standard contract has been used for the majority of acute, community, mental health and non-core primary care services nationally for over 10 years. CCGs are obliged to use the standard contract in commissioning services, and local authorities have flexibility in the form of contract used to commission health services under their statutory responsibility. The contract is updated annually and includes General Conditions and Service Conditions which cannot be amended. It also includes a “Particulars” section, allowing for local modification and tailoring to fit commissioner’s requirements. The use of the NHS standard contract is the “status quo” and requires no regulatory


Service

solution

options


procures services

on an individual

basis (status quo)


procurement with

notice placed in

the EU's Official

Journal


venture


(with sub-

contractors)

Single integrated

provider (fully

integrated MCP)


Service

solution

options


procures services

on an individual

basis (status quo)


procurement with

notice placed in

the EU's Official

Journal


venture


(with sub-

contractors)

Single integrated

provider (fully

integrated MCP)


form

NHS standard

contract

NHS Integrated

Care contract

Partially bespoke

contract

Fully bespoke

contract


approval for its use. It provides flexibility and continuity from current arrangements, minimising risks of delivery failure. This design feature is taken forward as the “status quo” feature and as the preferred feature.

Since the publication of the FYFV, NHSE has been developing a draft Integrated Care contract. It is envisaged that this should be used to contract an integrated organisation for the delivery of whole population health. However, it can only be used with NHSE’s permission and has been subjected to two judicial reviews in 2018 (with an appeal to be heard by the Supreme Court in later 2018). NHSE has committed to a public consultation on approaches to integrated care and it is not clear when or if the draft Integrated Care contract will be available for use by the CCGs. Although doubts remain, it would represent a nationally-approved tool for integrating care and as such it is rated amber and taken forward for consideration.

A partially bespoke contract would take either of the two options above as a starting point, with amendments made to localise contractual provisions. This process requires special dispensation from NHSE, and no assurances can be provided as to whether these amendments would be approved. Making these changes could require costly legal input. The nature of the tailoring would likely attract additional scrutiny at planning stage through NHSE’s Integrated Support and Assurance Process (ISAP) – potentially impacting upon timelines for delivery. And amendments may be subsequently challenged legally. For these reasons this feature is not taken forward for consideration.

A fully bespoke contract would require much more intensive and costly legal input, as it could effectively mean designing a contract from scratch. While this would provide for local flexibility and context, it would be expensive, time-consuming and subject to significant regulatory and legal scrutiny. The opportunity cost of this process would distract from the co-production of integrated models of care and preparation to deliver which is essential to achieving the CCG’s timelines for change. For these reasons this feature is not taken forward for consideration.

Figure 2.22: Output of evaluation of potential contact structure forms

Contract structure, length - options

Figure 2.23: Options for contract length

The length of the contract represents a balance. On the one hand commissioners naturally seek the flexibility to respond to circumstantial changes, unforeseen events and innovation. On the other hand, providers want to have the security to invest in and transform services, with the expectation of making financial returns in the latter years of a contract (i.e. once the service has been fully implemented and is operating smoothly).

In addition to the length of the contract, provisions for contractual termination are also important in determining the right balance between commissioner and provider perspectives. These may apply for “cause” (at fault) or no-cause (no-fault) circumstances. Cause is often defined by the parties. For example, the bankruptcy of one party could be a valid cause to seek termination of the agreement. No-cause could be triggered by a party wanting to exit a contract that no longer meets their business needs or purpose.


Service

solution

options


procures services

on an individual

basis (status quo)


procurement with

notice placed in

the EU's Official

Journal


venture

Prime contractor Prime Provider

(with sub-

contractors)

Single integrated

provider (fully

integrated MCP)


form

NHS standard

contract

NHS Integrated

Care contract

Partially bespoke

contract

Fully bespoke

contract


Service

solution

options


procures services

on an individual

basis (status quo)


procurement with

notice placed in

the EU's Official

Journal


venture


(with sub-

contractors)

Single integrated

provider (fully

integrated MCP)


form

NHS standard

contract

NHS Integrated

Care contract

Partially bespoke

contract

Fully bespoke

contract


length



“No fault’ is often triggered when a party wishes to end the agreement as it no longer meets their business needs. The table below evaluates the potential features for the time period the contract could cover.

Figure 2.24 describes possible features for contractual lengths. It should be noted that all contract lengths are plausible, but these features have been selected to test core principles. Additionally, all options for extension and termination rights (on both fault and no fault bases) are possible for any contract length, and so are not specifically applied as part of this appraisal. Possible features for contract length are subsequently evaluated against the critical success factors.



2-3 years Contract length - -

5 years - - - - -

7 years - - - -

10 years - - - -

Figure 2.24: Summary of evaluation of possible contract lengths

Contract structure, length - evaluation

A contract length of 2-3 years reflects the “status quo” position. At the last major contracting round, NHS England instructed CCGs to agree contracts for 2 years, from 2016/17 to 2017/18. This has been refreshed for the end of 2018/19. Many contracts in Hounslow and beyond are contracted on this basis and are often rolled over (i.e. extended) on an interim basis. This feature offers sufficient time to effectively pilot the delivery of the ICS with the provider alliance, and to assess the impact of new arrangements. At the end of this period the CCG can either procure the ICS from the alliance on a longer-term basis (if performing), or to explore alternative options including an open market procurement of a single contract (if falling short of CCG expectations). Additionally, the next 2-3 years will see the mobilisation of integrated care arrangements nationally and elsewhere within North West London, and so will provide the opportunity to incorporate learning about what works and what does not into future local plans. However it should be noted that providers may not consider this sufficiently long and attractive enough to invest in system transformation, and the CCG may need to drive this locally. Overall, as the option that best meets national policy and represents the lowest risk option to the CCG this design feature is taken forward as the preferred feature.

A contract length of 5 years offers an extended time on the “status quo” to effect change. It is an incremental step on from current arrangements though presents increasing risk to the CCG in a rapidly evolving system. At this length (and beyond) regulatory assurance may be required. This represents a medium-term duration that providers may not consider to be sufficiently long and attractive enough to invest in system transformation including enabling infrastructure. As such, there is a balanced position on this feature and so it is carried forward for consideration.

Longer contracts (i.e. 7 years and over) with or without termination rights shift the balance of benefits away from the CCG and towards providers. While these arrangements will be more attractive to providers, they potentially constrain the CCG’s ability to respond to opportunities and threats that arise, and hence may attract additional regulatory scrutiny. Provisions such as “no fault” termination clauses (with payable losses and a defined notice period e.g. 6 months) should be built in to provide additional safeguards, and may provide assurance for the CCG, providers and regulators. Overall, there is a balanced position on these features and so they are carried forward for consideration.

Figure 2.25: Output of evaluation of potential contact lengths


Service

solution

options


procures services

on an individual

basis (status quo)


procurement with

notice placed in

the EU's Official

Journal


venture


(with sub-

contractors)

Single integrated

provider (fully

integrated MCP)


form

NHS standard

contract

NHS Integrated

Care contractt

Partially bespoke

contract

Fully bespoke

contract


length



Contract structure, flexibility – options

Figure 2.26: Options for contract length

Building on the evaluation above, the design of the contract must allow for flexibility and variation. This will allow the CCG to make agreed changes (to scope, scale, contract duration i.e. to extend or terminate the contract, and to otherwise adapt, modify or update the contract). Otherwise these changes could require a new contract to be advertised under the Public Contracts Regulations 2015.

Figure 2.27 describes possible features for contractual flexibility. Reference is made to the contractual documentation necessary to achieve integration through both the alliance and an open market procurement. Features are subsequently evaluated against the critical success factors.



Provided for in the original contracting documents

Flexibility to vary the contract built into original documents

- - - - -

Not provided for in the original contracting documents but significant economic, technical or convenience barriers to a different provider

Flexibility is not provided for in the original documents but significant economic or technical barriers and/or significant issues in engaging a different provider(s)

- - - - - - -

Unforeseen circumstances, insubstantial or low value changes

Contract variation can be done where the changes (irrespective of monetary value) have been provided for in the initial documents in clear, precise and unequivocal terms, including, for example: a description of the additional services required and a method of calculation of the pricing for those additional services

- - - - - - -

New contracting approach (e.g. via procurement or alliance addition)

Flexibility is not provided for in the original documents but significant economic or technical barriers and/or significant challenges to engaging a different provider(s); and the value of those changes do not exceed 50% of the value of the original contract.

- - - - - - -


Service

solution

options


procures services

on an individual

basis (status quo)


procurement with

notice placed in

the EU's Official

Journal


venture


(with sub-

contractors)

Single integrated

provider (fully

integrated MCP)


form

NHS standard

contract

NHS Integrated

Care contract

Partially bespoke

contract

Fully bespoke

contract


length



flexibility

Provided for in

the original

contracting

documents

Not provided for

in the original

contracting

documents but

significant

economic,

technical or

convenience

barriers to a

different provider

Unforeseen

circumstances,

insubstantial or

low value

changes

New contracting

approach (e.g. via

procurement or

alliance addition)


Note that if this exemption is used, a modification notice must be published in OJEU explaining the need for the change

Figure 2.27: Summary of evaluation of possible contract flexibility

Contract structure, flexibility – evaluation

Providing for flexibility in the original documents would require the CCG to communicate clearly what, how and when it envisages out-of-hospital services to change over contract length. This would also need to include an assessment of impact, primarily how funding and performance management could change. As described in the economic and management cases, it is expected that some services (e.g. those commissioned by local authority) may be introduced into the ICS later, in phases. While challenging to set out changes up front, this approach offers the alliance or potential ICS providers with a clear framework for operating. As such this is taken forward as the preferred design feature.

If changes are not provided for in the original contracting documents, the CCG could instead opt to identify significant economic or technical barriers and/or challenges to engaging different providers to avoid the need to re-advertise and let the contract. However, the rationale for the barriers to procurement could potentially be challenged. As such this is taken forward as a potential design feature to be considered further.

An alternative is to provide for flexibility for unforeseen circumstances. This feature allows for unplanned changes that are deemed to be immaterial to the overall scope, scale or value of the contract. This rationale could be used to transfer additional services into the contract for example, though there exists a risk that these decisions could be challenged and/or subjected to regulatory scrutiny above a certain value threshold. As such this is taken forward as a potential design feature to be considered further.

The new approach feature would relate to the delivery of additional services by the providers of the ICS. Changes would trigger a procurement or contracting process with services potentially to be provided in parallel to the ICS under a separate contract. However, the CCG is seeking to work with its existing system partners and to avoid alternative routes. Additionally, procurement could lead to further system fragmentation (or duplication of service provision and contract management). As such, this feature is not taken forward for consideration.

Figure 2.28: Output of evaluation of potential contact flexibility


Service

solution

options


procures services

on an individual

basis (status quo)


procurement with

notice placed in

the EU's Official

Journal


venture


(with sub-

contractors)

Single integrated

provider (fully

integrated MCP)


form

NHS standard

contract

NHS Integrated

Care contract

Partially bespoke

contract

Fully bespoke

contract


length



flexibility

Provided for in

the original

contracting

documents

Not provided for

in the original

contracting

documents but

significant

economic,

technical or

convenience

barriers to a

different provider

Unforeseen

circumstances,

insubstantial or

low value

changes

New contracting

approach (e.g. via

procurement or

alliance addition)


Payment approach, core payment – options

Figure 2.29: Options for payment approach – core payment

The core payment for services determines how payment will flow from the commissioner to the ICS partner(s) for the delivery of out-of-hospital services. In the future ICS they will be derived from current CCG expenditure on services provided for the whole Hounslow population. Core payments are one of three constituent aspects of the proposed payment approach (incentive payments and risk sharing are evaluated below).

As with contract length, payment types are finely balanced between commissioners and providers. Commissioners seek appropriate safeguards and controls to ensure affordability. Providers need fair, secure compensation for service delivery, to support their financial sustainability.

Figure 2.30 describes features for the core payment approach. These are subsequently evaluated against the critical success factors.



Block A single, fixed payment, based on historic budgets; sometimes adjusted for growth, deflation or inflation and efficiency

- - - -

Capitation Single, variable payment, based on numbers of population covered; often updated on a regular (e.g. quarterly) basis; sometimes grouped into different segments

- - - -

Capacity-based Single, fixed payment, based on agreed costs for delivering a particular service

- - - -

Activity-based Status quo for many planned and unplanned acute care

- - -

Figure 2.30: Summary of evaluation of possible core payment approaches

Payment approach, core payment – evaluation


Service

solution

options


procures services

on an individual

basis (status quo)


procurement with

notice placed in

the EU's Official

Journal


venture


(with sub-

contractors)

Single integrated

provider (fully

integrated MCP)


form

NHS standard

contract

NHS Integrated

Care contract

Partially bespoke

contract

Fully bespoke

contract


length



flexibility

Provided for in

the original

contracting

documents

Not provided for

in the original

contracting

documents but

significant

economic,

technical or

convenience

barriers to a

different provider

Unforeseen

circumstances,

insubstantial or

low value

changes

New contracting

approach (e.g. via

procurement or

alliance addition)


core payment



Block payment is the “status quo” for the majority of Hounslow’s current out-of-hospital services. As such both the CCG and local providers are deeply familiar with this as an approach, and enabling infrastructure (management information and report templates, invoicing arrangements) are already well-established. It gives certainly to all parties about the level of payment flowing through the system. Block payments incentivise against over-delivery (i.e. activity provided above the block levels may not be remunerated, or remunerated at a marginal rate), so providing commissioners with added financial control. At the same time, it is widely acknowledged that block payments can impact transparency in service lines costs and may limit incentives for innovation. Ultimately, this is the default feature and likely to be the only practical option for the proposed ICS contract length, and so is taken forward as the preferred design feature.

A capitated budget is based on the size of the population covered. This would be an innovative approach for community and mental health services (although has been in use for primary medical services since the beginning of the NHS). The budget per head can be calculated “top down” (i.e. dividing a total budget by the number of potential users) or modelled “bottom up” (i.e. collecting patient level costs and activity and building a profile of forecasted analytical need). While this approach would better share responsibility for service affordability between the CCG and providers, the data needed to drive sophisticated analysis is only just beginning to be generated through the WSIC dashboard and would be costly to derive, model (e.g. actuarial analysis), test and implement a wholly new payment structure. As such, there is a balanced position on this feature and so it is carried forward for consideration.

A capacity-based payment is based on agreed costs for delivering an individual service. It could be a component of the core payment and may be appropriate where commissioners have traditionally bought community bed capacity for rehabilitation and hospital step-down support. The advantage is that it ensures the core payment is sufficient to meet (that proportion of) the provider’s costs. However, it requires a fair and true understanding of costs (across all services and partners) transparently shared with commissioners, which is challenging to obtain. Additionally, this does not necessarily incentivise providers to make technically efficient use of system resources. As such this design feature is not taken forward for further consideration.

Activity-based payments are commonly used nationally for most acute-based care. In hospital, tariff payments are paid for evidenced interventions. These have historically been challenging for commissioners to control (as there are no natural incentives for providers to constrain demand). Introducing an activity-based payment framework for out-of-hospital services would be a timely and expensive exercise, requiring high quality data to inform a meaningful and fair tariff. This is unrealistic within the timescales for delivery in Hounslow. As such this design feature is not taken forward for further consideration.

Figure 2.31: Output of evaluation of core payment approaches


Service

solution

options


procures services

on an individual

basis (status quo)


procurement with

notice placed in

the EU's Official

Journal


venture

Prime contractor Prime Provider

(with sub-

contractors)

Single integrated

provider (fully

integrated MCP)


form

NHS standard

contract

NHS Integrated

Care contract

Partially bespoke

contract

Fully bespoke

contract


length



flexibility

Provided for in

the original

contracting

documents

Not provided for

in the original

contracting

documents but

significant

economic,

technical or

convenience

barriers to a

different provider

Unforeseen

circumstances,

insubstantial or

low value

changes

New contracting

approach (e.g. via

procurement or

alliance addition)


core payment



Payment approach, incentive payment – options

Figure 2.32: Options for payment approach – incentive payment

In addition to the core payment, the CCG will confirm its approach towards determining incentive payments. These are key to encourage providers to work towards national initiatives and priorities, and to drive improvements in population, clinical and patient reported outcomes. Currently, CCGs nationally incentivise providers through CQUIN (commissioning for quality and innovation). Detail on the defined set of incentive payments and how they are measured will be developed through the full business case (FBC).

Figure 2.33 describes possible features for determining how these payments are used. These are subsequently evaluated against the critical success factors.



None No incentive payments - - - -

Pay-for-performance Multiple, variable payments for achieving particular performance metrics

- - - - - -

Pay-by-outcomes Building on pay-for-performance, with a greater emphasis placed on outcome measures of performance (often exclusively); and the greater proportion of payment at risk

- - - - -

Figure 2.33: Summary of evaluation of possible incentive payment approaches

Payment approach, incentives – evaluation

The CCG could propose no incentive payments for service delivery, with system partners receiving the entire core payment for providing services. This would remove the CCG’s main lever for effecting integration and to improve services and would be in breach of national CQUIN guidance. As such this design feature is not taken forward for further consideration.

