Appendix 1 Adult Mental Health – Integrated …...Adult Integrated Commissioning Intentions 2014...

Adult

Integrated Commissioning Intentions 2014

From crisis to recovery and

turning the system on its head

Adult Mental Health –

Commissioning Intentions 2014

(Draft 27/12/13)

From crisis to recovery and personalised support

urning the system on its head

1

Appendix 1

Commissioning Intentions 2014-15

personalised support -

Contents

1. Introduction

2. System change – delivering our

3. Embedding co-production

4. Commissioning / contracting architecture

5. Savings options and support for transition

Appendix 1 – Progress to date

Appendix 2 – Lambeth Council Outcomes

delivering our “Big Three” outcomes and resources

production – working toward an asset based approach

Commissioning / contracting architecture – levers

options and support for transition

Progress to date – LLWC (OCT 2013)

Lambeth Council Outcomes-Based Budgeting (Sept 2013)

2

outcomes and resources

working toward an asset based approach

Based Budgeting (Sept 2013)

1. Introduction

This paper sets out the CCG/LA

intentions for 2014/15 and direction of travel

AMH commissioning work will continue to

Collaborative (LLWC) partnership platform which aims to apply co

practice to the commissioning and delivery of care and support for people

experiencing serious mental illness (SMI). It will build upon 2013/14 commissioning

work which is outlined in the chart, “plan

(appendix 1).

Following three years of development work led by the

changes to the care and support for people are

2013. The key system changes and service deve

together with how it is proposed to address the significa

Local Government and the CCG. Section 3 outlines how we will continue to support

co-productive ways of working with people who use se

communities. Section 4 foc

contract for integrated care and support

addressing savings requirements across

requirements.

CCG/LA Adult Mental Health (AMH) commissioning

direction of travel up to 2016/17.

AMH commissioning work will continue to be supported by the Lambeth

partnership platform which aims to apply co-production



work which is outlined in the chart, “plan on a page” (page 4) and progress report

years of development work led by the LLWC major structural

changes to the care and support for people are being implemented from November

2013. The key system changes and service developments are outlined in section 2

together with how it is proposed to address the significant financial challenges facing

ocal Government and the CCG. Section 3 outlines how we will continue to support

productive ways of working with people who use services, carers and

Section 4 focuses on how it is proposed we will commission

contract for integrated care and support and lastly, section 5 sets out options for

addressing savings requirements across the LA and CCG and transitional fundin

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Adult Mental Health (AMH) commissioning

ambeth Living Well

production



and progress report

structural

implemented from November

lopments are outlined in section 2

nt financial challenges facing

ocal Government and the CCG. Section 3 outlines how we will continue to support

rvices, carers and

we will commission and

section 5 sets out options for

and transitional funding

Transforming Primary and Community Care Mental Health Services – Lambeth Living Well Collaborative 2013/14

QIPP Summary

Year to Date Full Year Forecast

Scheme

Annual

Plan Plan Actual

Variance

Over/(Under) Actual

Variance

Over/(Under)

Varian

ce

£'000 £'000 £'000 £'000 £'000 £'000 %

Review of Rehabilitation Services 776 194 97 (97) 388 (388) (50%)

Spot Placements 144 36 36 0 144 0 0%

Supported Housing Transfer 100 25 25 0 100 0 0%

Acute Bed Reductions 500 125 125 0 500 0 0%

CAMHS 200 50 33 (18) 130 (70) (35%)

MHOA -continuing care 750 188 188 0 750 0 0%

MHOA - acute/HTT 200 50 50 0 200 0 0%

Specialist 150 38 19 (19) 75 (75) (50%)

Prescribing 137 34 34 (0) 137 0 0%

Total 2,957 739 606 (134) 2,424 (533) -18%

Big 3 outcomes Six Design Principles Service User Priorities

1. Recover and stay well experiencing improved - Quality of life - Physical and mental health 2. Make their own choices & achieve personal goals, experiencing increased - Self-determination and autonomy

3. Participate on an equal footing in daily life specifically - To ‘connect’ with e.g. family, friends & neighbours

- To ‘give’ in the community e.g. community activities, volunteering, peer support

- To ‘be included’ especially in relation to education, employment, adequate income and stable housing

