Accountable Care

Partnerships (ACP)

Programme

Programme Initiation

Document (PID)

Executive Summary

INTRODUCTION 2

Through our work on integrating care delivery over the last few years, we have identified the need for a new approach in North West London – one that focuses on improving population health and which incentivises quality care delivery, rather than simply focussing on demand management or tracking the volume of services used. Designing a system that makes us accountable for joining up care for our population not only requires a redesign services but it also requires us to redesign our business models - the way we commission and pay for services, as well as the culture within our health and care system.

There is growing recognition both locally and nationally that accountable care ways of working provide the best opportunity to enable truly sustainable changes in provision of quality of care. Developing Accountable Care models across the 5 CWHHE CCGs1 is therefore recognised as the logical extension of our journey to date and as a necessary enabler for our local and national ambitions for health and care services.

The purpose of this document This document forms the executive summary of our Programme Initiation Document which has been developed to drive and guide our ambitions for sustainable integrated care across the boroughs covered by the CWHHE CCGs.

The items included in this summary reflect the discussions at the recent Governing Body seminar events, as well as giving an overview of the key elements of our programme structures and approach. The full PID document has been previously shared with Governing Body members and is also available by contacting ACPPMO@nw.london.nhs.uk

1 Comprising Central London, West London, Hammersmith & Fulham, Hounslow and Ealing CCGs

What the Programme Initiation Document (PID) is … 3

A document to capture and record basic information in order to set out, properly define and plan our programme

The document that describes the philosophy and aims for accountable care

A description of the programme of work we need to undertake – or the things we need to think about – in order to arrive at accountable care proposals, recommendations or options

A pre-planning document designed to set in motion the work that will take us to full action planning, engagement and co-design

A reference for key decision making points on our journey

What it is not.... A plan for implementing decisions – no decisions (for example around size, number, scope of ACPs) have

been taken

The document that provides the answers to challenging questions such as budgets, money flows – it only tells us the work we need to do to deliver them

A blueprint for ACP's or any other accountable care model – we need start the work to figure this out

A live document - once approved the PID is not usually updated until there is a fundamental change in the programme scope (for example once contracts have been awarded)

The last word on ACP programme plans – we are using a ‘gated’ programme structure, underpinned by a commitment to engagement and co-production, giving plenty of opportunity for Governing Bodies to steer and agree developments as they emerge

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Our journey towards an accountable care system

Our journey started with the Whole Systems Integrated Care (WSIC) programme which became part of NHS England’s Integrated Care Pioneer programme

WSIC programme led to integrated care pilots and latterly, sustainable service transformation; WSIC tools were also developed to support the early development of ACPs

Case studies - what is the evidence that it works? 5

In England there are a number of accountable care models emerging and now in operation. There is increasingly compelling evidence of the high impact of these approaches and a growing understanding of what works in the NHS. A recent report by the Policy Innovation Research Unit also highlighted some of the key benefits of integrated services and accountable care ways of working:

Across the world accountable care systems have been in operation for some years and the evidence of sustainable improvement and transformation is growing

Fit with the NW London Sustainability & Transformation Plan (STP) 6

The NW London STP vision is :

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

Accountable Care development is recognised as a key STP enabler. The programme in CWHHE aims to assist in achieving the STP vision by adopting the following motto to guide and drive our work:

One System, One Budget, Better Outcomes

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The implementation plans in summary...

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

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

Duplication of efforts: Without understanding the total story for each individual, providers duplicate efforts and together we over-consume health resources

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

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

Long-term system sustainability: All of the above combine to drive up expenditure and contribute to the long term unsustainability of the health and care system

ACP Transformation

• Commissioning• Financial Incentives• Risk/Reward• Organisation form

Business problems (BP)

1. Fragmentation of services2. Misaligned incentives3. Duplication of effort4. Unclear Access Points5. Long term sustainability

addresses BP

Enabling

ACP

EnablingCausing

Care Transformation (STP Delivery Areas)

DA1 - Radically upgrade prevention and wellbeingDA2 – Eliminate unwarranted variation and improve LTC managementDA3 – Achieve better outcomes for older peopleDA4 – improve outcomes for children and adults with mental health needsDA5 – Ensure safe and high quality acute care

Care Problem

1. Lack of self care and well being2. Unwarranted variation in care3. Poor quality care in the last phase of life4. Inappropriate care settings5. Unnecessary treatments6. Poor mental health outcomes7. Social isolation

addresses CP

Building on global best practice our ACPs will be:

Built around the registered population

Focused on Outcomes Based Commissioning

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

Inclusive of the functions most necessary to deliver those outcomes

Accountable for end-to-end population care, with integrated data systems

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

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

Embedding service users in decision-making and governance

Now

Publish DraftDefinitionFrameworkPublish Final

DefinitionFramework

Seek Expressionsof Interest

Decide onRoute to Market

Confirm Approachto Contract Award

Now‒ CCG GBs recap on ACPs‒ Initial draft of definition framework‒ CCG GB sign-off of framework draftPublish Draft Definition Framework

ContractAward

Mobilisation

ContractCommencement

Transition

Full ACP Operation

There is a compelling need for change… …our plans support STP transformation… and are based on evidence of what works.

We are working towards a phased implementation… using ‘gated’ delivery plans… …and a structured approach to contract award.

The PID describes the scale of resource that is required to manage

and deliver the programme

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Current Resourcing Work is currently being driven by a substantive Programme Director, supported by a small and interim team, with input from nominated functional leads in other teams and supported by some external expertise.

Future Resourcing The PID sets out the programme’s workstreams (below) and resource requirements for the next stage of work. The resource strategy is built on a set of overarching principles: sustainability, flexibility, expertise, and working & learning together.

The resource network model In order to access the different inputs needed, a network model is envisaged that brings together expertise and input from different sources, built around a strong core team with specialist input. The diagram below summarises this model – the highlighted circles (items 1-3) are the main programme requirements.

The programme workstreams The resource network model

Governance & Risk Management 9

Risk Management

Risk management structures and processes are outlined in the PID and are an essential part of the effective governance arrangements that are being developed. The diagram (right) provides an overview of the approach and principles that are being used.

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

Interim & formal governance

Interim governance arrangements have been established to support programme mobilisation. All CWHHE CCGs are represented at an initial programme board and workstreams are managed through an operations committee. The interim arrangements are described more fully in the PID itself

The current temporary arrangements are not sustainable and need to be replaced as soon as possible by formal structures. The principles guiding the development of formal proposals are set out in the PID.

Scheme of delegation

To ensure efficiency of decision making it is proposed that Governing Bodies delegate agreed levels of authority to the Accountable Care Programme Board once fully constituted. A draft Scheme of Delegation outlines the major decision areas that are being tested to determine where the most efficient (and safe) decision making authority lies. Final proposals on the most effective approach to delegation will be presented (along with proposals for formal governance structures) to governing bodies in January 2017.

More information… 10

For more information or for a copy of the full PID summarised in this

document please contact ACP.PMO@nw.london.nhs.uk