Pay-for-performance would see the CCG withholding aspects of the core payment in the event that providers fall short of agreed performance levels (assessed on input, process or outcomes measures). This reflects the way CQUIN works presently. Nationally, commissioners are exploring ways to improve the effectiveness and impact of


Service

solution

options


procures services

on an individual

basis (status quo)


procurement with

notice placed in

the EU's Official

Journal


venture


(with sub-

contractors)

Single integrated

provider (fully

integrated MCP)


form

NHS standard

contract

NHS Integrated

Care contract

Partially bespoke

contract

Fully bespoke

contract


length



flexibility

Provided for in

the original

contracting

documents

Not provided for

in the original

contracting

documents but

significant

economic,

technical or

convenience

barriers to a

different provider

Unforeseen

circumstances,

insubstantial or

low value

changes

New contracting

approach (e.g. via

procurement or

alliance addition)


core payment



incentive payment

None Pay-for-

performance

Pay-by-outcomes


pay-for-performance. This includes increasing the amounts of the core payment could be held back; and shifting the focus away from input and process measures initially towards outcomes measures over time. While providing the CCG with the flexibility it needs to drive integration iteratively with the provider alliance, this may fall short of regional and local ambitions. The single outcomes framework has been developed and agreed to set system expectations for improving population health. Input, output and process measures will only partly inform performance monitoring and system impact on this basis. As a plausible option (and one which is currently in place) this design feature is taken forward but it is not preferred.

Under pay-by-outcomes, increasing emphasis is placed on outcome measures of performance, with an increasing percentage of the core payment held at risk (up to 100%). As with pay-for-performance, aspects of this mechanism are already in place in Hounslow. This would work to deliver the single outcomes framework. While potentially a bold step, the risk can be managed by co-designing the performance payment with the provider alliance. This would also help to assure regulators if required. As such, this feature is carried forward as the preferred option.

Figure 2.34: Output of evaluation of incentive payment approaches


Service

solution

options


procures services

on an individual

basis (status quo)


procurement with

notice placed in

the EU's Official

Journal


venture


(with sub-

contractors)

Single integrated

provider (fully

integrated MCP)


form

NHS standard

contract

NHS Integrated

Care contract

Partially bespoke

contract

Fully bespoke

contract


length



flexibility

Provided for in

the original

contracting

documents

Not provided for

in the original

contracting

documents but

significant

economic,

technical or

convenience

barriers to a

different provider

Unforeseen

circumstances,

insubstantial or

low value

changes

New contracting

approach (e.g. via

procurement or

alliance addition)


core payment



incentive payment

None Pay-for-

performance

Pay-by-outcomes


Risk sharing – options

Figure 2.35: Options for payment approach – risk sharing

The risk share arrangement is the final component of the overall payment approach. It is intended to align incentives between individual providers with the performance of the wider system to achieve strategic objectives and to deliver in the most appropriate (and cost effective) setting of care. In the case of the Hounslow ICS, it should drive the provider alliance to deliver sufficient capacity and capability supporting the shift of more patient care outside of hospital.

For risk-sharing the level of provider risk exposure needs to be proportionate to their ability to influence the targeted risk, as well as their ability to absorb this. In addition, it may take significant time (potentially years) for providers to effect large-scale changes against some of the risk-sharing metrics incentivised (e.g. a reduction in non-elective admissions by focussing on more preventative care).

Figure 2.36 describes possible features for risk sharing. These are subsequently evaluated against the critical success factors.



None No arrangements for risk sharing - - - -

Smoothing transition Risk share operates in the contract between commissioner and provider, with operational and financial risk transferring to providers over time

- - - -

Aligning incentives Risk share operates in parallel to the contract between commissioner and provider, involving all health economy partners (including acute care providers)

- - -


Service

solution

options


procures services

on an individual

basis (status quo)


procurement with

notice placed in

the EU's Official

Journal


venture


(with sub-

contractors)

Single integrated

provider (fully

integrated MCP)


form

NHS standard

contract

NHS Integrated

Care contract

Partially bespoke

contract

Fully bespoke

contract


length



flexibility

Provided for in

the original

contracting

documents

Not provided for

in the original

contracting

documents but

significant

economic,

technical or

convenience

barriers to a

different provider

Unforeseen

circumstances,

insubstantial or

low value

changes

New contracting

approach (e.g. via

procurement or

alliance addition)


core payment



incentive payment

None Pay-for-

performance

Pay-by-outcomes


transition

Aligning

incentives

Smoothing

transition +

aligning

incentives


Smoothing transition + aligning incentives

Combining direct ICS incentives with shared incentives with other system partners

- - - - -

Figure 2.36: Summary of evaluation of possible risk sharing approaches

Risk sharing – evaluation

The CCG could propose no arrangement for risk-sharing. While this would require no additional resources or investment, it would not provide a formal mechanism for wider health economy working to achieve improved outcomes and efficiency across the whole system. The responsibility for managing system risk remains with the commissioner in its entirety. As such this design feature is not taken forward for further consideration.

A risk-share mechanism could be introduced through smoothing transition. This would see the risk share managed between the CCG and the provider alliance (defined contractually in the alliance agreement). Steps would be set out and agreed for transferring the risk to the alliance over contract life. For example, in years 1 and 2 the CCG could assume in full the downside risk of failing to make savings; in year 3 this could be equally shared between the CCG and the alliance; and in years 4 onwards the provider alliance could assume full upside and downside risks. Clearly establishing a risk share is a significant and complex undertaking and presents a step change in the way that system partners work together currently. However, this feature would track the increasing control the alliance should be able to exert, as they transform out-of-hospital services, while smoothing the process as they take on more responsibility. As such, there is a balanced position on this feature and so it is carried forward for consideration.

The aligning incentives approach aims to align the flow of money to the investments and activity in one part of the system and the benefits and disinvestments in another part. In practice, this would see a parallel contract for driving system integration developed alongside out-of-hospital services. This would need to be agreed between the CCG, provider alliance and CWHFT as the acute provider. In Hounslow, the complexity is partly reduced as CWHFT is a member of the alliance, although this simultaneously raises potential issues around conflicts and incentivisation (i.e. providing care in the right place for patients, and not for providers based on the payment they receive). Developing a mechanism to fairly measure, track and incentivise this shift would take a significant amount of time and resource. The contractual arrangements around this would also require significant assurance, as well as provider sign-up. Although it would likely drive effective integration and system working, it is recognised that it is unlikely to be deliverable in the near term. As such this design feature is not taken forward for further consideration.

Blending aspects of smoothing transition and aligning incentives could drive greater system working while minimising the costs of transformation and the delivery risks. Combining direct incentives with the provider alliance plus shared incentives with other system partners (with managed conflicts of interest and contradictory incentives) provides this feature with greater benefits and impact than the others alone, and so is the preferred option.


Figure 2.37: Output of evaluation of risk sharing approaches

Transformation phasing – options


Service

solution

options


procures services

on an individual

basis (status quo)


procurement with

notice placed in

the EU's Official

Journal


venture


(with sub-

contractors)

Single integrated

provider (fully

integrated MCP)


form

NHS standard

contract

NHS Integrated

Care contract

Partially bespoke

contract

Fully bespoke

contract


length



flexibility

Provided for in

the original

contracting

documents

Not provided for

in the original

contracting

documents but

significant

economic,

technical or

convenience

barriers to a

different provider

Unforeseen

circumstances,

insubstantial or

low value

changes

New contracting

approach (e.g. via

procurement or

alliance addition)


core payment



incentive payment

None Pay-for-

performance

Pay-by-outcomes


transition

Aligning

incentives

Smoothing

transition +

aligning

incentives


Service

solution

options


procures services

on an individual

basis (status quo)


procurement with

notice placed in

the EU's Official

Journal


venture


(with sub-

contractors)

Single integrated

provider (fully

integrated MCP)


form

NHS standard

contract

NHS Integrated

Care contract

Partially bespoke

contract

Fully bespoke

contract


length



flexibility

Provided for in

the original

contracting

documents

Not provided for

in the original

contracting

documents but

significant

economic,

technical or

convenience

barriers to a

different provider

Unforeseen

circumstances,

insubstantial or

low value

changes

New contracting

approach (e.g. via

procurement or

alliance addition)


core payment



incentive payment

None Pay-for-

performance

Pay-by-outcomes


transition

Aligning

incentives

Smoothing

transition +

aligning

incentives

Transforma

-tion options

Transformation

phasing

Initial focus on

four priority areas

Initial focus on

whole population


Figure 2.38: Options for transformation phasing

Implementing the ICS will be a major project requiring not only a transformation in care delivery, but the way that care is commissioned through closer collaboration. Breaking this down into phases potentially reduces the delivery risks. Consideration is given here to the options for this phasing.

Figure 2.39 describes possible features for transformation phasing. These are subsequently evaluated against the critical success factors.



Initial focus on four priority areas Focussing on the agreed priority areas – urgent care, patients and families with complex needs, patients with accumulating health deficits, and home visiting

- -

Initial focus on whole population No phasing – focussing on providing improved services for the whole population

- - - - -

Figure 2.39: Summary of evaluation of transformation phasing options

Transformation phasing – evaluation

The CCG has identified four priority areas where service improvements would make the greatest, and fastest, impact. This provides a defined and manageable cohort where new collaborative approaches and integrated models of care can be tested, releasing patient benefits and learning for future service improvement work. Clear communication would be needed with the wider population to outline when wider benefits of the ICS could be experienced. The opportunity to test and iterate transformation in a manageable way means that this is the preferred option to take forward.

Taking a simultaneous approach i.e. focussing on the whole population represents potential risks to the delivery of change at this scale. Additionally, there is a potential risk of disruption to service provision. This could be managed to an extent by rationalising the scale of transformation (breaking this feature into additional phases, linked to the potential for benefits realisation and/or the ICS financial plan). While this feature would share the benefits of integration across the whole Hounslow population, there may be a concurrent impact on the pace of delivery. As such – while practicable – is taken forward but not as the preferred option.


Figure 2.40: Output of evaluation of transformation phasing options

2.4 CONFIRMATION OF PREFERRED OPTION

This economic case has appraised a wide range of features for potential options. The evaluation is based on the critical success factors necessary to drive the benefits of integration. The process has identified those features: most likely to deliver the outcomes sought in Hounslow (marked green); that are not discounted but are not preferred (marked amber); and that are discounted and will not be considered further. Those features comprising the preferred option are shown in figure 2.41:


Service

solution

options


procures services

on an individual

basis (status quo)


procurement with

notice placed in

the EU's Official

Journal


venture


(with sub-

contractors)

Single integrated

provider (fully

integrated MCP)


form

NHS standard

contract

NHS Integrated

Care contract

Partially bespoke

contract

Fully bespoke

contract


length



flexibility

Provided for in

the original

contracting

documents

Not provided for

in the original

contracting

documents but

significant

economic,

technical or

convenience

barriers to a

different provider

Unforeseen

circumstances,

insubstantial or

low value

changes

New contracting

approach (e.g. via

procurement or

alliance addition)


core payment



incentive payment

None Pay-for-

performance

Pay-by-outcomes


transition

Aligning

incentives

Smoothing

transition +

aligning

incentives

Transforma

-tion options

Transformation

phasing

Initial focus on

four priority areas

Initial focus on

whole population


Figure 2.41: Confirmation of preferred design options

The following commercial, financial and management cases are based on a preferred option with these features. However, it must be noted that subsequent changes in local circumstances may trigger a need to refresh this evaluation, and to consider those features not discounted but not included in the preferred option. These changes could include for example:

Refreshed national, regional and local policy;

A rapid shift in local financial circumstances; or

A potential challenge to rolling over contracts.

For that reason, additional consideration is given in the following business case to appropriate contingency measures, specifically to the need to procure aspects of the ICS in the event of a provider challenge.

2.5 CONCLUSION

The economic case has appraised options and features based on an identified methodology designed to identify the features most likely to deliver the outcomes sought in Hounslow. This process has determined a preferred way forward for commissioning integrated care. This reconfirms the intention to commission an ICS through a series of iterative steps as best way to integrated out-of-hospital care. Second to this, the process has determined a preferred option for a local integrated system. The remainder of this business case assesses the commercial, financial and management considerations of this preferred option.


Service

solution

options


procures services

on an individual

basis (status quo)

Open market

procurement with

notice placed in

the EU's Official

Journal

Delivery model Alliance contract


form

NHS standard

contract


length

2-3 years


flexibility

Provided for in

the original

contracting

documents


core payment

Block


incentive payment

Pay-for-

performance

Pay-by-outcomes

Risk sharing Smoothing

transition +

aligning

incentives

Transforma

-tion options

Transformation

phasing

Initial focus on

four priority areas


3 COMMERCIAL CASE

Having identified the preferred design features in the economic case, the commercial case provides detail on the commercial design of the preferred option, the integrated system-level model of care, as well as the high-level commercial strategy for a well-structured contract. At this point in Hounslow’s programme further work is planned to understand attractiveness to the market. Taken together, this will allow for the selection of the most appropriate configuration of an ICS in Hounslow, driving the objectives and benefits described in the strategic case.

The contents of this case is subject to legal review by Hounslow’s appointed counsel.

3.1 THE CURRENT MODEL OF CARE – STRENGTHS AND ISSUES

The implementation of an ICS will result in a change in how out-of-hospital services are commissioned, and in how they are provided. Focussing on the latter (i.e. the services to be contracted), this section identifies what works well in the current system (to be maintained and/or expanded in the future ICS), and what works less well (to be addressed).

Since 2012 Hounslow CCG has worked with local providers to improve services and to integrate care. The examples below highlight what has been achieved and show how patient-centred and localised care can be planned and delivered through collaboration:

Facilitating the development of the Hounslow Consortium, which now holds the contract for enhanced primary care delivery

Developing the role of PCPCs to lead signposting and service navigation from every Hounslow GP practice

Designing and rolling out the ICRS and CRS – which provide effective wraparound support for older people to be safe and independent outside of hospital

Supporting West Middlesex to be one of the highest performing hospitals in the country in respect of the 4 hour A&E target and in maintaining capacity for elective procedures

Establishing out-of-hospital hubs bringing together primary, community and mental health services

Working with the London Borough of Hounslow to plan and deliver schemes through joint Commissioning and via the BCF and integrated BCF.

In parallel, there are identifiable challenges with the way that care services are currently provided. There is fragmentation between organisations, with gaps between services, multiple access points and overlapping pathways. Care integration, across contracts and pathways, is primarily led by the CCG, with limited service improvement negotiated between and driven by providers. The pace of change is incremental. This fragmentation is frequently referenced by patients as a source of frustration and poor experience and creates unnecessary transactional expense across the health and care system.

These issues have been recognised through a range of channels – including CCG performance monitoring, patient feedback (through Healthwatch and the GP Patient Survey), clinician feedback, and CQC reports on service quality. A selection of findings is provided below.

CCG performance monitoring

The CCG is responsible for monitoring and managing the performance of service providers. Over recent months, identified service issues include:

Community nursing services not routinely provided in care homes

Poor care planning with myriad impacts, particularly in end of life care

Poor cancer screening targets, leading to high rates of diagnosis via emergency hospital attendance

The deterioration in the provision of speech and language therapy services because of unintended consequences of changes to local authority funding

Comparatively high hospital readmission rates despite the excellent community provision

High hospital admission rates of children under the age of 5.


Emerging findings from the GP Patient Survey

Hounslow’s 2018 GP Patient Survey (published in August 2018) provides practice-level data about patients’ experiences of general practice and other NHS services, based on 4,833 responses to surveys.

There is significant variation in patient experience across Hounslow practices. For overall experience of their GP practice this ranges from 54% rating services as “very good” or “good” to 96%. For ease of getting through on the phone, this ranges from 38% rating access as “very easy” or “fairly easy” to 98%. For having enough support to help with the management of conditions, this ranges from 49% having received enough help to 92%.

In terms of access, 38% of patients were not offered a choice of appointment. 31% were not satisfied with the last GP appointment they were offered. Of the 7% who did not take up the appointment, 26% attended A&E (compared to 11% nationally, and 14% of Hounslow patients in 2013).

In terms of making use of other NHS services when their own GP practice was closed, patients accessed a wide range of other services. 14% received a telephone call from a healthcare professional (compared to 25% nationally), 2% received a home visit (compared to 5% nationally), 48% went to A&E (compared to 36% nationally), and 8% went to another GP practice (compared to 18% nationally). 59% of patients rated the non-GP services they accessed when their own practice was closed as good (compared to 69% nationally), with 20% rating them poor (compared to 15% nationally).

In terms of having the right support, 26% of people with a long-term condition felt that they have not received enough help from local services or organisations over the past 12 months to manage their needs.

These findings paint a picture of a system where general practice is generally well-regarded, but where demonstrable challenges with variation (in patient experience, access and quality) exist. Compared to the national picture, there is a need to provide people with greater clarity and support to manage their needs when practices are closed; and not just to default to A&E unless necessary. It is also apparent that more information and support needs to be provided to those people with long-term conditions, promoting their independence and ability to self-manage – and minimising the risk of deterioration.

Themes identified by Healthwatch

Healthwatch Hounslow is the independent consumer champion for health and social care in the borough. It is responsible for collecting and analysing feedback on services to inform patient choice, and to highlight areas where improvement is required.

In its latest annual report (released April 2018), Healthwatch identified consistent themes from patient feedback. The majority of feedback on service was positive, however consistent improvement areas identified include:

Access to outpatient hospital services, and waiting times for these services

Access to GP services including waiting times

Appointment availability for GP services

Difficulty in booking GP appointments, both in the administration of appointments and the availability

Access to community services

A varied picture of administration systems including booking appointments and appointment availability within GP services

To develop a more detailed understanding of carer experience, a review was undertaken in 2016/17. The Hounslow Review of Carers (2016/17) was based on a survey of 84 carers. Analysis of carer responses suggests that consideration must be given to the importance – and needs - of carers. They should be more actively involved in planning and delivering care for their loved ones. They would benefit from easier access to quality information and advice, and dedicated support in undertaking their caring roles.