- To ‘participate’ on an equal footing with others with reduced stigma & discrimination e.g. in access to mainstream services, housing, education and employment

1. Improved Access; “Easy in, easy out” arrangements for all services focused on supporting “recovery” and “independence”

2. Easier access: to secondary care assessment and treatment; support for primary care including link workers; easier access back “in” should users require this ; improved discharge arrangements

3. More and Better Information: a new resource information service – both virtual and physical

4. Better Guidance: personal guide/community recovery workers within the Voluntary sector

5. Capacity where it counts: improved capacity for primary care and GPs to support and manage mental health patients including easier access to social and community support options and peer support services led by service users

6. Getting Connected: ensuring social inclusion through various means including time banking.

1. Continuity of care when care is needed

2. Effective communication between all

3. Easy access and better Information

4. Steps to tackle stigma

5. Access to work and training

6. Reduced social isolation and actions to promote inclusion

7. Bespoke services that are cultural and gender specific

8. Services that respond outside of the traditional working week hours

Key Activity Targets/ success measures

Target population group 4500 people on SMI register. In secondary care there 1600 people in A&T team and 1100 people in R&S team. The key objective is to reduce the flow in and support the flow out

Q1 Q2 Q3 Q4

600 people access new offer monthly (via LWN and through discharge from CMHT) by Mar 2014 (13/14)

150 150 150 150

Reduction in residential care spot placements of 15% by Mar 2014 5 5 5 5

Reduction in acute OBDs/beds of 10% by Mar 2014 & 20% by Dec 2014 +8 +16

All people discharged from CMHT have a Recovery and Support plan and offered personal budget

na 100%

100%

100%

Support (min) 300 people to move on from secondary care and reduction (by 10%) of people case managed by CMHT (R&S teams) by mar 2014

75 75 75 75

Increase people accessing a Personal Budget to 150 people by Mar 2014 37 37 38 38

AMH scheme

The Collaborative’s Vision

“We will [work to] provide the context within which every citizen whatever their abilities or disabilities, can flourish, contribute to society and lead the life they want to lead.”

Co-production Principles (NEF/NESTA)

1. Recognising people as assets 2. Building on people’s existing capabilities 3. Peers support networks

4. Blurring distinctions 5. Facilitating rather than delivering 6. Mutuality and reciprocity

MHOA scheme CAMHS scheme

Road Map – Key Workstreams

Working with People Differently

Mobilising people and changing our culture

Integrated services to make a better offer

1.1 Timebanking

1.2 Peer Support

1.3 My Health Locker (patient held record)

1.4 Connecting Communities

2.1 Workforce and Culture Change

2.2 Communications Strategy – website etc

2.3 Personal Budgets

3.1 Revise Collaborative Principles/Values

3.2 Reduction in Residential Care

3.3 Deliver the Living Well Network

3.4 Rehab Service Review

3.5 Forensic/MDO services

3.6 Vocational and Employment services

3.7 SLaM AMH redesign / CMHTs

3.8 Integrated Talking Therapies

3.9 Improving info and choice options – Living Well Partnership

3.10 Community Medication Prototype

Changing the way services are commissioned

Collaborative Leadership

4.1 Commissioning Framework

4.2 Modelling

4.3 Support design led approach to service improvement

4.4 GSTT Charity Bid

4.5 Collaborative Alliance Contracting/Commissioning Framework

4.6 Development of Big 3/Health of the system Metrics

4.7 PbR/Personal Budgets

5.1 Develop the case for change/ evidence base to support economic case for co-production

5.2 Continue to engage and support development of the co-operative council and SLIC

5.3 Engage with regional and national organisation and networks to promote and share co-production

5.4 Continued development of the Collaborative platform and development of metrics to assess the ‘health’ of the Collaborative

Resources

Health and Social Care budgets Total budget (£000s) Forecast outturn (as at Q1)

CCG

SLaM Adults £42,120 0

Acute overspill £659 -200

SWLSTG £962 0

CNWL £182 0

Integrated Talking Therapy £3,018 0

MH NCAs £404 0

Adult Specialist £2,068 -81

VCS £3,151 0

Total £54,065 -281

LBL

Social Care package of support £8,395

Supporting People £3,391

Total £13,237 0

Combined total

£65,851

-281

2. System change – delivering our Big Three outcomes and

2.1 System change

The Collaborative has prioritised

support the Local Authority Social C

The Collaborative has developed a range of initiatives over the period 2011

support these including: Peer

Primary Care Support Team, SWOT Team, crisis house development, resettlement

support to enable timely hospital discharge, time banking, connecting communities project,

new resource centre and personal health budgets (

appendix 1).

