INTEGRATED CARE ORGANISATION FULL BUSINESS CASE FINAL PUBLIC – 12 April 2016 “At the centre of our renewed ambition is a clear vision for population health improvement, reaching beyond ‘out of hospital care’ to a single system of governance for health, care and wellbeing in Salford. The benefits will come with the shift of care from institutional settings towards the empowerment of citizens and communities to be independent, for longer.”
Transcript
INTEGRATED CARE
ORGANISATION
FULL BUSINESS CASE
FINAL PUBLIC – 12 April 2016
“At the centre of our renewed ambition is a clear vision for population health improvement,
reaching beyond ‘out of hospital care’ to a single system of governance for health, care and
wellbeing in Salford. The benefits will come with the shift of care from institutional settings
towards the empowerment of citizens and communities to be independent, for longer.”
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DOCUMENT INFORMATION
Title Integrated Care Organisation Full Business Case
As part of the Greater Manchester Devolution programme, Salford’s Local Sustainability
Plan sets out the strategic vision for Salford people to start, live and age well, with the
ambition to have the safest most productive health and wellbeing system in England, for
local citizens to shape and be fully engaged in this system with an emphasis on maintaining
their own health and for Salford partners to come together to create a fully integrated,
locally accountable offer with a focus on community provision.
This ambition sits in the context of the projected gap in health and social care finances
required to meet need, the current, prudent estimation is in the region of £157m for
Salford’s care system by 2020/21.
The locality plan financials are at a point in time and are being reviewed in light of confirmed funding settlements (for the CCG and Council) and revised provider cost
efficiency targets (for Salford Royal and Greater Manchester West). The final locality plan will be approved through the Health and Wellbeing Board in May and will include the most
up to date financial position for Salford locality.
The Full Business Case for the ICO reflects the financial assumptions set out in Salford’s
Local Sustainability Plan. The FBC identifies the proposed transactional savings associated
with the integration of services within the ICO. The longer term transformational savings
associated with new models of care, and a focus on prevention and reducing population
demand, will be led by commissioners in partnership with the ICO, and is being developed in
parallel with this business case.
The integration programme for adults and older people is one of a number of significant
partnership workstreams designed to transform care and that the creation of an ICO is both
an enabler for that transformation and also a means for delivering efficiencies.
Integrated Care System
The Local Sustainability Plan describes the creation of an Integrated Care System for adults
and older people, and an ICO as part of this system. Whilst the ICO FBC is focused on the
specific decision to transfer services and contracting arrangements, in parallel SCCG and SCC
have led a workstream to design commissioning processes for the new Integrated Care
System in which the ICO will operate.
This includes the extension of the pooled budget arrangements to adult services with a
supporting Service and Financial Plan. In addition, SCCG are facilitating a GP Design Group
to develop options for GPs to engage with the integrated system. The proposals for
commissioning and GP Design are outside of the ICO FBC, although these are fundamental
to making the overall system, in which the ICO will operate, work effectively.
The section focuses on the third workstream, in which detailed plans for the
implementation of the ICO are described in the Post Transaction Integration Plan and
Quality Governance Plan
The section concludes with a Benefits Realisation Framework and approach to post-
project evaluation
Recommendations
The recommendations of the FBC are as follows:
Section Recommendations for Approval Partners
Section 4 Recommendation a): Reconfirm support for the shared vision for the ICO.
All
Section 5 Recommendation b):
Note the prior approval at OBC of the preferred option to create the ICO:
SRFT as a prime provider for adult social care and physical health services with a focus on improving population health and wellbeing.
SRFT as a prime contractor for adult social care delivery and local adult mental health services, with agreements being reached in this FBC and supporting Transactions Documents to novate / assign or otherwise transfer responsibility for the contract for district and older adults mental health services that are currently in place between SCCG and GMW from SCCG to SRFT to subcontract to GMW.
Recommendation c): Reconfirm support for the preferred option.
All
Section 6 Recommendation d): Approve the risk mitigations identified through due diligence (SCC and SRFT Mitigations are attached at Appendix 1 Part B). Recommendation e): Note that the following transaction documents have been approved by SCC and SCCG and the expanded pooled budget has been established:
A high level service plan, and high level financial plan, describing commissioning intentions and the process for finalising the formal Service and Financial Plan (#10)
Recommendation f): Approve the following transaction document (attached at Appendix 1 Part A):
Risk Sharing Agreement (between commissioners and SRFT) (#1)
Recommendation g): To note the following transaction documents are in draft form and delegate authority to officers, as appropriate, to finalise and execute:
Draft Business Transfer Agreement (#11) (attached at Appendix 1 Part A)
Draft Support Services Agreement (#13) (to follow) Approve applying for admission to the Local Government Pension scheme on a restricted open basis (relating to the Admission Agreement #12). Approve entering into the Deed of novation (#14). Recommendation h): Note that Services Contracts will be produced by the end of May 2016. These will:
Use the NHS Standard Contract form for the ICO (#8)
Use the NHS Standard Form Subcontract for mental health services (#15)
Reflect the principles agreed in the Heads of Terms.
Contain no other supplementary terms. Recommendation i): Note that a Non Disclosure Agreement and Data Sharing Agreement have been approved by the relevant parties. Recommendation j): Delegate authority for officers, as appropriate, to finalise an Information Sharing Protocol (transaction document #5) to be in place by 1 July 2016. Recommendation k): Note the parallel approval and support for the following integrated system governance transaction documents:
Governance Framework (#2)
Alliance Agreement Deed of Termination (#3)
Commissioning and Operating Principles (previously Scheme of Delegation) (#4)
Section 75 Agreement between SRFT and SCC (#9)
Section 75 Agreement between SCC and GMW (#16) Recommendation l): Note the plan for the subsequent approval and support for the Phase 2 Service and Financial Plan (#10) in the May 2016 approvals cycle.
SRFT and SCC All All SRFT, SCC and GMW All All
Section 7 Recommendation m):
Note the following:
The size and composition of the commissioning pooled budget
The development of the Long Term Financial Model, incorporating
The modelling shows that the ICO has a neutral impact on SRFT Income and Expenditure position.
The financial risk management principles agreed through the Heads of Terms
Section 8 Recommendation n): Support the steps described in the Transactions, Approvals and Completions workstream. Recommendation o): Support the submission of the FBC to Monitor. Recommendation p): For SRFT Board of Directors – to note the need to make and submit the necessary Board statements in May 2016. Recommendation q): Note the new Integrated Care System governance arrangements, recognising that these are subject to a parallel approvals process. Recommendation r): Note and support the content of the Commissioning workstream. Recommendation s): With respect of the ICO Implementation workstream:
Note commencement of shadow governance arrangements
Approve the Post Transaction Integration Plan (attached at Appendix 1 Part A)
Approve the Quality Governance Plan (attached at Appendix 1 Part A)
Recommendation t): Note the support required for change management and programme resources and dependency on Vanguard funding. Recommendation u): Note and support the development of a Benefits Realisation Framework and the Post Project Evaluation approach.
All All SRFT All All SRFT and SCC All All
Summary of FBC
In summary, the FBC builds on the OBC and sets out more detailed information for the
preferred option, in particular it describes the transaction and implementation
arrangements, risks and mitigations includes the financial and risk management proposals.
The proposal to develop an ICO is one of a number of components to develop an Integrated
Care System that also includes work to develop commissioning, GP engagement with the
system and system development including a programme for transformation.
Whilst approvals for these elements of the system have taken place in parallel to this FBC,
they are a key factor on which the success of the ICO relies upon. The development of the
Integrated Care System is a key contributor to Salford’s Local Sustainability Plan.
This FBC is the third of three approval steps to progress the establishment of an ICO.
It revisits and confirms the preferred option for the ICO selected in the OBC and sets out the
arrangements for its implementation, including the detailed commercial, financial,
implementation and risk management proposals.
Notes on the structure of the FBC
The relevant recommendations are highlighted within each section of the FBC.
In addition, the FBC is accompanied by a number of supporting documents.
Appendix 1 contains a summary of supporting documents in three parts:
o Part A: Documents for Approval or Support.
o Part B: Due Diligence Documents.
o Part C: Supporting Documents.
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2. Strategic Case – Context
Summary In this section we outline the strategic context, updating analysis given first in a Strategic Outline Case (SOC) and then an Outline Business Case (OBC) which were approved by Salford Together partners in November 2014 and November 2015 respectively. Since the decision to proceed to Full Business Case (FBC), further changes in the strategic context include: development of Greater Manchester’s plan for health and social care devolution; the aligned creation of Salford’s Locality Plan; and the submission of our Value Proposition to NHS England’s new model team as part of our Vanguard programme. The direction of our journey towards integration remains the same, with the analysis below demonstrating that the strategic environment continues to support radical change and creates significant opportunities to deliver population health improvement through an ICO, operating as part of Salford’s Integrated Care System (ICS). Key points Partners in Salford Together have analysed the ways in which the strategic context has continued to develop since approval in principle was given to create an ICO (SOC, 2014) and selection of the preferred option with SRFT as prime provider (OBC, 2015). The main drivers, all of which are consistent with our plans, are set out in three sections.
National policy is highly supportive of improvement through integration. The Vanguard programme will help us rapidly develop and test new services and models of care. We will create an ICS which will give greater emphasis to prevention, reducing activity and shifting care from acute to community settings.
The strategic plan, Taking charge of our health and social care in Greater Manchester, describes a shared ambition to improve outcomes, increase independence and reduce demand on public services. The change programme will focus on people and place, not organisations, and calls for action across the whole range of care services. The Salford ICO is uniquely placed as a test-bed and exemplar for Greater Manchester in creating a Local Care Organisation (LCO) to drive transformation of community based care and support, alongside the wider reimagining of services across the whole care system.
Salford’s Locality Plan, Our vision for a healthier Salford, describes the strategy for population health improvement in Salford and route towards a clinically and financially sustainable system. Developed by the Health and Wellbeing Board (HWB) it explains the need for reform and its means of delivery, including an ICO fully aligned with our neighbourhood approach, driven by co-commissioning using Salford standards. Salford has a strong partnership culture which will support development of this new system.
Conclusions The strategic context confirms the drivers and opportunities for integration to support population health improvement in Salford. The detailed approach to creating an ICO set out in this FBC is built on the foundation of national, regional and local conditions supporting radical change.
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2.1 Strategic Context Below we review the strategic context for the creation of an ICO in Salford at national, regional and local levels. The analysis in this business case includes additional drivers since approval of SOC and OBC, and highlights key factors that have influenced the design and development of the ICO approach, as set out later in this document. 2.2 National Policy Context – Driving Integration and Improvement through the
Vanguard Closer integration of care has been a pervasive and recurrent theme of policy since the inception of the NHS. The Health and Social Care Act 2012 placed a statutory duty on the NHS and local authorities to promote and enable integrated care, further reinforced by the Care Act 2014. A raft of policy initiatives and incentives have been implemented to support greater integration and partnerships including the Better Care Fund, a national pioneer programme and, most recently, actions to support the vision for the NHS in England described in the Five Year Forward View. The new care models proposed in the Five Year Forward View are particularly aimed at overcoming barriers between hospital and community services. They are aligned with the wider policy direction of organising care around the needs of service users, shifting the focus from episodic and acute care to the long term, expanding preventative support that encourages independence and wellbeing. In January 2015, NHS England invited organisations and partnerships to apply to become ‘vanguard’ sites for the new care models programme, to lead the way in the improvement and integration of services. In March 2015, Salford Together was selected as one of the first sites to develop new models that integrate primary and acute care systems (PACS) – joining up GP, hospital, community and mental health services. Our approach was given in the Salford Together Value Proposition, July 2015, which was refreshed and re-submitted in February 2016 (see Appendix 1 Part C).
Key elements of Salford Together’s Vanguard programme include:
Building on the partnership of four successful statutory organisations to extend the existing programme of integration to all adults.
Creating an ICO to bring together responsibility for adult health and social care provision through a prime provider model – which will operate in a much more integrated system, underpinned by collaborative decision-making, whole-system transformation and the co-commissioning of services.
Incorporating key elements of the successful integrated care programme (ICP) for older people – multi-disciplinary working, use of community assets, creation of a single centre of contact – and aligning it with a new federated model of locality working for general practice, which is currently in development.
Our Vanguard proposal is based on an additional funding of £12.3m during 2016/17 and
£11.66m in 2017/18 to cover one-off and double running costs. The investment totalling
£29.1m (from 2015/16 to 2017/18) is expected to enable a savings contribution of £35.8m
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to closing Salford’s affordability gap, delivering a Return on Investment of 371%. The
savings will be achieved by creating new models that will absorb costs of demographic
changes (growth and ageing of the population and increasing demand) within resources
available to the system. Salford’s Vanguard programme is a key enabler to the related
transformation programme. As described in the Value Proposition also emphasises that:
The approach is firmly linked to a set of governance principles, including a partnership of equals, focusing on service redesign and improvement through significant engagement with health and social care staff, service users, carers and our local communities. Further details on the new single system of governance are given in Section 8, Management Case.
Delivery will be monitored and incentivised using a set of system-level improvement measures, summarised in Section 3 Strategic Case – Case for Change.
Impact will be evaluated as part of the National Institute for Health Research funded CLASSIC longitudinal study being undertaken by the University of Manchester.
The Vanguard will prototype new care delivery models to benefit local people and create learning to be shared and spread within GM and nationally.
The ICO is one element of a wider programme of work to better integrate health and social care, which includes phased work with GPs as equal partners for integrated care delivery and the development of a Collaborative Integrated Neighbourhood approach.
The priority enablers for the ICO have been identified as organisational and workforce development, IM&T (particularly shared records and systems) and payment reform.
The Vanguard provides investment for a new infrastructure including the ICO, which brings a unique opportunity for Salford Together to put in place conditions to meet our shared vision, and improve outcomes and experience at lower cost. 2.3 Greater Manchester Devolution The Greater Manchester Devolution Agreement aims to: “ensure the greatest and fastest
possible improvement to health and wellbeing of the 2.8 million citizens of Greater
Manchester”. The creation of an ICO within Salford’s new ICS is entirely consistent with the
aims of the strategic plan, Taking Charge of our Health and Social Care in Greater
Manchester. It describes a shared ambition to use the freedoms and flexibilities associated
with devolution to radically transform the health of our population and build a sustainable
model of care. It describes how, together, partners will take a combined approach to
growth and reform and address significant challenges – in terms of health, wealth and
wellbeing, as summarised overleaf.
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Key elements to the Greater Manchester Devolution plan and our shared context include:
The health outcomes for the 2.8 million people in Greater Manchester are not improving, despite the £6 billion spent across health and social care.
People die younger and become ill at a younger age than other places in England.
As more people have multiple chronic conditions the focus has shifted from curing illness to helping people live with chronic ill health.
There is significant market failure in domiciliary, residential and nursing care across social care, adversely affecting system resilience and hospital discharge planning.
If we do not radically change how things are done, more people will suffer from ill health and, as a system, we will face a £2 billion shortfall in funding by 2021.
Reforming services involves the integration of health and social care, and drawing together a much wider range of services which impact on health and wellbeing.
The system-wide ambition is coupled with a clear focus on local people and place based
services. Specific action will address the whole continuum of care, from prevention,
primary, community and social care, through to hospital and specialist services. The Plan
explicitly states that a ‘new deal’ must be reached with our populations – where public
services provide support, assistance and facilities, and people take greater charge of, and
responsibility for, their own health and wellbeing. In part this will be enabled and
encouraged through the life-cycle model, to help people start, live and age well, which we
apply further in this FBC.
Starting Well – all children have the best start in life and continue to develop well during their early years.
Living Well – citizens will achieve and maintain a sense of wellbeing by leading a healthy lifestyle supported by resilient communities.
Ageing Well – older people will maintain wellbeing and can access high quality health and social care, using it appropriately.
The ambitious programme of health and care reform is based around five interrelated
workstreams:
1. Radical upgrade in population health prevention
2. Transforming community based care and support – with new models of integrated
care closer to home, using evidence based approaches, including targeted case
management through appropriately skilled multi-disciplinary teams, as developed in
the Salford Integrated Care programme (ICP).
3. Standardising acute hospital care – including single shared services to improve
outcomes and productivity.
4. Standardising clinical support and back office services
5. Enabling better care – partly by creating innovative organisational forms and new
approaches to commissioning, contracts and payments.
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This approach is illustrated below:
GM Devolution Transformation Workstreams
Salford Together’s integration programme is fully aligned to the Transforming Community
Based Care and Support workstream. In creating an ICO, we are uniquely placed to further
develop the Local Care Organisation (LCO) model as a test-bed for Greater Manchester; with
learning that can be applied throughout the NHS. Alignment between the ICO and the LCO
model is explained further in Section 5, Economic Case. The four priorities within work to
transform community based care and support through LCOs are:
Enable conditions to be managed at home and in the community
Provide alternatives to A&E when crises occur
Support effective discharge from hospital
Help people return home and stay well
As part of the Comprehensive Spending Review (CSR) settlement between HM Treasury, NHS England and Greater Manchester, a GM Transformation fund has been created to support the transformation of health and social care. This fund will provide non-recurrent investment in new systems, processes and infrastructure as well as supporting the additional (double running) costs of building up new services while existing ones are wound up. The three main objectives are to:
Deliver improvements in clinical sustainability
Secure the activity and productivity shifts required to close the affordability gap
Ensure localities are well placed to manage the future health needs of their populations
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Distribution of the Fund is structured around the five GM workstreams above and must clearly contribute to delivery of the GM strategic plan and the Joint Commissioning Strategy. The ways in which Salford Together’s approach in creating an ICO within a wider ICS is aligned to the transformation initiatives, based on best practice and supported by robust implementation and financial plans are set out at the end of Section 4 Strategic Case – ICO Vision. 2.4 Salford’s Locality Plan
The Locality Plan – Our Vision for a Healthier Salford – describes our strategy for improving
health outcomes for the people of Salford and move towards a clinically and financially
sustainable system. Developed by the Health and Wellbeing Board, it explains why radical
reform is required and how it will be delivered, including the creation of an ICO fully aligned
with our neighbourhood strategy and driven by co-commissioning using Salford standards.
The main elements of the Locality Plan, incorporating integrated care, are illustrated below.
Salford Locality Plan – our vision for a healthier Salford
Enabling
Prevention
Better Care
Rationale, context, shared vision
• Integrated commissioning• Co-production and social value• IM&T• Estates•Workforce• Innovation • Public Engagement
Delivering
Improved outcomes and experience, with specific set of measures
Financial sustainability, tackling 2021 ‘do nothing’ gap of £157m
•Quality of care• Transforming primary care• Integrated care• Hospital care• Long term conditions•Mental health
• Social movement for change• Place-based working• Best start in life• Promoting healthy lifestyles• Screening and early detection•Wider determinants of health and wellbeing
The Life Course:Starting, living and ageing well
Governance, leadership and management
Transformationworkstreams
The Locality Plan’s vision is given below.
Start, live and age well in Salford – Citizens will get the best start in life, will go on to have a fulfilling and productive adulthood, will be able to manage their health well into their older age and die in a dignified manner in a setting of their choosing. People across Salford will experience health on a parallel with the current “best” in Greater Manchester (GM), and the gaps between communities will be narrower than they have ever been before.
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These ambitions have been the subject of public engagement. The Plan gives a set of ‘I’
statements, putting people at the heart of the approach, which will be aligned to specific
outcome targets. Delivery is supported by three strategic principles, all of which are entirely
consistent with, and supported by the ICO:
Salford will have the safest most productive health and wellbeing system in England, with
consistently high quality service standards and outcomes.
Our local citizens will help to shape and be fully engaged in this system, but they will also
recognise the vital role they have in sustaining it by maintaining their own health,
supporting neighbours and friends, and contributing to the local economy.
Across Salford, partners will come together across the public, private, faith, voluntary
and community sectors to create a fully integrated offer, local accountability and an
accompanying reduction in the acute health and care sector to reflect this shift.
The ICP for older people has been directly addressing the ‘Ageing Well’ area, and the ICO will extend this to the ‘Living Well’ domain, which itself will impact on ‘Starting Well’, such as by promoting healthy parents and parenting. Salford Together will contribute through reductions in demand and cost associated with both the transformational and enabling activities of new models of care, specifically including:
Reduction in emergency admissions to hospital.
Reduction in permanent admissions to care homes.
Reduced demand for hospital-based care (primarily medical specialties).
Reduced costs of care (fragmentation and duplication).
Avoidance or absorption of future costs (absorption of demand associated with projected population growth).
Targets for improvement are based on a jointly held set of planning assumptions which will be further refined as part of the implementation of Salford’s Locality Plan. Alongside work on integration within the Better Care workstream, other programmes that will help bridge Salford’s affordability gap include: public health, early intervention and demand management; integration of care and support for children and young people (‘Starting Well’); organisational efficiency programmes and consolidating the Salford estate. A further aspect of the strategic context in Greater Manchester and the North West Sector (Salford, Wigan, and Bolton) is reconfiguration and horizontal integration of acute hospital services, in line with Healthier Together. More joined-up care, to be delivered by the ICO, and improved access to primary care are both recognised as necessary preconditions to reforming hospital care. Also, Salford is leading on a separate Vanguard programme for Acute Care Collaboration, developing the Group model with Wigan.
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2.5 Salford Health and Care Economy – Population Vision and Neighbourhood Approach Approximately 234,000 people live in Salford, mainly in urban areas, and around 250,000 people are registered with a Salford GP. The health needs of Salford’s population are documented in the Locality Plan and the Joint Strategic Needs Assessment. Salford has more problems with smoking, drinking, lack of exercise and unhealthy eating and more people with serious long-term conditions than many other places in England. Similar to the rest of Greater Manchester and most parts of the UK, the care system in Salford is facing the challenge of significant and enduring financial pressures. The population’s need for services will continue to grow faster than funding, meaning that we collectively need to innovate and transform the way services are provided, within the resources available, to ensure that standards are maintained and population needs are met. Salford is a relatively stable and high performing health and social care economy, which is served by four statutory organisations: NHS Salford Clinical Commissioning Group (SCCG); Salford City Council (SCC); Salford Royal NHS Foundation Trust (SRFT); Greater Manchester West Mental Health NHS Foundation Trust (GMW). In addition, Salford has a range of other health and social care providers, including GP Practices, community optometrists, dentists and pharmacists, care homes and domiciliary care providers. In creating the ICO we will work with such partners and those in our vibrant voluntary, community and social enterprise (VCSE) sector.
Salford has a long history of collaboration and integration that predates the current reform agenda, further details on which are given in Section 4. In brief, the Salford Health Investment For Tomorrow (SHIFT) programme was one of the first whole health economy approaches to redesign care pathways, resulting in a transfer of care away from the hospital into community and primary care services. SCCG (and Salford PCT before it) and SCC have a strong history of integrated commissioning with pooled budgets for Learning Difficulties, Intermediate Care, Physical and Sensory impairment.
The Salford Together partnership has, for several years, been developing a formal programme (ICP) to improve and integrate services for older people. The structure provides for a dual line of reporting to each organisation’s governing committee and to Salford’s Health and Wellbeing Board (HWB). The partnership progressed to an Alliance Agreement (October 2014) which provides a financial, governance and contractual framework for integrated care, including a pooled budget (Section 75 Agreement, £112 million for 2015/16). Further detail on the ICP and Alliance Agreement are available within the schedule of supporting documents (see Appendix 1 Part C) and the new financial, commercial and governance arrangements for the ICO are set out later in this FBC. The progress made in this area reflects a shared vision of creating a single system of governance for health and social care, supporting health and wellbeing for the people of Salford. Partners have agreed that the ICO must incorporate a collaborative neighbourhood model for both commissioning and provision. This will involve city-wide Salford standards
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delivered through neighbourhood-level governance, accountability and delivery models, which could include:
Geographical communities of 45-60,000 people.
Significant shift in care away from hospital to community-based care, delivered on a neighbourhood basis.
Groups of GP Practices operating on a networked or federated basis.
GPs, specialists, community staff, social workers and mental health practitioners working together as a ‘partnership of equals’.
Much greater focus on person-centred care, application of standards and pathways
Clear accountability through multidisciplinary Locality Boards.
Building on this strategic context, the next section, Case for Change, explains further the population need, system constraints and opportunities to deliver improvement through integration in the form of an ICO.
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3. Strategic Case – Case for Change
Summary In this section we restate the case for change set out in the OBC, updating for recent changes and developments. The case for change, described below, demonstrates a clearly identified need – to improve health and wellbeing and reduce inequality – and summarises evidence which supports integration through an ICO as the best approach for partners in Salford Together. Key points
People in Salford have poorer health status and outcomes and use more acute hospital services than the national average. Our population have high rates of long term conditions and co-morbidities, reflected in a range of data indicating people face shorter and less healthy lives than the majority of people in England. There is also evidence of substantial inequality within Salford, such as life expectancy between the most and least healthy wards (which varies by 12 years for men and 8 years for women). The ageing of the population will amplify these issues.
Alongside this demographic challenge, like all economies, Salford faces significant financial challenges despite each organisation delivering sizeable cost improvement and efficiency programmes over recent years.
We have reviewed national and international evidence on integration in health and social care. Although research in this area is limited, there is great potential for integration to deliver improvements in people’s experience and outcomes, supporting the use our limited resources more effectively.
At a local level, we have engaged extensively with our professionals and partners. This has demonstrated an enthusiasm to build on our collective culture of innovation and improvement, as well as the positive experience of integrating health and social care for older people.
We describe anticipated benefits of an ICO from two perspectives – first for service users, carers and communities, and secondly for the health and care system. These are reflected in a set of improvement measures including targets for 2020, which are aligned to Salford’s Locality Plan.
Conclusions Our triple challenge of poor health outcomes, demographic pressures and financial constraints mean we cannot leave the system as it is. Salford Together, as commissioners and providers, have a shared view that radical change delivered through more integrated care is required, within a wider integrated care system. We have reviewed evidence on best practice in the UK and abroad and have reflected with our staff and partners on our local best practice. On this basis, the ICO proposal is a key element of our system’s approach to address the challenges we collectively face in Salford.
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3.1 Demography and Care Needs in Salford
Compared to the England average, Salford has a higher prevalence of most long term
conditions, including CHD (coronary heart disease), COPD (chronic obstructive pulmonary
disease), mental health, epilepsy and obesity.1 Long term conditions are more prevalent in
deprived groups and older people.2 In addition, older people are most likely to suffer from
multi-morbidity (defined as two or more long term conditions) and are frequently socially
isolated, with a poor quality of life. They often receive fragmented and sub-optimal care,
and are not fully or adequately enabled to care for themselves.