Themes identified through the Adult Social Care Outcomes Framework (ASCOF)

The ASCOF measures how well care and support services achieve the outcomes most important to service users and their carers. It is based on survey responses across a range of questions. In this context, it helps understand the relative performance of services in Hounslow against other local authorities and England overall. A selection of indicators from the latest ASCOF (2016/17) is shown in figure 3.1:


ASCOF domain Hounslow England mean

1A: Social care-related quality of life score (mean respondent score across 8 relevant questions)

18.1 / 24 19.1 / 24

1B: Proportion of people who use services who have control over their daily life (%)

68% 78%

1D: Carer-reported quality of life score (mean respondent score across 6 relevant questions)

6.9 / 12 7.7 / 12

1I: Proportion of people who use services and carers who reported that they had as much social contact as they would like (%)

34.6% 45.4%

1J: Adjusted Social care-related quality of life - impact of Adult Social Care services (utility weighted indicator based on responses to 18 relevant questions)

0.386 0.403

2B: Success and coverage of reablement services for older people (aged 65 and over):

Proportion of older people (aged 65 and over) discharged from acute or community hospitals to their own home or to a residential or nursing care home or extra care housing for rehabilitation, with a clear intention that they will move on/back to their own home (including a place in extra care housing or an adult placement scheme setting), who are at home or in extra care housing or an adult placement scheme setting 91 days after the date of their discharge from hospital (%)

Proportion of older people (aged 65 and over) discharged from acute or community hospitals to their own home or to a residential or nursing care home or extra care housing for rehabilitation, with a clear intention that they will move on/back to their own home (including a place in extra care housing or an adult placement scheme setting) (%)

75.4%

6.5%

82.5%

2.7%

2C: Delayed transfers of care from hospital, and those which are attributable to adult social care:

Mean number of delayed transfers of care for those aged 18 and over (per 100,000 population)

Mean number of delayed transfers of care for those aged 18 and over that are attributable to adult social care (per 100,000 population)

7.3

3.7

14.9

6.3

3C: The proportion of carers who report that they have been included or consulted in discussion about the person they care for (%)

62.7% 70.6%

3D: Proportion of people who use services and carers who find it easy to find information about services (%)

69.5% 73.5%

4B - Proportion of people who use services who say that those services have made them feel safe and secure (%)

76.2% 86.4%

Figure 3.1: Summary of ASCOF indicators

These findings present a mixed picture of local performance. On the one hand, it suggests that more should be done to improve people’s quality of life, alleviate loneliness, engage with carers as partners in care planning and delivery, and to empower service users to feel safe and secure. However, it also shows that the Hounslow system performs better than the national mean in terms of making use of step down pathways to support older people out of hospital and the effectiveness of these pathways in managing people to be independent outside of hospital. In terms of delayed transfers of care Hounslow outperforms the national position by a considerable margin. This indicates that the providers involved in complex discharges are working together effectively to support discharge so ensuring capacity in the hospital.

Workforce feedback

Staff morale is closely linked to service quality. Put simply, a satisfied workforce provides better quality services than one that is dissatisfied, insecure or inadequately supported. Workforce feedback is therefore an important indicator of the overall performance and challenges of individual health and care organisations and the wider system.


The national staff survey provides the most comprehensive dataset for the NHS workforce experience. The latest survey results (covering 2017-2018) were published in March 2018. For the main providers in Hounslow, these figures show that Hounslow responses consistently exceed the national mean for comparative providers. This suggests that the Hounslow workforce – across primary, community and acute providers – is more positive and engaged than in other parts of the country. Staff are more likely to recommend their employers as places to work or for treatment. Additionally, 2017 figures are universally higher than those in 2016, suggesting that the workforce recognises progress and improvement. This provides a strong basis to build on as integrated care requires a motivated and engaged workforce.

The satisfaction of staff working in primary care is not assessed through the NHS national staff survey. It is picked up at an aggregate level (i.e. for the whole medical workforce rather than at individual GP practice level) through the British Medical Association’s (BMA) quarterly staff survey. This covers the total national medical workforce, and analysis by staff grouping shows relative experience in terms of workload, morale and work-life balance.

The latest BMA quarterly survey (Q2 2018) shows for all staff suggest that the majority of the workforce are strongly in favour of a more collaborative and integrated way of working to achieve patient outcomes. It points to a need for improving access to mental health services. Additionally support is needed in primary care to ensure sufficient capacity, and to make it an attractive place to work.

3.2 FEATURES OF THE HOUNSLOW MODEL OF INTEGRATED CARE

The development of an ICS presents an opportunity to design a new system without the constraints of the historical approach to commissioning. Targeted to improve the things that patients, clinicians and system leaders find most frustrating, it will address the case for change and release the benefits described in the strategic case.

Integrated Care focuses on how the organisations within a system work together to deliver improved outcomes in patient health and experience. The work focuses on shared accountability for improving outcomes and the required change to existing approaches to delivery. It assumes there is an opportunity for improvement through collaboration and innovation from all staff working within the system. The success of the future model will be measured through the delivery of the NWL single outcomes framework, as well as assessment against the Hounslow “I” statements. These will drive all future performance monitoring and evaluation to understand how the system is improving health and care.

The system level model of care builds on previous work, including SaHF, WSIC and Future-proofing health in Hounslow. The model incorporates functions and features that are shown to have worked in improving care integration elsewhere. It is tailored locally by being based on patient feedback, engagement with clinicians (including Hounslow GPs) and input from existing providers.

By its nature, the model describes how health and care should work together across the whole system, to benefit the whole population. However, as set out in detail in the management case, it is expected that the transition to the new system will take place in phases. In terms of the population, the initial focus of integration will be the four identified priority areas:

Urgent care – unplanned support frequently required at short notice, including in emergencies.

Patients and families with complex needs – people typically requiring the most support from across a range of health and care professionals.

Patients with accumulating health deficits – people who are at the greatest risk of a change in their health and care needs e.g. following a crisis or deterioration which may result in requiring more intensive support in hospital or residential care.

Home visiting – ensuring all professionals work together to provide joined-up support in peoples’ own homes.

It is planned that service integration will initially take place at locality level with primary and community care providers working more closely together to deliver better services for people in the four priority areas. Once core principles have been established and embedded – based on learning about what works – then the model of care will be extended to include secondary care, community mental health, local authority and voluntary sector services, and will be rolled out across the whole population. This means that every child, adult and older person living in Hounslow and/or registered with a Hounslow GP practice will be able to benefit.

System-level model of care

The system model of care is set out in figure 3.2:


Figure 3.2: Hounslow system-level model of care

This reflects the following key design features:

Patients, their carers and families at the heart of the system – with maximum choice over and personal control of the care they receive. Residents will be empowered to take on this control (using the patient activation measure tool), while being supported to develop self-care skills enabling them to take better care of themselves.

Services will be wrapped around people - breaking down artificial barriers and gaps between providers and teams. There will be sufficient capacity to flex rapidly in response to changes in patients’ health and wellbeing status.

Collaborating with and supporting carers - involving carers in the planning and delivery of care, including MDT (multi-disciplinary team) reviews of their loved ones. Data will be collected to accurately record carers, and their rights and needs will be much better recognised and supported.

Improving access – by providing and promoting additional channels for accessing services (including digital access), making it easier for patients to find out how to access services (through signposting and

PATIENTS

CARERS

FAMILIES

Primary care

Community

care

Community

mental health

services

Local

authority

services

Voluntary

sector

services

Core general

practice

Primary care

practice

coordinators

Community

nursing

Therapies

Community

Recovery

Service (CRS)

Domiciliary care

Care home

services

Housing

services

Employment

services

Public health –

smoking cessation,

obesity, substance

misuse

Locality leadership

triumvirate structure

comprising a lead GP,

nurse / therapist

and operational

manager

Locality support

structure driving the

locality model of care

Locality MDTs to

manage & review

the care of people

with complex and

changing needs

Consistent locality

processes (care coordination,

case management, signposting

and self-management)

improving outcomes

Using data to

identify and support

those with the most

complex needs

and/or at the

highest risk of

deterioration

Pharmacy and

prescribing

Enhanced

primary care

contract

Paediatric

nursing

Heart failure

Diabetes

services

ICRS

IAPT and

counselling

Palliative

care

Dementia

care

Discharge

support

Advocacy

and support

CAMHS

Single point of

access

Community

mental health

teams

Perinatal mental

health

Appropriate

settings of care to

provide support in

the right place


navigation), and supporting people to access the right service for them (e.g. through GP triage in hospital A&E).

Locality teams comprising a virtual integrated workforce (both health and social care professionals) using consistent approaches, processes and shared data – with five teams covering the borough, with integration across primary care, community care, community mental health, local authority and voluntary sector services. The virtual integrated workforce will be organised around the population, and not employers. This will break down barriers, address gaps and promote workforce capacity and resilience, while opening up greater opportunities for clinical and professional development and collaborative innovation.

Supporting the growth of community capital - developing the role of local community groups, employers and the voluntary sector to support the development of community assets and resilience. This requires a strong and unified voluntary sector voice in the locality model.

Excellent links with a wider locality network with inreach into, and outreach from, the locality teams – with the network comprising the Hounslow Consortium, Hounslow Community Network, and wider primary care (community pharmacy, dentistry, ophthalmology).

Excellent links with acute care services, with inreach into and outreach from the locality model – with a specific focus on sharing care skills across settings of care and joining up pathway planning at West Middlesex hospital, as well as Ashford and St Peters hospitals.

To put these design features into practice, the following enablers will be required:

Locality leadership triumvirate – each locality will be led by a lead GP as part of a triumvirate bringing together a medical, clinical (nursing or therapeutic) and operational management perspective to managing care outside of hospital. This replicates the structure that supports effective governance and risk management in acute hospitals.

Locality MDTs – regular MDTs will take place in each locality, bringing together health and care professionals to jointly make decisions on the best way of managing the care of people with complex and/or rapidly changing needs. MDTs will be central to planning and reviewing the care of people identified through risk stratification, at identified risk of deterioration, and at the point of hospital discharge. MDTs will be appropriately supported in terms of administration (i.e. having access to the right data to inform decision-making) and technology (i.e. being able to attend and contribute to MDTs remotely).

Consistent locality processes - the locality model will drive achievement of the single outcomes framework, by underpinning deliver of consistent, quality care. Consistent, quality processes are key to this. The localities will develop and embed a common approach to identifying patients, planning their care, coordinating the delivery of this care, and reviewing the impact of care provided. This includes making use of common templates including individualised care plans.

Using data and embracing technology – the localities will have access to patients’ shared care records (with appropriate consent). The availability of this data will enable providers to identify patients at risk and to act to pre-empt crisis. The WSIC dashboard (developed at North West London level) shows how multiple data points can be brought together to better understand and track patient needs, and to drive towards a consistent set out outcomes. Going further, patients will be supported to make better use of technology to access and receive services. This includes digital channels for appointment booking and consultations, including NHS 111 and digital apps.

A range of settings to provide the most appropriate place for care – to support the aim of providing care closer to home, in the least intensive environment possible, the model will require the development of capacity and specialisation of care provided at four levels – in peoples’ own homes, the GP practice, the locality (including integrated out-of-hospital hubs), and borough-wide. The effectiveness of integration at each level will itself be supported by enablers including telehealthcare, remote working devices, and team co-location.

Underpinning the system-level model of care and its requirements will be a contractual agreement driving integration with the following features:

A single budget for the delivery of the ICS. The contract will include incentives (i.e. gainshare mechanisms) to encourage providers to act proactively in promoting wellness, as well as providing effective response for patients at times of illness and crisis.

Targeted to achieve the single outcomes framework, with a requirement to provide demonstrable impact on residents’ health and wellbeing as the foundation of contract performance management.

A focus on the health and wellbeing of the whole population, with a focus on prevention to minimise the future incidence of disease.


The development of an integration function supporting providers to work together to coordinate care. This will likely comprise aspects of the CCG’s current commissioning responsibilities, including the development of health outcomes and metrics, and the performance management to work assure quality delivery.

Contractual flexibility supporting providers to respond nimbly to system changes, to realise opportunities and to pre-empt emerging threats.

3.3 ICS SERVICE SCOPE

The ICS must be sufficiently large to provide the opportunity for integration to flourish across out of hospital services, and in proportion to the scale of the challenges described in the strategic case. Put simply, the more that fragmentation and contradictory service delivery is tackled, the greater the benefits that can be achieved.

Over many months, the CCG has developed an indicative ICS service scope. This has been discussed and refined further with system partners including the local authority and main providers. The scope is based on a set of simple principles for inclusion and exclusion of services. These principles are shown in figure 3.3:

Principle for service inclusion Principle for service exclusion

Service can improve outcomes by being delivered in a more joined up way – through integration between primary, community, mental health and/or aspects of acute-based provision

Service is commissioned locally

Service is primarily based outside of hospital (recognising that aspects of acute services including ambulatory care and the “front door” of A&E aim to appropriately redirect people to community services where possible, or to provide the least intensive intervention to avoid hospital admission where possible)

Core commissioning functions related to budget holding, outcomes-setting and performance monitoring that are key to the CCG’s statutory role

Service is provided as a statutory duty (e.g. safeguarding) that cannot be delegated and/or subcontracted

Service is commissioned nationally or regionally

Figure 3.3: Principles for scoping services

Based on these principles, service scope has been determined across three categories:

Service included – and will form part of the ICS contractual arrangement from outset

Service may be included – and will not form a part of the ICS contractual arrangement from outset, but will be subject to review with the potential for future inclusion

Service excluded – and will not form a part of the ICS contractual arrangement at any point

The scope for included services is set out below, with main care service lines provided under primary commissioning categories:

Acute services:

‒ Community heart failure

‒ Paediatric community nursing

‒ Support for the ICRS

‒ Urgent care centre

Community health services:

‒ Community services for children and adults (including community nursing, community therapies, ICRS, CRS)

‒ Diabetes service

‒ Domiciliary care as part of community provision

‒ Hospice care

‒ Intermediate care (including bed-based rehabilitation)

‒ Palliative care nursing

Mental health services:

‒ Community mental health services for children and adults


‒ Dementia liaison nurses

‒ Dementia services

‒ IAPT

‒ Single point of access

Prescribing:

‒ Prescribing costs

Primary care services:

‒ Enhanced primary care contract

‒ Primary care patient coordinators

‒ Proactive primary care

‒ Quality outcomes framework

A selection of local authority commissioned services is proposed for inclusion. These have been discussed with local authority officers and further discussion and a formal decision will be required prior to including these within the ICS contractual arrangement:

Community equipment funded as part of the BCF

Domiciliary care

Public health services concerning smoking cessation, obesity, and substance misuse

Residential care

Telecare funded as part of the BCF

Services that may be included at a later stage are set out below:

Acute services:

‒ Non-elective admissions

Ambulance services

Community health services:

‒ Community dermatology

‒ Community ophthalmology

‒ Community respiratory including home oxygen

‒ Services jointly commissioned with the local authority under BCF arrangements

Primary care services:

‒ Pathology

Other services:

‒ Interpreting services

‒ Patient transport

For completion, a summary of excluded services is set out below:

111

Acute inpatient and emergency activity (excluding interventions associated with ambulatory care sensitive conditions)

All core primary care contracts (GMS, PMS and APMS)

CCG running costs for core operations

Continuing healthcare and funded nursing care

Emergency (trauma) activity

Learning disability services


At this OBC stage, the scope presents a basis for further discussion and refinement. It has been necessary to do this to signal the CCG’s intent, as well as to enable the modelling described in the financial case. The value of the indicative ICS has been determined by taking in-scope service lines and using the 2018/19 budget to calculate an aggregate total.

It is anticipated that more work will be required to refine the scope with the local authority as a commissioning partner, with the provider alliance, and following legal advice (as required). Additionally the inclusion of services partly or wholly commissioned by the local authority will be subject to a parallel decision-making process. The outcome of these discussions will be confirmed as a final scope in the initial FBC.

The total value of services in scope – based on 2018/19 budgets values - is £103.5m. This represents 29% of the CCG’s total 2018/19 commissioning budget. Figure 3.4 shows how this is broken down by the primary commissioning categories:

Figure 3.4: Breakdown of ICS service scope by commissioning category and spend

3.4 COMMERCIAL STRATEGY

The model of care and scope of services describes what the CCG is seeking to develop as an ICS. This section describes the commercial steps to bringing the ICS into reality through:

Procurement – explaining how the ICS will be obtained; and

Contracting – explaining how the ICS will be secured by a formal and legally binding agreement.

3.4.1 Procurement strategy

This section describes how the CCG will obtain the ICS described in the economic case. This procurement strategy is based upon the principles listed below, and will:

enable the CCG to achieve best value (based financial and non-financial benefits) for the scope of the ICS it is seeking to establish;

offer opportunities to test and iterate the ICS definition with potential providers through market testing, while also informing an understanding of market appetite for the contract;

clearly articulate the innovation it is seeking in improving the current services;

provide the necessary information defining future requirements balanced with flexibility for creativity in provider response;

offer sufficient time for providers to foster the necessary local relationships and supply chain arrangements to deliver effectively;

provide for a robust assessment of organisational capability and the proposed delivery model for integrated care;

£31.4m

£29.6m

£26.5m

£8.5m

£4.1m

£3.3m


enable further assurance (including via engagement with NHSE ISAP if necessary) to validate the robustness of local decision-making as well as to better understand the potential impact on the regional health and care economy;

ensure appropriate arrangements for a potential transition between current and future providers so as to minimise the impact on patients and the workforce; and

maximise engagement with patients and the public throughout, providing opportunities to refresh the service prospectus based on feedback, while keeping the Hounslow population informed of plans and potential changes in the way their health and care services are provided.