The next phase of development is to introduce two major structural changes to th

of care and support via the new “front door”

help and support much earlier than the current system and provide a personalised and co

productive response via integrated multi

be social care and primary care led

voluntary and community sector and some functions currently performed by secondary

care – notably initial assessment. The LWN will support people to live in their own homes

through a network based approach ac

communities (connecting communities, time banking) and through peer support networks.

The LWN will rely on fast track access to high quality specialist secondary care advice and

support which will be enabled th

SLaM AMH redesign programme. This programme aims to ensure that secondary care

services, notably community teams, are focused on early intervention and recovery and

thereby reduce the “relapse” rates amo

to move on from secondary care by the SLaM specialist teams, which will work closely

with the resources within the LWN to achieve this. The big assumption is that this will lead

to a reduction in demand on

and opportunities to invest in upstream service

programmes are currently running in parallel and will be integrated during 2013/14, details

to be agreed. The diagrams overleaf outline the overlap.

The overall timeframe for system transformation is

five). A key dependency will be on

commissioning and contractual

delivering our Big Three outcomes and resources

prioritised the delivery of three big outcomes (see

support the Local Authority Social Care outcomes framework and national MH strateg

as developed a range of initiatives over the period 2011

eer Support, Support Planning, Community Options Team;


able timely hospital discharge, time banking, connecting communities project,

personal health budgets (for more detail see progress report

The next phase of development is to introduce two major structural changes to th

of care and support via the new “front door” – the Living Well Network

help and support much earlier than the current system and provide a personalised and co

productive response via integrated multi-agency, multi-disciplinary teams. The network will

social care and primary care led and will embrace all primary care, social care, the


notably initial assessment. The LWN will support people to live in their own homes

through a network based approach across the various agencies but also with local


will rely on fast track access to high quality specialist secondary care advice and

support which will be enabled through the second major element of system change; the

programme. This programme aims to ensure that secondary care


thereby reduce the “relapse” rates amongst the SMI population. People will be supported



to a reduction in demand on secondary care, including beds, and thereby offer savings

and opportunities to invest in upstream services located within the LWN. These two


rams overleaf outline the overlap.

for system transformation is a minimum of three years (

A key dependency will be on how quickly we can put in place more

and contractual levers.

5

resources

the delivery of three big outcomes (see page 4) which

are outcomes framework and national MH strategy.

as developed a range of initiatives over the period 2011-2013 to

lanning, Community Options Team;


able timely hospital discharge, time banking, connecting communities project,

for more detail see progress report

The next phase of development is to introduce two major structural changes to the system

Living Well Network which will provide

help and support much earlier than the current system and provide a personalised and co-

eams. The network will

will embrace all primary care, social care, the


notably initial assessment. The LWN will support people to live in their own homes

ross the various agencies but also with local


will rely on fast track access to high quality specialist secondary care advice and

rough the second major element of system change; the

programme. This programme aims to ensure that secondary care


ngst the SMI population. People will be supported



including beds, and thereby offer savings

located within the LWN. These two


three years (more likely

more effective

System Change

6

2.2 Resources

System change is necessary in order to achieve better outcomes but also as a means of

achieving substantial savings across the NHS and

AMH services across Health and Social C

NHS and Mental Health specific

yet to be fixed. It is likely to be in the region of a furth

per year for the next three years at least, as outlined below.