Salford has some of the highest rates of emergency admissions and admissions to care
homes in the adult and over 65 population, with too many people receiving end of life care
in hospital rather than at home. Services often fail to address the needs of older people and
adults with complex needs, and, despite the best efforts of professionals, where care is
provided it can be disjointed and delivered in inappropriate settings.
Salford has a resident adult population of 183,237, of which nearly 33,200 are aged 65 or
older.3 Compared to other areas, Salford is in the worst quartile or decile for a number of
outcomes relating to long term conditions in the adult population:
Health related quality of life for people with long term conditions.
Unplanned hospitalisation for chronic ambulatory sensitive conditions.
Under 75 mortality rate from both cardiovascular and respiratory disease.
Potential years of life lost from causes considered amenable to healthcare.
The elderly population is projected to increase by almost 37%, to over 45,600, by 2030.4 If
no changes are made to the way we support adults and older people, there will be a
corresponding growth in ill-health and demand on services:
There is likely to be a substantial growth in the number of older people with a limiting long-term illness, from an estimated 20,712 in 2014 to 27,110 in 2030.
It is estimated that 2,406 people currently live with dementia in Salford and this is set to rise to 3,413 by 2030. People with dementia are over-represented in acute beds, with longer lengths of stay.
1 Source: NHS England 2010/11 QOF data www.england.nhs.uk/wp-content/uploads/2012/12/ccg-pack-01g.pdf
2 Nationally, people in the poorest social class have a 60% higher prevalence than those in the richest social class and 30%
more severity of disease. Fifty-eight percent of people aged over 60 have a long term condition compared to 14% aged
under 40. Source: Department of Health, 2012
www.gov.uk/government/uploads/system/uploads/attachment_data/file/216528/dh_134486.pdf 3 Source: 2011 Census data (table KS102EW), NOMIS www.nomisweb.co.uk/census/2011/ks102ew
4 Source: Projecting Older People Population Information System (POPPI) www.poppi.org.uk
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Disability-free life expectancy in Salford is 60 years for men and 58.4 for women – 3.6 and 6.4 years lower than the England average respectively.5
The number of people aged 65 or over who live alone is projected to grow from 12,865 in 2014 to 16,643 in 2030. Older people often suffer from social isolation and have a negative perception of crime and their safety.
By 2030 an extra 5,318 people will have a hearing impairment, and there will be an additional 3,044 falls in the elderly.
In the same timeframe, an additional 4,653 people will be unable to manage at least one domestic task, and 3,817 one self-care task or more. This will increase the need for caring support in these communities.
Salford has significant health inequalities; the variation in Life Expectancy between the best and poorest wards in Salford is 12.1 years for men and 8.2 years for women.
As set out in Salford’s Locality Plan, responding to these challenges requires system change
and recognition that most of the solutions lie with the people of Salford, and needs new
relationships and behaviours – in the professional system and its leaders, and with local
citizens and their communities. The Plan sets out the wider context, reflecting both our
challenge to reduce the number of people with the three ‘biggest killers’ – cardiovascular,
cancer and respiratory disease – and to address the ‘causes of these causes’ such as
housing, environment and employment. The ICO will contribute in alignment with wider
programmes such as commissioning reform, place-based approach (using community
assets) and Salford Standards for primary care.
3.2 Financial Case for Change in Salford
We, like other health and care economies, face an extremely challenging trajectory of
growing demand and constrained resources. Services are already facing unprecedented
financial pressure, with each organisation implementing planned cost improvement
programmes (CIPs). These pressures will increase substantially as the population becomes
older and health and social care commissioners and providers deal with the ongoing
consequences of the economic downturn.
For example, it is estimated that the treatment and care for people with long-term
conditions accounts for around £7 in every £10 of total health and social care expenditure.6
Nationally, the number of people with three or more long-term conditions is predicted to
rise from 1.9 million in 2008 to 2.9 million in 2018. An ageing population and the increased
5 Source: Disability Free Life Expectancy (DFLE), ONS www.ons.gov.uk/ons/rel/disability-and-health-measurement/sub-
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prevalence of long-term conditions will have a significant impact on demand for health and
social care – and, if left unchecked, may require £5 billion additional expenditure by 2018.7
Salford’s Locality Plan – Affordability Challenge
Despite each organisation in Salford Together delivering sizeable cost improvement and
efficiency programmes over recent years, projecting the funding and expenditure forward
up to 2020/21, the “Do Nothing” scenario predicts an estimated shortfall of circa £157m
against baseline funding of £485m – this shown in the table below. The scale of this gap is
consistent with the picture across Greater Manchester, which has a projected financial
challenge of circa £2bn forecast for 2020/21 if current trajectories continue.
The locality plan financials are at a point in time and are being reviewed in light of confirmed funding settlements (for the CCG and Council) and revised provider cost
efficiency targets (for Salford Royal and Greater Manchester West). The final locality plan will be approved through the Health and Wellbeing Board in May and will include the most
up to date financial position for Salford locality.
Notes to Salford Financial Gap table:
SCCG funding will grow by 2% per annum for the next five years.
Continued reductions in SCC funding.
NHS tariff will reduce by 1.5% each year, while pay and prices grow by 2.5% annually, leading to implied efficiency
savings for providers of 4% per year.
Although the financial position of SCCG is currently strong, projecting forward beyond three
years shows that SCCG will be in recurrent deficit if nothing is done to deal with the
continued growth in secondary care admissions and other healthcare expenditure
associated with the growth in older people and long term conditions.
7 Ibid.
Salford Locality Summary: Financial Gap: Do Nothing Option
Total Locality Gap: Do Nothing -£22 -£62 -£83 -£108 -£133 -£157
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In the past five financial years, from 2011/12 to 2015/16, SCC implemented unprecedented
savings of £137m which were required as a consequence of the Government’s budget
reduction plan. In addition the Council expects to have to deliver further budget savings of
at least £37m for the years 2016/17 and 2017/18.
NHS providers also face significant financial challenges in the foreseeable future. SRFT’s
financial plans assume that cost savings of circa 5% per annum will be required for the next
4-5 years. This is equivalent to circa £25-30m of cost savings required each year, with the
ICO accounting for approximately £2m in each of the years. GMW’s financial plan for the
next two years requires recurrent savings of circa £5m per annum.
Closing the Affordability Gap The impact of delivering and investing in the priority areas identified in the Locality and GM
transformation plans has been assessed and go a long way to close the financial gap within
Salford. SCCG and SCC have already made a significant investment in integrated care for
older people (rising to circa £8m recurrently in 2017/18). Combining all programmes, the
Locality Plan indicates that the financial gap could be reduced to a £5m gap by 2020/21 if all
of relevant changes and initiatives deliver their intended outcomes. However, this is an
optimistic position predicated on the following assumptions:
New service models deliver expected outcome over the five year period prevention
(£15.9m for prevention and £18.2m for better care).
The locality receives significant funding in future years, including protection of adult care
funding (£17m) and Salford receiving a ‘fair share’ (£31m) of additional NHS resources.
Providers are able to achieve year on year savings (2% per annum).
Salford Together as a programme, including the ICO, is anticipated to contribute £35.8m
savings by 2020/21. These will be achieved through the following reductions in demand and
costs associated with both transformation and integrated care efficiency.
Better care transformation £18.2m
A&E attendances £2.1m
Emergency admissions to hospital £7.6m
Elective and outpatients £5.0m
Reduction in permanent admissions to care homes
£1m
Medicines optimisation £2.5m
Provider efficiency £17.6m
Integrated care efficiency £17.6m
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Programme level savings, as described in our Vanguard Value Proposition (see Appendix 1
Part C) are based on the following assumptions:
Absolute reduction in A&E attendances and admissions, including permanent care
home placements in an environment of annual rising demand over a “do-nothing”
scenario.
Elective and outpatient activity is expected to also be reduced, which will have the
impact of largely flat lining activity to 2014/15 baselines against a rising demand profile.
Investment will also enable the redesign of prescribing within the locality and is
expected to deliver a significant recurrent saving.
2% per annum ICO efficiency savings are achieved; supported by the integration of
health and social care services.
The five-year financial plan and assumptions for Salford are summarised in the Salford’s
Locality Plan (see Appendix 1 Part C).
As explained above, the financial context in Salford provides a significant driver for
improvement through integration, with its combined vision of more coordinated services
and increasing prevention, wellness and independence in the population (described further
in Section 4, ICO Vision).
3.3 National and International Evidence supporting Integrated Care
To support the development of the OBC, we commissioned York Health Economics
Consortium (YHEC), part of the University of York, to conduct a rapid review of evidence and
best practice relating to the organisation, opportunities and benefits of ICOs. The findings
remain highly relevant for the approach detailed in this FBC.
The review identified and considered evidence (both published and grey literature) on: the
structure and organisational models for ICOs; service changes that ICOs have delivered (e.g.
reducing service duplication, introducing new pathways, service models and roles for staff);
and specific benefits of ICOs, such as improvements in service efficiency, health and clinical
outcomes, access and equity.
Nearly 2,000 potential records were scanned, 82 included in a long list and 30 selected for
full text review. All of the case studies outlined in the SOC were reviewed. As is common
for such complex programmes, conclusive evidence is limited, partly due to the challenge of
attributing impact in differing systems and changing contexts. Despite this, several strong
messages emerged, summarised in the table overleaf (see Appendix 1 Part C, which includes
the full YHEC report).
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The report concluded that:
The policy context for increasing efforts to integrate care is compelling. Ham and Walsh8 describe the case for
developing “whole-system working to address the demands arising from an ageing population and increases in the number of people with multiple long-term conditions”. The aspiration of health systems around the world
is that by focusing care on the individual and overcoming barriers between different care providers, it is possible to identify problems and to intervene to prevent avoidable deterioration of the person’s condition,
avoiding unnecessary reliance upon health and social care.
Such findings have directly informed the approach to develop the ICO, including their use in
determining anticipated benefits (outlined below) and as part of engagement processes –
with the Alliance Board, the ICO Steering Group and wider engagement with health and
social care staff and service users.
Brief Summary of Literature Review – evidence on the implementation of ICOs (YHEC, York University – April 2015)
Ke
y m
ess
age
s
There is convincing evidence that integration leads to improved patient / person experience:
High patient satisfaction and reduced demand for hospital care (e.g. Alzira)
Easier and faster access to care and improved information and communication among professionals (e.g. Norrtalje)
Less evidence was found on improved outcomes and efficiency, but some case study examples identified benefits including:
Decreased utilisation of secondary care, social care and care homes (Torbay)
Reduced admissions, lengths of stay and emergency readmissions (Geisinger) Structural integration:
On its own it is not sufficient – the process of integration appears to be equally important
Needs to be planned and implemented for the long term to realise benefits
Wh
at h
elp
s?
Consistent messages in the literature suggest that ICOs should consider:
Population focus, e.g. pooling resources and use of capitated budgets with aligned incentives
Commissioning pathways of care
Incentives with shared risk and shared accountability e.g. hospital admission could be seen as a ‘failure’ of system to prevent deterioration of person’s condition
Role of primary care – particularly with prevention and risk management
Case management (the ‘care navigator’ role is often critical)
Bottom up development and attention to the process
Time and effort (consistent pursuit of ‘a clear, elevating goal’)
Aim for improved patient care / experience not just cost savings
Co
ncl
usi
on
s:
While the cost effectiveness of integration of care is not proven, there is evidence in the literature to
suggest that integration can lead to improvements in the effectiveness and cost-effectiveness of care
There is no clear ‘single model’ which is best
Key features of successful models are:
o financial risk sharing and ‘alignment of incentives’
o commissioning for ‘populations’ on a capitation basis
o commissioning whole pathways of care, including primary care
Bottom-up development and attention to the process of integration is important
There is a lack of robust studies to assess economic benefits
8 Ham C, Walsh N. Lessons from experience: Making integrated care happen at scale and pace. The King’s Fund; 2013
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The question of which factors should be considered when planning greater integration of
primary and community care was addressed in a separate literature review conducted for
the Department of Health (Bramwell et al, PRUComm, August 2014). While the YHEC review
informs the framework for the ICO (‘what is to be done’), this additional evidence points to
the issues around the approach we should take in Salford (‘how to do it’). The literature was
considered at three levels, with key messages summarised below.
Brief Summary of Literature Review – moving services out of hospital: joining up general practice and community services (PRUComm, August 2015)
Micro-level factors – effectiveness of multidisciplinary teams
Good communication between team members is a consistent underlying enabling factor, with shared IT and record systems important
Structural aspects of teams (e.g. size, shared training, organisation) probably act via helping or hindering communication
Clear agreed goals are important for collaboration
Good leadership is needed, with a strong commitment to partnership working
Meso-level factors – organisation and service delivery
The historical model means community nurses and GPs usually cover different populations
Proponents and opponents of larger scale coverage (multiple practices) both lack good evidence for their differing assertions
There is some evidence that co-location of teams facilitates communication and improves service delivery
New models such as federations of GP practices offer compelling case studies, but again there is limited research evidence
Models based on coordination around the patient appear to improve experience but not reduce admissions or cost
Macro-level factors – structural issues
Community services have repeatedly faced structural reform, but none can be clearly linked to improved performance
Different models for most structural issues (e.g. ownership, contracting and payment models) lack evidence, though fragmentation of providers may make good service provision more difficult as it inhibits communication
Such factors are being taken into account in the developing approach to federating primary
care in Salford and creating collaborative integrated neighbourhoods, within an ICS.
3.4 Local Conditions Supporting Integrated Care
As part of the development of the ICO, significant local engagement has been undertaken at
many levels. The most significant large-scale event was held on 26th March 2015 and
provided an update on the ICP and introduction to the ICO for over 130 health and social
care leaders and practitioners, along with a small number of older people previously
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involved in the process. Outputs from group exercises and feedback from individuals have
been analysed and the findings are summarised below (see Appendix 1 Part C).
Integrated Care Engagement Event 26th March 2015 Brief Summary of Consolidated Event Report
Summary The tone of the event combined a high degree of enthusiasm and optimism around integrated health and social care with an open and honest sharing of concerns and uncertainty about what fuller integration could mean, particularly for staff at a personal and professional level. Such a combination is unusual – many engagement events can veer towards either spiralling critiques, such as for controversial reconfiguration plans9, or rather stilted discussions where people do not feel the confidence and trust required to voice uncertainties in an open forum.
Progress with the ICP
Areas identified as ‘working well’ significantly outweighed those ‘not working so well’ and included: joint multi-disciplinary working; strong partnerships and relationships; commitment and enthusiasm; and improving outcomes.
Priorities for further improvement included: widening communication about the ICP to public and professionals; rolling out the model to others given its successes, so that other people and service users could benefit; and addressing ongoing issues such as IT, involvement of different sectors and balancing service delivery with supporting independence and self-care.
Plans for the ICP
The strategic direction of further integration to improve health and wellbeing for people in Salford was consistently recognised and supported. The continued emphasis on person / patient-centred care was particularly welcomed.
Given the initial development stage of the ICO at the time of the event there was considerable appetite for more detail about how it would run.
Areas of anxiety included the potential implications for culture and professional practice of many staff, particularly in social care, moving to a new organisation.
Event evaluation
Feedback from participants about the event was overwhelmingly positive, with around half assessing it ‘very useful’ and half ‘useful’. Only four people thought it was of ‘limited use’.
The most positive aspects were the opportunities for networking, working in mixed groups, and finding out about progress on the ICP and plans for the ICO.
Potential improvements for similar events were identified as: involving a broader range of people (e.g. district nurses, GPs and more from the Third Sector), providing more detail (especially on the ICO) and using a venue in Salford.
During the event, people were asked in their mixed groups to discuss ‘your sense of your
team’. The outcome illustrated a strong sense of togetherness, pursuing a shared purpose
of improving health and wellbeing through person-centred care and support. People
repeatedly described the work of Salford Together as ‘exciting’ and ‘positive’. Some
illustrative quotes are given overleaf.
9 For example, see: Independent Reconfiguration Panel Learning from Reviews (3
rd Edition, 2010) and Lloyd, A (2014)
Lessons learned – independent review of NHS service change and consultation exercises by Health Boards in Wales
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We are thinking about:
More joint working. This is the most logical step. Why hasn’t it happened before?
How will it work? How will it be managed?
How to improve the client experience, feel valued and consulted?
Today has been good in getting an overview of everything going on.
Things about to happen include:
Communication between organisations. Staff engagement and awareness on a wider level.
MDG [multi-disciplinary groups) embedded. Joint working with GPs. Information sharing.
We are wondering about:
How and when the changes will take place. How will it affect me?
How we coordinate it all in a timely manner?
How can I build up relationships with other providers?
The importance of keeping people central to everything we do.
In addition, participants helped to further develop the set of anticipated benefits,
summarised in the next section. The Engagement event was also the source of the
illustration reproduced on the cover of this document.
Further engagement has taken place and more is planned to seek views and keep people
informed about the health and social care integration in the city. Since 2013 this has
included:
A series of public engagement events at different locations across Salford – including
the Big Health Day, NHS Salford Clinical Commissioning Group's Citizen and Patient
Panel and other community groups.
Information stalls at Salford Royal’s Open Day, Peel Park Pink Picnic In the Park and
the Salford City Partnership Conference.
Presentations at public meetings to various groups, many whose members use, or care
for someone who uses health and social care services.
Articles in the local press, the city-wide Life In Salford magazine and other publications
across Salford, and in health and care organisations’ internal staff briefings.
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Consultation and Engagement
Between February and March 2016, the Salford City Council with Salford Royal Foundation
Trust and in conjunction with the Salford Together Partnership carried out a public
consultation setting out why we felt integrating adult social care and health services under
an Integrated Care Organisation was a positive change, in that it would offer.
Better health and social care outcomes by providing more person-centred and joined
up care for adults and older people,
Deliver more care in our communities and people’s homes,
Promoting prevention and independence,
Removing duplication and delivering more efficient services,
Making better use of our resources and reducing health and social care costs,
Improving co-ordination with care homes and the voluntary sector,
Create sustainable health and adult social care services.
How have people been involved so far?
Since 2013 have carried out a range of activities aimed at engaging people in Salford and
keeping people informed about the development of health and social care integration in the
city. This has included:
Series of public engagement events at different venue/ locations across Salford –
including the Big Health Day, NHS Salford Clinical Commissioning Group’s Citizen and
Patient Panel and other community groups,
Information stalls at Salford Royal NHS Foundation Trust Open Day, Peel Park Pink
Picnic In the Park and the Salford City Partnership Conference,
Presentations at public meetings to various groups, many whose members use – or
care for someone who use’s – health and social care services,
Articles in the local press, the city-wide Life In Salford magazine and other publications
across Salford,
Dedicated public website – www.salfordtogether – and Twitter account,
@salfordtogether, and
Staff newsletters and meetings at Salford City Council, Salford Royal NHS Foundation
Trust and Greater Manchester West Mental Health Foundation Trust – including trade
union consultation.
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The ICO consultation
In order to maximise the response from the public we raised awareness of the consultation
we displayed posters in the GP practices, libraries, community and leisure centres,
Children’s centres and nurseries as well as Local Authority and hospital buildings.
We focussed our consultation on two key questions and also offered the public the
opportunity to comment:
1) Do you support the proposal to create an Integrated Care Organisation (ICO to deliver integrated health and adults social care services?
2) Do you support the transfer of the majority of Salford City Council’s adult social care services to the Integrated Care Organisation?
Three quarters of respondents (76%) were supportive of the proposal to create and
Integrated Care Organisation with 71% of respondents supporting the transfer of Salford
City Council’s adult social care services to the ICO.
Next Steps for Engagement
Future events include one planned for April 2016 at which the concept of the collaborative
neighbourhood model will be developed further, identifying and exploring opportunities for
innovative new ways of working and shifts in services between primary and secondary care
(including physical and mental health and social care). Participants will include GPs, practice
nurses, other primary care and community care staff, joint commissioners and staff from
secondary care and mental health. Examples of greater integration and collaboration, both
national and local, will help stimulate thinking about how the five Salford neighbourhoods
can best develop and use the opportunities of health and care integration to better meet
the needs and support independence in local populations.
Overall, the above local evidence strongly supports our view that Salford Together has the
track record of delivering integration and the capacity to progress from ICP to ICO.
3.5 Anticipated Benefits and Improvement Measures
The ICO is being created to deliver benefits at two levels – for the people of Salford and for
the health and social care system. One of the key advantages of integrated care is that it
enables a more person-centred approach to the way care and support is provided to the
population. As well as providing organisational and system benefits, it is therefore
important to recognise the benefit that establishing an ICO will bring to individuals and
families, as summarised briefly overleaf.
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Benefits to individuals, carers, families and communities in Salford
Area of impact Benefit description
Greater independence Enabled to take a more active role in own care and supported to improve lifestyle.
Able to live at home longer.
Feeling safe and supported
Reduced isolation.
Increased opportunities to participate in community groups and local activities.
Confidence in managing own condition and care
Where required, increased support to manage own long term condition.
Sign-off own care plan and agree who it should be shared with.
Technology-enabled support to monitor own health.
Know who to contact when necessary
One main telephone contact number for advice and support.
Single centre of contact to coordinate health and social care. Increased community support with access to appropriate specialist care
Supporting prevention and wellbeing through community-based services, including primary health and social care.
Specialist care available when necessary, including secondary and mental health care.
Support to plan for later stages in life
Agreed plan of coordinated end of life care for last year in life.
Translating such words and aspirations to clear examples and tangible benefits was
achieved in the ICP through a social marketing approach, and the ‘Sally Ford’ family.10
Such methods will be developed further to reflect the broader focus on the entire adult
population. By engaging with people in Salford, the benefits descriptions for individuals
have been translated into outcomes, using ‘I’ statements structured using the life course
model:
Starting well
» I am as good a parent as I can be
» I am a child who is physically and emotionally healthy and able to cope with life in a
positive way
» I am a young person who will achieve their potential in life, learning and employment
Living well
» I am able to take care of my own health, wellbeing and manage the challenges that life
gives me
» My lifestyle helps me to stop any long term condition or disability getting worse, and
keeps the impact of this condition or disability from affecting my life
» I lead a happy, fulfilling and purposeful life
10
Sally is an illustrative Salford resident who, together with her family, is used by partners to identify person-centred
planning and care in Salford.
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Ageing well
» I am an older person who is looking after my health and delaying the need for care
» If I need it, I will be able to access high quality care and support
» I know that when I die, this will happen in the best possible circumstances
Salford has set out a clear vision for population health improvement, reaching beyond ‘out
of hospital care’ to a single system of governance for health, social care and wellbeing. The
partnership is pursuing the triple aim by promoting personal independence and community
resilience and delivering person centred care which will radically shift care and services
away from hospital settings to communities and home.
The table overleaf presents a summary of benefits from a system perspective. The high
level ambitions were enhanced by examples and descriptions given at a workshop held on
15th September 2015 involving the Alliance Board and a range of other senior leaders, and
which helped inform the ICO Vision set out in Section 4.
.
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Benefits to Professionals, Organisations and the Salford Together System
Area of impact
Benefit description Examples – what the ICO should be judged on
Integrated care
Extend the Integrated Care Programme
Integrate pathways, enabling more care closer to home, supporting reablement and independence
Develop a single health and social care shared record
Greater opportunity to engage staff in the design of pathways, creating greater ownership and commitment
Ability to be more responsive and timely in making service improvements
Delivery of single health and social care multi-disciplinary assessment and review, integrating disparate services.
Users’ feedback – with confidence in and understanding of provision.
Building on examples such as Salford Home Safe, which illustrate the natural progression from ICP to ICO, moving from people being brought together to using shared models.
A system which manages complexity and ‘works’ from user and system perspectives.
Improved quality and outcomes
Utilise the strengths and expertise of all partners – best of health and social care
Develop of a Salford-wide approach to Quality Improvement
Develop more personalised services focused on prevention, early intervention and improved outcomes
Establish robust governance and shared performance framework
Goal congruence – giving aligned incentives and avoiding care-shifting.
Real patient focus – not simply speeding up pathways, but building user confidence in services, managing transitions and care navigation.
Balancing local (neighbourhood) focus with consistent pathways – part of a significant emphasis on greater equity.
Sustainability of care services
Help sustain care, better able to continue to deliver high quality services in the context of rising demand and restricted funding
Safe and supportive organisational home with a supportive culture embracing collective leadership
Develop a flexible, future-proof workforce, breaking down professional barriers between health and social care staff
Financially viable and sustainable solution for the health economy
Developing users’ resilience and independence, with home-based care.
Systematically supporting carers, as a key part of the system, along with the Third Sector and community assets.
Supporting each partner organisation by contributing savings.
Workforce measures – demonstrable impact on qualitative and quantitative measures (e.g. turnover, vacancies, surveys), and creation of new roles.
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Benefits to Professionals, Organisations and the Salford Together System
Area of impact
Benefit description Examples – what the ICO should be judged on
Efficiency and value-for-money
Supports a whole-person approach to secure better value for money, focusing on life-cycle costs
Improved efficiency through vertical integration, reducing high cost care
Reduce management costs and duplication across health and social care
Achieving key improvement measures e.g. NEL admissions, lengths of stay.
Creating jointly agreed strategies to identify and deliver efficiencies.
Technical efficiency across pathways (doing things right).
Allocative efficiency through flexible governance (doing the right things).
Integrated commissioning – population focus
Consistent with and supports integrated commissioning of health and social care between SCCG and SCC, focused on health and wellbeing
Scale and integration to commission on a whole population basis
Outcome-based commissioning, with the ICO integrating the pathway, enabling commissioners to focus on population health.
Primary care ambitions for a consistent, standard way of working, far less dependent on individual providers and a person’s geographic location.
An ICO providing a single, consistent service for Salford residents.
Further integrating mental health services, focusing on recovery and specific pathways. Pooling resources could enable more and earlier intervention, to prevent intensive, reactive and expensive episodes of care – leading to greater parity of care.
Broader perspective of ‘place based’ approach, e.g. linking with schools.
Whole system fit
Supports the GM Devolution and Public Service Reform agenda, as well as the wider integration of care within the Salford health and social care economy
Builds on strong relationship between partners in Salford, retaining services and staff employment within Salford
Creates incentives and opportunities to shift care closer to home
Changing transitions of care (less duplication, greater efficiency and better experience).