The OBC (outline business case) describes the CCG’s preferred approach to create an ICS working with the provider alliance. The creation of the alliance is at an early stage and the management case describes the steps necessary to support alliance development including expectations on co-production of future plans, as well as assurance considerations to give comfort that the alliance can deliver in line with commissioner requirements.

Should the alliance demonstrate the ability to deliver the required service change the CCG may consider at a later stage how to signal this to the open market e.g. via a Prior Information Notice (PIN) for a direct award. This would require changes to the alliance delivery model (i.e. contracting arrangements so that a single organisation would be the holder of the contract to be awarded in line with NHS Regulations) that are as yet not planned for.

While this is assessed to be the route most likely to achieve integration in Hounslow, there remains a potential risk of challenge from an external provider(s)under the Public Contracts Regulations 2015. In response it is prudent to consider how the CCG would approach an open market procurement to contract its preferred approach. This provides the CCG with a plan to transact so minimising potential delays to achieving an operational ICS by April 2020.

Figure 3.5 sets out a routine approach to an open market procurement. The timetable assumes that NHSE ISAP has already been satisfactorily engaged (through “early engagement” on initial plans; and checkpoint 1 on the robustness of the propose procurement approach). It also assumes that regional partners (commissioners and providers) have been engaged and made aware of the potential impact of Hounslow plans on their local systems.

Procurement step Expected timetable

Description and rationale

Market engagement Prior to procurement commencing, with dedicated events to be scheduled as required

Dedicated events should be used to test market interest and appetite for the procurement of the ICS. It also provides a forum for partnerships and supply chain arrangements to develop.

Market engagement can be undertaken at any stage prior to the procurement formally commencing to test commissioner thinking on the proposed ICS key performance indicators (KPIs), scope, model of care delivery, payment mechanism, delivery timetable and procurement steps. Provider feedback can be used to iterate these plans.

Expression of interest

Day 0 This signals the formal commencement of the procurement. The purpose of this step is for interested providers to identify themselves. This stage is still subject to legal and procurement advice.

Contract notice issued on OJEU and Contracts Finder

Day 30 This step will give providers expressing an interest with significant information to support their decision to bid or to withdraw. This information will include e.g.:

Estimated contract value including expectations of growth (as described in the financial case)

Confirmed ICS scope, along with information on services that may become part of the scope in the future (with detail on the triggers for when and how this will happen)

The draft contract, schedules and particulars including service prospectus, goals, KPIs, payment mechanism and contract term

Standard Selection Questionnaire (sSQ) – describing the CCGs requirements for information to be submitted to assess the viability of the bidding organisation (including financial and legal standing)

Invitation to tender (ITT) and form of offer requirements, evaluation criteria and procurement timetable

ISAP requirements (if required)

Information on the preferred delivery model and relevant underpinning contractual arrangements e.g. a legally binding alliance agreement and mandatory sub-contracts for applicable services (including those being phased




into scope at a later date)

sSQ submission deadline

Day 90 Interested organisations will be required to supply detailed information regarding the corporate structure of their organisational form and their proposed delivery model (including partners and subcontractors) at submission of bid stage.

This step also provides an opportunity for bidders who are NHS organisations holding provider licences with Monitor to provide written support from NHS Improvement (NHSI) to proceed to the next stage of process and beyond based upon the materiality of potential business acquisition and transactions.

CCG evaluation of sSQ submission

To day 130 This period of 6 weeks provides the commissioner with the necessary time to review all sSQ submissions, and to seek clarifications from bidders on identified areas of ambiguity or concern.

Those unsuccessful at sSQ stage will be informed. Should any incumbent providers be unsuccessful then transitional planning processes will be agreed and initiated at this point in line with the on-going procurement timetable.

ITT submission deadline #1

Day 210 This provides a total of around 12 weeks for remaining bidders to develop and submit their ITT response leading to:

A full offer received from bidders including detailed supply chain arrangements and subcontracting proposals, describing how they will deliver the ICS in line with the scope and the model of care proposed

Mobilisation plan received including commitment to due diligence (and ISAP) and the timetable set out by the commissioner

Commitment to the contractual terms

Evaluation and clarification and selection

Day 211 to day 230

This period of 4 weeks provides the CCG with time to:

Evaluate ITT submission

Schedule interviews with remaining bidders

Seek clarification regarding any unclear matters or contradictions to CCG requirements

Finalise and moderate scores

Identify bidders to enter into competitive dialogue

Secure the approval of the Governing Body to select the qualifying bidders for dialogue

Those unsuccessful at ITT stage 1 will be informed. Should any incumbent providers be unsuccessful then transitional planning processes will be agreed and initiated at this point in line with the on-going procurement timetable.

Dialogue Day 230 to day 250

This step provides four weeks for the CCG to negotiate and refine the solutions put forward by remaining bidders in their ITT submissions. The aim of this is to iterate a delivery model that will best deliver the CCG’s objectives for integration.

The scope for dialogue will focus upon models of care delivery, the locations of care provision, transformation priorities and initiatives.

This process will determine responsiveness to the request for offers and for clarifying and reaching agreement on the technical care specifications.

It provides the CCG with a further two weeks to update the service prospectus and ITT documents.

ITT submission deadline #2

Day 280 This step provides the opportunity for remaining bidders to submit:

A best and final offer received from bidders including detailed supply chain arrangements and subcontracting methodology where required

A comprehensive mobilisation plan meeting the CCG’s expectations for the “go live” of the ICS, as well as for transitional arrangements with existing providers

Commitment to the final contractual terms from the bidder

Evaluation, clarification and selection

Day 281 to day 310

This period of five weeks provides the CCG with the ability to:

Finalise the evaluation of tender proposals




Interview bidders and conduct site visits if required

Seek clarification regarding any unclear matters or contradictions to CCG requirements

Finalise and moderate scores prior to identifying the highest scoring bidder i.e. the preferred bidder

Secure the approval of the Governing Body to appoint the preferred bidder

“Minded to award” letter issued

Day 311 At this step the preferred bidder will be announced via a “minded to award” letter and the engagement and milestone plan will be agreed with the CCG for the finalisation of the contract.

Should any incumbent providers be unsuccessful then transitional planning processes will be agreed and initiated at this point in line with the on-going procurement timetable.

Due diligence (and ISAP checkpoint 2, if necessary)

Day 315 to day 360

This period allows the preferred bidder and its board to undertake due diligence including assessment of the materiality of the transaction to include:

Engagement with incumbent providers on the transitional plan and the negotiation regarding transfer, leasing or acquisition of any assets and staff

Engagement with NHSI regarding the ability of the bidder to acquire business, staff and revenue of this value

If triggered by NHSI, opinion of the Competition and Markets Authority on the potential loss of competition as a result of the transaction

Approval of the provider board to sign the contract

This period allows the CCG to undertake further detailed review of:

the final arrangements and phasing of the supply chain proposed by the preferred bidder

risks and mitigation to completion of the “go live” date through the propose mobilisation plan

the treatment of stranded costs and unforeseen costs

approval of the final contract by the Governing Body of the CCG

Standstill and contract award notice

Day 360 to day 370

A legally compliant 10-day standstill period is required following the identification of the preferred bidder. Subject to no challenge the contract award notice will be published in OJEU.

Contract signature Day 371 to day 380

Contract is signed by the CCG and selected ICS provider

Mobilisation (and ISAP checkpoint 3, if necessary)

Day 381 The mobilisation plan is enacted by the selected ICS provider and a supply chain with regular checkpoints of progress with the CCG.

Service commencement

Day 560 “Go live” of the ICS following a 6 month mobilisation period

Figure 3.5: Indicative procurement timetable

Procuring the ICS through the open market would clearly be a significant and complex material transaction. This comes with associated risk. In response, this open market procurement timetable sets out the steps, timelines, decision-making and assurance checkpoints to manage this risk as far as possible to secure an ICS provider for Hounslow through an open market procurement. A separate plan would be required to manage the risk of service disruption and patient impact that could follow from a change at this scale.

It is anticipated that an open market procurement would require an 18-month duration from the initiation of the formal procurement (through seeking expressions of interest) through to service commencement. This would affect the commencement date of the contract as planned or would require procurement timelines to be compressed. In the event of the latter, careful consideration should be given to ensuring that the procurement strategy continues to represent the principles outlined at the start of this section.


3.4.2 Contractual approach

Whether the CCG secures its preferred ICS provision through provider alliance or through an open market procurement, plans are needed for how to contract the ICS to deliver the aim of better, integrated care.

The economic case sets out the preferred option for the ICS. The contractual features and implications of this option are set out below:

Delivery model

The CCG is seeking to develop its incumbent provider alliance. In an alliance contract model a set of providers enters into a single arrangement with a CCG to deliver services. Commissioners and providers are legally bound together to deliver the specific contracted service, and to share risk and responsibility for meeting the agreed outcomes. As such, they should be incentivised to innovate and identify efficiencies across the system, rather than solely within their organisation. Contracting this arrangement will require the CCG continuing to hold bilateral contracts with incumbent providers for the services in scope.

Members of the provider alliance will need to sign a legally binding alliance agreement, which will describe the aims, outcomes, principles and behaviours expected to achieve integration. It will set out the agreed mechanism for sharing risk and responsibility in working towards the single outcomes framework, as well as the incentives to innovate and identify system efficiencies. Bilateral contracts will need to be revised to make reference to - and include relevant details from - the alliance agreement.

This will provide a contractual framework which unifies providers towards a shared set out outcomes, without the integration of the totality of contracts. However the CCG will retain a leadership role for driving integration across contracts and along pathways through the use of non-contractual mechanisms, with some support from the underpinning alliance agreement.

In the event that the ICS is realised through an open market procurement, it is likely that this will take the form of a single integrated contract. Experience from national pilots suggests that a prime contractor or prime provider model will be the most likely delivery vehicle for this.

Contractual form

It is proposed to use the NHS standard contract for the ICS. This provides the security of a contract used for over 10 years and which is updated regularly. It also represents continuity from current arrangements with incumbent providers and will not require regulatory dispensation.

The standard contract may be localised for specific requirements of the Hounslow ICS through revisions and variations agreed with the provider alliance (or the ICS provider if procured). Contract particulars will likely need to be amended to reflect integrated outcomes, payments and incentives.

Contract flexibility

The preferred option in Hounslow is for contractual flexibility to be provided for in the original contracting documents through clear and unequivocal review clauses. This will enable future services to be integrated into the ICS over the life of the contract.

It is aimed that the ICS provides a forum for collaboration and innovation, and the contract must balance the CCG’s requirements to be legally compliant, with the ability to adapt and modify the contract over time. This recognises that the ICS is a step change in service commissioning and that it will not be possible to absolutely specify the evolution expected over the lifetime of the ICS.

Where possible, the alliance agreement and relevant bilateral contracts with providers will need to describe the anticipated changes to the ICS scope (with detail covered in the service prospectus), associated payment mechanism and risks that may emerge along with these developments. The management case provides detail on these steps that will be further refined in partnership with the provider alliance and confirmed in the initial FBC.

Contract length

It is proposed to use a contract length of 2-3 years. This provides the CCG with the flexibility needed to respond to emerging opportunities or unanticipated events (in in national policy) through contractual change. In a dynamic and evolving system, it also maximises the CCG’s control and safeguards.

3.4.3 Payments

A key enabler to driving the single outcomes framework and a more collaborative way of working is the proposed payment mechanism for the ICS. This determine what money flows, where it flows, and how it flows within the ICS. It is expected that putting in place the right payment mechanism will enable the ICS to make better decisions on the


use of system resources, by exploring ways to deliver more efficiently. This is core to achieving the strategic aim of system financial sustainability.

In line with recent NHSE guidance on integrated care partnerships, the proposed payment mechanism covers three components:

the core payment for the delivery of the services in scope, based on historically known costs of delivery balanced with expectations for future system funding (i.e. the CCG’s allocation from NHSE);

an incentive payment scheme to drive innovation and improvement, as assessed against a range of outcome measures; and

a potential gain/loss arrangement to drive the transfer of activity outside of hospital and into the community where this is clinically appropriate.

In response, the preferred option for the Hounslow ICS comprises:

A block payment for the core payment. This is the “status quo” for the majority of Hounslow’s current out-of-hospital services. It will be a single, fixed payment, based on historic budgets, with the potential for adjustment for growth, inflation and efficiency. It will be necessary to build on existing infrastructure to more accurately calculate block values and volumes. While it is recognised that block payments are unlikely to drive the scale of innovation sought, they are likely to be the only practical option for the mobilisation and early operation for the ICS. Over time, more innovative approaches (specifically a capitated budget) could be explored and tested through a shadow operating year.

Pay-by-outcomes for the incentive payment scheme. Under this approach the CCG will withhold an increasing percentage of the core payment to providers. This will be payable for achieving agreed milestones and/or performance levels. It is proposed that these are linked to prioritised aspects of the single outcomes framework to incentivise improving patient outcomes through integration. From outset it is likely these will include process and output measures as well as pure outcomes, with the balance shifting towards increasing outcomes in the future. Consideration will be given to how outcomes are selected and measured, as well as to the percentage to be held back. This should be discussed and agreed with the alliance at an early stage and described in the initial FBC. It is recommended that a smaller figure is initially proposed. This may be scaled up in time based on the mutual confidence between the CCG and the alliance.

A risk-sharing agreement smoothing transition and aligning incentives for the potential gain/loss arrangement. In Hounslow, it is proposed to explore and design a risk-sharing arrangement which blends aspects of smoothing transition and aligns incentives with partners across the whole system. The risk share would comprise direct incentives for managing patients outside of hospital within the ICS contractual arrangement between the CCG and the provider alliance (or procured ICS provider). Separately, it could include shared incentives with other system partners (in particular with CWHFT as the main acute provider).

Operational and financial risk should be managed from the commissioner to providers over time, with upside and downside risks being agreed with the alliance and other system partners before each financial year.

3.4.4 Market engagement

The CCG’s expressed preferred way forward to making the ICS reality is through working with existing providers to develop an alliance responsible for co-designing, implementing and operating the ICS. Formal market engagement has not commenced and there are as yet no plans to engage providers outside of the alliance. This presents a recognised risk of challenge to the CCG’s process in terms of equity of opportunity to the market (captured in the risk log in the management case). The procurement timetable in section 3.4.1 above provides summary detail on when, what and how market engagement would be progressed in the event of an open market procurement. At this point the CCG would obtain evidence of the market interest in meeting the CCG’s requirements for its ICS and begin to establish the viability of the delivery of its proposed ICS. Detail on this will be described in the initial and updated FBCs.

3.5 ADDITIONAL COMMERCIAL CONSIDERATIONS

A key rationale for progressing plans to develop the local provider alliance is to maintain continuity and manage risk in terms of disruption to service delivery, speed of ICS “go live”, and the minimisation of transition costs. It also supports the development of a system prepared to evolve over time, recognising that medicine and care are constantly evolving, and that the system should function in such a way as to maximise the opportunities this presents.

Securing the chosen model or an alternative could bring about a range of commercial risks to ICS costs and/or the procurement timetable. It is prudent to consider these while noting that at this OBC stage it is not possible to


accurately predict and/or to scale these risks. These can only be clarified as the procurement process progresses. However, based on experience from other parts of the NHS it is possible to identify these potential risks. A careful and considered procurement and mobilisation timetable will be key in mitigating and/or managing these in response.

VAT

Depending upon the form of delivery model creates by bidding organisations, VAT may apply differently. For example, NHS organisations can recover VAT for the majority of the costs incurred in the delivery of health and care services. If a non-NHS organisation e.g. a private provider or a JV company created from NHS organisations to bid for and deliver the ICS, is selected as the preferred bidder, consideration will need to be given to the impact on the costs of service delivery if unrecoverable VAT is applied. Innovative supply chain mechanisms involving multiple NHS and non-NHS organisations may also be impacted by this application.

In response it is recommended that specialist financial and VAT advice is sought at regular intervals throughout the procurement to understand and scale this risk. This input will also need to be reflected through the evaluation of bidder responses.

Pensions

Similarly, innovative delivery models and underpinning supply chain arrangements may have implications in terms of the pension arrangements for staff employed in delivering the ICS services in scope. The CCG’s position would be that all potential providers will need to honour the terms and conditions of the NHS pension scheme, as well as other schemes that existing staff may belong to. The practical implications of this will need to be carefully monitored throughout a procurement process.

TUPE

Changes in local providers will likely lead to the application of Transfer of Undertakings (Protection of Employment) Regulations 2006 (TUPE). This provides staff employed on service contracts with the security of having their employment transferred to a newly contracted service provider.

The application of TUPE is unknowable at this stage. However, the potential impact of TUPE would need to be reflected through:

flagging it as a consideration throughout the procurement;

collecting appropriate, anonymised information on staff to circulate with bidders (having signed confidentiality and non-disclosure agreements in advance);

sufficient time to map the flows of employees to potentially multiple new employers; and

detailed mobilisation planning (with appropriate time scheduled to engage and transition affected staff in line with the regulations).

3.6 CONCLUSION The commercial case has set out how the preferred option (set out in the economic case) will be enabled by necessary procurement, contracting and payment arrangements. These are proposed to drive and secure:

the system-level model of care reflecting the principles, functions and features needed to drive integration;

the scope of services included in the ICS wrapper; and

a clear and sustainable foundation for the Hounslow ICS.

Getting these steps right will ensure the development of an ICS that is commercially attractive to both the CCG and to its chosen providers.

The next section assesses the affordability of the preferred option, with a summary of potential scenarios and associated risks.