The Local Authority is required to identify

the next three years. If applied in full

plans for AMH particularly as the system change proposed is dependent upon having

good quality social care and support services provided by

mainstream budget of £8.4m (net) is split between

to SLaM as part of the integrated AMH service AND spend on placements and care

packages. The latter is a crucial resource to support the roll out of personalised care and

support, so reductions of 40% will significantly constrain progress i

area. The Social Inclusion budget of £3.4m is a crucial resource, and currently supports

c500 people at any one time within a range of supported housing services provided by the

VCS. The expectation is that we will require more of this

a crisis, bed based system of care and support to a future care system that is personalised

and recovery focused. The figures below

NHS and Adult Social Care;

possible transitional funding to support service change

Summary of QIPP/Social care savings targets 2014

(NB FIGURES NOT CONFIRMED)

2014-15

CCG

Social care

Total

The overall savings target needs to be viewed

on AMH services which is £66m, as outlined overleaf

The ambition for improving outcomes and managing the financial

NHS and Local Authority demand an integrated approach

in other care group areas, notably children’s and older people services via SLIC. Se

four outlines the recommended

Alliance Contracting.

We wish to increase the resources and support available in t

is essentially the community setting where all

secondary care. The current investment within the LWN is approximately £23m


achieving substantial savings across the NHS and Local Authority. The tota

AMH services across Health and Social Care is c£66m, see overleaf for detail

specifically, the actual savings target for 2014/15 and beyond has

t is likely to be in the region of a further £2m (across all MH care groups)

per year for the next three years at least, as outlined below.

required to identify up to 40% reductions in social care spend over

. If applied in full, this will have an extremely negative impact on our


good quality social care and support services provided by the VCS. The

mainstream budget of £8.4m (net) is split between; social work staff that is



support, so reductions of 40% will significantly constrain progress in this key strategic

nclusion budget of £3.4m is a crucial resource, and currently supports


VCS. The expectation is that we will require more of this type of service as we move from


. The figures below do not take account of the transfers between the

are; through the Integration Transformation

possible transitional funding to support service change from the CCG/LA

Summary of QIPP/Social care savings targets 2014-2017

(NB FIGURES NOT CONFIRMED)

2015-16 2016-17 Total

6,00

4,700

10,700

The overall savings target needs to be viewed within the context of the overall investment

on AMH services which is £66m, as outlined overleaf.

The ambition for improving outcomes and managing the financial challenges across the

demand an integrated approach. This is already

in other care group areas, notably children’s and older people services via SLIC. Se

the recommended approach to integration for adult mental health

to increase the resources and support available in the Living Well Network,

the community setting where all care and support is provided outside of

The current investment within the LWN is approximately £23m

7


. The total spend on

, see overleaf for detail. For the

14/15 and beyond has

er £2m (across all MH care groups)

up to 40% reductions in social care spend over

ly negative impact on our


. The Social Care

taff that is made available



n this key strategic

nclusion budget of £3.4m is a crucial resource, and currently supports


type of service as we move from


the transfers between the

Fund (ITF) and

from the CCG/LA (see section 5).

Comments

Estimate

40%/£11.8m

16%/£66m

the overall investment

challenges across the

. This is already being developed

in other care group areas, notably children’s and older people services via SLIC. Section

mental health services via

he Living Well Network, which

provided outside of

The current investment within the LWN is approximately £23m which

includes substantial resources (social work staff and VCS

toward meeting support organised and managed

incentivise a shift in investment from secondary care into the LWN (c£7m) in addition to

the £10.7m savings as outlined below

Figure 1

LWN (£23m)

Year 1 - 2014

LWN

(£30m)

Year 3/5 - 2016

investment £55m)

substantial resources (social work staff and VCS services)

toward meeting support organised and managed by secondary care. We are proposing


m savings as outlined below.

Secondary

Care (£43m)

LWN (£23m)

2014-15 (total investment

£66m)

Secondary

Care (£25m)LWN

(£30m)

2016-17 / 2018-19 (total

investment £55m)

8

which are orientated

by secondary care. We are proposing to


9

Summary of system wide flows

As of 31st March 2013 4,548 people

Mental Illness (SMI) in Lambeth.