Re-branding / re-imagining services as community based care for Salford.
Impact judged by scalability and pace – of delivering whole system benefits.
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3.6 Improvement Measures
In 2013, Salford agreed seven system-level improvement measures including health, social
care and wellbeing indicators which reflect the breadth of our ambition. These metrics have
informed the construction and composition of our model of care for the ICP (community
assets, centre of contact, MDGs) designed to deliver the improvements in these outcomes.
1. Reduce emergency admissions and readmissions
2. Reduce permanent admissions to residential and nursing care
3. Improve Quality of Life for users and carers
4. Increase the proportion of people that feel supported to manage own condition
5. Increase satisfaction with care & support provided
6. Increase flu vaccine uptake
7. Increase proportion of people that die at home/in usual residence
The measures were selected and refined through a four stage ongoing cycle, informed by
evidence (local, national and international) and supported by extensive engagement.
Long list of potential outcomes
A long list was produced from the three national outcome frameworks, with indicators selected based on their fit to the target population (initially older people but now extended to full adult population) and the degree of dependency on partnership effort to secure improvement.
Medium list of outcomes
A medium list was selected based on the fit to our triple aim (better outcomes, improving experience, and reducing costs) and the opportunity for improvement (Salford’s distance from top quartile or decile performance).
Engagement and support
Each of the statutory organisations was asked to vote on the medium list of indicators, with the results debated as a partnership to ensure shared ownership and support. Bespoke engagement was undertaken with Salford residents to ensure the indicators reflected areas they felt needed improvement (this resulted in the inclusion of a target relating to End of Life Care).
Plausibility, evidence base and target setting
Each target was assessed for plausibility (the ability for integrated care to impact on the outcome) and cross referenced to the evidence base (what has been delivered in other integrated care systems). Targets were set on moving to either the top quartile or decile by 2020.
As we are broadening the scope of our model of care from older people to adults we have
re-tested the applicability and validity of these measures and, where applicable, refined the
improvement target and expanded the measures. During the course of the Salford Together
programme, using the cycle above, we will further refine outcome measures to reflect the
enlarged population coverage and evidence. The current set of improvement measures
agreed by the system, to which the ICO contributes, is given overleaf and will be enhanced
as part of the performance framework introduced in Section 8, Management Case.
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Improvement Measures
Measure Target Rationale
1. Reduce emergency attendances and admissions for adults and older people
16.2% reduction in non-elective admissions by 20/21 against a 2014/15 growth baseline. 17.6% reduction in emergency attendances by 20/21 against a 2014/15 growth baseline.
Presently in bottom quartile in the North West for both admissions and readmissions. Emergency admissions improvement target is to move mid-point between top quartile (best) and 2nd quartile.
2. Reduce permanent admissions to care homes
26% reduction in care home admissions (from 946 to 699 per 100,000 65+ ppn): a reduction of 84 admissions, against a 2011/12 baseline of 322 admissions.
Presently in bottom quartile in the North West. Improvement target to move to top quartile.
3. Reduce demand for planned hospital care
11.5% reduction in planned admissions by 20/21 against a 2014/15 growth baseline. 11.4% reduction in outpatient appointments by 20/21 against a 2014/15 growth baseline.
4. Improve Quality of Life for users and carers
Maintain or improve ranking position (or equivalent) from 2011/12 baseline.
Presently in upper quartile position nationally. Subjective and difficult nature of measures recognised. Given infrequent national measurement, local ‘proxy’ measures will also be required.
5. Increase the proportion of people that feel supported to manage own condition
6. Increase satisfaction with care & support provided
7. Increase flu vaccine uptake
Increase flu uptake rate to 85% (from baseline position of 77.2% in 2011/12).
Presently ranked 17th nationally (top decile). Aiming to exceed top performing area.
8. Increase proportion of people that die at home/in usual residence/preferred place of dying
Increase to 50% (from baseline of 41% in 2011/12).
Presently in third quartile in the North West, though this position has improved over time. Improvement target would move Salford into the upper (best) quartile
9. Improved estimated diagnosis rate for Dementia
Diagnosis rate for people with dementia (local metric within GM Dementia United programme) – target to achieve diagnosis rate of 73.7% (2015/16) vs. baseline of 69.5%
10. Medicines optimisation
Containment of growth rate for primary care prescribing, avoiding £2.5m in projected in increased costs
Strongly aligned to focus on chronic disease management supported through robust medicines management
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As we extend and embed our new model through the ICO and wider Salford Together programme, we are considering a range of additional potential
improvement measures, given below, which are based on the three national frameworks relevant to the ICS and linked to Salford’s Locality Plan.
Potential Additional Improvement Measures
Overarching measures used in Salford’s Locality Plan at end of 5 years to see the difference made:
Deprivation score (Index of Multiple Deprivation)
Potential years of life lost
Life expectancy / Healthy Life expectancy
Disability free life years
Outcomes for people Outcome measures Indicators used for quarterly / annual monitoring
Living Well Citizens will achieve and maintain a sense of wellbeing by leading a healthy lifestyle supported by resilient communities
I am able to take care of my own health, wellbeing and am economically active
Healthier lifestyles and situation for Salford people
Long term unemployment (ICO contribution)
2.12 Excess weight in adults or (ICO contribution)
2.13ii Percentage of physically active and inactive adults (inactive adults)
7.01 Alcohol-related hospital admission (subset of existing ICO indicator)
1.17 Fuel poverty (ICO contribution)
My lifestyle helps me to stop any Long Term Condition or disability getting worse, and keeps the impact of this condition or disability from affecting my life
Improved lifestyle, which lead to longer, more contented lives for those with long term health conditions
Smoking attributable hospital admissions (subset of existing ICO indicator)
Mortality rates (various long term conditions) (ICO contribution)
Long-term health problems or disability: % of people whose day-to-day activities are limited by their health or disability (ICO contribution)
I lead a happy, fulfilling and purposeful life, and am able to manage the challenges that life gives me
Increased happiness and life satisfaction, with improved personal resilience
2.23iii - Self-reported wellbeing - people with a low happiness score OR 2.23v - average Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) score
1.11 Domestic abuse (assuming reliable data available)
A&E attendances (ICO contribution)
Health Watch Salford collected Wellbeing Star survey (wellbeing measures)
Number of falls in the over 65s or over 80s (ICO contribution)
People that supported to manage own condition (existing ICO indicator)
Avoidable emergency admissions and re-admissions (existing ICO indicator)
ASCOF 2B(1) proportion of older people who were still at home 91 days after discharge from hospital into re-ablement / rehabilitation (ICO contribution)
ASCOF 2A(2) Permanent admissions of older people (aged 65 and over) to residential and nursing care homes per 1000 population (existing ICO indicator)
If I need it, I will be able to access high quality care and support
Increased quality and personalisation of care for older people
Estimated diagnosis rate for people with dementia (existing ICO indicator)
Quality of Life of service users and carers (existing ICO indicator)
Patient / service user experience or satisfaction measure (existing ICO indicator)
I know that when I die, this will happen in the best possible circumstances
Improved end of life care
Proportion of people that die at home/in usual residence (or preferred place of dying) (existing ICO indicator)
4.15i Excess Winter Deaths Index (single year, all ages) (ICO contribution)
The measures in the table include a combination of National Framework indicators supplemented by locally sourced measures and surveys.
Some of the local surveys will be new and some of the existing indicators may have changed their definition or methodology, and therefore at this
time there may be no baseline figures or historic performance data.
For each indicator measure, we will monitor current performance including direction of travel. Where possible, we will set a future ambition for
indicators based on a comparison with the best in Greater Manchester and whole UK, as well as a possible trajectory showing the improvement
each year that would be required.
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3.7 Summary
In summary, this section on the Case for Change demonstrates that:
In Salford we must improve outcomes and change the health and care system to be
sustainable and close the future gap between demand, costs and funding.
Reviews of local and external evidence on best practice and extensive engagement
inform our view – that Salford needs an ICO operating as the integrating vehicle within
the ICS, underpinned by collaborative decision-making, system transformation and co-
commissioning services.
Based on this compelling case for radical change, the next section describes our vision for
the ICO and this is followed by an explanation of how it will best be delivered and what it
should cover in terms of population and services.
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4. Strategic Case – ICO Vision
Summary In this section we restate the Salford Together joint vision for delivering improved care and greater independence for our local population, supported by a sustainable health and care system. In the context of Salford’s Locality Plan, our vision is to create ICO as a means to achieving our shared aims, within a wider integrated care system. Key points
Partners in Salford have, over many years, collaborated to pursue shared ambitions: from the SHIFT programme of long term service improvement starting in 2001, through the Integrated Care Programme for older people first developed in 2012, to the current Salford Together partnership, that has been supported by an Alliance Agreement and shared governance.
Each organisation has its own set of values and responsibilities and brings a different emphasis and contribution to improving health and wellbeing in Salford; and together we have a shared vision for outcomes-based population health improvement.
The NHS England New Care Models Vanguard Programme provides a unique opportunity to more rapidly create an integrated health and care system.
To move to the next level of individual and system benefits, and to sustain and spread integrated care, Salford Together partners agreed in principle to create an ICO (SOC, November 2014) and approved the model with SRFT as prime provider (OBC, November 2015).
The ICO is a core component of an integrated system and a mechanism that supports providers and commissioners to deliver shared objectives. In doing so, the ICO will work alongside others, particularly GPs, as equal partners in delivering improvement.
Conclusions We note the decision at OBC to develop an ICO as a vehicle for Salford Together to deliver and support outcomes-based population benefits. This will help the system address growing demand and demographic changes in the context of the significant financial challenges we face.
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4.1 Table of OBC Strategic Case Recommendations and their Status
This section begins with a review of the OBC ICO Strategic Case recommendations and their
current status.
OBC Recommendation Status
Recommendation a): Support the aims of the Integrated Care System and its further development, agreement and formal approval by 1st April 2016
This recommendation was approved by all approving bodies at OBC and the description of the Integrated Care System and approval processes set out in this for approval in the FBC fully reflect these aims.
Recommendation b): Support the shared vision for the ICO
The shared vision was supported by all approving bodies at OBC and the Commercial, Risk and Implementation arrangements set out for approval in the FBC have been devised to support realisation of this shared vision.
4.2 How will the ICO help Salford residents?
Before explaining our history of collaboration and the contributions of Salford Together
partners in creating an ICO, we explore how these changes will directly affect our
population. Below are a series of vignettes explaining, from different perspectives, the
impact of an ICO.
Perspective Explanation / illustration
Population and communities
The ICO, as part of a wider integrated health and care system, will help people to see their own health as something they invest in personally, as well as improve by receiving health and care services. Opportunities will be identified and exploited to promote healthier choices, taking actions that help not harm health outcomes. Community assets also has a significant role to play at a population level, supporting social cohesion, building relationships, establishing networks that bring mutual support and wellbeing
Service Users For service users, the impact of an ICO will be clear when people are able to reflect:
I was quickly put through to the right service
I only had to give information once
I felt all the people helping me knew about my situation and had talked to each other, behind the scenes
I knew what was going to happen next and what I could do to help myself
Carers Carers play a crucial role for many people in Salford, particularly the vulnerable and frail. The ICO will help carers by being: more aware of the care plans for the service user; clearer on what can be done to avoid deterioration or crisis; and where to go for help that will quickly return them to independence, at home.
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The impact of a new integrated care system on the people of Salford at each of the three life course stages (Starting Well, Living Well and Aging Well) are set out as ‘I’ statements, as given earlier. In developing our care model this approach has been used to extend the descriptions in accordance with the ‘six principles’ from Five Year Forward View People and Communities Board, and are given below.
I will be listened to by those in voluntary and professional health and social care services.
I will be supported to look after myself or the person I am caring for.
I will have a single telephone number to access:
o Health and social care advice. o Health and social care support.
If I decide to make changes to my lifestyle. If my situation changes, or that of the person I am caring for. If I need urgent support.
Where I need regular contact and support from health and social care services:
o I will agree a plan of care with those involved in supporting me and they will know my wishes and have ready access to my information (or relating to the person I am caring for).
o Where I, or the person I am caring for, need checks, tests and reviews as part of my ongoing condition I will access these within my neighbourhood wherever possible.
o I will have one person to act as my point of contact for any care and support that I am receiving regardless of whether this is a physical, mental health or social need.
o If my situation changes – whether planned or unplanned - health and social care voluntary and professional services will work together and with me to plan my support with commitment to reable me and increase my resilience.
For people with dementia:
o Where I am living with dementia I will have access to a key worker 24 hours per day, 7 days per week who will support me to live well with dementia.
o I will be supported to co-produce a package of support and care which meets my needs which is reviewed and updated at least once per year.
o I will have access to technology that will help me and or my carer to monitor my health, enrich my social life and navigate local services in a way that is helpful to me.
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4.3 Our Story of Collaboration
Salford Together comprises four high performing partners with a track record of working
together to improve health and wellbeing in Salford, as illustrated in the table below.
Programme Content and Achievements
Salford Health Investment for Tomorrow
(SHIFT, commenced in 2001)
Innovative long term transformation programme:
Service change management and delivery workstream, which introduced new models of care.
Major hospital redevelopment programme at SRFT.
Establishment of Health and Social Care Gateway Centres.
Workforce development, including new roles.
Investment in IM&T, including the collaborative Salford Integrated Record (SIR).
Unscheduled Care Partnership
(commenced in 2009)
Whole-system approach to unscheduled care, removing fragmentation and duplication, reducing the cost to Salford:
Integration and consolidation of urgent care services.
Improvements in access to General Practice.
Assertive Alcohol Outreach Service providing support to individuals with alcohol, personality disorder and drug misuse problems that frequent presenters to A&E.
Transforming Community Services
(commenced in 2010, services transferred to SRFT in April 2011)
Transfer, integration and transformation of community health services that were previously managed by Salford PCT:
Integration of community and acute health services.
Increased skill mix within the Care Homes Practice and joint working with COTE and care homes.
Increased community-based provision, e.g. Anticoagulation and Dermatology clinics in the community
Stable and resilient home for community services, with a unified culture.
Standards-based approach (e.g. Community Assessment and Accreditation System and improvements in quality.
Salford Integrated Care Programme for Older People
(ICP, commenced in 2012)
Partnership programme with the triple aim of: delivering better outcomes; improving the experience of service users and carers; and reducing care costs. Collaborative improvement model across health and social care to implement three core components:
Increased use of local community assets to support independence and resilience for older people.
Established an integrated Centre of Contact to support navigation, monitoring and support.
Multi-Disciplinary Groups (MDGs) to support those who are most at risk, focus on prevention and signpost to community support.
The ICP led on to the development of a wider Alliance Agreement, with a pooled budget and shared governance arrangements.
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Our collaboration is supported and assured by a broader network of partners and a clear
governance framework; our focus on integrated care also forms a key element of Salford’s
Joint Health and Wellbeing Strategy. Through the process of working together we have
learnt and are able to demonstrate:
Shared ambition and clear alignment of activities within primary, community, acute and
mental health care organisations along with social care and a range of voluntary,
community and social enterprise (VCSE) partners.
Strong commitment to move towards an ambulatory model of care, delivering Salford-
based outpatient services in community settings wherever this is safe and sustainable.
A shared view that as a health and care economy we must move towards maintaining
population health and independence, and away from reliance on service provision,
especially acute, unplanned and episodic care.
A track record of pursuing methods such as care coordination and pro-active case
management to help address the growing demands from the people in Salford with the
highest needs.
4.4 Building on the Best of Partners’ Contributions
Partnership working is essential to a Salford wide approach responding to population
demands and system resource constraints. In creating a shared purpose, it is important to
recognise differences and the respective contributions from partners. As part of the process
to develop the OBC and inform this FBC, a joint ICO-visioning exercise was held on 15th
September 2015. This highlighted partner perspectives and is summarised overleaf.
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Partner Perspective and Contribution to Vision
Partner Perspective and Contribution to Vision
SCC Population access to an adult social care function supporting enhanced quality of life for the people of Salford.
Enabling people to live in their own homes as long as possible, building community resilience – with less need for acute, urgent and hospital based care.
Compliance with the Care Act, safeguarding and other statutory requirements.
Alignment with outcomes framework and approaches such as ‘just enough care’.
Building on the ICP, including community of assets, centre of contact and MDGs.
SCCG Strategic vision to improve health and wellbeing, reduce health inequalities and improve quality, safety and efficiency.
Compliance with statutory duties and alignment with five programme areas, all of which are affected by the ICO (quality; community based care; integrated care; long term conditions and mental health; hospital based care).
ICO to be an integrator of pathways
Citywide objectives for integrated care, delivered at a neighbourhood level – with particular emphasis on greater equity (of access, care and outcomes).
ICO to provide greater resilience in provision and cost-effectiveness, but recognising the risk of placing many services in one organisation.
Forging stronger relationships with the broader community e.g. schools.
SRFT Providing safe clean and personal care.
Focus on end-to-end provision based around the patient and service user.
Creating incentives to avoid duplication and increase efficiency, particularly through better management of boundaries between services.
Creating (freeing up) capacity and resource to support changes in hospital services driven by Healthier Together.
Attracting the right workforce and improving the health and social care record.
GMW Strategic vision to achieve 'Improved lives and optimistic futures for people affected by mental health and substance misuse problems'.
Specific strategic context as a specialist provider of mental health services across three districts (Bolton, Trafford and Salford), each taking different approaches to integration.
Focus on early intervention, prevention and recovery to enable the best possible outcomes for the service user.
Providing an integrated approach to care to support patients’ physical, mental and health and social care needs.
Building on the work of the ICP for Older People, integrating pathways for the broader population and extending Multi-Disciplinary Groups across adult services.
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4.5 Our Shared Vision – what the ICO is for
Partners in Salford Together summarised their desired future for an integrated care system
in the Vanguard Programme value proposition.
At the centre of our renewed ambition is a clear vision for population health
improvement, reaching beyond ‘out of hospital care’ to a single system of governance for
health, care and wellbeing in Salford. The benefits will come with the shift of care from
institutional settings towards the empowerment of citizens and communities to be
independent, for longer.
The creation of an ICO is a means to this end: to deliver improved health and wellbeing for
the people of Salford. The following presents the vision for the ICO. At its core, partners
speak about having an ‘outcomes-based vision for our population’ – this is the shared,
elevating goal around which we will coordinate all our activities.
ICO Vision: Partners in Salford Together have a shared vision to create an ICO that delivers significant improvements in experience and outcomes for service users by:
Promoting prevention and independence.
Providing person-centred health and care services.
Delivering more care in our communities.
Supporting our staff through new models and integrated systems.
Using pooled resources more efficiently.
The ICO will build on the experience, achievements and relationships of the Integrated Care
Programme (ICP) for older people. It will create the conditions to spread the methods and
improvements from the ICP, ensuring they are reliably sustained for the adult population.
In addition, the depth of integration will be taken to the next level by progressing from
strong partnership working to the consistency enabled by becoming part of a single
organisation. For example, professionals working in multi-disciplinary groups, and those in
separate services that have been co-located, will be able to communicate better, which we
know from evidence is a key factor promoting effective team working. Forming an ICO will
enable them to use the same rather than parallel systems, and act more quickly to achieve
common rather than disparate goals and organisational objectives.
The vision for the ICO draws on the distinct strategic objectives, priorities and duties of the
four partner organisations. The following summarises the outcome of the ICO visioning
exercise and also draws on previous input from practitioners, such as that expressed at the
large-scale engagement event on 26th March 2015.
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Greater Manchester West• Creating optimistic futures for people• Through specialist services • Focusing on early intervention, prevention, recovery and support
Salford Royal NHS FT• Safe, clean and personal care• End-to-end provision based around patients and users• Better management of transitions• Developing the new workforce and integrating care records
Salford CCG• Improve health and wellbeing• Greater equity of care and outcomes• Citywide standards with neighbourhood provision• Developing model for GP services
Salford City Council• Population access to adult social care• Live at home for longer• Safeguarding with ‘just enough care’• Invest in health and wellbeing
ICO VisionTo deliver significant improvements in experience and outcomes for service users by - promoting prevention and independence- providing person-centred health and care services- delivering more care in our communities- supporting our staff through new models and integrated systems-using pooled resources more efficiently
Salford Integrated Care System – Vision for the ICO
The vision, as approved by all partners in the OBC, is to create an ICO by transferring the
direct provision of adult social care services and the contracting arrangements for adult
social care delivery and local adult mental health services, to be subcontracted to GMW, to
one organisation in order to integrate adult social, mental and physical community and
acute care for the people of Salford.
4.6 Our Shared Ways of Working – how the ICO will act:
As a single system of governance for health, social care, mental health and wellbeing for
all adults in Salford – aligned goals and objectives will be aligned across the ICS
Shift services away from institutional settings into communities and closer to home.
Through a neighbourhood model of delivery and accountability, which will empower
people, help them invest in their own health and when they need services use more
ambulatory, preventative interventions.
Target resources where they have most impact, building more resilient communities to
better meet growing demand with improved outcomes, experience and efficiency.
Deliver consistent, seamless and standards-driven care, responding to need and building
trust, mutual commitment and shared responsibility with service users.
Break down barriers and provide the infrastructure (e.g. information systems, records
and facilities) staff need to provide high quality, safe and effective services.
Accountability to co-commissioners who prioritise population outcomes and prevention.
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4.7 Creating the ICO as part of System Transformation
The vision for the ICO has been developed in the context of emerging wider system
transformation, as set out in the Vanguard Value Proposition and Salford’s Locality Plan.
The Partnership will deliver the ambition for population health improvement by broadening
its focus from older people, aged 65 and over, to adults, aged 18 and over, then moving to
neighbourhood model, as illustrated in the three phased approach below. Partners must
move together on this journey, taking each measured step supported by a broad and co-
ordinated programme of system reform.
Three Stage System Transformation
Stage 1 Stage 2 Stage 3
Co
re C
om
po
nen
ts
MDGs
Community Assets
Centre of Contact
Care Homes standards
Extend care model to adults
(18+)
Long term conditions redesign
Incorporate adult
commissioning strategies e.g.
mental health, carers
Fully embedded neighbourhood
model
Pilot Integrated Collaborative
neighbourhood approach
Salford Standard
Key
En
able
rs
Alliance Agreement
and S75 Pooled Budget
for Older People
Revised system governance
and accountability
framework
Extend S75 Pooled Budget to
Adults
General Practice Provider
Leadership and Engagement
Neighbourhood commissioning
budgets & accountability
ICO Workforce Planning &
Redesign
Integrated Care
Organisation
Estates
Contract & Payment System
design
Capacity for change
IM&T
Improvement & Evaluation
Communications and Engagement
3. IntegratedNeighbourhood
Model2. ICP for Adults1. ICP for Older People
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The stages described here are mutually supportive. Change in each phase becomes self-
sustaining and then functions as enabler to the next phase. In this way the positive
momentum we have created can be sustained and steadily increased so that the
partnership can deliver solutions that outpace the problems it faces. The Integrated Care
Programme is now delivering real service and behavioural changes for the benefit of the
older population. The pace at which this is sustained and rolled out to the wider adult
population with a neighbourhood focus is being facilitated by the Vanguard programme and
the resources that it brings to Salford.
Through the development of this business case and aligned ICS, we have created an adult
care model based on our evidence review, emerging data analysis and learning from our
Integrated Care Programme for Older People. It uses the risk stratification model approach
and four levels of support from the older people’s programme to refine our model of care
for adults with a neighbourhood focus.
At its core, the ICO will be the supply mechanism that extends the reach of the programme
to the entire adult population (for the services in scope), changing the way services are
delivered at a neighbourhood level, and in parallel putting in place the governance and
structural changes to align incentives and goals, from organisational level to front line staff.
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The detail of the approach is given later in this FBC is being implemented in the context of
multiple, coherent transformation programmes including the following.
Strategic commissioning
o Focuses more on outcomes and creates incentives to support health
improvement rather than respond to ill health. Continued growth of NHS
allocation (to move towards Salford’s ‘fair share’ NHS funding allocation) and
redirection from lower value added interventions will create investment for
service innovation. A particular focus of commissioning is to address unwarranted
variation (variation not due to service user need or preference) which can mean
some effective interventions are underused (e.g. preventative responses to
diabetes) and other supply-sensitive interventions are overused.
Culture and behaviour of the population
o Promotes behaviour and action that improve health and wellbeing. Public Health
has a leadership and delivery role in supporting this transformation as described
in the Salford’s Locality Plan. The ICO will contribute, alongside a range of other
system elements, many of which are outside health and social care, such as
housing, employment and the VCSE sector.
Culture and behaviour of the system
o Promoting a new way of working, though service integration and greater
coordination, requires a broad and deep process of organisational and people
development.
Primary care
o As confirmed by external evidence on integration, plays a hugely significant role in
managing both demand and supply for health and social care. The model of
general practice and wider primary care to support the shared aims of the ICO
and wider Vanguard are under development, led by primary care providers and
facilitated by SCCG.
A further element of transformation is the next stage of our journey to become the safest
and most productive health and wellbeing system in England. As an example of this,
partners in Salford are currently engaging on our Making Safety Visible campaign which has
the guided by the following approach (and is work in development).
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Pri
nci
ple
s Use Making Safety Visible methods to underpin the development of our integrated care system
Focus on medication safety, communication and hand-offs
Move on from past harm to include elements of present and future
Aim
s
To ensure the reliable handover of care from one agency to another, minimizing the risk of patient harm
To ensure that medication is prescribed, dispensed, administered and reviewed safely and effectively in order to minimise the risk of harm to patients
Asking is care safe today? o Analysing real time individual and aggregate data o Using technology to provide rapid feedback on perception of safety
Questioning will care be safe in the future? o Using Failure Modes & Effect Analysis to assess safety of emerging care pathways o Safety climate surveys to underpin the development of a safety culture
The development of workstreams to make safety improvements in front-line services will
link with the existing structures of the ICP, which will be incorporated into the ICO, such as
the Care Homes collaborative working group. Governance structures to support the Making
Safety Visible approach will be aligned with those of the ICO and ensure appropriate clinical
and service user input. As an example of our ambition, we are exploring whether integrated
working, especially between secondary, community and primary care will enable
improvements in the Summary Hospital-level Mortality Index (SHMI), such as through
reducing deaths within 30 days following hospital discharge.