4 FINANCIAL CASE

Having identified the preferred option design features in the economic case and set out the broad commercial approach in the commercial case, the financial case provides detail on the current state of development of a cost envelope for services in scope and tests affordability in the long-term by reference to modelling of overall CCG finances. At this point in Hounslow’s programme there is limited data to support assessment of the potential financial impact of different operational and/or commercial approaches to delivering integrated care.

The work described in this financial case represents an important first step towards building an understanding at a high level of the possible financial implications of integrated care delivery within a sustainable long-term financial plan for the CCG as a whole. This will allow the CCG to move onto more detailed work on the financial implications of different operation and/or commercial approaches to delivering the ICS, the key components of which are set out in the management case.

4.1 COST TO COMMISSION SERVICES IN-SCOPE

The review and classification by the CCG of commissioned services has led to all services in the current financial year 2018/19 being classified as either in-scope, ‘maybe/later’ or out-of-scope, where ‘maybe/later’ indicates that services may be brought into scope either before or during any new delivery arrangement, subject to further review and decision-making.

The values in the 2018/19 financial plan associated with each of these classifications is shown in figure 4.1:

CCG Area of Spend 2018/19 Plan £'000

In-scope £'000

Maybe/later £'000

Out-of-scope £'000

Acute 200,727 4,131 53,082 143,514

Mental Health Services 38,703 26,248 - 12,456

Community Health Services 46,805 29,568 10,694 6,543

Continuing Care 14,509 - - 14,509

Primary Care Co-commissioning 39,511 3,325 - 36,186

Primary Care Other 13,727 8,542 2,875 2,310

Prescribing 31,423 31,423 - -

Other 5,893 - 225 5,667

Total Programme Spend 391,298 103,237 66,876 221,185

Running Costs 5,442 - - 5,442

Contingency 1,799 - - 1,799

TOTAL 398,539 103,237 66,876 228,426

Figure 4.1: Value of services in scope, by commissioning category, 2018/19 budget values

The total of £103.2m in 2018/19 plan for services in-scope, split over areas of spend as above – 26% of total planned spend – is the value and analysis used in the financial modelling that forms the remainder of this financial case.

4.2 MODELLING OVERALL CCG FINANCES

4.2.1 Building a long-term CCG financial model

Before attempting to test the affordability of the preferred option for delivery of integrated care, it is necessary to develop a high-level financial model for overall CCG finances in the long-term (i.e. more than 3 years).

It should be noted here that the CCG’s financial planning cycle, in common with other CCG’s locally and nationally, is predominantly an annual one, dependent on the development and approval of a single year financial plan e.g. the 2018/19 plan set out in the previous section.


For Hounslow, as for other North-West London CCGs, there is also the NWL 3-year planning model, which uses some common assumptions, to set out a high-level plan for each CCG; in particular, addressing certain inter-NWL transactions.

However, there is at present no long-term plan of CCG finances or one that relies on assumptions generated by the CCG. Therefore, a long-term financial planning model has been developed to inform this business case, which builds on the NWL 3-year planning model and the CCG’s 2018/19 plan and depends on the following key assumptions, determined by CCG Finance:

3.5% commissioning allocation growth throughout;

Treatment of the phasing out of NWL-wide cross-subsidies as agreed with NWL Finance;

Mental Health growth matched to allocation growth at 3.5% to reflect implementing Mental Health Forward View and comply with the national Mental Health Investment Standard;

Primary care co-commissioning allocation and spend growth at 2.5% throughout, such that spend equals allocation throughout;

Prescribing growth of 4.4% and QIPP of (1.5)%, net 2.9%, throughout;

Other spend growth at 0.5% throughout;

Running cost allocation and spend growth at 0.6% throughout;

Otherwise with the assumptions stated below for each scenario modelled;

Outputs will be reported for the 5-year period 2019/20 to 2023/24.

The model developed has been used to test the implications of varying assumptions for spend growth, QIPP and therefore growth net of QIPP and to test the impact on the CCG’s bottom-line surplus or deficit in each year and to show where growth/QIPP assumptions would need to be calibrated to avoid any in-year deficits. The tested scenarios and their outputs are set out in the next section.

4.2.2 Scenarios testing and outputs

Four scenarios have been selected by CCG Finance to test the financial implications of varying growth and QIPP assumptions. They are:

Scenario 1: low acute growth

Scenario 2: medium acute growth

Scenario 3: high-acute growth

Scenario 4: acute growth back-solved

There are some differences in the way that these scenarios are modelled, which are explained below:

In scenarios 1 and 2 (low and medium acute growth), there is in each year a bottom-line surplus; therefore, no need to mitigate this by adjusting any of the other (non-acute) assumptions;

In scenario 3 (high acute growth), there is a bottom-line deficit in each year, prior to mitigation and a bottom-line breakeven, after adjusting other (non-acute) assumptions;

In scenario 4, acute growth net of QIPP has been back-solved to give a bottom-line breakeven in each year. This indicates the level of acute growth above which other (non-acute) assumptions would have to change to avoid in-year deficits.

4.2.3 Scenario 1: low acute growth

The assumptions tested in this scenario are as follows:

CCG Area of Spend Gross QIPP Net

Acute 4.50 % (2.00)% 2.50 %

Mental Health Services 3.50 % - % 3.50 %

Community Health Services 2.50 % (1.20)% 1.30 %

Continuing Care 3.00 % (1.50)% 1.50 %

Primary Care Co-commissioning 2.50 % - % 2.50 %

Primary Care Other 2.50 % (1.20)% 1.30 %


Prescribing 4.40 % (1.50)% 2.90 %

Other 0.50 % - % 0.50 %

Figure 4.2: Scenario 1 modelling assumptions

Note that assumptions for Mental health, Primary care co-commissioning, Prescribing and Other are common to all scenarios tested, as stated in section 4.2.1.

The QIPP requirement in nominal terms at 2018/19 prices would be as follows:

CCG Area of Spend QIPP £m

Acute 4.0

Mental Health Services -

Community Health Services 0.6

Continuing Care 0.2

Primary Care Co-commissioning -

Primary Care Other 0.2

Prescribing 0.5

Other -

Total 5.5

Figure 4.3: Scenario 1 QIPP requirements

Total QIPP of £5.5m (as above) represents 1.6% of the commissioning allocation.

The bottom-line surplus/deficit generated in this scenario is in all years a surplus, as follows:

19/20 20/21 21/22 22/23 23/24

Surplus/(deficit) £'000 3,841 6,300 10,433 14,786 19,370

Figure 4.4: Scenario 1 summary of surplus/deficit generated

4.2.4 Scenario 2: medium acute growth



Acute 6.00 % (2.00)% 4.00 %



Continuing Care 3.00 % (1.50)% 1.50 %



Prescribing 4.40 % (1.50)% 2.90 %

Other 0.50 % - % 0.50 %


Note that the Acute gross growth assumption has increased by 1.5%, from 4.5% in Scenario 1 to 6.0%; all other assumptions are as Scenario 1.

The nominal values of QIPP and QIPP as a share of total allocation would remain materially the same for Scenario 1. However, the higher acute growth coupled with no material change in QIPP has the effect of eliminating most of the in-year surpluses; taking the bottom-line close to breakeven.


The bottom-line surplus/deficit generated in this scenario is in all years a surplus, as follows:

19/20 20/21 21/22 22/23 23/24

Surplus/(deficit) £'000 816 9 668 1,327 1,986


4.2.5 Scenario 3: high acute growth



Acute 7.50 % (2.00)% 5.50 %



Continuing Care 3.00 % (1.50)% 1.50 %



Prescribing 4.40 % (1.50)% 2.90 %

Other 0.50 % - % 0.50 %


Note that the Acute gross growth assumption has increased by 1.5%, from 6.0%.in Scenario 2 to 7.5%; all other assumptions are as Scenarios 1 and 2.

The nominal values of QIPP and QIPP as a share of total allocation would remain materially the same for scenarios 1 and 2.

The bottom-line surplus/deficit generated in this scenario is in all years a deficit, as follows:

19/20 20/21 21/22 22/23 23/24

Surplus/(deficit) £'000 (2,209) (6,372) (9,382) (12,725) (16,428)


However, because it is not viable to plan for a deficit, the model has been re-run with the QIPP for Community services, Continuing care and Primary care other back-solved to give a bottom-line breakeven. This increases the QIPP for each service to slightly below 6%, such that the revised table of assumptions for all services becomes as follows:


Acute 7.50 % (2.00)% 5.50 %


Community Health Services 2.50 % (5.81)% (3.31)%

Continuing Care 3.00 % (5.81)% (2.81)%


Primary Care Other 2.50 % (5.81)% (3.31)%

Prescribing 4.40 % (1.50)% 2.90 %

Other 0.50 % - % 0.50 %

Figure 4.9: Scenario 3 updated modelling assumptions underpinning a breakeven position


Note that Community services, Continuing care and Primary care other QIPP assumption has back-solved to yield a bottom-line breakeven in all years; all other assumptions are as stated above in this section.

There would be no material change in the nominal values of QIPP for Acute, Mental health, Primary care co-commissioning, Prescribing and Other. However material changes for Community services, Continuing care and Primary care other would result as below:

CCG Area of Spend Scenarios 1 and 2

£m

Scenario 3 £m

Variance £m

Acute 4.0 4.0 -

Mental Health Services - - -

Community Health Services 0.6 2.0 1.4

Continuing Care 0.2 0.6 0.4

Primary Care Co-commissioning - - -

Primary Care Other 0.2 0.6 0.4

Prescribing 0.5 0.5 -

Other - - -

Total 5.5 7.7 2.2

Figure 4.10: Scenario 3 updated QIPP requirements underpinning a breakeven position, compared with Scenarios 1 and 2

Total QIPP of £7.7m (as above) represents 2.2% of the commissioning allocation; an increase of 0.6% of total allocation when compared to Scenarios 1 and 2.

It should be noted that this increased QIPP requirement represents high nominal values and a share of total allocation, which arguably would be unsustainable over the long-term and would most likely place the safety and/or quality of services in jeopardy.

4.2.6 Scenario 4: acute growth back-solved

In this scenario, all assumptions other than Acute QIPP have been retained from Scenario 1 and the Acute QIPP requirement calculated to deliver a bottom-line breakeven in all years modelled.

The result is an acute QIPP of (0.3)% (mean over 5 years) and growth net of QIPP of 4.17%, as set out alongside the other retained assumptions as below:


Acute 4.50 % (0.33)% 4.17 %



Continuing Care 3.00 % (1.50)% 1.50 %



Prescribing 4.40 % (1.50)% 2.90 %

Other 0.50 % - % 0.50 %


Note that the Acute QIPP assumption has been back-solved to yield a bottom-line breakeven in all years; all other assumptions are as Scenario 1.

The nominal QIPP requirements would be unchanged from Scenarios 1 and 2, other than the Acute QIPP, which would be £(0.2)m per year compared to £(4.0)m in Scenario 1, 2 & 3, as follows:

CCG Area of Spend Base £m QIPP £m Variance £m


Acute 4.0 0.2 (3.8)

Mental Health Services - - -

Community Health Services 0.6 0.6 -

Continuing Care 0.2 0.2 -

Primary Care Co-commissioning - - -

Primary Care Other 0.2 0.2 -

Prescribing 0.5 0.5 -

Other - - -

Total 5.5 1.7 (3.8)

Figure 4.12: Scenario 4 updated QIPP requirements underpinning a breakeven position, compared with Scenarios 1 and 2

Total QIPP of £1.7m (as above) represents 0.5% of total allocation; a decrease of (1.1)% of total allocation when compared to Scenarios 1 and 2.

4.2.7 Commentary on the scenarios tested

The following comments may be made on the model outputs:

• The growth net of QIPP represented by the base assumptions in Scenario 1 appears affordable to the CCG; in fact, would yield material in-year surpluses in each year modelled; and

• Acute growth net of QIPP that was 1.5% higher than the base assumptions – as in Scenario 2 - would still appear to yield small in-year surpluses in each year; whereas

• Acute growth net of QIPP that was 3.0% higher than the base assumptions – as in Scenario 3 - would yield in-year deficits without considerably higher QIPP assumptions for Community services, Continuing care and Primary care other;

• The higher QIPP requirement for Community services, Continuing care and Primary care would have a mean value of slightly below (6)% or respectively an additional £(1.4), £(0.4) and (0.4)m each year over the period modelled; an increase in total QIPP required of £(2.2)m, from £(5.5)m to £(7.7)m;

• The point at which acute growth net of QIPP will start to demand QIPP for Community services, Continuing care and Primary care other higher than in the base assumptions has been estimated at c. 4.2%; therefore, only slightly above the medium acute growth scenario;

and therefore that:

• The level of acute growth net of QIPP will be critical to maintaining other budgets and achieving the 3.5% commitment to Mental Health, and avoiding net reductions in spend on other budgets, which may put at risk safety and/or quality of those services and/or put at risk the CCG’s ability to deliver the mental health commitment; also, that

• For the CCG to achieve the MH 3.5% and deliver minimal growth in Community services, Continuing care and Primary care other, growth in acute spend net of QIPP will need to be contained at or below c. 4.2% which is at the lower end of net growth rates being assumed elsewhere in NWL in similar long-term planning work.

4.3 ESTIMATING AN INTEGRATED CARE SYSTEM COST ENVELOPE

The modelling of long-term CCG Finances reported on in the sections above may be used by the CCG to start to build up an understanding of the possible cost envelopes for commissioning integrated care in the preferred option.

This is performed in the financial model developed for this business case by relating the growth and QIPP rates for areas of spend from the various scenarios modelled to the analysis of in-scope service values, starting with the c. £103m value of in-scope services in the 2018/19 financial plan, as set out in section 4.1.

Using Scenario 3 (high acute growth) after mitigation – from section 4.2.5 – and Scenario 4 (acute growth back-solved) – from section 4.2.6 – which give respectively the lowest and highest results, the following cost profiles may be generated:


2019/20 plan

2020/21 plan

2021/22 plan

2022/23 plan

2023/24 plan

CCG3.2 - high acute growth with mitigation, £’000

104,718 105,295 106,542 107,705 108,783

CCG4 - acute growth back-solved, £’000

105,945 108,579 111,320 114,136 117,038

This is represented in figure 4.13:

Figure 4.13: ICS cost to commission profiles

4.3.1 Commentary on the cost profiles illustrated

The following comments may be made on the cost profiles illustrated:

• The scenarios modelled yield materially varying cost profiles, with a range after 5 years of £109-117m; a spread of £8m or c. 7.5% of the base, which illustrates the material impact that services out-of-scope – e.g. the majority of acute – may have on the funding available for services that are in-scope;

• In the lower of these cost profiles – which assumes acute growth net of QIPP at 5.5% - the value of Acute and Mental Health is increasing year-on-year but Community services, Continuing care and Primary care other are falling each year at a rate - net (3)% - that may put at risk service safety and/or quality, if not viability;

• Even in the higher of the cost profiles – which assumes that acute growth net of QIPP is no higher than 4.24% - the values of Community services, Continuing care and Primary care other are growing only at or around forecast population growth (1.2-1.5%), which may not be sufficient to maintain service volumes and quality;

• The cost profiles, being derived directly from commissioning costs in the 2018/19 plan do not include any elements of CCG running cost, which the CCG may decide are attributable to an integrated care service; for example, functions which may transfer from CCG to an integrated care provider (e.g. medicines management);

Therefore, the CCG may wish to:

• test further scenarios in which, for example, acute growth and QIPP are split between elective and non-elective, with different growth and QIPP assumptions; and/or

• test further scenarios in which, for example, services in- and out-of-scope are assumed to grow at different rates e.g. a lower net growth in non-electives where non-electives are assumed to be in-scope;

• consider what would be the maximum QIPP deliverable for each service (e.g. Community services, Continuing care and Primary care other) without materially reducing the scope of the services; and/or

104.7105.3

106.5

107.7

108.8

105.9

108.6

111.3

114.1

117.0

98

100

102

104

106

108

110

112

114

116

118

2019/20 plan 2020/21 plan 2021/22 plan 2022/23 plan 2023/24 plan

£m

CCG3.2 - high acute growth with mitigation CCG4 - acute growth back-solved


• consider how cash releasing savings above the assessed maximum QIPP might be achieved from these services, if required, and what would be the priority order for realising these savings, if needed;

• and by doing so further develop both its long-term financial modelling and its understanding of possible integrated care cost profiles, balancing CCG financial sustainability in the long-term with affordability of the integrated care services and promoting quality and transformation of those services.

4.4 CONCLUSION

The financial case has set out the first key step developing an understanding of how a cost to commission the preferred option (identified in the economic case) may be managed within a realistic and flexible long-term financial planning regime. This is founded on the premise that planning the finances of integrated care must be carried out in the context of long-term planning of overall CCG finances.

The scenario modelling indicates that the funding likely to be available for integrated care services will be heavily dependent on the forecast and actuals for acute expenditure and illustrates the impact of different acute growth assumptions on the funding available for other services.

The financial case includes some commentary on steps the CCG may wish to take to further develop both the long-term planning of overall CCG finances but also for the integrated care cost envelope, which may be taken forward alongside the other next steps set out in the management case.


5 MANAGEMENT CASE

The management case sets out how the objectives of the ICS will be achieved. At this stage, there remains a range of options (and hence necessary enablers including decisions) for progressing this approach locally. This management case explores the two main approaches available to deliver this change – by developing a local provider alliance bound by an alliance agreement, and by procuring a single contract. The decisions, activities, required capacity and capabilities, key programme risks and proposed mitigations are described for each main phase of work required including preparation for, mobilisation and implementation of the ICS.