Lambeth although there will be people with SMI not known to their GP (perhaps

because they have not yet presented) and others with SMI who are not registered

with a GP (perhaps because they are newly arrived in Lambeth). 16% of people on

the SMI register (707 people) are over 65 years. At the end of August SLaM

recorded a total of 3,740 people under the

of whom were on CPA. About 1100 people are in recovery and support (R&S) teams

and 1600 are in Assessment and Treatment (A&T) teams. Over time many of these

people will use acute, rehab and other specialist

as other health services (GP, community

The Collaborative offer is not restricted to people with

useful starting point for considering

work and the scale of what i

admissions into both A&T and R&S services and reduce length of time spent in

receipt of SLaM services, especially in R&S and rehabilitation services. This is to be

achieved by diverting new people into other more appropriate holistic interventions

and support; ensuring people receive prompt and appropriate treatment from SLaM

services, and by facilitating existing clients to move more rapidly towards recovery

and out of secondary care.

people case managed within R&S teams and a reduction (minimum) of 25% of

people managed within A&T over the next 3 years.

Summary of system wide flows

March 2013 4,548 people were known to their GP as having

Lambeth. This is a good indication of the level of SMI in

although there will be people with SMI not known to their GP (perhaps

yet presented) and others with SMI who are not registered



recorded a total of 3,740 people under the care of CMHTs in Lambeth, 32


in Assessment and Treatment (A&T) teams. Over time many of these

people will use acute, rehab and other specialist mental health services as well

other health services (GP, community, acute hospital).

The Collaborative offer is not restricted to people with SMI, but the figures

useful starting point for considering the size of the target group of the

and the scale of what is required. The objective of system change is to reduce


especially in R&S and rehabilitation services. This is to be

diverting new people into other more appropriate holistic interventions

ensuring people receive prompt and appropriate treatment from SLaM


We are working towards a reduction (minimum) of 50% of


people managed within A&T over the next 3 years.

10

were known to their GP as having Severe

This is a good indication of the level of SMI in

although there will be people with SMI not known to their GP (perhaps

yet presented) and others with SMI who are not registered



care of CMHTs in Lambeth, 32% (1200)


in Assessment and Treatment (A&T) teams. Over time many of these

th services as well

the figures are a

of the Collaborative

system change is to reduce


especially in R&S and rehabilitation services. This is to be

diverting new people into other more appropriate holistic interventions

ensuring people receive prompt and appropriate treatment from SLaM


We are working towards a reduction (minimum) of 50% of


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2.3 Service developments

2.3.1 Living Well Network (LWN)

Implementation of the Living Well Network – went live from 18th November 2013 in

North Lambeth and will be rolled out across the Borough from April 2014. This is

being delivered by the Provider Alliance Group (PAG) within existing contracting

arrangements.

The LWN integrates various elements of the evolving service offer (Community

Options (COT), Primary Care Support (PCSS), Social Care, Peer Supporters and

assessment function (from CMHT A&T). This is located at a central hub (Stockwell)

with outreach into appropriate service settings across the borough such as primary

care practices. This will require non recurrent funding to assist with service transition

and double running during 2014/15 and 2015/16 (see section 5).

A primary care community incentive scheme to support primary care (building on the

learning from the PCSS) is being worked up with the aim of having a new scheme in

place from April 2014, funding of c£400K will be required in order to support c1,000

people (see section 5).

A key component of the LWN will include roll out of the social care enablement

function (the Assessment Action & Planning process) which will provide 12 week

intensive social care support (for eligible) people from April 2014.

System wide modelling of activity, capacity flows will be undertaken to support the

various change programmes (e.g. LWN, AMH redesign) and achievement of

outcomes.

SWOT (social work and occupational therapy) team – will continue to assess and

support people to move on from high support placements/residential care. A further

10% will be moved on during 2014/15 (baseline tbc). This initiative will be absorbed

within the proposed transforming rehabilitation services initiative (see 2.3.2 below).

Personal Health Budgets – will be scaled up from current baseline of c110

(September 2013) – with 300 people accessing PB by March 2015. People moving

on from secondary care will be prioritised. This will be funded by top slicing the care

cluster costs (see link with PbR in section 4).

Development of personal assistants (PA) – support the development of PA market

with Lambeth Council including offering opportunities to peer supporters – 100

recruited by March 2015.

Crisis House – undertake prototype of crisis house in order to support alternative

placements for people experiencing crisis from Jan 2014 to July 2014 and agree

sustainable strategy by Sept 2014. We will undertake a whole system review of crisis

care support; details will be confirmed following discussion with Lambeth and

Southwark CCGs and local authorities.