4.8 Alignment of ICO Vision and ICS approach to GM and National criteria
The creation of an ICO in the context of an ICS in Salford, driven by the vision set out above
and wider approach described in this FBC, meets the requirements of the NHS England New
Care Models Programme (as a PACS initiative) and the criteria guiding GM’s Transformation
Fund. The New Care Models team have identified five core components of PACS.11
Accountability for the whole population
A care model for population health and wellbeing
Integration of organisations to support population health
Contracting and payment systems that support population health
Regulatory environment to support population health
The table overleaf demonstrates how the implementation of Salford Together’s proposals
and associated model of care meets the core PACS components.
11
Draft framework, published 18 December 2015.
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PACS Approach Salford Together – alignment with PACS core components
Accountability for the whole population
Covers entire adult population within Salford (~180k)
All relevant health and social care services included within the ICO
Incorporates ‘living well’ and ‘ageing well’ outcomes from the Locality Plan
Reduction in hospitalisation and care homes admissions, plus associated
costs
A care model for population health and wellbeing
Population health management focus (risk stratification, care planning)
Enhanced primary (federated working, Salford Standards, care homes)
Integrated community teams (MDGs, Centre of Contact)
Integrated access to acute & emergency care (Centre of Contact,
comprehensive assessment process for older people)
Improved access to specialist opinion (specialist input into MDGs, Centre of
Contract, long term condition specialists working in neighbourhoods)
Self-care (wellbeing plan, use of telehealth, expansion of community assets)
Rapid community response teams (intermediate care, MDGs)
Community engagement & activation (expansion of community assets,
Integration of organisations to support population health
ICO includes community health, hospital care, mental health and social care
for adults, delivered through a prime provider (and supply chain) model
General Practice aligned through a federated neighbourhood delivery model
Single pooled budget established for adult health and social care services
Full co-commissioning model between SCCG and Salford City Council
Wider system leadership through Salford Locality Plan and Health &
Wellbeing Board
Contracting and payment systems that support population health
Pooled budget in place for 2016/17
Single contract for Integrated Care Organisation, including supply chain
Risk share arrangements established
Longer term commitment to move to a outcome based / capitated payment
model
Regulatory environment to support population health
Joint working with Monitor to address regulatory requirements of ICO
formation
Pilot site for CQC ‘Quality in a Place’ assessment
Risk share arrangements in place to deal with impacts of reducing acute
activity
Assessment undertaken of competition implications and mitigation
established
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The Greater Manchester Transformation Fund as explained in Section 2, Strategic Context,
sets five operating principles to guide investment, and the table below demonstrates how
these are met by the Salford Together approach, creating an ICO in an ICS.
GM Plan Criteria Salford Together – alignment with Transformation Fund Criteria
Alignment to GM Strategy
Locally owned and co-created strategy, aligned to GM and nationally
validated
Population health and integrated care consistent with life-stages approach
ICS and ICO fully aligned with neighbourhood delivery model
Fully supports GM ‘Transforming Care in Localities’ theme
Aligned system with joint health and social care commissioning standards
Wider Stakeholder Support
Comprehensive programme of engagement for ICP for Older People
Wide-scale engagement programme with adult population is planned
Person-centred model, care planning: MDGs and Centre of Contact
Fully aligned with the GM strategy of a ‘new deal’ with the community
Robust Financials Reduction of acute activity, increased investment community services
Contributes £35.8m to closing the affordability gap in Salford’s Locality Plan
Plan is benchmarked against international evidence of savings ROI of 371% against the £29.1m Vanguard investment by 2020/21
Robust Delivery Plan
Long history of successful system-wide change programmes
Clear rationale and evidence base for activities and interventions
Agreed delivery plan, with staged investment (2015/16 - 2017/18)
Robust governance through Health & Wellbeing Board and Integrated Care
Board arrangements, milestone plan and risk register reported monthly
Foundation for further transformation
Salford’s Integrated Record, covering physical, mental health and social care
System wide governance of quality monitoring
Single prime provider contract for health, mental health and adult social care
Longitudinal academic evaluation (CLASSIC) and real time evaluation
In summary, the section above explains Salford Together’s shared vision for the ICO which
will be created and operate as a key element of Salford’s response to the challenges we
face. The next section (Section 6, Economic Case) explains how the option for an ICO and
our approach to its development was chosen and what it will entail.
4.9 Table of Strategic Case Recommendations
Recommendation a): Reconfirm support for the shared vision for the ICO.
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5. Economic Case – Options
Summary In this section we restate preferred option approved in the OBC. In forming an ICO, the partners in Salford Together face key questions around ‘who’ (the population to be served); ‘what’ (the services to be provided); and ‘how’ (the way it should be delivered). This section sets out how we have addressed these issues and the framework used to determine our proposed approach to creating an ICO. Key points
Each partner has articulated an outcomes-based vision for the local population which is framed by their values, accountabilities and resources.
Limitations on what the current collaborative approach to service integration can deliver and recognition of opportunities from taking the next step further led to a consensus – create an ICO to act as a system integrator, for the services in its scope. In acting upon this approach we have handled issues involved in such an innovation, including procurement arrangements and ensuring choice for clinicians and patients.
Informed by the ICO vision and using a set of criteria to assess options, we took two key decisions at OBC stage:
- SRFT as Prime Provider will deliver services for all adults (18 years and older) through a
combination of direct provision and supply chain management. - SRFT will directly provide healthcare services for the people of Salford and the Adult Social
Care assessment function (including statutory review), with mental health services delivered through a contract with GMW.
Within the ICS and aligned to the ICO, primary care is pursuing a federated approach, with contractual and delivery models continuing to be developed.
Specialist and children’s services are out of scope of the ICO.
Outcome-focused commissioning will align standards across all services and the approach. Conclusions The ICO model, explained in this section, provides the opportunity to deliver benefits through transformation of the services that are integrated through this model. The proposed approach of SRFT as prime provider for a defined population and service scope will ensure Salford is able to deliver person-centred services, supporting wellness, independence and resilience in our communities.
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5.1 Table of OBC Economic Case Recommendations and their Status
This section begins with a review of the OBC Economic Case recommendations and their
current status.
OBC Recommendation Status
Recommendation c): Approve the selection of the preferred option for the ICO as follows: - SRFT as a prime provider for adult social care and
physical health services with a focus on improving population health and wellbeing.
- SRFT as a prime contractor for adult social care delivery and local adult mental health services, with agreement in principle to novate/assign or otherwise transfer responsibility for the contract for district and older adults mental health services that are currently in place between SCCG and GMW from SCCG to SRFT to subcontract to GMW.
The preferred option for the ICO was approved by all approving bodies in the OBC.
The Strategic Context, Case for Change or Shared Vision continue to support the preferred option selected at OBC.
5.2 Approach
The section explains the core of the proposed development: what the ICO should comprise
and how it can best be delivered. The following presents the staged approach that has been
taken to develop, evaluate and reach a consensus on the configuration of the ICO.
The first stage, at high level, explains the consensus reached through SOC and OBC,
addressing:
o Contracting model – prime provider
o Choice of provider – SRFT
o Geographic scale – whole of Salford
In moving to the second stage of determining the population and service scope we
developed an evaluation framework that complements the outcomes (improvement
measure) approach used for the ICP and adapted for the ICO, as set out in Section 4,
Strategic Case – Case for Change. This evaluation framework is informed by the shared
vision and description of desired benefits, and links to the wider integrated system and
Salford’s Locality Plan.
Extensive engagement and discussion amongst partners, using the integrated
governance arrangements, has resulted in a consensus on the ICO’s optimal
configuration, in terms of population coverage and service scope (further details of
which are given in Section 7, Financial Case, and Appendices).
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Before setting out how we decided upon the preferred option for Salford Together, we
briefly explain the ICO model.
5.3 Explanation of the ICO Model
The central argument for developing an ICO is that integrated care requires a higher degree
of service, functional and financial integration than can be delivered through collaboration
alone. Bringing the full range of care within a single management and contractual
arrangement enables more effective, efficient and person-centred services – and creates
powerful incentives to better manage population demand. As illustrated in the Figure
below, there is a continuum of potential options available to support integrated care, from
greater co-operation to full organisational merger12.
Continuum of Integration
The ICO concept has a long history and is being increasingly adopted in various international
settings and across health and social care sectors. In the English NHS the approach came to
prominence through the NHS Next Stage Review (Department of Health, 2008), known as
the Darzi Review. A research study, Where next for integrated care organisations? (Nuffield
Trust, 2010) stated that:
“The [Darzi] review also introduced a new concept – the ‘integrated care
organisation’ (ICO) – that might achieve truly integrated care. The premise of
integrated care is that it will not only help to improve the coordination of care for
patients and therefore prevent avoidable ill health, but also that it will result in
greater value for money. While the formal evidence on integrated care is as yet
underdeveloped, the wide variations in avoidable use of hospital care suggest there is
scope for large gains in efficiency through better coordination of services.”
The scale, scope and model of ICOs vary enormously, but all are explicitly intended to
deepen and widen integration, to move beyond the benefits that can be delivered by
partnership working alone. Areas that have sought to integrate services without some form
of structural or functional integration have frequently experienced a number of difficulties
in making integration ‘stick’, including:
12
Adapted from Leutz (1999).
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Inability to align service delivery ‘on the ground’
Organisational and professional silos
Inconsistent operational procedures and policies
Fragmented IT, information and reporting systems
Different approaches to managing performance, risk and governance
Difficulties in spreading the benefits from ‘islands of excellence’ and in sustaining them –
being able to withstand changes in context and partner relationships
Although care can be integrated without creating an ICO, the advantage of this approach is
that a single organisation with one funding envelope, a single set of goals and a shared
vision for Salford’s health and social care economy is able to avoid many of the problems of
fragmentation experienced in virtually integrated systems.
5.4 Decision on a Preferred Approach – SRFT as Prime Provider
Partners reviewed potential organisational forms in the lead up to approving the SOC in
November 2014. At the visioning session in September 2015, the Alliance Board and
colleagues tested and reconfirmed the rationale for selecting a prime provider model led by
SRFT. The strategic context continued to develop and the key changes (Vanguard and new
models of care; Greater Manchester devolution and Salford’s Locality Plan; and greater
emphasis on neighbourhood delivery and accountability) were taken into account in the
OBC which recommended the local approach.
A range of potential options and commissioning routes were available to SCCG and SCC, as
co-commissioners, for selecting the prime provider for the ICO. In theory the role could
have been fulfilled by any of the existing providers or a new provider. Commissioners
carefully considered their options, took account of their obligations under EU procurement
and competition law, and determined that the most credible and preferred option is that
this role is undertaken by SRFT. The rationale for this is set out in the figure overleaf. This
approach already has the support of Salford’s four statutory organisations and was
approved in the OBC.
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Prime Provider Options for the ICO
Options Advantages Disadvantages
SRFT
Strong performing and stable organisation, with a record in service transformation
Main provider of both acute and community healthcare in Salford
Provides the largest proportion of services that are likely to be in-scope (circa 55% of the proposed ICO)
Some experience in primary care and adult social care (intermediate care)
Existing member of the ICP
Positive relationship with statutory and other partners
SRFT’s strategic intent is to develop part of the organisation into an ICO
Limited knowledge / experience of social care and mental health
Limited experience in sub-contracting services
SCC
Strong performing organisation
Already deliver social care services within Salford
Experience in subcontracting adult social care services (circa 25%, using the pooled ICP budget as a proxy)
Existing member of the ICP Positive relationship with statutory and
other partners
Provides a small proportion of the services that are likely to be in-scope (circa 33% of the proposed ICO)
Limited experience in delivering healthcare services
Not part of the SCC’s strategic intent, the focus has been to develop an enhanced commissioning approach, supporting partners to deliver services
GMW
Strong performing and stable organisation
Principal provider of mental health services within Salford
Prime provider for drug and alcohol services in Salford
Already manage mental health social workers on behalf of SCC
Existing member of the ICP Positive relationship with statutory and
other partners
Provides a small proportion of the services that are likely to be in-scope (circa 12% of the proposed ICO)
Does not have experience in physical health services
Not part of the GMW’s strategic intent
Other provider in Salford
None identified All other providers in Salford are deliver a relatively small proportion of the services that are likely to be in-scope
Lack of credible existing provider with sufficient capability and capacity
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Options Advantages Disadvantages
Whilst good relationships existing with the independent and third sector, these are not as mature as those between the four statutory organisations
External provider
None identified In order to fulfil the prime provider role (as opposed to lead contractor), this would require re-commissioning existing services with the associated disruption and loss of momentum
Lack of historical relationships / engagement in the ICP
Loss of geographical focus Lack of credible provider with
sufficient capability or capacity
In addition to the Prime Provider options set out above, Salford Together considered the ‘do
nothing’ option. This would entail collaboration continuing at a partnership level, based on
the models developed through the Integrated Care Programme. The potential
consequences of continuing with current demographic, activity and finance trajectories has
an impact presented most clearly in Salford’s Locality Plan, as summarised in Section 2
Strategic Case – Context. This estimates that Salford will face a significant financial gap by
2020/21 without radical action, despite high performing local organisations. The non-
financial limitations of the ‘do nothing’ scenario include:
Goals and performance – inability to align goals and appropriately monitor and
Integrated, person-centred care models – restricting the potential to challenge
existing practice, experiment and innovate in creating new approaches which
address service user needs, particularly the ‘I statements’ given earlier.
More preventative, coordinated and efficient services – continuing with programme
level collaboration would entail organisations and services remaining restricted by
differing responsibilities and perspectives, including professional boundaries, silo
working and conflicting priorities.
Procurement
The CCG and Council have both considered their procurement law duties and consider that
they can award a contract to Salford Royal NHS Foundation Trust as the ‘prime contractor’
in the ICO without the need to advertise and run a competitive tender process. The
rationale for this decision is described overleaf.
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The stated aim of the partners in developing the ICO is to bring together adult social care,
community and hospital mental and physical health service provision, with a view to
providing better, more integrated services and support for the full adult population.
Both the CCG and Council consider that the ICO is the only provider capable of achieving the
integration of a combination of services through contractual arrangements of all of the
partners and therefore a tender process is not required.
Compliance by CCG with its procurement law duties
For commissioning healthcare services from the ICO the CCG is required to comply with the
Public Contracts Regulations 2006 and the National Health Service (Procurement, Patient
Choice and Competition) (No. 2) Regulations 2013 (the ‘Section 75 Regulations’). The CCG
does not need to consider the Public Contracts Regulations 2015 as the process to secure
the ICO has commenced prior to 18 April 2016.
The test for whether a tender must be conducted in respect of healthcare services (in so far
as the Public Contracts Regulations 2006 and EU law position is concerned) is whether there
is a realistic prospect of a cross border interest in the contract in question – i.e. are there
any providers in other European Member States who currently operate in the UK or who
wish to expand into the UK market to provide the services?
If there is no realistic prospect of a cross border interest in the contract opportunity in
question then there is currently no legal requirement on the CCG to tender the contract
under EU law. The CCG has considered this test and does not consider there to be a cross
border interest for these services given the nature and the need for an integrated approach.
Notwithstanding the requirements above, the CCG has considered the Section 75
Regulations.
The Section 75 Regulations provide that if there is genuinely only one capable provider a
CCG may use that reason to exempt itself from the requirement to conduct a tendering
process (the "one capable provider exemption").
The CCG's requirements have been based upon objectively justifiable criteria and the CCG
consider that there is only one capable provider.
Monitor Substantive guidance on the Procurement, Patient Choice and Competition
Regulations (December 2013) (the Substantive Guidance) emphasises that decisions as to
how to best secure services in the interests of patients is for the commissioner.
The CCG has produced a clear audit trail of the rationale for its decision. The CCG has
considered its duties under the Section 75 Regulations and considers that the ICO is the only
provider capable of delivering the objectives referred to in regulation 2 in relation to the
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services, and providing best value for money in doing so. The CCG considers that the ICO
meets the best interest of its patients.
Compliance by SCC with its procurement law duties
The Council has considered its procurement duties under the Public Contracts Regulations
2015, in particular the Light Touch Regime. The Light Touch Regime applies to services over
£589,148, although a tender process is not required where the Council can justify that there
is only one provider.
The Council considers that there is only one provider as competition is absent for technical
reasons and no reasonable substitute exists, and consequently the Council is not required to
run a tender process. The Council does not consider that competition is absent due to an
artificial narrowing down of the parameters of the requirement. The ICO is the only
provider capable of meeting the Council’s stated aims.
Compliance by SRFT with its procurement law duties
GMW
The Trust has considered its procurement law duties for when it is sub-contracting mental
health services to GMW.
The Public Contracts Regulations 2015 apply to the Trust and therefore the Trust is in a
similar position to the Council when considering its obligations.
The Trust considers that GMW is the only mental health trust within the locality that can
serve its patients. Additionally, the Council is delegating certain mental health functions to
GMW and hence GMW is the only provider who can provide these services as part of the
ICO. The Trust therefore considers that GMW is the only provider as competition is absent
for technical reasons. The Trust does not consider that a reasonable substitute exists.
Consequently the Trust is not required to run a tender process. The Trust does not consider
that competition is absent due to an artificial narrowing down of the parameters of the
requirement.
ASC supply chain contracts
In relation to transferring ASC supply chain contracts to the Trust, the Trust does not
consider that a tender process is required. Whilst the novation of these new contracts
could result in a new contract opportunity, as there will be no changes to the existing
contract provisions (the majority of which were previously competed) other than to the
identity of the commissioner, the Trust does not consider that there is a requirement to run
a tender for these contracts as there is no new opportunity to advertise.
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In addition, the care home market is a mature market with no new market entrants and
hence there is no need to re-tender these contracts at this time. The Trust, in conjunction
with the Council, will consider its procurement law requirements when new contract
opportunities arise.
It is the view of SCCG and SCC that the selection of SRFT as the prime provider for the ICO is
consistent with EU procurement law, the 2013 Regulations and Monitor’s procurement
guidance.
Given the diverse responsibilities of each organisation, a full merger would be neither
suitable nor appropriate to realise the desired benefits. There is a lack of other credible
providers within or outside the Salford economy.
The consensus decision to appoint SRFT as the prime provider is based on SRFT’s:
Strong and stable performance and track record in service transformation.
Status as main provider of acute and community healthcare in Salford.
Strategic Intent to develop part of its organisation into an ICO.
Strong relationships with statutory and other partners.
In reconfirming this decision we also reviewed the development of new models of care, such
as multispecialty community providers (MCPs) and integrated primary and acute care
systems (PACs), as briefly reviewed in the summary of our Vanguard programme in Section
2 (Strategic Case – Context). Partners agreed that they had been included, albeit with
different descriptions, in our appraisal of prime provider options.
5.5 Plurality of Provision, Competition and Choice
One of the advantages of using the prime provider model to create the ICO is that it
supports plurality of provision through the supply chain, within an integrated delivery
system, where this is deemed to be in the interests of service users or to be best method of
securing value for money. It will be for the commissioners to specify where a plural market
would be beneficial for subcontracted services and where the degree of concentration of
services is at the discretion of the prime provider.
As part of the ICP, a number of safeguards have already been agreed to ensure that there
are not inappropriate constraints on GP referral behaviour, patient or client choice.13
These will be extended, where applicable and necessary, to include in scope services for the
adult population, and are summarised overleaf.
13
Including patient choice where this is nationally mandated by the Department of Health.
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Summary of Safeguards relating to Referral Behaviour and Choice14
Potential Issue Established Safeguards
Patient Choice of Acute Elective Provider
Compliance with all current and future legislation or Department of Health guidance regarding patient choice of acute elective care provider.
Use of the Choose and Book system for referrals. Clear information to all patients / clients as to which services the
providers have responsibility for and where a referral is being made from one sector to another.
Provision of an appointment letter when referring a patient for elective care, setting out the right to a choice of provider.
Compliance with any written directions Monitor may give for the purpose of securing compliance with the assurances.
Provision of information to the commissioners, including referral patterns and complaints.
Patient Choice of Mental Health Provider
Compliance with all current and future legislation, NHS England or Monitor requirements regarding the rights of patients to choose any clinically appropriate provider of mental health services.
Choice of Care Home People using Adult Social Care who are assessed and require support in the form of permanent residential care are covered by the Choice Directive. This allows the individual to select a CQC registered care home which is capable of meeting their need and in which they will live permanently.
SCC is obligated to meet the cost of the placement up to the value of the standard ‘local’ rate determined by SCC, if the placement is within Salford. If the home is outside the Salford area the cost of the placement met by SCC will be the ‘local’ rate agreed by the Local Authority where the home is located.
Choice of a Care Home for individuals assessed as eligible for NHS Continuing Healthcare
Individuals who have undergone a formal assessment and have been identified as eligible for NHS Continuing Healthcare are able to choose a care home that has agreed the terms and conditions of the Northwest Framework Agreement.
SCCG will then pay for the care costs of the individual based on the locally agreed ‘affordability threshold’ and an assessment of need. If for any reason the care homes within the Framework Agreement cannot meet the needs of the individual, SCCG will then consider the options available.
5.6 Maintaining Statutory Responsibilities
In establishing the ICO, it is important to ensure that all parties are clear what
responsibilities have been delegated to the ICO, through the prime provider and sub-
14
For further details see Schedule 6 of the Alliance Agreement (see Appendix 1 Part C)
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contractors. Commissioners need to be assured that statutory responsibilities can be
effectively discharged through this arrangement. Equally, it is essential that the
responsibility of providers in the supply chain is clearly defined and that any implications for
regulators (such as Monitor and the CQC) are understood. These matters will be addressed
within the Services Contracts and sub-contracts, and approach explained in Section 6
Commercial Case.
Particular attention is paid in this section and Section 7, Management Case, to ensure that
SCC continues to fulfil its statutory responsibilities, including those required of Director of
Adult Social Services and the Caldicott Guardian for adult social care. These matters are
addressed in the Business Transfer Agreement and set of Transactions Documents which
form the basis for the services contract for adult social care.
5.7 Organisational Arrangements for Delivery
Under the prime provider model, the co-commissioners (SCCG and SCC) will contract from
SRFT, which will be given the responsibility for establishing the ICO through a combination
of direct service delivery and supply chain management, i.e. subcontracting from other
providers.
As the prime provider, SRFT will take responsibility for the day-to-day management of other
providers that deliver care within the contracted scope or pathway. The prime contractor
manages this supply chain through individual sub-contracts with each of the other health
and social care providers. Commissioners remove that specific function from the contract
with the provider and the prime contractor novates these terms in the sub-contract for that
service. Any subsequent changes are subject to joint review.
5.8 Features of the Prime Provider ICO
The features of the prime provider ICO model are entirely consistent with the ‘Primary and
Acute Care Systems’ and ‘Multi-Specialty Community Provider’ models that have promoted
by NHS England15, as explained in our Vanguard Value Proposition and the criteria given at
the end of Section 4, Strategic Case – ICO Vision. Key aspects of the approach are
summarised overleaf.
15
NHS England (2014) ‘Five Year Forward View’ www.england.nhs.uk/ourwork/futurenhs/ (pages 20-21)
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Proposed features
Prime provider commissioned to deliver (or subcontract from a supply chain) the entire continuum of health and social care for the adult and elderly population.
Responsibility for acute and community healthcare services, adult social care and mental health services, supporting primary care services.
Bundled payment or capitation formula for population health needs. Commissioners retain overall accountability for the commissioned services
through their direct relationship with the prime provider, while the prime provider holds each of the sub-contractors individually to account.
Prime provider takes responsibility for designing a delivery model that will most effectively meet the terms of the contract. They use the terms of the sub-contracts to stimulate the necessary behaviours and performance across other care providers.
Benefits of service, functional and financial integration
Full alignment of service aims, reinforced through unified service management.
Simplified decision-making and governance, without risk of organisational veto (as required in collective, unanimous decision-making).
Increased direct control over provision across a pathway and enables money to be moved within the pathway.
Clear governance arrangements through contractual / sub-contractual mechanisms.
Regarding payment mechanisms, whilst many US systems have identified sophisticated
approaches to managing financial risk and incentives,16 there are significant challenges
associated with any large scale change in payment systems. In the US, capitation and pay-
for-performance models have been informed by a wealth of insurance-based data which is
not available in the UK. It has taken many years for organisations such as Kaiser
Permenente to develop sophisticated data and measurement systems. Building on such
evidence it has been agreed that a planned multi-year approach will be required within
Salford.
Partners recognise the need for person-centred, locally responsive services to deliver care
closer to home. This principle is more fully reflected by taking a standards-driven approach,
focusing on co-terminus neighbourhoods of 30,000 to 50,000 people, and pursuing
equitable service delivery. A single provider of sufficient scale will be a far more reliable and
cost effective means of delivering these benefits to service users and the wider system, than
the deployment of multiple providers in a geographic area of Salford’s small size and relative
homogeneity.
The next section explains the criteria that have been used to determine the ICO model and
which will also support the developing Salford wide outcomes-led approach, which binds
the ICO to other elements of the integrated health and care system.
16
Gleave et al, 2009
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5.9 Evaluation Framework – Improving Population Health Outcomes
Building on the description of anticipated benefits – to individuals, carers and communities
and to our health and care system – as set out in Section 3, Case for Change, we determined
four domains of outcomes to guide creation of the ICO and determine the appropriate
option and configuration. The outcomes reflect opportunities for us to improve health and
wellbeing for our population, service users and their carers. It also builds on our review of
evidence and learning, including emerging work in other Vanguards.
Outcome domain
Description
Maintain and improve standards of care
NHS Constitution measures and standards
Social care statutory requirements
Accreditation by system regulators and assessors
Safety for service users
Safeguarding, particularly for vulnerable adults
Promoting equity and reflecting diversity
Other national guidance and standards
Risk management and creation of incentives to support delivery of the 2020 Outcome Measures
Improve outcomes
Improving population health
Improving quality of life
Reducing inequalities
Helping people be independent
Ensure our system is effective and sustainable
People experience personalised care which encourages choice and control
Timely, responsive access to effective, value-adding care
Financial sustainability across the health and care system
Partners collaborate as an integrated system
People have a positive experience of services and trust the system
Transform services
Prevention, early intervention and continuous care are prioritised
New care models and pathways create person-centred care
Our workforce is prepared and developed to help improve outcomes
Information technology and records are joined up
Estates and facilities are used to better effect
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5.10 Optimal Configuration – Population Scale and Service Scope
Following detailed review of potential configurations, including segmentation by age,
service and condition, partners reached a consensus that the ICO will take responsibility for
health and social care provision for the entire adult population of Salford (aged 18 years and
over) for the services in scope. The rationale for a whole population approach is that it:
Best supports our vision to improve the experience and outcomes for the all adult
residents of Salford.