This case does not pre-determine a preferred way forward, recognising that this is a decision for the Hounslow Governing Body to take. Rather it sets out the required steps to realise the preferred option of the ICS described in the economic case. Should this be agreed, an initial FBC will be developed to provide greater clarity and more detail on the expected benefits and value to be secured by the CCG. An updated FBC case describing the output of co-production with the provider alliance will provide a final checkpoint for the Governing Body. This document will present a full blueprint and timetable for implementing integrated health and care in Hounslow.

The CCG has bold ambitions to integrate health and care in response to the challenges it faces. The aim is to implement a new ICS by April 2020. This is likely to be a significant, complex and resource-intensive transformation, requiring changes to the way that services are both commissioned and delivered.

To make this a reality, a number of key decisions are required over the coming months. These will determine the scale of integration, the approach to achieving it, the partners involved, the resources available to support mobilisation, and the timelines for delivery. This sequence will put in place the safeguards, controls and checkpoints essential to appropriately manage risk. It also included engagement with NHSE’s ISAP process to provide regulatory assurance on the robustness of local plans. The key decisions to be taken are set out in the table below (organised by phase):

Decision Indicative date of decision

Ph

as

e 1

– c

on

firm

ing

th

e a

pp

roach

To proceed on the basis of the OBC – confirming the preferred way forward, service scope, desired features of the ICS, commercial approach (i.e. expectations and checkpoints for assurance of the provider alliance), and investment required in progressing the change

Q2 2018/19

To engage NHSE ISAP (“early engagement”) testing the risks, validity and deliverability of the approach agreed as part of the OBC, and understanding if further ISAP engagement is required

Q3 2018/19

An assessment of plans for future co-production with the alliance based on the model of care outputs for the four priority areas

Q3 2018/19

To proceed on the basis of the initial FBC – with detail on how the provider alliance will deliver the objectives and benefits of integration through the agreed models of care for the four priority areas

Q3 2018/19

The appropriate involvement of patients and the public throughout Q3 2018/19

The preparedness for change based on assessment of the achievement of agreed in-year objectives (QIPP, CQUIN, qualitative objectives)

Q4 2018/19

Ph

as

e 2

–

imp

lem

en

tin

g t

he

ch

an

ge

The suitability of the draft service innovation and improvement prospectus and underpinning integrated care contractual arrangements

Q1 2019/20

To engage NHSE ISAP (Checkpoint 1) to test the methodology and evaluation criteria for provider assessment

Q1 2019/20

The preparedness of the provider alliance to begin operating a new shadow payment system (comprising the core, incentive and risk share payments)

Q1 2019/20

The outcome of the provider evaluation based on an assessment of organisational responses

Q2 2019/20


Decision Indicative date of decision

To proceed on the basis of the updated FBC – confirming the selection of a preferred ICS partner(s), with detail on how the proposal will deliver the objectives and benefits including driving value for money, along with detailed analysis of the provider and health economy impact of this procurement

Q2 2019/20

To engage NHSE ISAP (Checkpoint 2) to test the robustness of the process and decision-making underpinning the award of contract

Q3 2019/20

The safety and efficacy of the new models of care established for the four priority areas, with evidence patient and public engagement

Q3 2019/20

The robustness of the implementation plan and constituent workstream plans, and the proposed arrangements for programme management

Q3 2019/20

The effectiveness of risk logging and management, as well as contingency planning ahead of service commencement

Q4 2019/20

Ph

as

e 3

– m

an

ag

ing

an

d i

mp

rovin

g t

he n

ew

syste

m

To engage NHSE ISAP (Checkpoint 3) to test the readiness to “go live” with the ICS Q1 2020/21

The suitability and appropriateness of a proposed model of integrated care for the whole population

Q1 2020/21

The readiness of the alliance to transition from shadow operating to full operation of the ICS payment system (comprising the core, incentive and risk share payments)

Q1 2020/21

The appropriateness of a proposed performance management framework Q1 2020/21

The appropriateness of proposed continuous improvement plans Q3 2020/21

The transition from transformation to “business as usual”, triggering reinvestment of programme resources into day-to-day activities

Q4 2020/21

The commissioning approach to most effectively drive continued integration following the conclusion of the single contract

6 months prior to the end of the ICS contract arrangement (assuming no early termination on either side)

Figure 5.1: Anticipated key decisions

One of the most fundamental decisions to be determined by the Governing Body on 11 September is the commercial approach to realising the ICS. This will determine the CCG’s direction and strategy for how it considers transacting the commissioning and system model based on the features set out in the economic case.

This could be achieved by developing a local provider alliance comprising the current key local providers – the Hounslow Consortium, HRCH, WLMHT, CWHFT, London Borough of Hounslow, and the voluntary and community sector. This route assumes that an open market procurement is not undertaken at this time, to allow the development of a local alliance. The CCG may choose to undertake an open market procurement at a later date once the principles and processes of alliance working between local providers are established. This should drive the development of system principles and an integrated model of care which reflects local demography, geography and clinical expertise, through providers who are familiar with each other and with the CCG.

Doing this will require a detailed provider development plan, with commensurate investment in building the alliance infrastructure and capability in line with the expectations on the individual providers and providers collectively both during transition, following “go-live” and in full implementation. The plan will need to identify the milestones and assurance gates so that the CCG can be confident in using the alliance to deliver out-of-hospital services. It will need to cover transitional activities including extending and amending bilateral contracts, as well as the development of a binding alliance agreement to drive the collaborative behaviours sought.

An alternative route to making the system a reality is through an open market procurement. This would see the services in scope brought together as a single contract to be let through a competitive procurement process open to the wider market. This could reduce a potential risk of challenge from an external provider under the Public Contracts Regulations 2015.

However, procurement can be time-consuming and costly. It would require the specification of a single contract for the ICS which could stifle the innovation and flexibility in incentives and outcomes sought. Getting it right for


change of this nature would require careful planning. As such, it is proposed that a procurement plan is developed as a contingency to a potential challenge to the CCG’s preferred approach. The sections below provide detail on these respective approaches over the main phases of work required.

5.1 PHASES OF CHANGE

The figure below sets out the three broad phases of change envisaged – confirming the approach, implementing the change, and managing and improving the new system. It provides indicative timelines and the required high-level deliverables and activities underpinning each phase.

Figure 5.2: Overview of ICS delivery timeline

As with all major change programmes, there are significant risks that run across the three phases. It is essential that the change proposed is managed in a proportionate and considered way. In response, there is a need for detailed planning, effective governance and appropriate programme management capacity to get this right – achieving the CCG’s objectives and releasing the benefits sought.

To do this, the CCG recognises a need to:

Establish a robust governance structure (working with London Borough of Hounslow as a commissioning partner) and supporting process to oversee and take responsibility for timely decisions necessary to drive this change.

Agree a clear and detailed plan identifying what deliverables, milestones and activities are required – and describing how these are going to delivered by relevant system partners.

Follow and apply principles of effective programme management for complex change, including lines of reporting, arrangements for escalating issues, and robust risk identification and management.

Engage with system partners and stakeholders to clearly communicate objectives, process and roles of the transformation programme – as well as to secure the support and resources necessary to make borough-wide.

Continue to support the development of ICS delivery infrastructure – including the provider alliance, “at scale” primary care, integrated out-of-hospital hubs and local infrastructure including information management and technology (IM&T) and data sharing.

Identify leadership and management responsibilities for overseeing this change.

Management case – title, reference, version

Co

nfi

rmin

g t

he

ap

pro

ac

h

Q2 18/19 Q3 18/19 Q4 18/19 Q1 19/20 Q2 19/20 Q3 19/20 Q4 19/20 Q1 20/21 Q2 20/21 Q3 20/21 Q4 20/21

Imp

lem

en

tin

g th

e c

ha

ng

eM

an

ag

ing

an

d i

mp

rov

ing

th

e n

ew

sy

ste

m

Draft OBC

GB decision on OBC approach

Drafting initial FBCGB decision on initial FBC

New models of care covering the 4 priority areas

Developing integrated contracting documents

Contract documents prepared

ITT, bidder responses, evaluation

Contract award

Implementation

Integrating primary and community care with initial focus on implementing the model of care for the 4 priority areas

Expanding new models of care to the whole population, and integrating secondary care, community mental health, voluntary sector

and Local Authority services

End of contractual

term

Transformation programme completed

Ongoing performance monitoring supporting a programme of continuous improvement

Contract end triggering commissioning

decision

Implementing and managing the new payment and incentive model in full

Ongoing care transformation

Ongoing patient and public engagement


(A) Full open market procurement

Evaluating and assuring provider readiness

(B) Developing the provider alliance

Patient and public engagement

Market engagement

Co-producing new models of care

Ongoing redesign work (including QIPP) and service improvement

OR:

Drafting the updated FBC

GB decision on updated FBC

ISAP: early engagement

ISAP: checkpoint 1 ISAP: checkpoint 2

ISAP: checkpoint 3

ICS “go live”


Make best use of existing system resources (across commissioners and providers) to align focus, build sufficient capacity, and ensure timely access to those resources.

Continue to oversee the day-to-day functioning of the local system while transacting change in parallel.

Ensure the local Hounslow plans are consistent with developing North West London ICS thinking and that providers are supported consistently where required.

This management case captures further detail on each of these phases in turn.

5.2 PHASE 1: CONFIRMING THE APPROACH FOR INTEGRATED CARE

Overview

The objective of this phase is to develop and agree the approach to implementing an ICS in Hounslow, comprising an identified set of features agreed as the preferred option. This is the phase that the CCG is currently at, with current focus on developing and approving this OBC.

In line with HM Treasury’s Five Case Model (as described in the Green Book guidance 8) which provides a

framework for developing a comprehensive and appropriately detailed proposal, this OBC covers:

Strategic case - an outline of the local case for change with the rationale for developing an ICS in response, along with a demonstration of strategic fit i.e. how the ICS fits with wider policy

Economic case - a summary of the options appraised in determining the detailed option for the ICS

Commercial case – identifying the detail of the ICS to be developed, and the proposed commercial approach to make this a reality

Financial case – testing the affordability of the ICS

Management case – this case outlining describing steps to successfully deliver the ICS.

This OBC provides the information necessary to inform the Governing Body decision on next steps. However it will not provide the full detail required to initiate the contractual agreement with an ICS. Further work will necessarily be required to engage patients and the public on plans, and to prepare the provider alliance to play a full role in co-designing the ICS in line with the CCG’s preferred approach.

Subject to approval to proceed with the OBC, it is proposed that a draft FBC will be developed with the alliance for consideration by the CCG’s Governing Body in early 2019. This will provide additional detail on how Hounslow will achieve its objectives for integration through:

the implementation of integrated models of care for the four priority areas, co-produced by the provider alliance and local population;

a description of how the ICS will function in terms of decision-making and operational delivery; and

the steps to develop the system delivery infrastructure to prepare for the mobilisation of the ICS. This will include steps on building the structure and capability of the provider alliance, as well as continuing to embed “at scale” primary care working.

It is expected that engagement with NHSE’s ISAP will be required after the Governing Body’s decision on this business case, as part of the “early engagement” aspect of the process. ISAP exists to assure novel and complex contractual changes, including the development and implementation of new care models. Early engagement on the CCG’s plans for integrating care will help understand if further engagement with ISAP is required. In the event it is no longer required, ISAP provides a helpful assurance framework with which local plans can be tested so as to give the Governing Body greater comfort in decision-making.

Delivery timeline:

8 The Green Book: appraisal and evaluation in central government

Management case – title, reference, version

Co

nfi

rmin

g t

he

ap

pro

ach

Q2 18/19 Q3 18/19 Q4 18/19 Q1 19/20 Q2 19/20 Q3 19/20 Q4 19/20 Q1 20/21 Q2 20/21 Q3 20/21 Q4 20/21

Draft OBC

GB decision on OBC approach

Drafting initial FBCGB decision on initial FBC

New models of care covering the 4 priority areas

End of contractual

term

Patient and public engagement

Market engagement

Co-producing new models of care

Ongoing redesign work (including QIPP) and service improvement

ISAP: early engagement

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/685903/The_Green_Book.pdf


Figure 5.3: Overview of phase 1 timeline

Deliverables:

The key outputs of this phase are:

This OBC – detailing the case for change, an appraisal of features to determine the preferred option for the commercial and contractual approach, a system-level definition of the preferred model of integrated care, an assessment of the affordability of this model, and an assessment of the deliverability of the transformation to make this model reality.

A draft FBC – detailing additional and updated information, key changes and developments from the OBC, detail on the development and assurance of the provider alliance, detailed integrated models of care for the four priority areas, value for money assessment of the proposal, and detailed arrangements for the project management and monitoring for implementing these changes.

A long-term financial plan – the duration of the ICS will be significantly longer than traditional NHS contracts. From the CCG’s perspective, this will outstrip current CCG financial plans and forecasts. A long-term local plan is required (building on the assumptions identified and scenarios modelled in the financial case) to help inform future decision-making.

An alliance memorandum of understanding – informally joining the provider alliance members together to focus on mobilising the next phase of ICS development. This should describe the objectives, aims and principles required from collaboration.

Models of care for the four priority areas – in preparation for launching the ICS, detailed models of care focussing on improving outcomes for the four priority areas (urgent care, patients and families with complex needs, patients with accumulating health deficits, and home visiting) will be co-produced with patient and provider representatives, including clinicians. Building on what works well currently, and incorporating learning and good practice from elsewhere, the models will be the focus of integration in year 1.

A patient and public engagement plan – describing the messages to take out to the Hounslow population, the channels proposed for this communication, and events to engage with the population. It should also set out the process for patient engagement in the co-design of the system model of care, as well as for feeding back on experience.

A provider development strategy and engagement plan – describing the CCG’s proposal for working with the provider alliance to prepare it to play a full role in the design and implementation of the ICS. This should clearly describe provider accountability, responsibilities, expectations and the resources (time, staff and capital) available to support this work, as well as a balanced appraisal of risks and proposed ways to manage these.

A draft continuous innovation and improvement prospectus - describing the new models of integrated care that the CCG is seeking to embed in Hounslow. It is expected that these models of care will be co-developed with providers and patient representatives and will be subject to sign-off by the Governing Body. The initial focus will be on the four priority areas – with the design of subsequent models of care taken place in phases 2 and 3. The prospectus will also detail the outcomes, incentives and structure through which the ICS will monitored to evidence success.

A draft contractual arrangement (including a legally binding alliance agreement, reflected in individual bilateral contracts) – this will describe the relevant terms, conditions, clauses and particulars required to underpin the service innovation and improvement prospectus.

An equality impact assessment (EQIA) – this will provide an assessment of the new service innovation and improvement prospectus on the population with particular regard to people with any of the nine protected characteristics identified in the Equality Act, 2010. This will also set out recommended actions for mitigating disproportionate impacts on any of those groups.

Contingency plan – following the principles of effective programme management, the CCG will develop a contingency plan setting out actions to take in the event of a major programme issue or shortfall. This should reflect the risk register described in section 5.8.

In preparing for system change, the CCG will remain responsible for managing the performance of providers delivering existing contracts. This includes overseeing the achievement of contractual standards, delivery of financial efficiencies (as part of QIPP), and implementation of service improvements previously agreed with providers.

The phased nature of this transformation implies that some contracts may need to be extended incrementally to bring them within the ICS scope at the right time. The contracts in scope will be identified as part of the detailed service transformation plan.


In the event that an open market procurement is undertaken, then differences in the approach of this phase would be as follows:

PIN – issuing a notice to signal the intention to embark on an open market procurement. The PIN would be registered in OJEU advising potential providers on the CCG’s plans and intended approach to integrate care in Hounslow.

Engaging the market – presenting initial plans to interested providers (in addition to incumbent providers) through dedicated market engagement events. As well as informing the market, this provides an opportunity to iterate the approach.

Provider development – to maintain an equitable playing field, there would be no targeted provider development in advance of an open market procurement. It is similarly unlikely that co-production of models of care could be progressed with any given provider. Instead market engagement would provide a forum with an expanded range of providers to test elements of these activities.

5.3 PHASE 2: IMPLEMENTING THE CHANGE

Overview

The objective of this phase is to progress on the basis of the OBC and initial draft FBC to begin implementing the ICS. Taking forward the CCG’s preferred option, the provider alliance will be supported to develop in line with the initial FBC.

The alliance will be expected to work together to implement the models of care co-produced in phase 1. The learning and experience from this process will help the CCG to understand the viability of the alliance to deliver the full scope of the ICS across the whole population. This will be determined through regular scheduled checkpoints to assess provider readiness. The outputs of these processes – along with further co-production with the alliance - this will inform the development of an updated FBC, which will:

Confirm the value of the ICS and how the most economically advantageous offer (i.e. maximising value for money) is being progressed through a robust and legally compliant process

Set out the detailed commercial and contractual arrangements for the ICS including proposed contract value and contractual terms

Confirm the detailed affordability including investment in transformation and the proportionate and affordable plans for successful delivery.

It is expected that engagement will continue with NHSE’s ISAP. Checkpoint 1 will follow from the consideration of the initial FBC. This will provide the CCG with confirmation that its proposed approach to develop and test the alliance will best deliver its objectives for integration and improve care outcomes. Checkpoint 2 will take place following the satisfactory completion of the CCG’s alliance assurance process. It will test the robustness of the decision reached, based on the evidence assessed.

Once satisfactorily completed, the CCG can formally award the contract to the provider alliance in line with the CCG’s legal advice. This will see a legally-binding alliance agreement (or equivalent) put in place linking system partners together. Individual service contracts will need to be updated to reflect the collaborative behaviour identified in this agreement.