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Development of housing provision – we will further develop housing projects such as

BRiL and Norwood Rd (which were developed during 2013) and provide

personalised support attached to long term housing in collaboration with Lambeth

Council.

2.3.2 Adult Mental Health (AMH) Redesign

Remodel community and acute services – SLaM will commence service change from

April 2014. This builds on the evidence base of early intervention services (such as

Lambeth Early Onset in psychosis and OASIS in Lambeth) which have been

effective at providing treatment support on a more holistic and collaborative basis.

Headlines include reduction in caseloads of CMHTs and focus on improved recovery

and relapse rates which it is assumed will result in less demand on acute beds and

enable closure of an 18 bed ward December 2014. The CCG has made available

£750k non recurrent funding over 2013/14 and 2014/15 to support service transition

Medication management – (1) review impact of community medication prototype and

agree next steps by April 2014, (2) medication clinic review by Dec 2013 and agree

action for roll out (including QIPP) from April 2014 and (3) Review LPP review of

medication and agree local action.

Specialist services – (1) Develop alternative model for pyscho-sexual disorders with

primary care – June 2014, (2) Review consultant to consultant referrals and agree as

part of 14/15 SLaM contract and (3) Develop alternative model to current specialist

ADHD and autism assessment and treatment pathways .

Rehabilitation services – following the Rehabilitation services review (Oct 2013) it is

proposed to recommission the current in-patient services provided by SLaM (and all

residential care placements) via a single negotiated (alliance contract) procurement

process in order to secure integrated personalised care and support packages

(including housing) for the existing c200 people currently in receipt of these services

and manage future demand (see section 4 and 5).

Community Forensic Services – we will continue to develop the pathways out from

secure forensic services in collaboration with NHSE and VCS.

2.3.3 Common Mental Illness

Physical and mental health – we will work with patient groups, peer supporters to

improve the information they receive on anti-psychotic drugs; continue to support

stop smoking initiatives and work closely with other LTC initiatives (e.g. diabetes) to

ensure an integrated approach to support and treatment for people with long term

mental illness.

Access to Talking Therapies – we will extend the reach of talking therapies to older

people, people with long term conditions and people from BME communities.

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2.3.4 Equalities

Data recording - we will continue to improve recording of MH conditions within

primary care specifically to gain a better understanding of equality and equity of

access to health services for people with mental health conditions'

Access and quality of services – we will continue to monitor the impact of current and

new/redesigned services across equality groups. Whilst service take up (across

secondary care, social care and VCS) appears generally reflective of the population;

people from black communities continue to be over represented within in-patient bed

settings.

2.3.5 Health and well-being programme

We will continue to support the implementation of the health and well-being

programme across all of our key workstreams and initiatives. This will include the

development of an SLA with SLaM to support health promotion work across Lambeth

and Southwark.

3. Embedding co-production – working toward an asset based approach

During 2014/15 the Collaborative will continue to embed co-production practice

within commissioning and delivery of care and support.

Leadership – the CCG and partners will work with the Innovation Unit to test out a

system transformation road map which has already been trialled via the executive

SLIC team. This will focus on the wider system conditions we need to address to

transform services and support QIPP/LA savings over the period Dec – April 2014.

Peer support – we will scale up the number of peer supporters across all service

setting and numbers of people accessing PS from current c600 contacts to 2000 by

March 2015. This will be achieved largely by existing providers developing

opportunities within existing resources building on the funded initiatives

commissioned by the CCG/LA.

Time banking – we will continue to support (with Lambeth Council) the growth and

reach of time banking initiatives across the Borough which will further support our

“asset” based approach to meeting peoples support needs.

Community connecting – we will support the scaling up of the community connectors

initiative (the CCG developed in partnership with Certitude) in collaboration with

Lambeth Council across other LTC workstreams (including SLIC) to enable xxx

number of people to be supported. .

Workforce – We will build upon the co-production practice training which developed

out of our personalisation programme (including PHBs, support planning) and will

further develop our understanding (working with SLIC) of the competencies needed

for a workforce (clinicians, providers and users and carers and commissioners)

14

equipped to support co-production practice. Funding will be sought from HESL to

support this work.