Enables us to coordinate services and create models that address widespread and
longstanding inequalities (both between Salford and the English average, and within the
communities of Salford).
Avoids the complications involved in segmentation (such as by disease or health status)
which relies on often limited data sources.
Alongside the whole-population focus, we will prioritise specific services and interventions
to target those individuals who need it most.
To support development of an ICO we have reached a shared understanding of the scope of
services to be provided. Our process to identify what to include was supported by analysis
of the current situation, specifically including activity, workforce and financial data. This led
to the decision approved at OBC to carry out the detailed planning and due diligence which
informs the final configuration and arrangements set out later in this FBC.
By way of explanation, starting on the basis of including all health and care services, we
determined the grounds for excluding services on the basis of three key criteria:
1. Relevance for care coordination – the key question is whether inclusion would
stimulate integration and improvement for service users. Some services, such as
dentistry, while linked to other sectors operate as a natural unit, so are out of scope
because they require less coordination with the wider system.
2. Speciality of service – areas such as tertiary hospital specialties are highly complex,
costly and relatively low volume, often drawing on populations much wider than the
city of Salford, so for this reason are excluded from the ICO. Children’s services are also
excluded as they are subject to a separate review process, following which different
organisational solutions may be required.
3. Timing, ease of inclusion and implementation – services may be more difficult to
include because of structural, cultural and contractual arrangements so need to be
excluded at this point in time. For example, primary care is out of scope of the ICO,
with a separate workstream facilitated by SCCG is developing the role of general
practice within an integrated system. Similarly Public Health is out of scope of the ICO
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but plays a critical role in creating and implementing the Salford Together shared vision.
It is recognised that the scope may be refined over time.
Informed by this approach we developed a spectrum of potential configurations for the ICO
service scope, from the minimum (‘do nothing’) to the widest possible (‘maximise – include
all services’).
The minimal approach provided the baseline, with no services in the ICO and simply a
continuation of the ICP model, extended to adults under existing partnership
arrangements. This approach has been discounted based on the rationale given earlier
in this section.
The maximum approach would include services which, similarly, have been excluded
based on the three criteria above.
Within these bounds we have considered a range of models, the core of which see the
ICO having responsibility for adult population health and social care needs – promoting
prevention and providing services including: urgent and intermediate hospital care;
community health services; adult social care (assessment function) and mental health
services (delivered operationally by GMW). The potential to widen the scope further
has considered additional secondary and specialist hospital services, in both surgery and
medicine, but these have been discounted at this stage.
We determined the population and services to be included in the ICO through a process of
emerging consensus, taking in to consideration factors such as risk, professional links, likely
benefits and delivery of statutory requirements. The list of services included is given in
Section 7 Financial Case and Appendices. In summary, the Salford Together partners
approved at OBC the following optimal configuration for the ICO:
SRFT was selected as the prime provider for adult social care and physical health services
with a focus on improving population health and wellbeing
SRFT acts as the prime contractor for adult social care delivery and local adult mental
health services, with agreement in principle to assign or otherwise transfer to the ICO
responsibility for the contract for district and older adults mental health services (i.e.
contracts currently in place between SCCG and GMW are transferred to SRFT which will
subcontract to GMW).
In reaching this consensus position, there has been extensive engagement and deliberations
over a considerable period, including:
Identification of the desired benefits and creation of design principles by the ICO
Steering Group (26th February 2015).
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Preparation of materials and system-wide engagement on the ICO model (at the event
on 26th March 2015).
Ongoing, fortnightly development of the ICO model led by the OBC and Finance Steering
Group.
Wider governance and consensus building led by the Alliance Board for Integrated Care
(which meets bi-monthly).
Specific events to further engage on the process and develop partnership consensus,
(such as the Alliance Visioning Session held on 15th September 2015).
The SCC led consultation process conducted in Feb and March 2016 described in Section
3.4 provided further evidence of support for the proposals directly from Salford Citizens
As part of the process to develop the detailed approach to the ICO model partners
considered the appropriate pace of change – balancing the need for improvement through
system integration and to provide assurance for service operation and quality.
Beyond the timing of the ‘transactional’ steps (service and staff transfers, changes in
contracting arrangements), it is clear from international evidence that creating a mature ICO
and delivering the benefits will take several years. Sufficient time will need to be given,
following the establishment of the ICO on 1 July 2016, to embed services, align systems and
processes and address any residual risks. This has informed the approach outlined later in
the FBC, with an emphasis on service continuity and safety in Section 8 Management Case,
including the Post Transaction Integration Plan (PTIP) and Quality Governance Plan.
Many of the system-level benefits, particularly changing population outcomes, have a
significant time-lag and therefore it will be important that partners continue to discuss and
reach consensus on the rate at which benefits are likely to be realised.
As a consequence, a phased approach will be taken in Salford to mitigate risks to
commissioners, SRFT and partners in the supply chain. A ‘maturity’ model will be used in
which the balance of payments and contracting arrangements will gradually shift from
existing mechanisms towards outcome-based methods. In this way, there will be a phased
increase in both incentives and risks for population-based outcomes toward the ICO. It is
recognised, as stated in Salford’s Local Sustainability Plan, that the ICO:
...will operate within the context of a much more integrated care system,
underpinned by collaborative decision-making, whole-system transformation and the
co-commissioning of services. Given the need to significantly improve outcomes, this
will require innovation and experimentation – testing different model of care and
funding across the health and social care economy.
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In evaluating the ICO approach we have also considered alignment with the key features of
fully integrated Local Care Organisations (LCOs) as described in the Greater Manchester
strategic plan. The ICO and its care model encompass all of these aspirations for LCOs as
demonstrated below.
Key Features of LCOs Salford ICO Configuration
Health and social care providers work collaboratively to provide care for a defined population
Clarity given on defined population – adults in Salford as a city, with five coterminous neighbourhoods
Integration and collaboration being supported at a locality level through the ICO and working with federated primary care in an ICS
Secures principle features of a proactive, preventative, population health model to deliver consistently high outcomes
Based on an ICO vision and set of benefits and improvement measures to enable and incentivise population health improvement
Founded on strong reputations and track record in delivering excellent outcomes
Collectively accountable for delivery, with key programme elements (April 2016)
1. Enable conditions to be managed at home and in the community
2. Provide alternatives to A&E when crises occur
3. Support effective discharge from hospital
4. Help people return home and stay well
Based on multi-disciplinary neighbourhood integrated teams
Strengthening links to community groups and the voluntary sector, such as through community assets work
Builds on ‘virtual wards’ and similar approaches developed in primary and community care in Salford
Establishes a common set of objectives, focused on outcomes with appropriate ‘step up / step down’ as developed in the ICP Care Model
5.11 Delivering Improved Outcomes – Health and Wellbeing Board leadership and
Salford’s Locality Plan
Partners recognised that the outcomes framework to inform, assess and incentivise the ICO
must be broader than a set of improvement measures, particularly given the ambition of
population health improvement and significant scale and pace of transformational change.
The Health and Wellbeing Board (HWB) provides the strategic, overarching leadership for
improving outcomes as described in the Salford’s Locality Plan. We summarised the
approach in Section 2 Strategic Case – Context, and in Section 3 Case for Change describe a
set of additional measures linked directly to the Locality Plan.
The approach applied to the broader scope of the HWB delivers outcome measures at three
levels, explained further in the Locality Plan and summarised overleaf. The HWB will
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monitor performance across the Salford health and care economy using a dashboard, which
will enable the ICO’s impact to be assessed, as part of a wider ICS.
Priority outcome measures which we will use to understand the impacts of the Locality
Plan on the health and wellbeing of Salford’s citizens.
Programme outcome measures, used in transformational programmes and business
plans of our partner organisations.
Outcome framework measures such as the Public Health Outcomes Framework or NHS
Outcomes Framework, which the HWB will use on an annual basis in ‘horizon scanning’
to check whether the Salford’s Locality Plan is still focussing on the right issues.
To highlight a few examples, detailed measures for the Living Well and Aging Well domains
could range from: alcohol-related admissions, to cancer screening coverage, rate of injuries
due to falls; and broader measures of quality of life, satisfaction with care and support,
through to proportion of people able to die in their preferred place of care.
In conclusion, we have built a consensus on the preferred model to create the ICO:
Partners have a shared vision for outcomes based population health improvement by
promoting community and personal independence, within an integrated care system.
The ICO will be the provider mechanism to deliver integrated secondary and community
health care, adult social care and mental health services.
It also enables the interface for the integrated care system to connect with federated
primary care, along with other services beyond the ICO scope.
The radical, innovative service model is achieved by co-commissioning aligned standards
across all providers and delivering care through integrated collaborative
neighbourhoods.
5.12 Table of Economic Case Recommendations
Recommendation b):
Note the prior approval at OBC of the preferred option to create the ICO:
SRFT as a prime provider for adult social care and physical health services with a focus on improving population health and wellbeing.
SRFT as a prime contractor for adult social care delivery and local adult mental health services, with agreements being reached in this FBC and supporting Transactions Documents to novate / assign or otherwise transfer responsibility for the contract for district and older adults mental health services that are currently in place between SCCG and GMW from SCCG to SRFT to subcontract to GMW.
Recommendation c):
Reconfirm support for the preferred option.
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6. Commercial Case
Summary
Forming an ICO is a complex undertaking which carries significant risk to the participants as well as
the opportunity to realise great benefits for the population. This section sets out the commercial and
risk management arrangements to establish the proposed ICO model. Since the approval of the OBC,
partners have agreed Heads of Terms, undertaken formal due diligence on the proposed model and
made significant progress in developing the commercial agreements to establish the ICO.
Key Points
Financial and operational due diligence has been undertaken on the proposed ICO services and
on SRFT as the proposed host of the services. This chapter describes the approach and risks and
agreed mitigations.
The commercial transaction to create the ICO is based on transferring Adult Social Care services
to SRFT from SCC. SRFT will also become responsible for Salford Adult and Older Adult Mental
Health services and will subcontract the delivery of those services to GMW.
The ICO will be established on 1 July 2016 and will be supported by the following interlinked
commercial agreements:
o Heads of Terms, which sets out the overarching commercial principles for the ICO
arrangements, the key terms for the transfer and delivery of Adult Social Care services, the
key terms for the delivery of Salford Adult and Older Adult Mental Health services and the
agreed co-operation from SCC;
o Transaction documents relating to the creation of the ICO, including Business Transfer
Agreement and Risk Sharing Agreement.
o Transaction documents relating to the commissioning of services and the governance of the
new system that the ICO will operate within, including Section 75 Agreement on expansion
of pooled budgets, the Service Contract for commissioned services and Governance
Framework;
The ICO Programme arrangements set out in Section 8 Management Case includes phases and
workstreams which incorporate the agreement and commencement of the above commercial
arrangements.
Conclusions
Partners will execute 16 transaction documents between 1 April and 1 July to establish the ICO.
Approval, or delegated authority to execute, is sought for particular transaction documents that
are directly relevant to this full business case.
The agreed mitigations of stage 1 and stage 2 Due Diligence are set out.
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6.1 Table of OBC Commercial Case Recommendations and their Status
This section begins with a review of the OBC Commercial Case recommendations and their
current status.
OBC Recommendation Status
Recommendation d): Formally adopt the Commercial Principles and to progress agreement at FBC of finalised Heads of Terms.
The Heads of Terms, which incorporate these principles, have been finalised.
Recommendation e): Approve actions to address and mitigate risks identified through stage 1 due diligence.
Actions and mitigations complete or in progress, and reflected in ICO transaction documents.
Recommendation f): Commence formal due diligence on the preferred option model.
Stage 2 Financial, Service and Legal reports are included in this FBC.
Recommendation g): Enact such governance arrangements as necessary to manage the period between OBC and the start of an ICO arrangement.
The Alliance Agreement was extended to cover the adult population and Vanguard arrangements during Q3 2015/16.
This FBC describes governance arrangements for the shadow period that bridges FBC approval and formal establishment of the ICO on 1 July 2016.
Recommendation h): Commence development of a system wide governance and accountability framework effective from 1st April – to be developed in parallel to the FBC.
This FBC describes the governance arrangements to take full effect by the establishment of the ICO on 1 July 2016.
Recommendation i): Commence work on the Business Transfer Agreement enshrining the whole agreement for the establishment of the ICO (each party engaging such advisors as necessary to conclude the agreement by 1st April 2016).
Business Transfer Agreement (BTA) in draft form, based upon the Heads of Terms. The FBC seeks delegated authority to execute the BTA on this basis.
Recommendation j): Develop and finalise sub-contractual arrangements for the delivery of adult social care delivery to take effect from 1st April 2016, ensuring rights and obligations flow through appropriately between parties.
Adult Social Care (ASC) contracting principles are approved in the Heads of Terms. The FBC proposes to use the standard form NHS contract template for ASC and to reflect these principles as supplementary terms in the final contractual documentation.
Recommendation k): Develop and finalise sub-contractual arrangements for the delivery of district adult (including older peoples’) mental health services, effective from 1st April 2016, ensuring rights and obligations flow appropriately between commissioners to SRFT, and between SRFT and GMW.
Mental Health contracting principles are approved in the Heads of Terms. The FBC proposes to use the standard form NHS sub contract template for Mental Health and to reflect these principles as supplementary terms in the final contractual documentation.
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6.2 Description of the ICO Model & Transaction
The ICO will preserve and protect the delivery of adult health and social care services in
Salford, whilst aligning the services under a consistent management structure in order to
provide the platform to deliver the transformation programme to sustain services in the
long term.
Partners will establish the ICO through a structured business transaction comprising multi-
lateral governance and risk share arrangements, bilateral commissioning arrangements
between SCC and SCCG, and bilateral provider arrangements to transfer Adult Social Care
services between SCC and SRFT. As part of these arrangements SRFT will also become
responsible for Salford Adult Mental Health services and will subcontract the delivery of
those services to GMW. Together these arrangements are set out through the agreed
Heads of Terms (see Appendix 1, Part A).
At the system level, this means that services to the adult population of Salford will, from the
perspective of service users, will not change in 2016/17. Front-line teams, funding and
service processes will be maintained. Future integration and transformation work will aim
to improve links between the different aspects of the services, such as through referrals and
handoffs.
SCC and SCCG as commissioners have agreed to fund the services in 2016/17 as they have
done in 2015/16. This means that the commissioned service contracts for Adult Social Care
services and Salford Adult and Older Adult Mental Health services will initially structure on
the same basis. As part of the transaction agreements, the commissioners have agreed to
meet specified transaction related costs (e.g. VAT) so as to minimise the impact on services
after the transfer. Thereafter during the five year contractual arrangement, the
commissioners will work with the partnership to identify and implement service
transformation and delivery efficiency opportunities in that the services meet future
commissioning intentions.
At provider level, the transaction documents will enact SRFT to become the prime provider
of the ICO services in scope. These will include acute-based Salford Adult Services which are
currently provided by SRFT. A subcontract arrangement will enable GNW to continue to
deliver Salford Adult Mental Health services.
Governance arrangements and operational model
In order to achieve the ICO vision, partnership governance arrangements have been agreed
to ensure that service planning and configuration decisions reflect the Salford Integrated
Care System objectives.
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The ICO will bring commissioners together so as to focus their respective commissioned
service contracts on a single set of objectives. The Integrated Adult Health & Social Care
Commissioning Joint Committee will be accountable to SCC and SCCG as commissioners. It
will act as a pooled group, with membership including GPs, to set the details of the
commissioned ICO services. This allows commissioners to utilise the risk sharing
arrangement and focus upon the core service requirements. It will also allow the
integration of the design and outcomes of transformational changes which are consistent
across the services and seek to provide better integration at the point of care and a shift to
community/home based care.
The ICO will also streamline and enhance commissioner-provider relationships by aligning
service provision to the overall objectives for the city as set out in the Salford Locality Plan,
as well as including providers (SRFT and GMW) in advisory capacity and to scrutinise overall
progress of the integrated service.
The provider operating models at the service level will not change initially. However, SRFT
will arrange a single management team to oversee service delivery, and create a sub-
contract management function for Adult social care and mental health service delivery. This
approach will be incorporated into SRFT’s overall management structure through the
enlargement and re-shaping of the current Salford Healthcare division.
Enabling activities and back office
The ICO services will benefit from both the transfer of service support functions
(management, administration, finance, workforce management, IM&T) as well as
management support through the SRFT structure.
Investment in further enabling activities will be agreed upon through the joint
commissioning, pooled budget and risk share arrangements. These will be funded and
overseen through the ICO commissioning and governance model.
At provider level, the support functions to front-line services will be incorporated into SRFT
management arrangements.
The transfer and delivery arrangements for enabling areas are included in the Heads of
Terms and transaction documentation and is summarised as follows:
Staff – staff will transfer to SRFT under TUPE with protection of terms and conditions.
SCC will be responsible for all liabilities prior to the Completion Date. SCC and SRFT will
work together to mitigate risks e.g. liabilities from any redundancies, and agree handling
of Annual Leave (accrued, or banked), and ensure access to Local Government Pension
Scheme.
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Transferring assets – the service transfer will operate on an ‘asset-lite’ basis, based on
the transfer of Adult Social Care services contracts, identified equipment and intellectual
property to support the services, plus relevant service information including service user
records.
IM&T – SCC will grant a licence to SRFT to use ICT assets, including those to support
payment of care providers and collection of income.
Estates – the four partners will work together to increase the proportion of services
delivered in community settings, improve utilisation of the estate in Salford and reduce
overall cost. The partners are currently conducting an ICO premises review. The
partners are making arrangements permitting the Transferring Employees, other SRFT
staff (as may be reasonably required to support delivery of the Services), and other
existing subcontractors (as required to deliver the Services) with appropriate obligations
(e.g. SCC to keep the properties in proper repair, SRFT to keep their use clean and tidy).
Adult social care requires a range of specialist support services, summarised below. Staff
and responsibilities that are transferring to SRFT are shown in the column entitled SRFT.
Support services are secured by SLA are shown in the column marked SCC. SLA
arrangements will be formalised in the Support Services Agreement in the Transaction.
Function Description SRFT
SCC
Finance Management Accounts
Accounts Payable & Receivable
Debt Recovery
Client Affairs
Charging Assessors
Strategy & Change Provision of management information and reporting
General / administrative
Certain services delivered by the customer services team are captured in the finance schedule e.g. post, printing which are included in the Support services Agreement.
- -
Marketing & Comms
Impact is minimal and will be absorbed by SRFT - -
HR Transactional HR impact is minimal and will be absorbed by SRFT - -
HR Advisor support to be seconded (0.6WTE) backed by an SLA. Staff member to be based in the HR dept
Care act development and supervision of Social Workers (AYSE)
ICT (IM&T) Support services to delivered though an SLA initially for a 12 month period, during which time longer term arrangements will be agreed through a formal review mechanism.
Estates Global generic license to be issued by SCC for a 12 month period, during which time longer term arrangements will be agreed through a formal review mechanism.
Procurement Procurement staff for ASC delivery contracts to transfer
Legal Services Proposed SLA with Manchester and Salford Shared Legal Service
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Client Income, Direct Payments and Payment of Adult Social Care Providers Following a review of operational practice and having taken legal advice in respect of the delegation of functions, the following arrangements are proposed for day 1 of the ICO in relation to:
Client Income (comprising weekly income collection and deferred payment agreements)
Direct payment agreements
Payment of providers These aspects of Adult Social Care practice are grouped because of technical, operational and legal interdependencies in their delivery.
SCC staff involved in paying providers and collecting income will transfer to SRFT.
SCC systems (CareFirst, SAP, Paris, DeS) will continue to be used for paying ASC providers and collecting income until such time as SRFT set up their own systems to take over.
A notional target date for completing the transfer all of the necessary processes to SRFT is 1 April 2017 (subject to further definition of the solution)
Deferred payment agreements between individual citizens and SCC will not novate to SRFT on Day1
Direct Payment agreements between individual citizens and SCC will not novate to SRFT on Day1
Contracts between SCC and ASC providers will novate to SRFT on Day 1.
Procurement staff managing ASC delivery contracts will TUPE to SRFT
Debt recovery will remain with SCC on Day 1 Transaction Flow & Reconciliation
SCC’s bank account will be used for collecting income and paying providers until the processes are transferred to SRFT systems.
There will be no need for a new bank account or for a new company to be set up on SAP within SCC systems
Transaction flow:
SCC pay gross service cost less client income to the pool.
SCC will pay client income to the ICO (SRFT).
The pool will pay gross service cost less client income to the ICO (SRFT).
The ICO will pay SCC the value of payments to third parties and care providers that SCC will be making on behalf of the ICO.
There will be a regular monthly financial reconciliation between SRFT and SCC to provide the basis on which decisions can be made to manage cash flow risk in line with principles in the heads of terms.
A review will be undertaken during the first year to determine the longer term arrangements in these areas.
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6.3 Commissioning Governance
There is a recognised need for system wide governance and accountability arrangements
sitting alongside Services Contracts and Section 75 arrangements, in order to align vision,
objectives and goals across the wider system, and to ensure democratic accountability to
the arrangements. Such arrangements will also provide a mechanism to agree the
overlaying risk and benefit sharing arrangements between partners.
Integrated Care System
SCC and SCCG have worked to develop a robust governance infrastructure that will both be
aligned to the creation of the ICO but furthermore, support the wider aspiration of strategic
joint commissioning.
The partners have agreed to establish the governance arrangements for the Integrated Care
System set out below:
Integrated Care System Governance Infrastructure
The governance arrangements include the establishment of the following groups:
Integrated Adult Health and Care Commissioning Joint Committee – a joint
commissioning committee between SCC and SCCG; and an
Advisory Board for Integrated Care – a board comprising representatives of Salford
Clinical Commissioning Group, Salford City Council, Salford Royal NHS Foundation Trust,
Greater Manchester West Mental Health NHS Foundation Trust and General Practice.
Integrated Adult Health and Care Commissioning Joint Committee
Adult Health and Care Pool including ICO
Commissioner Group (City Council & CCG)
Membership to include GPs and SCC Members
Service & Financial Plan (Commissioning Plan Integrated Care System & ICO)
Decision Making Body (Up to £1m) in relation to: o Service strategy o Service design o Annual Programme Plan o Market Management
Management of System & Performance
Advisory Board for Integrated Care
ICS and ICO Adult Health and Care
Engagement of ICO and ICS stakeholders
Advisory in relation to: o Service strategy o Service design o Annual Programme Plan
Decision making (up to £1m) by consensus in relation to: o Vanguard o Other elements on a case by case basis that
are agreed by each of the four partner organisations
Salford Health and Wellbeing Board
Oversee Locality Plan
Oversee Integrated Care System
SRFT Board of
Directors GMW Board of
Directors
Salford Council – City Mayor & Cabinet Sets high level strategy & outcomes Approves contribution to pooled fund
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The Integrated Care System will operate with the principle of collective decision-making,
recognising that certain decisions will ultimately be taken by commissioners or providers.
Although the Integrated Adult Health and Care Commissioning Joint Committee and the
Advisory Board for Integrated Care have discrete and defined responsibilities, they will need
to work closely together and, to this end, have some common membership. They will work
alongside the Health and Wellbeing Board, recognising the role of the latter in setting the
Locality Plan and promoting integrated care and partnerships. They will also be subject to
review by the Health and Adult Scrutiny Committee and audit, where appropriate.
Approval and Commencement
A framework, including the Terms of Reference of both the Integrated Adult Health and
Care Commissioning Joint Committee and the Advisory Board for Integrated Care, is part of
a parallel approval process involving all partners.
The framework will be implemented as follows in the table below. The system changes will
commence in April 2016 with the establishment of the Pooled Budget and there will be a
period of transition, as other changes are implemented, concluding with the ICO being
formed in July 2016.
1 April 2016
Establishment of the Adult Health and Social Care Pooled Budget, as set in the section 75 partnership agreement
Level 2 decisions for Older People retained by the Alliance Board
Level 2 decisions for Adults retained by the CCG Governing Body and SCC City Mayor
31 May 2016 Alliance Board for Integrated Care dis-established
1 June 2016
Alliance Board for Integrated Care dis-established
Adult Health and Care Commissioning Joint Committee formally established (Level 2 decisions transferred to the Joint Committee for Adults and Older People)
Advisory Board for Integrated Care established
1 July 2016 ICO formed (subject to separate approvals process and regulatory consent)
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6.4 Arrangements for Services
The arrangements for services and services contracts are summarised in the tables below
under the headings “Salford Adult Social Care Services” and “Salford Adult and Older Adult
Mental Health Services”.
Salford Adult Social Care Services
Summary of key terms
Service Contract
Partners intend to develop a long-term arrangement through the ICO.
Agree to period of relative stability and certainty on commencement.
Initial service contract will be for five years, and anticipated to be extended for a further five years.
All four Partners will work together over the first 12 months after completion to identify opportunities for efficiency and service transformation and to address any material risks that emerge.
Includes: o Joint review no later than 12 months after completion o Arrangements for termination if issues or risks cannot be resolved o Safeguards to ensure no inappropriate constraints on GP referral
behaviour, patient or client choice o Potential for unidentified or unresolved risks, which could affect
performance and if so the Council excuses SRFT its relevant obligations, and partners will work together to resolve underperformance
o Council is liable for any historic pension deficit
Partners will work together to avoid any increase in risk in the system
Managing financial and other risks
The council is responsible for all liabilities for the conduct of ASC prior to Completion and SRFT will be responsible after (indemnities and warranties).
The Council and CCG will establish a contingency reserve in the pooled budget for the Service Contract to address risks as a result of the ICO transaction including: excess demand; client income; VAT and insurance; exit costs.
The Council, CCG and SRFT will collaborate to understand the materiality of such risks, and all partners will endeavour to reduce the financial burden placed on the Council and CCG pooled budget.
The standard form NHS sub contract template will be used for the sub contract between
SRFT and GMW for Mental Health services. The key supplementary terms to the standard
NHS contract are set out overleaf.
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Salford Adult and Older Adult Mental Health Services
Summary of key terms
Service Contract between commissioners and SRFT
Partners are committed to the effective integration of health and social care services and to develop a long term arrangement.