Delivery timeline:


Deliverables:


An updated FBC – describing the detailed approach to assess the alliance’s commitment and capability to deliver the ICS, confirmation of the outcome of the CCG’s evaluation (and the evidence base underpinning

Management case – title, reference, versionQ2 18/19 Q3 18/19 Q4 18/19 Q1 19/20 Q2 19/20 Q3 19/20 Q4 19/20 Q1 20/21 Q2 20/21 Q3 20/21 Q4 20/21

Imp

lem

en

tin

g th

e c

ha

ng

e

Developing integrated contracting documents

Contract documents prepared

ITT, bidder responses, evaluation

Contract award

Implementation

Integrating primary and community care with initial focus on implementing the model of care for the 4 priority areas

End of contractual

term


(A) Full open market procurement

Evaluating and assuring provider readiness

(B) Developing the provider alliance

OR:

Drafting the updated FBC

GB decision on updated FBC

ISAP: checkpoint 1 ISAP: checkpoint 2


this) and its fit to the objectives and benefits described in the OBC. This will cover in detail the value for money of the proposed ICS solution, comprehensive benefits analysis and framework, suggested governance arrangements to safely transact the ICS, legal opinion, provider capacity and capability to lead the transformation required, the financial sustainability of the contracted ICS, market analysis, analysis of impact on providers, the appropriateness of contracting documentation, and robust contingency plans.

A finalised continuous innovation and improvement prospectus – building upon the models of care for the four priority areas to describe integrated care for the whole population. The prospectus will include updated detail on what outcomes and incentives are sought, and requirements on how the relationship between the CCG and the alliance should function to ensure integration is being achieved.

A finalised contract for alliance partners with aligned schedules for each provider – updated to reflect changes in requirements and/or detail from phase 1.

A finalised alliance agreement – legally binding the alliance to the legal requirements of each other and the CCG.

Agreed evaluation methodology and selection criteria – setting out the process for assessing the provider alliance, including the abilities they need to demonstrate and evidence in order to be directly awarded the single contract.

Evaluation outcome following assessment of provider readiness – using the evaluation methodology and selection criteria to assess the alliance readiness to deliver the ICS, and confirming the outcome of that process through OJEU.

Contract awarded – progressing through the necessary steps in awarding the contract in compliance with the Public Contracts Regulations 2015.

Models of care embedded for the four priority areas – bridging transition from the current to the future system, during this phase the integrated model of care for the four priority areas will be introduced borough-wide. The model will be delivered initially through integrated primary and community care functions.

Implemented shadow payment, budget and incentive mechanism – as a preparatory step towards the implementation of the ICS payment system (comprising the core, incentive and risk share payments), it is intended to pilot the system in shadow form for 12 months. Learning from experience will refine ways of working so that the provider alliance can proceed on this basis in full form from April 2020.

Updated patient and public engagement plan – building on the 2018/19 engagement plan, this updated plan will set out the objectives of engagement with the patient and public. It will cover in detail the key messages, channels, opportunities and events to engage with people. This will include making sure all residents are informed of the changes planned for their health and care services.

Updated provider development strategy – building on the 2018/19 provider development strategy, this will set out the plan for supporting the alliance and its members as it transitions from a forum for innovating and designing services into a partnership responsible for overseeing and coordinating implementation and service delivery.

An implementation plan – this will set out the detailed steps (milestones, activities and owners) to transition to the new integrated model of care. It will be produced by the provider alliance, and assured by the CCG as part of programme governance.

Refreshed contingency plan – the CCG will review and refresh (as required) the contingency plan to ensure it appropriately reflects the context and activities of phase 2, while setting out detailed responses for issues arising in phase 3.

In the event that the procurement approach is taken forward, then differences in the approach of this phase would be as follows:

Final approved version of (PIN) and contract notice – to formally launch the procurement process.

Procurement documents – including an sSQ and an ITT, providing the templates for interested bidders to detail how they would work to realise the CCG’s vision and principles for integrated out-of-hospital care.

Formal evaluation outcome – detailing the outcome from the procurement process, underpinned by the qualitative and quantitative assessment of bidder responses.

Implementation – in the event that non-incumbent providers are selected through the procurement as formal ICS partners, then a dedicated mobilisation period (of around 6 months) will be required. This will see incoming providers working with incumbents in preparation for transferring patients, staff and contracts.


This complex process presents risk, and a formal implementation plan will be an assessed part of the procurement evaluation.

5.4 PHASE 3: MANAGING AND IMPROVING THE NEW SYSTEM

Overview

The objective of this phase is to build on the implementation of the ICS, transitioning into operational “business as usual”, and putting in place the drivers for continuous refinement and improvement.

Kicking off this phase, there will be a final assessment from both the CCG Governing Body and NHSE ISAP to determine readiness to “go live”. Engagement with ISAP would take place just prior to scheduled service commencement. Checkpoint 3 would confirm readiness for the start of the comprehensive new service delivery arrangements. Decision-making and supporting evidence about the implementation progress should satisfy the requirements at this stage (whether or not the process is formally applied).

Delivery of this phase will see expansion of integrated care to the whole population, with evolutionary development of the supporting infrastructure. This includes the full implementation of new payment and incentive systems to further drive integration and improved patient outcomes.

Delivery timeline:


Deliverables:


Models of care embedded for the whole population – building on the implementation of the models of care for the four priority areas in the previous phase, learning will be used to drive the development of integrated models of care for all Hounslow residents. These will continue to be co-produced by the provider alliance, building out from primary and community care to include secondary care, community mental health, local authority and voluntary sector services.

A blueprint for on-going care transformation – as part of the provider assurance process, the alliance should be expected to set out a plan for continually refining and tailoring models of care, including through service and pathway redesign. This process should integrate feedback from patients, carers and clinicians; learning and best practice from other areas; and local data (making use of clinical, performance and financial metrics). While the provider alliance will be responsible for designing improved care, the process will be safeguarded through CCG decision-making, and the use of independent clinical review.

Implemented payment, budget and incentive mechanism – building on the shadow operating period in phase 2, this work will implement in full the agreed ICS system financial approach (comprising the core, incentive and risk share payments) to manage the distribution of money and risk with appropriate incentives across the provider alliance.

Established performance monitoring system – this will be designed by the CCG and agreed with the provider alliance. The system will reflect the move to an outcomes-based contract, with new metrics introduced to assess the impact of work to integrate health and care across multiple partners. The detailed form, content, channels for and assurance of reporting will be captured within this system.

Conclusion of the transformation programme – it is intended that transformation activities conclude with the outcome that the ICS is fully established by April 2020. From this point, it is anticipated that the underpinning transformation programme will be gradually wound down, with programme resources reinvested into “business as usual” activities including continuous improvement.

Updated patient and public engagement plan – building on the 2019/20 engagement plan, will set out how the ICS will inform, engage and consult with patients and the public in 2020/21 and beyond.

Management case – title, reference, versionQ2 18/19 Q3 18/19 Q4 18/19 Q1 19/20 Q2 19/20 Q3 19/20 Q4 19/20 Q1 20/21 Q2 20/21 Q3 20/21 Q4 20/21

Man

ag

ing

an

d im

pro

vin

g t

he

ne

w s

ys

tem

Expanding new models of care to the whole population, and integrating secondary care, community mental health, voluntary sector

and Local Authority services

End of contractual

term

Transformation programme completed

Ongoing performance monitoring supporting a programme of continuous improvement

Contract end triggering commissioning

decision

Implementing and managing the new payment and incentive model in full

Ongoing care transformation


ISAP: checkpoint 3

ICS “go live”


Assuming system sustainability and the delivery of care in line with the new contractual arrangements, this phase will naturally conclude at the end of contract. Per the economic case, this is expected to be April 2022 or April 2023. At this point, the CCG will need to agree a preferred approach for commissioning these services on-going.

The steps required for this phase under the open market procurement approach would be the same.

5.5 GOVERNANCE

Implementing an ICS across Hounslow is a change of significant scale. It also requires a transformation of the traditional roles of commissioner and provider. As such, careful consideration must be given to the right forums and milestones for decision-making (ensuring appropriate control), as well as the assurance mechanisms proposed to provide further safeguards in managing risk. This section provides detail on the proposed governance principles, key decisions and arrangements for the three phases.

Governance principles

The following principles inform the governance framework proposed for the phases of this transformation:

All governance arrangements are targeted towards the safe achievement of Hounslow’s integrated care aims and objectives. These will act as the guiding light for all decision-making.

The Hounslow CCG Governing Body holds overall accountability for agreeing and overseeing the transaction of this transformation and so must be suitably satisfied with the appropriateness, robustness and detail of preparedness and delivery across every phase.

London Borough of Hounslow are expected to become a commissioning partner for the ICS and governance arrangements must detail their role and responsibilities particular in regards to their statutory duties. Potential fora for their involvement include the Health and Wellbeing Board, and the Joint Commissioning Board.

There is clear definition for the roles and responsibilities of decision-makers, as well as appropriate measures for assurance and scrutiny to hold decision-makers to account.

Appropriate fora and channels for decision-making are identified or established when required, providing transparent “line of sight” from the Governing Body through to the frontline of service delivery.

There is a consistent approach to recording and managing risks, and for escalating issues should they arise.

NHSE and NHSI as the regulators are engaged about intentions and plans throughout, and involved in decision-making as required. This is particularly pertinent in the event that ISAP is applied.

Regional stakeholders (i.e. the commissioners and providers comprising the NWL STP) are kept informed about plans and progress in Hounslow. This will ensure consistency in achieving regional ambitions, as well as providing a platform for discussion on those issues that transcend the borough’s boundaries e.g. patient flows across the border, and the integration of services commissioned at a regional level (including secondary care).

There are opportunities for stakeholders including patient and carer representatives, clinicians and other provider staff to contribute to governance arrangements throughout the phases.

Another key principle to be adhered throughout is the management of potential conflicts of interest. It is recognised that GP members of the Governing Body may be conflicted through their involvement at a senior level with the Hounslow Consortium. While the input of GP members is essential to developing an integrated model of care with resilient primary care at its heart, the Governing Body should continue to manage potential conflicts of interests in line with its current policy and arrangements.

Governance arrangements

To support robust governance and appropriate decision-making throughout the three phases, the programme structure described in figure 5.6 below is proposed:


Figure 5.6: Proposed governance structure for the ICS implementation

The responsibilities of each of these bodies is summarised below:

Hounslow CCG Governing Body – holds overall accountability across all three phases. Will make the ultimate decisions (including decisions at OBC, initial and updated FBCs and end of phase checkpoints) review and approve all programme deliverables.

Hounslow CCG Finance and Performance Committee – responsible for consideration of the potential financial implications of decisions at each phase.

Integrated care transformation steering group – a proposed new body which would provide oversight of the programme and make decisions on the overall direction of travel and the detailed next steps. Members will include commissioner and provider leads.

Provider alliance programme executive – evolving from the existing STP Implementation Group, this forum will bring together senior representatives from the alliance partners to take day-to-day decisions informing the management of the implementation programme, and the future “business as usual” operations. Throughout implementation it will hold primary responsibility for reviewing and reporting progress, and for managing and escalating risks and issues as appropriate.

Implementation workstreams – the workstreams will be responsible for putting decisions in practice, driving the progress of the change programme. Each will have an agreed provider lead, with a supporting structure and specialist technical input as necessary to put change in practice.

Locality patient participation group (PPGs) – will continue to provide the main forum for patient and public engagement in developing, challenging, rolling out and communicating about change.

These responsibilities will be captured in new or updated terms of reference documents providing for clarity in all governance arrangements.

Assurance arrangements

The governance arrangements described above will provide for an environment with robust, safe and effective decision-making. This will be augmented by appropriate assurance arrangements, offering an additional level of oversight and scrutiny for local decision. The programme will engage with the assurance bodies listed below:

Key:

Reporting line

Communication

of decisions

Hounslow CCG

Governing Body

Integrated care

transformation

steering group

Provider

alliance

programme

executive

Locality Patient

Participating

Groups

Hounslow CCG

Finance and

Performance

Committee

Implementation workstreams including:

Model of care development

Locality planning

Workforce and organisational development

Payments and incentives

Communications and engagement

IM&T and digital

Estates

Reporting


Hounslow Health and Wellbeing Board – the scope of this transformation and the involvement of the local authority warrants the use of the Health and Wellbeing Board as a coordinating committee for integration. It will bring together CCG and local authority colleagues to oversee progress and to jointly scrutinise provider plans. It will also provide a forum where key challenges and opportunities can be explored together.

Hounslow Oversight and Scrutiny Committee (OSC) – the involvement of the local authority (including financial commitments to this programme) may require engagement with the OSC. This will present an opportunity to debate local plans, and to provide assurance over the robustness of decision-making throughout the process.

NHSE – as the health system regulator, it will be essential to maintain close links with NHS England throughout this process. They will be informed of plans, and kept updated on progress. If a procurement is required, then the CCG will also be required to interface with ISAP to assess the suitability and robustness of the procurement approach.

NWL CCGs – in line with the principles of the NWL collaboration, Hounslow CCG will continue to update fellow NWL CCGs on local objectives and plans – highlighting areas of potential impact on other health economies.

5.6 CAPABILITY AND CAPACITY REQUIREMENTS

The delivery of each phase will require the right skills and resource. If these are not in place, then there is an enhanced risk of falling short in terms achieving a successful conclusion within the timescales described. While the detailed requirements of each phase imply a varying emphasis on the expertise and capability necessary, the capabilities needed to drive progress throughout the programme are listed below.

Capability Required by commissioners?

Required by providers?

Business and organisational design – driving provider alliance development, to ensure that the right functionality and form is in place to drive the outcomes of integration

Change management – supporting the development and implementation of a structured approach to moving the system overall and partners individually from the current state to the desired ICS model

Managing significant and complex programmes – to drive the programme forward, with the skills to flexibly respond to challenges as they arise. This will also include the experience to effectively plan for – and release – the benefits sought

Innovative payment mechanisms – to support the deeper integration of care through new payment and incentive mechanisms (including capitated budgets, outcomes-based payments and gainshare), with practical input to resolving technical challenges

Integrated governance – developing effective ways of decision-making across the ICS, with clarity over structures and processes to safely and effectively manage the delivery of care between partners

Legal advice – to support the selection or procurement of an ICS, as well as to provide specialist legal input to ad hoc queries and issues as they arise

New model of care development and pathway redesign – to facilitate the co-production of models of integrated care models with additional input from patients and clinicians

Organisational development – to support the cultural change required to support integration at all levels – leadership, management and operational

Specialist procurement, contracting and financial expertise – if a procurement is required, there will be a need for the technical expertise to


Capability Required by commissioners?

Required by providers?

set up and successfully manage a robust procurement exercise

Stakeholder management – to identify, map, and support the engagement with a significant number of local and regional stakeholders with a wide range of communication and information requirements

Subject matter expertise for technical matters including HR, IM&T, VAT and pensions – to inform the provider selection process as required, and to then support the development of system infrastructure by providing specialist input to overcome recognised implementation issues

Supply chain management – recognising that designing, implementing and operating the ICS will require excellent relationships (between providers, and between the commissioner and providers) potentially including formal subcontractor arrangements

Transformational leadership – to steer the move away from transactional towards transformational care delivery, bringing partners along the journey, to realise the objectives of integration

Figure 5.7: Required system capabilities for ICS implementation

The CCG and its system partners will have some of these capabilities in place already. Further expertise is accessible at North West London level. A system audit would be helpful to identify the skills available to the programme.

Additionally, plans should be put in place to ensure that specialist expertise and sufficient capacity is available at the right times. Capacity requirements will naturally flex up and down through different phases of the programme. In response contingency plans should exist – including accessing support from outside the system where necessary.

It is proposed that a programme team is hosted and resourced by the CCG to provide a consistent level of capacity, drive and momentum to this complex and challenging programme of work. It is not possible to quantify an estimate at this OBC stage. As system requirements become clearer through co-production with the provider alliance, an estimate will be calculated and included in the initial FBC for Governing Body consideration. This will reflect national and regional experience of programmes of similar nature and scale.

Changes currently taking place at regional (North West London) and local level may release resource and capacity to support this programme. Regional teams are taking on some local responsibilities, and this could offer additional capacity for this work in Hounslow. At the same time, changes in team structure at the regional level may lead to experienced, capable staff becoming available to work in Hounslow either permanently or on secondment.

Discussions are on-going as to how the necessary external expert support can be provided to all CCGs in North West London e.g. via a call-off order or shared appointment of advisors. The CCG would expect to require advice on finances, contracting and procurement, legal and VAT.

Progressing with the development of an ICS will also require additional capacity from existing system leadership and management capacity to:

oversee the parallel workstreams of preparing the system for the ICS, while also designing and implementing the change. This will take place in the context of the CCG’s “business as usual” and plans must be in place to oversee transformation without detriment to day-to-day operations;

continuously engage the public, partners, and the market (as required), with system partners holding each other to account in demonstrating the right behaviours;

fund backfill for providers partners (including clinicians) play a full role in co-designing the ICS and its implementation. This will include freeing up sufficient resource to oversee specific workstreams;

refresh local plans (including commissioning intentions, QIPP, CQUIN and provider continuous improvement plans) to ensure these coherently work towards achieving the CCG’s strategic integration aims; and

maintain links with the NWL Collaboration and the CCG’s own membership to ensure common understanding of the rationale for the ICS will also be important and resource intensive.


5.7 COMMUNICATIONS AND ENGAGEMENT PLANNING

The CCG recognises and is committed to its responsibility and duties to engage with patient representatives and the wider public. Going further, this business case describes an evolution in respective responsibilities, and the CCG is proposing to work even more closely with local people to drive more integrated care.

Building on this commitment, the CCG has prepared an integrated care engagement plan setting out how the CCG and the local authority propose to work together with Hounslow stakeholders (including residents, patient representative groups, community leaders, GPs, primary care teams, local councillors, Healthwatch and voluntary sector organisations).