Patient held record – we will scale up the number of people who possess their own

care plans and records in collaboration with primary care and SLaM through the My

Health Locker initiative.

Commissioning for co-production framework – we will further develop the

commissioning framework developed during 2012 and seek to enhance the insight

function with peer supporters and users and carers to help the CCG/LA become

more people /patient centred and in order to address the Francis report

requirements.

15

4. Commissioning / contracting architecture – levers

4.1 Alliance Contract

During 2013 the CCG has supported the development of a provider alliance group

(PAG - primary care, social care, VCS and SLaM) with the aim of working toward an

integrated care / support solution for people with severe and enduring mental illness

via an alliance contracting framework. The PAG is delivering the Living Well

Network but through existing contracting arrangements. The next stage is to put in

place an actual alliance contract. It is proposed to adopt a phased approach, with

stage 1 being to enter into an alliance contract for rehabilitation services with the

existing PAG from July 2014 and the second stage applying it to the whole system

from April 2015.

Benefits of alliance contracting over traditional and prime contracting:

• It champions the diversity of skills, expertise and perspectives that

different organisations bring

• It allows each organisation to maintain its own identity while working in

a legally binding way without having to create a new legal entity

• The risk share between all parties mean that everyone succeeds if the

whole service succeeds in meeting the outcomes within the budget and

everyone is at risk if it doesn’t.

• No one party or organisation dominates – it is truly collaborative.

16

Rehabilitation services transformation – stage 1 from July 2014

The CCG and SLaM recently completed a review of in-patient rehabilitation services;

the outcome was that the service could not demonstrate best value and especially

good outcomes for the level of investment of c£5.6m for c55 patients. It has been

identified that there is much overlap with the client profile supported by the social

care residential care placements budget (£5.1m) which is a service area which the

CCG and LA want to transform to support personalisation of care and support. It is

proposed that we work with the existing PAG through an alliance contracting

mechanism (subject to satisfying procurement rules) for the combined (rehabilitation)

health and social care budget of £10.7m (c200 clients) in order to achieve fully

integrated personalised care and support packages (including housing support) at

substantially reduced cost c25-30%.

Whole system integration and transformation – stage 2 from April 2015

An alliance contracting framework proposition encompassing the full Lambeth

CCG/LA spend (c£66m pa) on AMH services is being worked up during 2013 and

2014/15 with the aim of transforming the current service / support system, delivering

vastly improved outcomes (Collaborative Big Three) and providing significant

savings for the LA and CCG as outlined in section 5.

The basis of an alliance proposition would entail the award of a contract of c£66m to

an alliance of providers (across the whole system i.e. primary care, VCS/social care,

secondary care) for a minimum 7-10 year term with the aim of going live April 2015.

This would reduce the transaction costs for commissioners and providers and

crucially offer a more realistic timeframe to bring on board radical transformation

through innovation and savings, which the current stop start contracting framework

largely prohibits.

This will involve significant development work on alignment of providers, satisfying

procurement and competition rules, commercial framework, management of clinical

and financial risks etc. This has synergy with similar work being carried out by SLIC.

A key issue which will need to be resolved is how we incentivise the reduction in

demand for specialist secondary care services in order to support a more co-

productive service offer and support upstream (i.e. within the LWN) in a context

where secondary care acts as gatekeeper and provider of the majority of

interventions. This will need to be resolved and it is likely that the preferred direction

will be for a primary care, social care led system; this will have implications for the

structure of the alliance contract.

4.2 Commissioning for Quality and Innovation - CQUINs

These will be developed across Lambeth, Southwark, Lewisham and Croydon

CCGs. Priority areas are likely to be: incentivising reduction in admissions to acute

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beds; improved management of physical health; continuation of easy in and easy out

and support of recovery / personalised care – to be agreed by Feb 2014.

4.3 Payment by Results (PbR)

MH PbyR enters a shadow year during 2014/15, as yet it is unclear how this fits with

our planned system changes outlined and the development of an outcome based

approach to care and support as outlined.

4.4 Personal Budgets

We have supported over 100 people to access one off and integrated health and

social care budgets. This has been achieved within existing resources. In order to

expand and scale up we now need to access wider mainstream resources. It is

proposed that we will apply a top slice of 20% for a number of cluster cohorts to

support the development and growth of Personal budgets, a key component of the

collaborative service offer – an additional 300 people with PBs by March 2015.