An initial period of relative stability and certainty will support the changes.
Commissioners will award a Service Contract for SRFT to deliver adult and older adult mental health services through a sub-contract with GMW.
The Service Contract will be for an initial period of five years.
Any variations will be dealt with using NHS standard contract processes.
Mandatory terms around service reviews and termination rights included in the ICO Service Contract are replicated in the GMW contract.
Sub-Contract between SRFT and GMW
SRFT and GMW are committed to supporting the new arrangements, with only minimal changes to services in 2016/17, and to work to integrate mental and physical health and social care from 2017/18 onwards.
The initial term is co-terminus with the ICO Service Contract, which if terminated for any reason will lead to termination of the Sub-Contract.
For procurement, the services provided by Salford ICO under the Service Contract will be treated as a whole and not sub-divided.
GMW will indemnify SRFT against all liabilities relating to these services prior to Completion. SFRT will be responsible for and indemnify GMW after Completion for any liabilities to GMW arising from acts of omissions of SRFT.
Finances
The total funding provided for GMW Services under the current block contract arrangements for 2015/16 will continue in 2016/17.
GMW shall continue to receive the amount of funding previously received under the block contract and will not suffer a decrease in the Sub-Contract, provided the 2016/17 contract value may be adjusted to reflect national adjustments and local agreements
The contract for 2017/18 and subsequent years will similarly be based on the previous year’s contract value with the adjustments above.
Funding for GMW Services will be fully passed on through the service contract and sub-contract mechanisms with the prime provider SRFT
GMW will only be required to comply with nationally set efficiency measures as part of its cost improvement programme for these services.
SRFT and commissioners will not seek to reduce the funding to GMW under this Sub-Contract unless mutually agreed
Reporting, performance and quality requirements
Partners will develop a reporting, performance and quality regime that support the need of both Salford ICO and GMW’s responsibility to deliver services across Greater Manchester.
Reporting requirements in the Sub-Contract will align with SRFT’s main Service Contract.
SRFT and commissioners agree that any contractual penalties and deductions under the Sub-Contract will be proportionate to the value of services provided by GMW.
The principles will be adjusted from 2017/18 as necessary to reflect the transformation of mental and physical health services in the ICO, following agreed review and variation processes under the Sub-Contract.
Other Issues
Arrangements are made for any changes in funding that relate to services currently provided through a Section 75 agreement with SCC.
Subject to discussion, the Packages of Care budget for these services currently held by the Council will be the financial responsibility of SRFT.
Parties recognise that GMW delivers services in neighbouring conurbations, which bring significant benefits. ICO partners will work to ensure GMW does not suffer material adverse consequences in relation to such these services.
Commissioners and SRFT will not make any changes in the Service Contract which impact on GMW services unless mutually agreed, and recognise that this Sub-Contract will not restrict GMW in delivering and potentially changing wider Greater Manchester services.
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6.5 Stage 1 Due Diligence – Risk based framework and mitigations
The partnership agreed to undertake due diligence in two stages. The first stage was a
financial and legal review of the programme work undertaken in order to identify and
quantify the material risks posed to partners by an ICO. The second stage is a formal due
diligence exercise by SRFT and SCC encompassing financial, legal and service due diligence
on the option and financial baseline proposed for the ICO in the OBC.
Deloitte and Hempsons acted for all parties in the first stage of due diligence. These joint
engagements were agreed to establish a shared view of risk between partners and to
establish a jointly owned and externally validated risk based framework to proceed to FBC.
Stage One Reports Summary
Both reports exhibited a high degree of consistency on the main areas of risk in the
programme. These included the need for greater clarity, at FBC stage, on:
System wide governance and accountability arrangements.
Services contracts and payment mechanisms.
Pensions Liabilities.
TUPE implications.
VAT implications.
The legal report was clear that there is no indication that the ICO model as proposed could
not lawfully proceed. Both reports are clear that Pensions liabilities were potentially the
most significant area of risk.
The recommendations of both reports were complementary and provide strong indication
that robust actions could be taken to control the likelihood and impact of identified risks but
that more detailed work would be required to quantify risk at FBC stage.
The key recommendations were:
Partners enter into detailed governance agreements to ensure that the allocation of risk,
benefit and accountabilities is clearly understood so that the system can be
appropriately managed going forward. Commissioning further due diligence on the
transactional implications of the ICO e.g. TUPE, Pensions, taxation issues.
Structured regulatory engagement (Monitor and CQC) to secure the necessary consents
or approvals.
Agreement of system wide governance and accountability arrangements encompassing:
o Formalised business relationships between partners.
o Agreed decision making processes.
o Long term strategic planning (e.g. 5 years).
o Risk and benefit sharing arrangements.
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Agreement of services contracts with clear allocation of risk and accountabilities through
the prime and sub-contractor arrangements and of sufficient duration to support
transformation.
The Stage 2 Legal Due Diligence report describes the status of risks set out in the Stage 1
report and is attached at Appendix 1 Part B. Also attached at Appendix 1 Part B is a schedule
showing the status of the Deloitte Stage 1 risks and next step actions. All actions from stage
1 have been concluded and risks mitigated. This includes where the risk mitigation is
captured within the stage 2 mitigations.
6.6 Stage 2 Due Diligence
Due Diligence has been undertaken by both SRFT and SCC in the period between OBC and
FBC (“Stage 2”).
The SRFT approach is based upon the OBC and Monitor Transaction Guidance and has been
verified by external advisors and Monitor. External advisors were commissioned in areas of
potentially significant risk resulting from the transfer of services and responsibilities. A local
approach was taken where the ICO arrangements are specifically designed to have minimal
impact on services and supporting arrangements. This approach is summarised below:
Ref Monitor Category Service
Comments ASC MH
1 Clinical / Service Service (Deloitte)
Local Commissioners have provided local assurance to SRFT on the quality and performance of mental health services
2 Human Resources & Pensions
Legal (Hempsons)
N/A No Mental Health staff or pension liabilities are transferring therefore this category is not applicable.
3 Financial Financial (Deloitte)
Local Commissioners have provided local assurance to SRFT on the funding of mental health services
4 Contract Legal (Hempsons)
Local Commissioners have confirmed that the NHS standard form of contract will be used for Mental Health services and that there are no supplementary terms.
5 Legal Legal (Hempsons)
Local Commissioners have confirmed that the NHS standard form of contract will be used and that GMW are in full compliance with their regulatory licence conditions.
6 Commercial N/A
N/A The ICO is a part of a long term strategy for quality and sustainability, rather than a business development initiative therefore this category is not applicable.
7 Estates / Property Legal (Hempsons)
Local Premises arrangements for Mental Health staff do not change. ASC staff will not change location, with the exception of a small number of back office staff and the ASC directorate leadership team. A licence arrangement is proposed for premises occupied by ASC staff.
8 IT Local Local IT services for ASC will continue to be provided by SCC under their standard SLA. No assets will transfer, devices will be licenced. There is no change to mental health IT provision.
9 Tax Tax (E&Y)
Local The subcontract arrangements for mental health do not impact upon taxation regimes
10 Environmental Local
Local Any matters of this nature will be handled through estates licencing or by transferring staff becoming subject to existing policies depending on their location.
11 Health & Safety Local
Local Any matters of this nature will be handled through estates licencing or by transferring staff becoming subject to existing policies in the receiving organisation depending on their base.
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SRFT Due Diligence on Adult Social Care
A full Due Diligence review was commissioned from Hempsons and Deloitte covering legal,
financial and service areas. The findings are summarised below.
Financial
Potential financial pressures identified in 2015/16 that could result in recurrent
pressures in 2016/17.
The scope of financial Due Diligence has been limited by the availability of management
information due to the constraints of time.
The resulting lack of detailed information presents some difficulty in reconciling staff
and contract costs to ICO income.
Legal
There are no legal show stoppers or technical impediments.
Some limitations in the availability of information e.g. staff and third party contracts
poses some potential risk.
Service
No significant service risks identified.
Many areas of good practice were highlighted.
Limited ability to predict future demand was noted and some further work is required is
required in relation to service specifications and KPIs.
The following summary table sets out the risks identified through the stage 2 Due Diligence
process commissioned by SRFT. The agreed schedule of SRFT risks and mitigation is provided
in Appendix 1 Part B, together with the full advisor reports.
The table overleaf sets out the risk and the timing of the agreed mitigation:
FBC: Risk mitigation to be concluded for and referenced within the FBC
Completion: Risk mitigation to be addressed by contractual protection in Transaction
Documents or by other means by the Completion date (1 July 2016)
Post: Risks to be resolved post Completion, preferably within the first year
Text redacted
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Summary table redacted
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Mental Health Services
SRFT undertook a local Due Diligence exercise seeking assurance from GMW and
Commissioners in relation to the areas set out in SRFT’s overarching framework.
SRFT have reviewed existing performance reports and contract meeting minutes, and held
meetings with commissioners and GMW to understand services delivery in more detail.
Text redacted
Summary table redacted
No material risks have been identified through local due diligence. The nature of the agreed
subcontract means that all contractual obligations, risks and benefits associated with
Mental Health services remain with GMW.
Text redacted
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SCC Due Diligence of SRFT
SCC commissioned KPMG to undertake a high level desktop review of SRFT from a financial and
operational perspective. The outcomes are summarised below.
Financial
SRFT like many NHS organisations face significant financial pressures.
Currently projecting a deficit in 2015/16, with a significant cost improvement plan in future years
needed to return to surplus.
SRFT will need to deliver efficiency savings through the ICO from 2017/18.
Operational
Effective governance arrangements are in place.
Recent “Outstanding” CQC inspection.
Areas of remaining action and improvement relate to harmonisation of processes and monitoring
benefits of integration in community services.
The following table summarises the risks and applies the same approach to the timing and form of risk
mitigation. Many of the actions referenced here are addressed in the PTIP and Quality Governance plan,
included within Section 8 of this Full Business Case. The agreed SCC risks and mitigations and full advisor
reports are included at Appendix 1 Part B.
Summary table redacted
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6.7 Description of ICO Commercial Arrangements
The Heads of Terms sets out the overarching commercial principles for the ICO
arrangements, the key terms for the transfer and delivery of Adult Social Care services, the
key terms for the delivery of Salford Adult and Older Adult Mental Health services and the
agreed co-operation between partners. The Heads of Terms (see Appendix 1, Part A):
Set out the principles on which partners will establish the ICO as part of a wider ICS;
Provide a high level summary of the basis on which partners intend to give legal effect to
the ICO from the Completion Date;
Apply from date of finalisation until execution of the Business Transfer Agreement and
other Transaction Documents.
The transaction structure and sequencing is complex and are best summarised under the
following headings:
Integrated Care System – agreements between commissioners and providers.
Commissioning – agreements between commissioners.
Adult Social Care – agreements between SCC and SRFT.
Mental Health – agreements between SRFT and GMW, and SCC and GMW.
All transaction documents will be formally executed by the establishment of the ICO. Prior
to execution, Partners will approve the documents in a particular sequence according to
their purpose and signatories.
These arrangements are summarised overleaf.
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Transaction Documents
# Name Purpose
SCC
SCC
G
SRFT
GM
W
Oth
er
ICS documents
1 Risk Sharing Agreement
(to be incorporated in
Service Contract)
To document agreed risk and benefit sharing terms for the ICO as between Commissioners
and SRFT (e.g. including funding commitments from commissioners for ASC demand risk).
√ √ √
2 Governance Agreement To document post-Completion Date governance arrangements. √ √ √ √
3 Alliance Agreement
Deed of Termination
To terminate the Alliance Agreement dated 30 September 2014. √ √ √ √
4 Commissioning and
Operating Principles
(previously Scheme of
Delegation)
To document the responsibilities delegated by the Council to, and commissioned by the
Council and CCG from, SRFT as prime provider, and the core principles for direct service
delivery and supply chain management; the parties will agree the principles in this
document and then incorporate relevant terms in the Service Contract and Section 75
Agreement between the Council and SRFT.
√ √ √ √
5 Information Sharing
Protocol
To enable the parties to share Information between themselves post-Completion Date. √ √ √ √
Commissioning Documents
6 Risk Sharing Agreement
(single document with
#7 below)
To document agreed risk and benefit sharing terms for the pooled budget. √ √
7 Section 75 Agreement A new agreement to enable co-commissioning and pooling of budgets including but not
limited to the ICO Arrangements; and to terminate existing section 75 Agreements.
√ √
8 Service Contract To enable SRFT to deliver the SRFT Services, Salford Adult and Older Adult Mental Health
Services and Adult Social Care Services in accordance with the principles set out in Schedules
4 and 6 of the Heads of Terms.
√ √ √
9 Section 75 Agreement To enable SRFT to be delegated relevant functions by the Council to enable SRFT to deliver
the Adult Social Care Services, and to terminate the existing Section 75 Agreement.
√ √
10 Service and Financial
Plan
To set out agreed service and financial principles of the commissioners including in relation
to the pooled budget, and to terminate the existing plan.
√
A
√
A
√
S
√
S
Adult Social Care Documents
11 Business Transfer
Agreement
To give legal effect to the transfer of staff, contracts and, where applicable, other assets to
SRFT and licensing of premises / ICT equipment and any other relevant assets, in accordance
with the principles set out in [Heads of Terms] Schedule 6.
√ √
12 Admission Agreement To permit Transferring Employees to access the Local Government Pension Scheme and to
document agreed principles for funding of potential deficit / employer contribution
shortfalls.
√ √ √
13 Support Services
Agreement
To provide for the Council to provide ICT/IM&T services to SRFT from the Completion Date. √ √
14 Deed of Novation To transfer Adult Social Care Contracts from the Council to SRFT. √ √ √
Mental Health Documents
15 GMW
Sub-Contract
To set out terms (currently anticipated to be in the NHS standard sub-contract form) for
GMW to provide the GMW Services, including secondment of staff from SRFT (being those
staff previously seconded to GMW from the Council under a Section 75 Agreement).
√ √
16 GMW Section 75
Agreement
To enable GMW to be delegated relevant functions by the Council to enable GMW to deliver
the services previously provided by employees seconded from the Council and now
seconded from SRFT.
√ √
A = Approve, S = Support
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6.8 Approval Sequence
Partner organisations have agreed to approve the transaction documents in a particular
sequence, prior to their formal execution. The documents have been bundled in the
following sequence in order allow a streamlined approvals process (the numbers refer to
the designated number of the transaction document).
Bundle 1 – Pooled Budget (Complete)
SCC and SCCG as commissioners approved on 23 and 29 March 2016 respectively:
A high level service plan, and high level financial plan, describing commissioning
intentions and the process for finalising the formal Service and Financial Plan (#10)
The content of these documents were combined with a single Section 75 agreement for
approval. Note that these transaction documents have been approved by SCC and SCCG.
Bundle 2 – Full Business Case
SRFT March 2016 Board cycle, SCCG and SCC April 2016 approving body cycle and GMW
May 2016 Board cycle
The following documents are referenced within this Full Business Case with the following
recommendations:
For approval:
Risk Sharing Agreement (between commissioners and SRFT) (#1) (attached at Appendix
1 Part A)
To note the following documents (attached at Appendix 1 Part A) are in draft form and
delegate authority to officers, as appropriate, to finalise and execute:
Draft Business Transfer Agreement (#11) (attached at Appendix 1 Part A)
Draft Support Services Agreement (#13) (to follow)
Approve applying for admission to the Local Government Pension scheme on a restricted
open basis (relating to the Admission Agreement #12).
Approve entering into the Deed of novation (#14) (attached at Appendix 1 Part A).
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To note that Contracts will be produced which reflect the principles agreed in the Heads of
Terms and using the standard form NHS contracting templates:
NHS Standard Contract form to be used for the ICO (#8)
NHS Standard Form Subcontract to be used for mental health services (#15)
Finally, to note that a Non Disclosure Agreement and Data Sharing Agreement have been
approved by the relevant parties, and to delegate authority for officers, as appropriate, to
finalise the Information Sharing Protocol (#5).
Bundle 3 – Commissioning Governance
SRFT March 2016 Board cycle, SCCG and SCC April 2016 approving body cycle and GMW
May 2016 Board cycle
The following documents are included within this bundle.
Governance Framework (#2)
Alliance Agreement Deed of Termination (#3)
Commissioning and Operating Principles (previously Scheme of Delegation) (#4))
Section 75 Agreement between SRFT and SCC (#9)
Section 75 Agreement between SCC and GMW (#16)
The recommendation of this FBC is to note the parallel approval and support for these
transaction documents.
Bundle 4. – Service and Financial Plan
SCCG and SCC May 2016 approving body cycle (SRFT and GMW to note in their May 2016
Board cycle)
The following document is included within this bundle:
Phase 2 Service and Financial Plan (#10)
The recommendation of this FBC is to note the plan for subsequent approval and support
for this transaction document in the May 2016 approvals cycle.
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6.9 Table of Commercial Case Recommendations
Recommendation d): Approve the risk mitigations identified through due diligence (SCC and SRFT Mitigations are attached at Appendix 1 Part B).
Recommendation e): Note that the following transaction documents have been approved by SCC and SCCG and the expanded pooled budget has been established:
A high level service plan, and high level financial plan, describing commissioning intentions and the process for finalising the formal Service and Financial Plan (#10)
Recommendation f): Approve the following transaction document (attached at Appendix 1 Part A):
Risk Sharing Agreement (between commissioners and SRFT) (#1)
Recommendation g): To note the following transaction documents are in draft form and delegate authority to officers, as appropriate, to finalise and execute:
Draft Business Transfer Agreement (#11) (attached at Appendix 1 Part A)
Draft Support Services Agreement (#13) (to follow) Approve applying for admission to the Local Government Pension scheme on a restricted open basis (relating to the Admission Agreement #12). Approve entering into the Deed of novation (#14).
Recommendation h): Note that Services Contracts will be produced by the end of May 2016. These will:
Use the NHS Standard Contract form for the ICO (#8)
Use the NHS Standard Form Subcontract for mental health services (#15)
Reflect the principles agreed in the Heads of Terms.
Contain no other supplementary terms. Recommendation i): Note that a Non Disclosure Agreement and Data Sharing Agreement have been approved by the relevant parties. Recommendation j): Delegate authority for officers, as appropriate, to finalise an Information Sharing Protocol (transaction document #5) to be in place by 1 July 2016. Recommendation k): Note the parallel approval and support for the following integrated system governance transaction documents:
Governance Framework (#2)
Alliance Agreement Deed of Termination (#3)
Commissioning and Operating Principles (previously Scheme of Delegation) (#4)
Section 75 Agreement between SRFT and SCC (#9)
Section 75 Agreement between SCC and GMW (#16) Recommendation l): Note the plan for the subsequent approval and support of the Phase 2 Service and Financial Plan (#10) in the May 2016 approvals cycle.
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7. Financial Case
Summary This section sets out the financial implications of the ICO in its approved configuration and factors in the commercial terms, due diligence outcomes and governance arrangements described in Section 6. The narrative uses the “system” perspective taken in the Locality plan whilst detailed supporting analysis focuses on the impact to the pooled budget and providers. Key Points
Like all health and social care economies Salford faces significant financial challenges over the next five years. There is expected to be a significant financial deficit or ‘gap’ between the cost of delivering the services in scope and funded income.
The Integrated Care Organisation will provide the platform and framework to transform the services and drive through integration and efficiencies to contribute to bridging the anticipated financial gap.
The city’s financial gap can only be addressed through partnership action from commissioners and providers. The existing pooled budget arrangements between SCCG and SCC will be extended to include all services within the ICO.
The pooled budget will allow the partners to provide direct funding to priority service areas over the contract period. It will also allow the partners to take a combined view on financial risks to the services and agree actions to address these for the benefit of front-line services and the population of Salford.
Initially the service contracts transferred to SRFT will be based on protected commissioning contract values, with existing liabilities fully funded. The services will be transferred with a ‘clean’ opening balance sheet.
These factors combine to provide the ICO with a ‘secure’ financial starting point, from which integration and transformation can be delivered to address the anticipated financial gap.
Conclusions
The financial agreements and overarching financial principles of the ICO arrangements are covered in the Transaction Documents as described in Chapter 6 Commercial Case.
Financial planning will, including relating to transformational planning and identifying potential savings, will be a key priority activity after the transfer of the services on 1 July 2016. This Full Business Case, along with the SRFT Long Term Financial Model, will be assessed by Monitor.
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7.1 Table of OBC Financial Case Recommendations and their Status
This section begins with a review of the OBC Financial Case recommendations and their
current status.
OBC Recommendation Status
Recommendation l): Commence arrangements to extend the Section 75 pooled budget to the adult population (18 years of age and over) with effect from 1 April 2016, which must include the full scope of services delivered through the ICO – to be developed in parallel to the FBC.
The Section 75 pooled budget was created on 1 April 2016 and it includes the full scope of services delivered by the ICO.
Recommendation m): Commence development and negotiation of contractual arrangements between commissioners and SRFT (as the ICO prime provider), to take effect from 1st April 2016, including health, adult social care, mental health and any other specified services.
Contractual arrangements are substantially complete and are captured in the Heads of Terms.
Recommendation n): Develop a long term financial model as part of the FBC.
A Long Term Financial Model for SRFT has been developed.
Recommendation o): Refine the financial benefits realisation.
Financial benefits realisation for the ICO has been agreed through the Heads of Terms and is reflected in the LTFM. Governance arrangements at a system level ensure these plans align with commissioner plans at a Locality level.
7.2 Financial Context in Salford
Current position The base financial position for health and social care services in Salford reflects a forecast annual deficit reaching £157m by 2020/21, of which £71m relate to adult social care and adult mental health services and £86m relate to community health and acute services. If services continue to be delivered in their current form and structure, they will cease to be fully funded and will become unaffordable. This is due to the following factors:
Both NHS and adult social care services will receive reduced funding in real terms by
their respective Government Departments.
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Recent trends and demographic data indicate that there will be an increasing demand
for services from the Salford population, and therefore service activity and costs will
increase over time in line with volumes.
Opportunities to reduce costs through service delivery efficiencies or staffing changes
are limited in the current structures.
In the past five financial years, from 2011/12 to 2015/16, SCC implemented unprecedented
savings of £137m which were required as a consequence of the Government’s budget
reduction plan. In addition the Council expects to have to deliver further budget savings of
at least £37m for the years 2016/17 and 2017/18.
Although the financial position of SCCG is currently strong, projecting forward beyond three
years shows that it will be in recurrent deficit if nothing is done to deal with the continued
growth in secondary care admissions and other healthcare expenditure associated with the
growth in older people and long term conditions.
NHS providers also face significant financial challenges in the foreseeable future. SRFT’s
financial plans assume that cost savings of circa 5% in 2016/17 and 2-3% per annum will be
required for the next four years, compared to expected national average requirements to
reduce costs by 2% per annum. This is equivalent to circa £30m of cost savings in 2016/17
and £20m per annum thereafter, with ICO services accounting for approximately £2m in
each year. GMW’s financial plan for the next two years requires recurrent savings of circa
£5m per annum.
As noted in the Strategic Case, despite each organisation in Salford Together delivering
significant cost improvement and efficiency programmes over recent years, the projections
for the funding and expenditure profile up to 2020/21 under the ‘Do Nothing’ scenario
predicts an estimated shortfall of circa £157m against baseline funding of £485m in 2015/16
(this shown in the table overleaf). The scale of this gap is consistent with the picture across
Greater Manchester, which has a projected financial challenge of circa £2bn forecast for
2020/21 if current trajectories continue.
The locality plan financials are at a point in time and are being reviewed in light of confirmed funding settlements (for the CCG and Council) and revised provider cost
efficiency targets (for Salford Royal and Greater Manchester West). The final locality plan will be approved through the Health and Wellbeing Board in May and will include the most
up to date financial position for Salford locality.
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Notes to Salford Financial Gap table:
SCCG funding will grow by 2% per annum for the next five years.
Continued reductions in SCC funding.
NHS tariff will reduce by 1.5% each year, while pay and prices grow by 2.5% annually, leading to implied efficiency
savings for providers of 4% per year.
Salford Locality Plan - Bridging the gap
The Salford Locality Plan sets out a series of measures which can be taken by the partners to
address the funding gap. These include:
Funding solutions, including protection of adult care funding and additional NHS
resources.
New service models to reduce or manage acute service volumes (‘Better Care’).
Savings achieved through ‘Provider Efficiencies and Reform’.
The Salford Locality Plan, and the Salford Together Value Proposition, sets out how these
measures may help to bridge the funding gap in the following chart:
Salford Locality Summary: Financial Gap: Do Nothing Option
Total Locality Gap: Do Nothing -£22 -£62 -£83 -£108 -£133 -£157
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Delivery of the Locality Plan may substantially address the funding gap, but this remains
very challenging.
Proposed option - Integrated Care Organisation to address Salford funding gap
The creation of an ICO in Salford is consistent with the aims of the Greater Manchester
Devolution agreement and is an enabler to create the structures that will be expected to
contribute to reducing the financial gap through new models of care which will seek to
reduce demand for hospital and residential care and to deliver efficiencies through reduced
fragmentation and duplication.
The following initiatives in the Salford Locality Plan are dependent upon the creation of the
ICO:
Better Care transformation.
Provider Efficiencies and Reform, based on driving efficiencies through delivery
remodelling and integrated care.
The achievement, or even partial achievement, of the city funding gap will not be possible
without closer integration of services. The ICO will therefore provide an enabling platform
to deliver these initiatives.
The ICO transaction will require a period of relative stability to enable SRFT to implement a
range of organisational changes associated with the transaction. The partners have agreed
a range of measures to provide this financial stability in order to support an effective
transfer and integration (which is seamless to service users) and to provide a sound
platform for transformation planning. These measures include:
Awarding of five year service contracts to SRFT for adult social care and adult mental
health services;
Expanding the value of the Section 75 pooled budget to include all adult health and
social care services that are within the scope of the ICO;
Services protected from efficiency savings requirements for 2016-17 by agreement with
commissioners, although 2% savings on total operating costs are expected to be
required thereafter (subject to agreement of the programme with commissioners);
Inflationary impacts on Adult Social Care delivery costs (such as standard pay and price
inflation and implementation of the national living wage) will be fully funded;
Potential additional costs to the system as a result of establishing the ICO to be
minimises and avoided wherever possible;
Agreement that historical liabilities remain with the transferring party
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A Section 75 pooled budget is currently in place in Salford between SCCG and SCC pooling
funds (£112 million) to purchase Health and Social Care services for older people, as part of
the Integrated Care Programme for Older People. The extension to adults is an expansion on
a current arrangement with a track record and access to benefits and lessons learned from
the existing pool arrangement.