At the heart of this are detailed proposals for working with communities to improve health together. This reflects evidence suggesting that the most effective health and care services are those that have been developed and designed in partnership with the people that use them. The plan also describes how patient needs and experience of care delivery will become even more integral to care planning and delivery.

It is expected that this plan will be formally agreed by the CCG in September 2018. It will form an annex to this OBC and will be used to practically direct the engagement described in the management case.

5.8 RISK REGISTER

Figure 5.8 sets out the primary risks to the implementation of an ICS are split into three categories:

1. Common programme risks;

2. Risks specifically associated with implementing the ICS through an open market procurement approach; and

3. Risks specifically associated with implementing the ICS through a collaborative approach based on further developing the provider alliance.

These will need to be reviewed and refreshed at each stage to ensure risk level and proposed mitigations remain appropriate and proportionate.

Common programme risks are set out in the table below.

Key:

L = likelihood, with 1 being virtually impossible, and 5 being probably will occur

I = impact, with 1 being minimal impact, and 5 being major impact

Σ/25 = the total risk rating based on likelihood x impact

Category Risk Mitigation L/5 I/5 Σ/25 Owner

Engagement; scope

If the CCG cannot confirm the local authority’s appetite to include its services and budgets in the ICS and, in particular for a non-binding signal to the market that this option is being considered, there is a risk that the opportunity of an ICS scope beyond CCG-commissioned services might be delayed or lost

Senior liaison with the local authority is required to establish its position

3 4 12 CCG senior responsible officer (SRO)

Engagement, scope

If the commissioner does not seek the views of fellow commissioners (e.g. local authority, and other NWL CCGs) on the services in scope then this may lead to negative financial impact and non-viable services

Formal consultation with fellow commissioners on the proposed scope of the services

3 3 9 CCG SRO

Engagement If the London Borough of Hounslow Overview and Scrutiny Committee challenges the level of public engagement to date and in the future, there is a risk of delay to the programme

Opening and then on-going engagement with the OSC

Provision of clear evidence of engagement to date

Assessment of the requirements for consultation at every stage

3 3 9 CCG SRO; engagement lead



of the programme

Engagement If there is adverse public opinion regarding the programme, there is a risk that this will undermine the perception of stated benefits and the reputation of the CCG

Establish effective and appropriately resourced communication and engagement function for the programme

Senior clinical and officer input into delivery


Engagement If relationships with incumbent providers and STP partners are not maintained throughout the procurement, there is a risk that adverse opinion forms that undermines the credibility of the CCG and the development of the ICS

Establish effective and appropriately resourced communication and engagement function for the programme

Senior clinical and officer input into delivery


Engagement If the CCG’s Governing Body is not provided with sufficient information, support and briefing time then there may be delay to decision-making on the outline and full business cases

Review of OBC at September Governing Body

Confirming FBC on forward agenda for Governing Body in 18/19

3 4 12 CCG SRO and programme management office (PMO)

Engagement If the CCG’s approach is misaligned with that of the STP overall or individual NWL CCGs then there may be a loss of confidence in the programme by incumbent providers, potential bidders and stakeholders leading to challenge and delay

Close liaison with the STP and other NWL CCGs to align approaches to provider development, financial improvement and approach to market

Agreement of respective timetables and communications plans

4 4 16 CCG Chair, MD and AO

Regulation If the regulators confirm that ISAP is applicable, there is a risk that the assurance phases take longer than accommodated in the programme plan leading to delays

Liaison with NHSE/I for an early identification (or informal steer) on whether ISAP will apply; updating of programme plan based on information from other care systems on ISAP timelines

On-going close liaison with NHSE and NHSI through the ISAP checkpoints

3 3 9 CCG SRO

Regulation If the regulators (during ISAP early engagement and/or Checkpoint 1) feel that the CCG’s investment decisions present excessive financial risk to a potential provider then this may result in significant delay and potential closure of the programme.

ICS budget and proposed contractual terms are designed to provide sustainable provision of core services

Effective long-term financial planning by the CCG

Effective interventions for savings identified for pre-procurement, pre-award and after go-live

4 4 16 CCG finance lead

Contract management

If the programme plan does not keep to schedule over 2018/19 and 2019/20, there is a risk that existing contracts will need to be extended to ensure continued operational delivery, impacting contractual arrangements

Proactive management of programme plan

Early engagement with current contract holders to manage the extension of existing contracts as required

Financial planning for

3 3 9 CCG SRO, CCG contracts lead



2019/20 to include potential requirements for the mobilisation phase, including transitional costs incurred by the provider, transformational investment, etc.

Programme resources

If the CCG does not/cannot secure and deploy the necessary resources (people and/or funding), there is a risk that the post-September Governing Body programme plan will be delayed

Long-term resource planning; alignment of internal resources and identification of external support requirements

3 4 12 CCG SRO, PMO

Programme resources

If there is change to CCG leadership team and Governing Body during the process this could lead to loss of corporate memory, competing priorities and changes to levels of support for the ICS

Governing Body is supported to develop broad and deep ownership of the ICS and its risks and benefits

Succession planning is undertaken

3 3 9 CCG Chair, AO and MD (managing director)

Engagement If an NWL-wide programme for integrated care develops this could lead to delays and/or distraction from the approach in Hounslow

Proactive briefing and engagement with STP partners to explain the approach and benefits of the Hounslow approach

2 4 8 CCG SRO

Finance If the investment in an ICS is not supported by a credible long-term financial plan then there could be challenge in the Governing Body supporting the business case and/or achieving progression through ISAP Checkpoint 1

Develop a financial recovery plan that can support the potential affordability of the ICS

3 3 9 CCG finance lead

Governance If conflicts of interest are not managed appropriately throughout the process – (including during a procurement stage) then there is a risk that the integrity and robustness of the process will be challenged

ICS steering group terms of reference that set out the CCG’s approach to conflict of interest management

Seeking legal advice to update conflict of interest management

Future Procurement Steering Group (or similar) terms of reference that include approach to conflict of interest management

2 4 8 CCG SRO

Quality If the clinical pathways developed by the ICS for the new service contract do not dovetail with services left outside of the scope, there is a risk of continued fragmentation of care at hand-offs and sub-optimal health and wellbeing outcomes

Early engagement with existing service providers to understand existing processes and identify interfaces

Assurance through procurement responses

2 4 8 CCG SRO, quality lead

Figure 5.8: ICS programme risk register

Risks specifically associated with implementing the ICS through an open market procurement approach are set out in figure 5.9.


Procurement, If there is a legal challenge Early engagement with legal 2 4 8 CCG SRO



legal during the procurement process, there is a risk of delay to or cessation of the programme

advice to cover all relevant questions, including engagement and procurement

On-going engagement with legal advice to manage ad hoc queries

Contract management

If incumbent providers do not form a bid or are unsuccessful during the procurement process then there is potential for uncooperative behaviour leading to delay and additional cost to the CCG

Early requests of data (e.g. TUPE, IT and estates)

Proactive involvement of NHSI and NHSE in the process of contract management

Continued engagement with incumbent providers alongside a fair and transparent procurement process followed

Establishment of contingency budget for unforeseen expenditure

2 4 8 CCG SRO, CCG contracts lead

Programme resources

If the enabling workstreams (IT, estates etc.) are insufficiently resourced then there could be delay in provision of information to bidders leading to potential uncertainty for bidders and reduced value from bids

Recruit to all key roles with discrete objectives and functions within each workstream

4 3 12 CCG SRO

Finance If incumbent providers are not maintained throughout the procurement, there is a risk that “care-taker” arrangements need to be put in place which could have financial consequences for the commissioner

Effective engagement with existing and potential providers

Proactive engagement with regulators

3 3 9 CCG SRO, CCG finance lead

Finance If unforeseen significant costs (e.g. estates backlog maintenance) emerge during the procurement process, there is a risk that this results in a reduction of value for money from the bid or additional costs for the commissioner

Full disclosure by providers of relevant information regarding transfer of resources and provide this to bidders

CCG to make provisions for unforeseen costs in its financial plan

3 3 9 CCG SRO; CCG finance and procurement leads

Market engagement

If market engagement provides insufficient evidence of credible market interest then this will lead to delay of the procurement and delay to achieving the intended benefits of an ICS

Structured, open and honest sharing of information and views between commissioner and potential providers

Consideration of expression of interest phase prior to sSQ

2 4 8 CCG procurement lead

Procurement If the procurement attracts limited interest/contest from credible ICS partners then this may reduce the CCG’s ability to secure a high-quality offer from the market that provides the expected benefits

Thorough and informative market engagement phase

Clearly articulating an attractive commercial deal for providers through the contracting documents

Opportunities for (specified) dialogue during the

3 3 9 CCG SRO



procurement

Procurement If the procurement identifies that there is no suitable partners for or providers of an ICS then this will lead to loss of benefits

Creation of contingency plan for each phase of procurement (expression of interest, sSQ, ITT1, ITT2, mobilisation and go-live)

3 4 12 CCG SRO and procurement lead

Procurement, legal

If there is a legal challenge during the procurement process, there is a risk of delay to or cessation of the programme

Early engagement with legal advice covering all relevant questions, including engagement and procurement

On-going engagement with legal advice to respond to ad hoc queries and issues

2 4 8 CCG SRO

Quality If uncertainty affects incumbent providers’ ability to recruit and retain staff during 2019/20 and 2020/21 there is a risk that the quality of care may deteriorate in advance of the ICS launch date

Enhanced quality monitoring of relevant metrics and devise direct communication channels to staff, in partnership with incumbent providers

2 3 9 CCG SRO; CCG quality lead

Figure 5.9: Risk register for implementing an ICS through an open market procurement

Risks specifically associated with implementing the ICS through a collaborative approach based on further developing the provider alliance are set out in figure 5.10:


Procurement, legal

If there is a legal challenge during the renewal of contracts for incumbent providers in 19/20 and 20/21, the programme could be delayed, there would be significant costs of responding to the action and the resource intensity of accelerating towards procurement

Early engagement with legal advice covering all relevant questions, including engagement and procurement

On-going engagement with legal advice to respond to ad hoc queries and issues

Contingency planning for procurement

2 5 10 CCG SRO

Procurement, legal

If, as a result of neighbouring CCGs’ procurements/market activity, there is increased interest in the approach taken in Hounslow then there is a risk of potential challenge (Public Contract Regulations 2015) to the alliance development in 19/20 and 20/21 leading to potential delay and additional cost

Provide clear notices to the market (e.g. PIN, award notices etc) for transparency of decision making

Effective communications through public governing body documents or equivalent

If required, stipulate the timetable for a full open procurement

3 4 12 CCG SRO



Contract management

If incumbent providers do not respond positively to the proposed scope, specification, savings profile and contractual terms from the CCG then there is a risk of a loss of benefits in 19/20 and 20/21 leading to delay in outcomes improvement and pressures on future financial sustainability

Create detailed commercial (including negotiation) strategy for each contracting round

Identify the support requirements for the alliance through assessment process

Establish co-production approach with alliance partners

Analysis of available and expected benefits required in 19/20 and 20/21

Assessment of investment strategy and methodology for 19/20 and 20/21

3 5 15 CCG SRO

Contract management

If the pre-procurement savings approaches, procurement process and procurement outcome for similar regional programmes (including Ealing’s procurement of a single out-of-hospital provider) disrupts Hounslow’s alliance providers then this may lead to a loss of focus on the alliance and challenge to the sustainability of the existing services in scope leading to loss of benefits expected for Hounslow

Tracking of similar regional programmes through regular interaction

Scenario planning of potential outcomes from regional approaches

Combining financial savings programmes (pre-procurement outcome and following award of contract)

5 4 20 CCG AO, MD, finance lead and SRO

Figure 5.10: Risk register for implementing an ICS through continuing collaboration with the provider alliance

5.9 CONCLUSION

This management case recognises the scale and impact of the implementation of an ICS in Hounslow. Timescales are tight, and require the involvement of multiple committed and capable partners. To do this right, it will be essential that each stage is carefully planned to produce the deliverables sought.

This case sets out the activities, milestones and decisions required from the respective phases of designing, implementing and managing the change. It also describes the building blocks underpinning the entire transformation programme – the governance principles and arrangements – to oversee progress and manage risk.

Effective controls will be key to success. The CCG Governing Body will hold overall responsibility for the programme, and be accountable for its safe implementation. As well as the internal governance arrangements described, the programme should also interface with external bodies to provide assurance. This scrutiny provides an additional safeguard.

Change at this scale requires expertise and sufficient capacity. The CCG should work with its local partners to identify those in place currently. It must address gaps as a matter of priority, ensuring that the programme has access to the right skills and external input (e.g. legal advice) at the right times to succeed.


A. DICTIONARY OF ABBREVIATIONS USED

Term Definition

A&E Accident and emergency

AO Accountable officer

ASCOF Adult social care outcomes framework

BCF Better Care Fund

BMA British Medical Association

CCG Clinical Commissioning Group

COPD Chronic obstructive pulmonary disorder

CQUIN Commissioning for Quality and Innovation

CRS Community recovery service

CWHFT Chelsea and Westminster Hospitals NHS Foundation Trust

FBC Full business case

FYFV Five Year Forward View

GLA Greater London Authority

GP General practitioner / general practice

HRCH Hounslow and Richmond Community Health NHS Trust

HWBB Health and Wellbeing Board

IAPT Improving access to psychological therapies

ICS Integrated care system

ICRS Integrated community response service

IM&T Information management and technology

ISAP Integrated support and assurance process

ITT Invitation to tender

JV Joint venture

KPI Key performance indicator

LSOA Lower super output area

MD Managing director

MDT Multi-disciplinary team / multi-disciplinary team meeting

NHS National Health Service

NHSE National Health Service England

NHSI National Health Service Improvement

NWL NHS North West London Collaboration of Clinical Commissioning Groups

OBC Outline business case

OJEU Official Journal of the European Union

ONS Office for National Statistics

OSC Oversight and Scrutiny Committee

PCPC Primary care practice coordinators

PIN Prior Information Notice


Term Definition

PMO Programme / project management office

PPG Patient participation group

QIPP Quality, Improvement, Productivity and Prevention

SaHF Shaping a Healthier Future

SRO Senior responsible officer

sSQ Standard selection questionnaire

STP Sustainability and transformation plan

TUPE Transfer of Undertakings (Protection of Employment) Regulations 2006

WLMHT West London Mental Health NHS Trust

WSIC Whole Systems Integrated Care


B. NORTH WEST LONDON SINGLE OUTCOMES FRAMEWORK

Outcome Domain Outcome

1. People have an overall quality of life

A. 'I am aware of the choices and options I have to manage my health and social wellbeing'

B. 'I am given choices about how to manage my wellbeing and feel supported to make decisions'

C. 'I establish my own goals, feel confident about achieving them, and am helped to do so'

D. 'My overall experience of care helps me to improve my quality of life'

2. Care is safe, effective and people have a good experience

E. 'I feel safe, secure, in control, and respected'

F. 'I receive care at the right time and in the right place'

G. 'My carers are fully involved in my care and feel empowered'

3. Professionals experience an effective integrated environment

H. 'As a care professional, I feel jointly responsible for the outcomes that service users achieve'

I. 'As a care professional, I work as an integrated team and trust my colleagues'

J. 'As a care professional, I feel empowered to make the right decisions and find it easy and not bureaucratic to do so'

K. 'As a care professional, I feel supported in my development by local training and management practices'

4. Care is financially sustainable

L. 'The care I receive is part of a system that is sustainable for the long term'

M. 'I benefit from proactive care to maintain my health and wellbeing as well as reactive care when I need it'

5. Care is efficient, process defined and personalised

N. 'I receive a seamless and efficient service across different teams and care professionals'

O. 'I have a shared care plan and my time is not wasted by the repeated gathering of information'


C. HOUNSLOW “I” STATEMENTS

Patients I receive safe and appropriate care at the right time, preventing my needs becoming more complicated where possible.

I’m confident that I received support designed to deliver the best health and social care outcome for me

I am supported by a great team that work well together and enjoy their work

I know how and can make use of voluntary and community services that offer support I need in addition to the health and care services I receive

I know that technology is used to innovate and improve the support I receive – including providing the tools and information I need to help me live a healthier, independent life

I’m confident that available resources are used in the most effective way to provide my care

Carers My dependant receives safe and appropriate care at the right time, preventing my needs becoming more complicated where possible.

I’m confident that I received support that enables me to deliver the best health and social care outcomes my dependant.

I am supported by health and social care professionals who enjoy their work

I know how and can make use of voluntary and community services that offer support I need in addition to the health and care services I receive

I know that technology is used to innovate and improve the support I receive – including providing the tools and information I need to help my dependant live a healthier, independent life

I’m confident that available resources are used in the most effective way to provide my care. I feel I am valued as an individual person as well as a carer

Professionals I’m confident that I provide safe, effective services that deliver the same quality outcomes as my professional peers

I am able to work with partners – without barriers or constraints - to improve the availability and quality of services available

I love my work in Hounslow and I’m motivated to contribute to make the system even better

I feel like have influence and control over my workload and the way that services work around me and Hounslow residents

I can direct people to make use of a range of voluntary and community services – improving wellbeing while reducing my workload

I can use new and innovative technology and tools to make my work easier while improving patient care

BUSINESS CASE FOR INTEGRATING CARE...1.5 DELIVERING ON NATIONAL, REGIONAL AND LOCAL INTEGRATED CARE...

Documents

Transcript of BUSINESS CASE FOR INTEGRATING CARE...1.5 DELIVERING ON NATIONAL, REGIONAL AND LOCAL INTEGRATED CARE...