4.5 Contracts for VCS

We will seek to rationalise contracts across NHS/LA where there are multiple funding

streams to help support service transformation and deliver LA/CCG savings (see

Savings - Option 2).

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5. Savings options and support for transition

5.1 Savings

Three approaches to achieving savings of £10.7million across the CCG and LA over

the period 2014-2017 are outlined below. No account has been made for the impact

of the Integration Transformation Fund. The need for transitional funding is outlined

below also; there are a number of possible sources for this which needs to be

agreed. and progressed.

Option 1 – Traditional

Option 1 set out a more traditional approach to realising savings which is for LA and

NHS to identify their own initiatives and implement largely independently. The

template completed as part of the council savings process sets out this traditional

approach and includes proposals to reduce numbers of staff (social worker) reduce

savings; achieve (marginal) efficiencies by tendering and rationalising the number

(reducing) contracts (see Appendix 1). The one advantage to this option is that it is

very clear and specific about what will be done to achieve savings. However, it also

runs the risk of the Council not meeting its statutory obligations as most services are

currently supporting people for which it has a duty to provide for. This option does

not support our service transformation goals.

Option 2 – Mixed

Option 2 provides a number of initiatives to be managed and progressed across LA

and NHS together with discrete NHS and LA initiatives. The first is in respect to re-

commission the SLaM in-patient rehabilitation service and the social care

residential/care packages budget. It is proposed we seek fully personalised care and

support packages for the current 200 people supported by this budget and achieve

savings (estimate) of 30% over 3 years as a starting point, with a 5-7 year contract

term. This approach would be extended to support discharge from longer term

complex patients supported by secondary care. The second is a rationalisation of

contracts with our larger VCS providers in receipt of multiple funding streams (Social

care, social inclusion and the CCG). The balance of savings required within the LA

would be achieved through a combination of reductions in staffing levels and service

provision as above. The overall impact would still result in significant service

reduction and therefore reduce the potential for achieving transformational change.

Option 3 – Fully integrated

The third (and preferred) more radical approach is to go for a fully integrated

approach through alliance contracting which would bring together most of our

existing provision and funding through an alliance contracting framework as outlined

in section 4. It is proposed that the CCG and LA set out the key outcomes (the Big 3)

and savings requirements in return for a 7-10 year contract, with review and break

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clauses. The contract would provide a base contract sum, with additional payment

dependent upon the delivery of minimum and more ambitious stretch outcomes.

Initial development work has commenced to work up how this might be structured

with the aim of a two stage approach as outlined.

Summary of AMH savings options across CCG QIPP/LA social care savings

(draft)

To follow

5.2 Support for system / service transition

Transitional funding is required in order to support double running and pump priming

of service changes, a summary is given below together with potential funding

sources which includes CCG non recurrent funds, the SEL Community care strategy

fund and Local authority non recurrent funding. Requirements need to be modelled

in more detail

It should be noted that there have been on-going discussions with GST Charity who

have indicated a willingness to support the funding of a number of strands of work.

Additionally there should be opportunities to secure support via SLIC as a number of

work streams overlap e.g. capitation.

Full Year

Effect

2014-15

2015-

16

2016-17 Funding source

Development costs –

collaborative/

commissioning/contracting

£175k 150k 75k 75k CCG NR, GSTC &

SLIC

Primary care – community

incentive scheme

£400k

Recurrent

tbc tbc tbc SEL Cty Care

strategy fund

Living Well Network and VCS

development

£400k

Recurrent

tbc tbc tbc LA social care

NR; GSTC

Design support £75k 75k 75k 75k CCG NR

Community connections (Cross

LTC)

£100k LA social care

NR; SLIC, GSTC

Dr Raj Mitra – CCG Board Member

Dr Ray Walsh – CCG Board Member

Denis O’Rourke - Integrated Commissioning Team

27 December 2013

Integrated Provision – Alliance ContractAlliance Contract

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Appendix 1 - Progress on Collaborative

PDF file embedded.

What has been achieved to date in brief 231013.pdf

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