7.3 Scope of transfer and financial impact
The scope, activity and current cost of services to be transferred to and delivered by the ICO are summarised as follows:
Adult Social Care services and support. These include, for example, residential and
nursing care, support for people with learning disabilities, social work, occupational
therapy and a range of support services including management and safeguarding /
quality activities. The value of the services in 2015/16 was circa £83.2m, with opening
contract values for 2016/17 to be finalised prior to Completion. The 2016/17 estimate of
opening contract value is £87.2m.
Adult & Older Adult mental health services. These services are the established mental
health services delivered to the Salford population as part of the current service
contract. They are based on, for example, inpatient, and psychology and CMFT services,
supported by corporate overheads. The value of the services in 2015/16 was circa
£29.3m, with opening contract values for 2016/17 to be finalised prior to Completion.
The 2016/17 estimate of opening contract value is £29.6m.
Salford Health Care services already provided by SRFT. These represent acute &
community services delivered to the Salford adult population and are covered by the
commissioner contract for the registered Salford population and NHS England
specialised commissioning for specialist services. The contract value of these services in
2016/17 has been agreed as £96.4m.
Post-transfer, SRFT will deliver adult social care, adult and older people’s mental health and
adult acute and community medical specialties through an expanded and reconfigured
division (currently with the provisional working title of Salford Care) in order to separately
manage integrated adult services.
In 2016/17 it is anticipated that the ICO services will account for £213m, or 90% of total health and social care spend, within the proposed adult pooled budget. The 10% of services outside the scope of the ICO but within the pool largely relate to third
sector organisations and reserves to cover the impact of policy changes such as The Care Act
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and other variables, such as VAT and insurance. Once these values become known, the
quantum of ICO services within scope will increase.
The following table shows how the proposed ICO services values compare to the total proposed adult pooled budget value.
In addition, there are specific activities relating to the creation of the ICO, the partner agreements and transformation planning. The activities were summarised by Salford Together in its Vanguard funding bid:
Engagement, activation and asset building.
Assessment, co-ordination and care navigation.
Enhanced models of care for people with long-term conditions and complex needs.
Enabling activities.
Evaluation.
These activities cost £5.2m in 2015/16, with a further £24m of transformation activities
planned for 2016/17 and 2017/18 subject to confirmation of Vanguard funding in these
years.
The detailed breakdown of service and programme activities, along with the anticipated
cost of delivery, is shown in Appendix 1, Part C entitled “ICO List of Services”.
Value of Services
Within Scope of
ICO
£000
SRFT Acute Services 66,547
SRFT Community Services 29,893
Mental Health Services 29,575
Total Health Spend 126,015
Adult Social Care Services 2 87,160
Salford City Council Social Care Spend 87,160
Total Health & Social Care Spend 213,175
Total Adult Pooled Budget 237,505
ICO as % of Total Adult Pooled Budget 90%
Note 1 : SCCG ICO proposed spend is health services purchased for registered adult population
of Salford from SRFT & GMW
Note 2 : SCC ICO proposed spend is adult social care provided for resident adult population
of Salford
1
Services
No
tes
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7.4 Integrated Care Organisation – Funding
Service funding
The following principles will apply to the proposed opening contract value for planning
purposes in 2016/17:
Value will be based on 2015/16 outturn adjusted for:
o Changes already agreed through the ICP Service and Financial Plan and any other
pre-agreed changes
o Pay inflation and other increased employer costs e.g. employer pension
contributions for directly employed ASC staff will be fully funded
Text Redacted
Table Redacted
Text Redacted
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The planning assumptions applied to funding for 2016/17 and beyond are in the following
table:
The following table shows at high level the impact on funding and expenditure for the
services transferring to the ICIO for 2016/17 to 2020/21 using the above planning
assumptions regarding inflationary and other uplifts to subsequent years.
Partners will work together to minimise volume risk relating to demand, recognising the
long term intention to establish an outcome based payment mechanism:
o Agreement of activity volumes between the Council, CCG and SRFT at the start of
each year
o SRFT applying the Council’s eligibility criteria (any changes to which will trigger a
review of the Service Contract value)
o A process being established for monthly monitoring of demand and assessment
of management control by SRFT
o Partners working together to offset and mitigate changes in activity that exceed
planned levels
o Residual risk managed through the pooled budget
Expenditure Area Local or National Information source Basis of Assumption 2016/17 2017/18 2018/19 2019/20 2020/21 2021/22
Tariff inflation / (deflation) National Monitor Latest draft guidance from
Monitor issued in Dec 2015
for 1617 and Salford Locality
Plan
1.03% 0.45% 0.52% 0.58% 0.58% 0.58%
Non pay inflation National Monitor Latest draft guidance from
Monitor issued in Dec 2015
1.70% 1.60% 2.10% 2.60% 2.60% 2.60%
Pay Award / Increments / Pensions National Monitor Latest draft guidance from
Monitor issued in Dec 2015
3.30% 3.00% 3.00% 3.00% 3.00% 3.00%
NIC Rebate Reduction National Monitor
Insurance - cost of claims payout in
excess of premiums paid
Local SCC Assumed annual cost of
CSHC claims per annum over
the last 5 years
£0.1m
Pensions Local SCC Assumed annual cost of 1%
of pay bill. Included in
Heads of Terms
154 160 167 174 180 180
Annual Leave Carry Forward Local SCC TBC
Living wage impact Local SCC SCC estimate of living wage
Total Operating Expenditure (87.6) (116.7) (117.9) (119.1) (120.4) (121.6)
* From 2017/18 onwards a 2% efficiency saving is built into the operating expenditure value year on year
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The Council, CCG and SRFT will establish mechanisms to manage risks arising from:
o client income;
o any additional costs arising from the transaction e.g. those relating to VAT and
insurance.
There is no efficiency requirement for the adult social care services transferring in
2016/17.
The opening balance sheet will be ‘clean’ but any assets or liabilities that SRFT will have
responsibility for from the 1st July will be funded as part of the transfer.
For the contract period after 2016/17, the funding of services will be arranged in
accordance with the following principles:
The value for each year will be set according to an agreed activity volume, taking into
account changes in demand and the move towards an outcome-based payment model.
The planning assumption is for a 2% efficiency saving applied to ICO.
Any surpluses delivered by SRFT through efficiency savings in excess of those required
by commissioners will be returned to the Council and CCG pooled budget.
As for 2016/17, pay inflation, increased employer costs e.g. employer pension
contributions and non-pay inflation will be fully funded.
As for 2016/17, activity volumes between the Council, CCG and SRFT will be agreed at
the start of each year
Funding of ICO programme activities The ICO programme activities to date of £5.2m have been funded by the new care models Vanguard funding agreement. An application for further Vanguard funding of £24m to meet 2016/17 and 2017/18 ICO programme activities has been submitted to NHS England’s New Care Models team. The outcome of this is expected to be confirmed in June 2016. Should this funding not be fully secured, SRFT will identify essential and priority ICO programme activities and will agreed the funding of those through the pooled budget arrangement. The partners have agreed that essential ICO enabling activities, including those relating to the Transfer phase including the finalisation of the Transaction Documents, will be underwritten by the SCCG through the pooled budget arrangement.
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7.5 Financial Risk Management
Financial risk will be managed in accordance with the principles agreed in the heads of terms and reflected in the commercial arrangements. A detailed breakdown of the financial risks and mitigations identified in Stage 2 Financial Due Diligence is shown in Section 6 Commercial Case. 7.6 Financial Impact of ICO on Prime Provider
SRFT has examined the impact on its financial forecast by updating its Long Term Financial Model for the anticipated cost of the services. Text redacted
Table Redacted
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The impact of developing the ICO on the Trust’s cash flow projections is summarised below: Table Redacted
7.7 Financial Risks
Financial risks associated with the ICO transaction have been considered and addressed
through a series of mitigations. These include the expanded health and social care
commissioner pooled budget covering all ICO services and single contract with Salford Royal
for health and social care services together with the partner transaction documentation,
principally through the risk share agreement.
Beyond 2016/17, Salford Royal may continue to experience risks to the assumptions
planned in the LTFM. These risks may include:
o Sustainability funding (or equivalent) beyond 2016/17 is lower than included in the financial plan;
o Better Care Lower Cost savings achieved are lower than plan; o NHS activity delivers lower income compared to cost than included in plans
(e.g. due to changes to tariffs, changes to the NHS contract, under-performance by Salford Royal).
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Part of the mitigation of these risks for Salford Royal will continue to be delivering cost
reductions through internal efficiencies as part of the Better Care Lower Cost programme.
In addition, the cost reduction programme for Salford Royal will increasingly focus on
working collaboratively with partners to develop new approaches to managing demand and
building a clinically and financially sustainable system. The strategic context of the ICO, part
of the strategy described in Salford’s Locality Plan, is to adopt a city-wide approach to
ensuring population health improvement in Salford as part of an integrated care system.
The Integrated Care Organisation will provide the platform and framework to transform
services and drive through integration and efficiencies to contribute to bridging the
anticipated financial gap identified in the Locality Plan.
Salford Royal is also involved in a second Vanguard project to deliver transformational
changes in the way in which clinical services are managed and delivered to high quality and
reliable standards of care across multiple organisations expected to release costs through
The pooled budget will enable financial monitoring of the pooled budget on a monthly basis to support any adjustments required by commissioners’ in-year SRFT will create budgets for the full range of ASC and adult mental health services included in the ICO in its general ledger and will report income and expenditure on a monthly basis both internally and externally as part of the regular financial reporting timetable. There will be requirements to align reporting deadlines between SRFT and SCC to ensure that income and expenditure transactions that will continue to be managed by SCC in 2016/17 can be provided to SRFT on a timely basis. No material issues have been raised by either SRFT or SCC that highlight this as a risk to financial reporting. The contract between SRFT and the pooled budget will specify activity currencies which require monitoring. For adult social care and mental health services this will be provided using data held on SCC and Greater Manchester West managed systems initially in 2016/17. It may be necessary during 2016/17 to develop procedures to collect this data in the SRFT data warehouse and monitor all activity using the SRFT Service Level Agreement Monitoring system (SLAM) so that all ICO related activity and financial data is provided through a single source to commissioners. This work will be undertaken post transfer. 7.9 Accounting treatment
SRFT will assume that the income and costs relating to the ICO services will operate to the same monthly timing as is currently arranged. Therefore there will be immaterial timing or cash flow impact on SRFT and recovery of costs through income will be managed within each month.
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7.10 Financial Benefits Realisation Framework
The delivery of critical elements of the Salford Locality Plan and the associated savings is
dependent on the availability of integrated services and pooled budget provided by the ICO
as an enabling activity.
As part of the Vanguard Value Proposition partners identified areas of investment that will
contribute to the delivery of the recurrent savings gap for the health and social care
integrated care system by 2020/21 associated with the transformation and integration of
adult health and social care services. Targeted areas to contribute to the locality gap are to
be made through the following reductions in demand and cost:
Reduction in emergency admissions to hospital.
Reduction in permanent admissions to care homes.
Reduced demand for hospital-based care (primarily medical specialties).
Reduced costs of care (fragmentation and duplication).
Avoidance or absorption of future costs (absorption of demand associated with
projected population growth).
These financial planning assumptions and the associated benefits realisation will be further
developed through the Local Sustainability Plan process.
The development of the ICO will create the structural change which will enable efficiency-
related cost reductions and a contribution towards closing the projected financial gap for
health and care services, through transformational change activities.
The transformation programme is currently being developed. This will include a framework
to develop and approve investment cases. The joint commissioning and pooled budget
arrangements will allow for enhanced robustness in the governance, decision-making and
monitoring around transformation/efficiency schemes. For the first time, the partners will
be able to identify and demonstrate causal links between Social Care, Mental Health and
acute services and therefore the impact and financial benefits of transformation.
7.11 Table of Financial Case Recommendations
Recommendation m):
Note the following:
The size and composition of the commissioning pooled budget
The development of the Long Term Financial Model, incorporating the ICO as a “Service Development”
The modelling shows that the ICO has a neutral impact on SRFT Income and Expenditure position.
The financial risk management principles agreed through the Heads of Terms
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8. Management Case
Summary The management case explains how we will create the ICO. The transactions and approvals necessary to create the ICO are described, as well as the system wide governance arrangements. We focus on implementation which is described primarily from a provider perspective through the Post Transaction Implementation Plan (PTIP) and Quality Governance Plan. This section also describes our approach to transformation, through which the main benefits of the ICO will be delivered, supporting our shared vision for integration, better care and improved outcomes. Key Points
The process to create the ICO comprises three main workstreams: o Transactions, approvals and completion – including organisational and partnership
approvals, regulatory review, and steps for completion. o Commissioning – including new governance and contracting arrangements. o ICO Implementation – including the PTIP and Quality Governance Plan.
Planning for the ICO has been undertaken in five phases: (1) mobilisation (completed at the OBC stage); (2) detailed planning (captured in this FBC); (3) shadow and transfer arrangements; (4) technical integration; and (5) transformation (enabled by the ICO as an integrating provider vehicle for all adult physical, mental and social care).
The PTIP explains our approach to phases 3-4, covering the shadow period (1 April 2016 to 30 June 2016), formal transfer (1 July 2016), ‘Day 1’ arrangements and the plan for first 100 days of the ICO. The main theme is continuity, to enable a ‘soft landing’ for the new organisation, supporting our staff and assuring service users receive continuous, safe and high quality services. It also expands on our approach to: workforce and organisational development; IM&T and Information Governance; and provider transformation including the new care model.
The Quality Governance Plan describes the integration of governance systems (e.g. for serious incident reporting, complaints and service user experience); risk management arrangements and how assurance will be given during the change process.
Partners have agreed an ambitious programme of transformation, as set out in the most recent Vanguard Value Proposition, for which the ICO is a key enabler.
The management case concludes with an explanation of the necessary programme resources, the Benefits Realisation Framework and Post Project Evaluation approach.
Conclusions The PTIP and Quality Governance Plan set out the implementation arrangements for the ICO. Revised governance arrangements will ensure ongoing alignment of the ICO with broader system transformation ensuring the main benefits of integration are delivered.
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The management case commences with a stocktake of relevant OBC recommendations and
explanation of scope.
8.1 Table of OBC Management Case Recommendations and their Status
OBC Recommendations Status
Recommendation p): Produce a Post Transfer Implementation Plan capturing transfer, functional and technical integration arrangements.
A Post Transaction Integration Plan (PTIP) is included within the FBC.
Recommendation q): Develop a comprehensive staff and stakeholder communications and engagement plan.
An ICO communications and engagement plan is included as part of the PTIP. This is aligned with wider communications activity supporting system transformation in Salford.
Recommendation r): Agree the service and contractual expectations for the ICO on Day 1.
Contractual and service expectations for Day 1 of the ICO have been agreed through the Heads of Terms and Stage 2 Due Diligence, as reflected in the PTIP during the transfer and technical integration phases.
Recommendation s): Develop the longer term ICO transformation proposals.
ICO transformation proposals are described in the PTIP.
Recommendation t): Develop a longer term strategic workforce plan for the ICO and integrated care system.
ICO proposals on workforce are described in the PTIP.
Recommendation u): Progress proposals that support behaviour change in the population through ‘community activation’.
Detailed proposals are in development through the Salford Locality Plan.
Recommendation v): Commencement of formal consultation with affected staff groups in relation to TUPE legislation with the aim of adult social care transfer by 1st April 2016.
Extensive engagement has taken place with affected staff groups. Formal consultation in accordance with TUPE legislation will commence following FBC approval.
Recommendation w): Agree a joint local approach to a performance and quality framework to realise population health improvement for further development and implementation during 2016/17.
Agreement of revised system governance arrangements provides the framework to develop local performance and quality arrangements going forward.
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8.2 Introduction and Scope
The management case describes the structures and processes that partners in Salford
Together have put in place to ensure the safe, successful and sustainable creation of an ICO.
As a collaborative enterprise, all partner organisations have a specific role and stake in the
process. We present briefly the transaction process for the ICO and the wider framework
being developed to support the Integrated Care System (ICS). Most of the case focuses on
implementation of the ICO, led by SRFT as prime provider and described mainly through the
Post Transaction Integration Plan (PTIP) and the Quality Governance Plan. A summary is
provided of the Vanguard transformation programme, for which the ICO is a key enabler.
This section closes with an explanation of our approach to change management, benefits
realisation and post project evaluation.
8.3 Implementation Approach
The approach to integration provides for an initial period of stability, to provide continuity
and no immediate service change (or service disruption) as new arrangements are put in
place. Building on this smooth transition a transformation period will commence in Quarter
4 2016/17, such as the progressive integration of service lines in pursuit of opportunities
and priorities identified and agreed with co-commissioners.
As a ‘significant transaction’ for SRFT, our approach is guided by and compliant with
Monitor’s regulations including Risk Assessment Framework (updated August 2015) and
Supporting NHS providers: guidance on transactions for NHS foundation trusts (updated
March 2015). It is important to emphasise the particular nature of creating the ICO – it is a
means to integrate groups of staff and a set of distinct services around a shared vision and
objectives. It does not involve the merger of organisations, acquisitions or significant
investment or capital development.
Success on Day 1 of the ICO will, from a service user and carer perspective, be experienced
as no change in service access, provision and quality. For each organisation and partners
involved, establishment will see the start of the next main phase of the integrated care
journey in Salford, as reflected in the perspectives below.
SRFT – sees the creation of the ICO division, incorporating social care with other local
community and secondary care services, along with responsibility for contracting mental
health and range of residential, domiciliary and social care support.
SCC – increasing focus on population health and wellbeing improvement, as a co-
commissioner of health and social care.
SCCG – collaboratively creating an ICS, creating joint strategic commissioning with SCC
and pursuing Salford standards.
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GMW – continuing service delivery supported by new arrangements through the ICO
which enables the extension of integration from older to all adult service users.
General Practice – working with a new collaborative provider of health and social care,
while creating models of federated primary care and neighbourhood delivery.
VCSE – delivery of Salford’s Locality Plan will also require deep, ongoing collaboration
with the voluntary, community and social enterprise Sector (VCSE), and will build on the
relationships developed in the ICP. The role will continue to develop, particularly in
supporting community activation and independence.
8.4 Implementation Workstreams and Governance
The diagram below summarises the purpose and content of the three main workstreams
through which the ICO will be created.
Managing a programme of this technical complexity in a partnership environment requires
extremely strong, alert and responsive governance. Of the three principle workstreams to
create the ICO, Workstreams 1 and 3 are directly managed through the ICO project
structure and Workstream 2 is led by commissioners.
In tandem with this approach, which is specific to the ICO, there are a set of related but
separately managed programmes and activities are underway, detail of which is captured
within Salford’s Locality Plan. These include IM&T, particularly the Salford Integrated Record
(to support the new care model) and integrated data (to enable population risk stratification
in neighbourhoods), and estates (making best use of the combined Salford estate).
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Workstream 1: Transactions, Approvals and Completion
Details of the ICO transactions and approvals processes leading to completion are given in
Section 6, Commercial Case. In summary, the processes and production of necessary
transactions and supporting documents have been aligned through the ICO Steering Group
which reports to each of the four statutory partners. Beneath this level, the Business
Transfer Agreement (BTA) Group and Heads of Terms Group have coordinated other
elements. Processes solely concerned with commissioning have been managed outside this
structure, with alignment via the shared membership and representation in the Salford
Together and ICO programme structure. The three core elements of Workstream 1 are
outlined briefly below: organisational and partnership approvals; regulatory review and
assessment; and completion, including external legal and financial advice.
Organisational and partnership approvals – each organisation has determined the
relevant internal governance arrangements leading to the scheduling of document
circulation, briefings and decision making meetings which are necessary to support the
establishment of the ICO. The SRFT Council of Governors unanimously voted to support
the transaction on 30 March 2016. The remaining key elements for SRFT, as prime
provider, are as follows:
o 1 April 2016: Creation of Shadow arrangements
o March 2016 Board Cycle: Board of Directors to approve FBC and governance
arrangements
o 23 May 2016: SRFT approval of Board Certification and external opinion
o Early June 2016: SRFT receives regulatory review and risk rating from Monitor
o By 23 June 2016: Final execution of BTA and all other Transaction Documents
o 1 July 2016: ICO established (Day 1)
Regulatory review and risk assessment – Monitor has determined that the creation of
the ICO is a ‘significant transaction’, under its risk assessment framework, and will be
undertaking a review of the impact of the transaction on SRFT (as the prime provider).
Informal fieldwork has started with the formal review due to commence in early April.
The steps necessary to support this include:
o Monitor’s review of working capital, financial reporting and quality governance
o Approved FBC submitted to Monitor, with supporting evidence (April 2016)
o SRFT Board of Directors make Board statements (May 2016):
Board Certification and Corporate Governance Statement
Medical Director Certification
PTIP Statement
Quality Governance Statement
o Deloitte provide external opinion to Monitor that Board Statements have been
made after “due and careful enquiry”
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o Monitor provide transaction Green / Amber risk rating (June 2016)
Completion – supported primarily through Hempsons, acting as legal advisor and
Deloitte undertaking financial and service due diligence on behalf of SRFT, as prime
provider. Stage One due diligence was completed post-OBC, with Stage Two recently
concluded to inform the FBC. Partners have gained their own independent assurance
advice relevant to their roles in the programme. The Heads of Terms were finalised
prior this FBC and set out the commercial principles and Transactions Documents which
will form the legal basis of the new ICO. Shadow arrangements commence on 1 April
2016, which will expire on the target Completion Date, 1 July 2016.
Delivery of Workstream 1 has been coordinated by the ICO Programme Management Office,
with direction and accountability through the governance structure shown below. This will
change with the creation of the ICO and new joint commissioning arrangements between
the CCG and City Council. Future governance arrangements are set out in the next section.
ICO Steering Group
ICO Finance ICO Care Model Heads of Terms
GMW Board of Directors
SCC Mayor / Asst Mayor
SRFT Board of Directors
SCCG Governing Body
ICO Heads of TermsFinance BaselineDue Diligence Business Case
Day 1 ICO
ICO Programme Board
Business Transfer Agreement
ICO Transaction Documents
Executive Strategic Programmes Board
Strategy & Investment Committee
ICO Implementation
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Workstream 2: Commissioning
The Commissioning workstream comprises of three key elements: establishing a new governance structure for the ICS and ICO; developing effective contracting processes that supported integrated care; and creating a Transformation Plan which prioritises resource allocation and sets out areas for improvement that will help deliver Salford’s Locality Plan.
Governance arrangements – the new arrangements, described in section 6, will support
commissioners and providers to contribute to, and make collective decisions with
regards to, the development of integrated health and social care. The governance
arrangements include the establishment of the following groups:
o Integrated Adult Health and Care Commissioning Joint Committee – a joint
committee of SCCG and SCC and responsible for the Service and Financial Plan
for Adults and Older People’s Services.
o Advisory Board for Integrated Care – the forum where the four statutory
partners, in conjunction with General Practice, jointly set the overall strategic
direction and integration of adult health and care services.
The timetable for implementing these arrangements is set out in section 6.
Contracting governance – the four partners to the ICO have, collaboratively, developed
a contracting governance framework to support delivery of the ICO aims and objectives
(see Appendix 1, Part C). This is anchored to well-established arrangements already in
place, and supports shared learning and best practice across the partner organisations.
The governance arrangements will be implemented in three phases, over 12-24 months.
The principal overarching consideration of the governance is to:
o Build on established arrangements currently in place.
o Maintain existing collaborative, network arrangements between Salford and
other Greater Manchester (GM) providers and commissioners.
o Ensure the new Governance Structure supports the key ICO objective of
delivering transformational change.
o Ensure any consolidation of contracting arrangements only takes place after due
consideration by all the partners.
The contracting governance arrangements are provisional and will be further developed
over the coming months as partners gain a greater understanding of the different
services and how integrated service delivery can be best supported.
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Transformation planning – SCCG and SCC will jointly develop a Service & Financial Plan
(2016/7 – 2020/21) for health and social care services contained in the pooled budget.
The process to develop this plan will include a review and consolidation of plans which
are:
o Within the Older Peoples Service & Financial Plan (2014/5 – 2017/8).
o Pre-planned Council and CCG commissioning intentions and service reviews.
o Proposals within the Salford Together (PACS) Vanguard.
The plan will outline commissioning intentions for adult services. Sources of funding to the
pool will include Council and CCG commissioning contributions, the Better Care Fund and
other income streams including time-limited Vanguard and Greater Manchester
Transformation funding. The plan will be developed in partnership with the SRFT, GMW and
other providers. The plan will be governed by the Integrated Adult Health and Care
Commissioning Joint Committee. The phased development of the plan is described in the
High Level Service and Financial Plan (see Appendix 1 Part C).
Workstream 3: ICO Implementation
The ICO implementation workstream sets out the actions, primarily led by SRFT as prime
provider, to establish the ICO and support operational delivery. The context for the ICO is
the integration of existing services, directly provided and commissioned, with the local
community and secondary care delivery provision into the Salford Healthcare Division – to
be renamed through an engagement exercise involving all affected staff, but with a
provisional working title of ‘Salford Care”. Our actions will enable staff to continue to
deliver care, with a minimum of disruption, and to assure access and quality for service
users and carers. The approach is illustrated by the very small number of staff who will be
relocated on creation of the ICO, and the licensing approach to key support such as IM&T,
telephony and facilities. In effect we will integrate current services without being distracted
by extensive transfer of assets or the replacement of well-functioning processes.
A phased approach to implementation is being taken, underpinned comprehensive
communications, workforce and organisational development. The five phases are:
Mobilisation – completed at OBC; this focused on establishing the ICO leadership
and governance team, the transfer project team and initial planning. Mobilisation
also included engagement with a range of stakeholders and extensive discussions
and negotiations amongst partners.
Detailed planning – completed for this FBC; this work has involved broader and
deeper engagement of leaders and other stakeholders, and the forging of new
relationships and greater mutual understanding of services within the ICO’s scope.
The output of this work is PTIP and Quality Governance, which are summarised
below, and approach for Post-Project Evaluation and Benefits Realisation.
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Shadow and Transfer arrangements – includes the creation of shadow period and
other detailed arrangements, such as TUPE for staff transfer, performance
management and assurance processes, IM&T and HR support necessary for
successful creation of the ICO on 1st July 2016.
Technical integration – commencing July 2016; services are stabilised with an
emphasis on continuity during the initial period of the ICO, following which
structures, systems and processes are progressively integrated and post-Completion
issues raised during due diligence are addressed.
Transformation – led by strategic commissioners, at a provider level this will be
delivered through service line integration, identifying and exploiting opportunities
for improvement that address ICO aims and shared objectives.
Our approach comprises two main elements – the Post Transaction Integration Plan (PTIP)
and Quality Governance Plan, both explained below. This is followed by the remaining
elements of the management case: summary of the Vanguard transformation programme,
an equality impact assessment; change management and programme resources; benefits
realisation framework; and a post project evaluation plan.
8.5 Post Transaction Integration Plan (PTIP)
The Post Transaction Integration Plan (PTIP, see Appendix 1 Part A) describes how the ICO
will be enacted; commencing with a shadow period from 1 April 2016, formal transfer (1
July 2016) and technical integration (1 July to 31 October 2016). It covers service assurance
and delivery, development of our people and putting in place the supporting structures to
enable successful operation from Day 1, leading over time to transformation and
improvement. The PTIP and the Quality Governance Plan also include actions arising from
the Due Diligence conducted by SRFT and SCC (see below).
Up to the commencement date (1 July 2016) there will be no change to legal or other
responsibilities. The shadow period will provide a learning opportunity for each partner to
understand and inform how the new system and the ICO will work and to address residual
issues identified through the business case and Due Diligence process.
In developing and implementing the PTIP, and the broader transformation programme, we
have been guided by a set of key principles:
Maintain safety and business continuity throughout each phase of the plan.
Create lasting benefits for service users, carers, the system and workforce by integrating
service provision in response to strategic commissioning priorities, Salford standards and
wider transformation programmes within Greater Manchester Devolution.
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Develop and support all staff through each phase of the process.
Risk-based approach to managing periods of significant change (such as potential
disruption through transactions), providing clear escalation routes and fast response
from dedicated teams.
Prioritisation of action to address issues and risks identified through the service and
operational Due Diligence process (see below).
Underpinned by an ICO Communications and Organisational Development plan.
Integration activities arising from Due Diligence
SRFT Service Due Diligence SCC Operational Due Diligence
Post Transfer review of service specifications
Review of existing contingency plans for
provider failure within the supply chain
Joint approach to managing risk across health
and ASC
Review of information systems to support
performance monitoring and improvement
Review of complaints handling for ASC
Review of appraisal arrangements
Variation in the ASC staffing structure is
reduced to ensure all managers have
appropriate oversight
Review of sickness policy and procedures
Development of demand forecasting
Bespoke approaches to measure productivity
Invest to save models for equipment and
technology to promote independence
Identification and quantification of main
benefits associated with the transfer and
integration of ASC services
Operational governance structures, policies
and processes are appropriately amended
Creation of KPIs to monitor the success of
the transfer and integration of ASC services
Description of asset based community work
to ensure the effective running of ASC
services is maintained post-transfer
Data flows between acute, community and
social care staff are described
Pace and extent of change from
transformation is shared with staff to set
expectations and ensure success
The PTIP will be reviewed during the shadow period and updated as necessary.
8.6 Quality Governance Plan
As is the case with other elements of ICO implementation, our Quality Governance Plan (see
Appendix 1, Part A) is based on continuity and a phased approach to integration. The
starting point is to build on sound, proven governance structures – in community and
secondary care, adult social care and mental health – and for harmonisation over time of
relevant systems with SRFT’s systems, as the prime provider.
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Further work during the shadow period and the first 100 days of the ICO will enable the
integration of systems, while assuring quality and safety for our service users – with
particular recognition of the requirements for safeguarding in adult social care, the Mental
Health Act and other provisions for users of mental health services.
Our Quality Governance Plan will be further developed during the Shadow period and initial
Transfer and Technical Integration phases. We will continue to apply the three main
components of quality, developed by Lord Darzi and enshrined in legislation: (1)
effectiveness; (2) patient / service user safety; and (3) patient / service user experience. Our
model also mirrors the four themes underpinning Monitor’s guidance Quality governance:
How does a board know that its organisation is working effectively to improve patient care?
(Monitor, April 2013). As illustrated below, this emphasises the importance of engagement,
and building on insights to manage risk and improvement.
The Quality Governance Plan encompasses the services that will be integrated through the
ICO. It comprises of five main elements: due diligence for transferring services, integration
of quality governance arrangements; integration risk management; quality improvement;
and the provision of assurance. These also address the requirements of the Quality
Governance Statement that SRFT’s Board of Directors will need to submit to Monitor.
8.7 Vanguard Transformation Programme
The Salford Together Vanguard Transformation Programme sets out ambitious plans to
improve the care, health and wellbeing outcomes for the adult population of Salford and
make a significant contribution to closing the projected funding gap. The recently Value
Proposition (see Appendix 1, Part C) describes the creation of an ICS and ICO, with an
emphasis on prevention, reducing activity and shifting away from acute to community
settings. Through our Vanguard Programme, we will develop and test new models of care,
using the ICO as an enabler for integrated care.
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The following diagram overleaf provides an ‘at a glance’ explanation of our approach and its
multiple, interrelated components.
Vanguard Programme – Salford Together
Greater Manchester Devolutionstarting, living and ageing well
Radical upgrade in population health prevention
Transforming community based care and support
Standardising acute and specialist care
Standardising clinical support and back office services
Enabling better care
Salford Locality Plan closing health, care and efficiency gaps (£157m by 2021)
Integrated care model – risk stratified assessment, case management, care planning, community activation and navigation
Embed for older people(c.35,000) and extend to all adults (c.185,000) – with benefits tracked across improvement measures
Fully integrated neighbourhood model • shift activity and capacity to communities, closer to home• more prevention
Salford Together – better experience, outcomes and efficiency• Create an Integrated Care Organisation (a Local Care Organisation) – SRFT prime provider for full range of physical health, social care and mental health services for all adults• Aligned to federated Primary Care and standards-driven, integrated co-commissioning
Delivering place-based transformation
Reflecting local integration context
NewCare Models –Vanguard
Underpinned by Salford Integrated Record, estates and workforce developmentFull engagement with public, communities, service users and carersInnovation, improvement and evaluation expertise – to enable replication
Bain Hypothesis tree
The model of care developed through the Vanguard Programme builds on the three stage approach set out in the Outline Business Case.
The model is based on our evidence review, emerging data analysis and learning from our
Integrated Care Programme for Older People. It uses the risk stratification model and four
levels of support from the older people’s programme, extending this approach to the full
adult population but with an increasing neighbourhood focus.
3. IntegratedNeighbourhood
Model2. ICP for Adults1. ICP for Older People
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Integrated Care Model for Adults
The key features of our care model are entirely aligned with the approach being promoted
within Greater Manchester to create ‘Local Care Organisations’:
Core Features Salford Together – alignment with GM ‘Local Care Organisation’ model
Enable
conditions to be
managed at
home and in
the community
People will only need to tell their story once
MDGs supporting care coordination and chronic disease management
Care navigation and health coaching through Centre of Contact
Expansion of community assets to support self-resilience
Enhanced use of telecare and assistive technologies
Provide
alternatives to
A&E when
crises occur
24/7 support through Centre of Contact
Enhanced care home support for the most vulnerable
Case management for people most risk of being hospitalised
Increased use of intermediate care facilities
Effective
discharge from
hospital
Standardised approach to hospital discharge
Care coordination through MDGs and Centre of Contact
Joint care planning, supported through single enhanced care record
Help people
return home
and stay well
Care planning approach the focusses on reablement and resilience
Increased community based support
Increased access to community assets
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8.8 Equality & Community Impact Assessment Summary Statement
The Salford Together Partnership conducted the first Equality Impact Assessment (EIA) for
the Integrated Care Programme (ICP) for Older People in early 2013 (see Appendix 1, Part C
for the Service and Financial Plan). This EIA enabled the partnership to systematically assess
the effects and impacts of the ICP on vulnerable and protected groups under the terms of
the Equality Act 2010. As set out in section 3.4 of the EIA, there were a range of activities
aimed at engaging people in Salford to support the development of the service model.
Engagement and consultation continues to inform the service model.
The establishment of the ICO, including Adults and Older People’s services, is a significant
‘enabler’ in delivering an integrated health and care system and as such will drive
transformation across the health and social care service within its scope. In response, the
Salford Together partnership has established that through an ‘initial screening’ process that
Equality Assessments will be required for each transformation/service development areas as
they are rolled out across Adult Health and Care Services.
An Engagement Officer has been recruited, via Vanguard Funding, to continue to work with
Project and Service Managers to ensure that engagement and the EAI process is embedded
within all service developments that are taken forward over the coming five years. This will
ensure that the ICO can eliminate, reduce or mitigate any detrimental impacts on vulnerable
groups within Salford’s population.
8.9 Change Management and Programme Resources
Creation of the ICO and implementation of the PTIP and Quality Governance Plan will be
supported by a comprehensive change management programme. The scale and scope of
our approach is best represented by the McKinsey 7-S model, as illustrated below.
Strategy – how the ICO will deliver a shared vision in our context
Structure – distribution of authority, governance and organisation
Systems – processes and procedures, how the ICO works
Shared Values – core values and principles guiding ICO culture and behaviour
Skills – competencies and capabilities of staff and the ICO as a whole
Style – of senior leaders and management
Staff – the people, their background, capabilities and development
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SRFT’s previous experience of integration and transformation highlights the need for
supporting systems and structures, but the most critical factor is people – our workforce,
service users, carers and our communities. Attending to culture, values and supporting
change as a social movement will require significant investment in people and programmes.
Creating the ICO through an emergent, person focused approach, as an enabler of
innovation and transformation, is supported by literature on large scale change. In an NHS
Institute review (2011) of leading such programmes, Don Berwick is cited claiming:
“At present, prevailing strategies [in healthcare] rely largely on outmoded theories of control
and standardisation of work. More modern, and much more effective, theories seek to
harness the imagination and participation of the workforce in reinventing the system.”
And the original publication (BMJ quality and safety 2003) continues:
“This requires a workforce capable of setting bold aims, measuring progress, finding
alternative designs for the work itself, and testing changes rapidly and informatively. It also
requires a high degree of trust in many forms, a bias toward teamwork, and a predilection
toward shouldering the burden of improvement, rather than blaming external factors.”
Delivery of both supporting infrastructure and the culture of improvement through
integration will require dedicated implementation capacity, as summarised in the table
below and set out in the Vanguard Value Proposition.
Table redacted
We will also draw on a range of existing resources to support implementation of the ICO,
including the current management infrastructure of SRFT, adapted for the new scope and
range of services, along with improvement and innovation support from Haelo. The PTIP
and Quality Governance Plan are the two main components of successful delivery and, in
managing the change process, we will continue to draw on best practice evidence.
As an indication of the areas to be considered, a joint King’s Fund and Health Foundation
research report Making Change Possible: a transformation fund for the NHS (2015) reviews
lessons from previous transformation programmes. Although focusing on national
programmes, the evidence highlights the following themes which are relevant to the ICO.
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Lessons for the design and administration of transformation processes – and ICO Approach
Having clear and
coherent objectives
Agreeing and continuing to refine a shared vision has been a key task for
leaders, operating through our developing integrated governance
structures.
Engaging
stakeholders in
transformation
Importance of having a dialogue about change is recognised and informs
our communication and engagement strategy.
For example, a clinical and professional engagement event is arranged for
19 April 2016, at which the Vanguard including ICO will be introduced and
the approach to integrated neighbourhood working further developed.
Leading change Coordinating and enabling change at all levels, with an emphasis on bottom-
up development of improvement s, will be the primary role of the ICO.
Evidence-based
planning
Ensuring proper consideration is given to the evidence base underpinned
ICO development (see Section 4 Strategic Case – Case for Change) and will
continue to inform our implementation, refining our theory of change.
Balancing
implementation,
innovation and risk
Both implementation and innovation are important – spreading what
already works, building on the best local practice, and developing new
solutions to tackle problems and deliver benefits.
Allocation of
funding
Alongside creation of the ICO, new funding mechanisms are being
developed to support and incentivise improvement, across the whole ICS.
Considering
workforce
requirements
We will both engage and support staff in the change process and respond to
the workforce implications that will emerge as we move into the fifth phase
of transformation. It is helpful to note the evidence emphasises focusing on
models of care, particularly to support professional leadership.
Investment in
learning and
evaluation
Evaluation forms a key part of our ICO approach, building on our work on
the ICP for older people, as explained earlier in this FBC. Our investment in
learning is also supported by the Vanguard approach and relates to the
evidence which emphasises the importance of transformation becoming a
‘common preoccupation’ for staff.
Accountability Our attention to governance structures and supporting systems illustrates
the importance of proper accountability at all levels for the creation of the
ICO, in the context of the ICS and common objectives, as set out in the ICO
vision and Salford’s Locality Plan.
Timescale The balance between setting challenging targets and realism about
timescales is regularly considered by partners leading the ICO and ICS – and
has informed our decisions around a phased approach and emphasising a
‘soft landing’ and continuity to the initial set up.
Unexpected
consequences
Evidence including case studies point to the likelihood of unknown and
unintended consequences – some can be beneficial, others problematic. A
strong supporting PMO infrastructure is critical to managing the emergent
process and the concurrent evaluation will consider indirect effects.
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8.10 Benefits Realisation Framework
Conducting benefits realisation for the creation an ICO, in a wider ICS, will need to differ
substantially from the traditional approaches relevant to developments such as major
building infrastructure or individual service changes.
In developing our approach, we will draw a distinction between:
Internal changes to deliver better service integration and deliver provider efficiency
savings (as required from 2017/18 onwards).
Benefits enabled by the ICO, some of which will be delivered within the wider ICS, and
supported through commissioner-led transformation.
It is the second element, transformation in the wider ICS that will deliver the main benefits,
such as through the testing and implementation of new models of care. The three main
stages of our benefits realisation framework are given briefly below.
Stage 1 – refining investment objectives and scoping benefits
o Building on the ICO vision, shared ambitions and the refined scope of services
o Delineating between ICO internal efficiency benefits and those to be enabled as
part of commissioner-led ICS transformation
Stage 2 – identifying and detailing benefits
o Based on improvement measures
o Linking to specific targets such as in Salford’s Locality Plan
o Developed with stakeholders, particularly ICO leadership team
Stage 3 – review and realisation
o Using existing sources such as performance management and evaluation work,
complemented by additional reviews to monitor progress against benefits
In developing our detailed plan, we will build on best practice in benefits realisation which
emphasises factors such as:
Determining different categories of benefit, such as:
o Quality improvement, such as improved experience and outcomes, reducing
unwarranted variation, and helping service users develop optimistic futures.
o Direct cost saving, targeting changes that directly reduce unnecessary
expenditure, such as reducing duplicate, overlapping activities.
o Resource releasing benefits, which create and redirect capacity, particularly staff
input, towards greater value added work.
o Cost avoidance, particularly relating to demand risks and shifting to more
preventative support and community activation.
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Understanding what needs to change to realise the benefits, including:
o People changes including roles, relationships.
o Process improvements, particularly on handovers and transitions between
currently separate health and care inputs.
o Technological advances, including extending support from the Centre of Contact
and making more use of telecare and telehealth mechanisms.
The PMO, including finance input, will lead the development of the benefits realisation plan,
based on the framework above, during the shadow and first 100 days period. Once finalised,
this will be owned and monitored by the ICO Programme Board, with progress reported
through the Advisory Board for Integrated Care.
8.11 Post Project Evaluation
Post Project Evaluation will assess the implementation of the ICO and support benefits
realisation. As set out earlier in this document, the ICO is primarily a vehicle for enabling a
new care model in pursuit of shared aims, including the ICO vision and broader objectives in
the Salford Locality Plan. We will therefore link our approach with the wider ICS and
commissioner led transformation plans. The benefits specifically related to the
establishment of the ICO that will be assessed in the evaluation are summarised below.
Integrating a full range of services within a single management arrangement – more
effective, efficient and coordinated care.
Creating a collaborative environment without the need for new organisational forms.
Aligning interests of commissioners and providers, removing organisational and
professional ‘silos’ that contribute to fragmented and sub-optimal care.
Ensuring collective ownership of opportunities and responsibilities; any ‘gain’ or ‘pain’ is
linked to overall performance.
Supporting a focus on outcomes and better management of population demand.
Delivery of these benefits will be pursued through the PTIP, Quality Assurance Plan and by
creating a single system of governance. The Post Project Evaluation will explore the transfer
and technical integration phases, along with progress made on transformation. Six months
after completion, a detailed review will be undertaken which focuses on the following areas.
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Domain Description Measurement
Service
integration
Review of integration progress for
directly managed services
Review of integration progress for
sub-contracted services
Audit of service line integration
Survey of organisational / managerial /
clinical leads (internal and external
stakeholder engagement)
Operational Review and management – impact
on targets (service and human
resources)
Assessment versus Quality Governance
Plan
Cultural Impact on organisational culture
and extent of development
(integrating workforce)
Staff feedback – planned and
ad hoc
Processes Review of processes, policies and
procedures affected by ICO
integration
Desk-based review informed by
feedback e.g. IM&T integration, shared
records
Financial Impact on financial performance
and targets
Review of performance vs. service
contract (activity and finance)
Contribution of Division to
wider Trust
System ICO role in Integrated Care System
Relationships and alignment with
Primary Care Development
Progress with aligned strategic
programmes
Review of ICO development vs.
implementation schedule
External stakeholder assessment
Status reporting on strategic
programmes
8.12 Summary
This section has set out how the ICO will be created. It has described the transactions and
approvals necessary to create the ICO, as well as the system wide governance
arrangements. The management case has focused on implementation from a provider
perspective, which is described in more detail in the PTIP and Quality Governance Plan. This
section has also set our approach to transformation, as described in the Salford Together
Vanguard Value Proposition, through which the main benefits of the ICO will be delivered.
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8.13 Table of Management Case Recommendations
Recommendation n): Support the steps described in the Transactions, Approvals and Completions workstream. Recommendation o): Support the submission of the FBC to Monitor. Recommendation p): For SRFT Board of Directors – to note the need to make and submit the necessary Board statements in May 2016. Recommendation q): Note the new Integrated Care System governance arrangements, recognising that these are subject to a parallel approvals process. Recommendation r): Note and support the content of the Commissioning workstream. Recommendation s): With respect of the ICO Implementation workstream:
Note commencement of shadow governance arrangements
Approve the Post Transaction Integration Plan (attached at Appendix 1 Part A)
Approve the Quality Governance Plan (attached at Appendix 1 Part A)
Recommendation t): Note the support required for change management and programme resources and dependency on Vanguard funding. Recommendation u): Note and support the development of a Benefits Realisation Framework and the Post Project Evaluation approach.
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9. Conclusions and Recommendations
9.1 Introduction
The Salford Together partners have a strategic aim have a strategic aim to improve
population health for the people of Salford. Partners have been working together on
proposals to create an Integrated Care System (ICS) for adults and older people to improve
population health, experience of care and efficiency.
The proposal to develop an ICO is one of a number of components to develop an Integrated
Care System that also includes work to develop commissioning, GP engagement with the
system and system development including a programme for transformation. The
establishment of the ICO and the development of the Integrated Care System are key
elements of Salford’s Local Sustainability Plan.
This FBC is the third of three approval steps to progress the establishment of an ICO. It takes
forward the Case for Change identified in the SOC and identifies a preferred option to create
an ICO by,
Transferring adult social care to SRFT, as a prime provider.
Transferring commissioning arrangements for local adult mental health services to SRFT.
so that adult social care, mental and physical health services are integrated within an ICO.
This FBC is the third of three approval steps to progress the establishment of an ICO.
It revisits and confirms the preferred option for the ICO selected in the OBC and sets out the
arrangements for its implementation, including the detailed commercial, financial,
implementation and risk management proposals.
Before setting out the recommendations of the business case in full, the table overleaf
provides a summary of the overarching risks and mitigations associated with entering into
the ICO arrangements.
2016 04 12 ICO FBC PUBLIC 4.2 Section 9. Conclusions and Recommendations
Inability to complete key phases in timely manner results in delays to benefit realisation.
Formal programme management approach in place covering each approval and integration stage.
Legal, technical and other business requirements are not adequately addressed
The Business Transfer Agreement ensures all appropriate staff and assets are transferred and legal requirements are satisfied to ensure the sustainable delivery of services from day 1.
Material risks to ICO establishment not identified and mitigated, with adverse impacts on partners.
Formal Due Diligence activities undertaken by both SCC and SRFT using independent external advisors with agreed mitigations in the transaction documents.
Transition / Integration
Loss of service continuity for services transferring into the ICO.
Detailed plan for each stage of the transfer including Day 1, first 100 days and longer term integration based on the principles of maintaining safety and quality.
Lack of cultural alignment between professional groups slows or impedes integrated working.
Clear OD plan to align organisational cultures pre and post the establishment of the ICO.
Loss of key staff and knowledge during the transfer.
Integration arrangements include a clear communications and engagement plan to ensure all staff are kept informed and engaged at each stage of the transition.
Service and support staff lose access to key systems and data and planned system integration activities are delayed or unworkable.
Detailed IM&T integration plan covering transfer, technical integration and transformation phases.
Sub-optimal transition of supply chain management functions.
Commissioning and Operating Principles for services have been agreed, and a contracting governance framework has been developed, to ensure continuity of performance and quality through the supply chain.
Quality Risks Inability to sustain the quality and safety of services in the ICO.
Divisional management and governance structures agreed, including arrangements for Mental Health and the broader supply chain. Detailed Plans in place to integrate quality governance systems taking the best from both Health and Social Care practice, and ensuring clear sight at Board level.
Transformational Risks
Benefits of integrated working are not secured for the system and the citizens of Salford.
Transformation proposals are set out in the Vanguard plan, and the ICO integration plans are focused on preparing services to deliver this transformation within an agreed Commissioning and Operating Principles framework.
Inability to impact on the drivers of demand. Revised governance arrangements ensure the system can jointly tackle the drivers of demand through joint strategic commissioning aligned with greater service integration through the ICO.
Financial Risk Scale of budgetary pressures in the Health and Social Care system adversely impact upon partners.
Long term financial plans are in place through the S75 pooled budget arrangements and Service and Financial Plan. Risk sharing arrangements are in place to ensure that financial risk is managed optimally.
Services moving into the ICO are not sufficiently resourced at the point of transfer.
The Due Diligence process confirmed resourcing levels for Mental Health and Adult Social Care. Mitigations agreed through the Risk Sharing Agreement and Services Contracts.
Key to Controls: FBC = Full Business Case – PTIP / QGP = Post Transaction Integration Plan and Quality Governance Plan -- BTA = Business Transfer documents -- Service Contracts = Services Contracts, Risk Share
and Commissioning and Operating Principles -- Gov. = System Governance Documents
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9.2 Recommendations
The recommendations of the FBC are as follows:
Section Recommendations for Approval Partners
Section 4 Recommendation a): Reconfirm support for the shared vision for the ICO.
All
Section 5 Recommendation b):
Note the prior approval at OBC of the preferred option to create the ICO:
SRFT as a prime provider for adult social care and physical health services with a focus on improving population health and wellbeing.
SRFT as a prime contractor for adult social care delivery and local adult mental health services, with agreements being reached in this FBC and supporting Transactions Documents to novate / assign or otherwise transfer responsibility for the contract for district and older adults mental health services that are currently in place between SCCG and GMW from SCCG to SRFT to subcontract to GMW.
Recommendation c): Reconfirm support for the preferred option.
All
Section 6 Recommendation d): Approve the risk mitigations identified through due diligence (SCC and SRFT Mitigations are attached at Appendix 1 Part B). Recommendation e): Note that the following transaction documents have been approved by SCC and SCCG and the expanded pooled budget has been established:
A high level service plan, and high level financial plan, describing commissioning intentions and the process for finalising the formal Service and Financial Plan (#10)
Recommendation f): Approve the following transaction document (attached at Appendix 1 Part A):
Risk Sharing Agreement (between commissioners and SRFT) (#1) Recommendation g): To note the following transaction documents are in draft form and delegate authority to officers, as appropriate, to finalise and execute:
Draft Business Transfer Agreement (#11) (attached at Appendix 1 Part A)
Draft Support Services Agreement (#13) (to follow) Approve applying for admission to the Local Government Pension
SRFT and SCC All SRFT, SCC and SCCG SRFT and SCC
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Section Recommendations for Approval Partners
scheme on a restricted open basis (relating to the Admission Agreement #12). Approve entering into the Deed of novation (#14). Recommendation h): Note that Services Contracts will be produced by the end of May 2016. These will:
Use the NHS Standard Contract form for the ICO (#8)
Use the NHS Standard Form Subcontract for mental health services (#15)
Reflect the principles agreed in the Heads of Terms.
Contain no other supplementary terms. Recommendation i): Note that a Non Disclosure Agreement and Data Sharing Agreement have been approved by the relevant parties. Recommendation j): Delegate authority for officers, as appropriate, to finalise an Information Sharing Protocol (transaction document #5) to be in place by 1 July 2016. Recommendation k): Note the parallel approval and support for the following integrated system governance transaction documents:
Governance Framework (#2)
Alliance Agreement Deed of Termination (#3)
Commissioning and Operating Principles (previously Scheme of Delegation) (#4)
Section 75 Agreement between SRFT and SCC (#9)
Section 75 Agreement between SCC and GMW (#16) Recommendation l): Note the plan for the subsequent approval and support for the Phase 2 Service and Financial Plan (#10) in the May 2016 approvals cycle.
All All SRFT, SCC and GMW All All
Section 7 Recommendation m):
Note the following:
The size and composition of the commissioning pooled budget
The development of the Long Term Financial Model, incorporating the ICO as a “Service Development”
The modelling shows that the ICO has a neutral impact on SRFT Income and Expenditure position.
The financial risk management principles agreed through the Heads of Terms
All
Section 8 Recommendation n): Support the steps described in the Transactions, Approvals and Completions workstream.
All
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Section Recommendations for Approval Partners
Recommendation o): Support the submission of the FBC to Monitor. Recommendation p): For SRFT Board of Directors – to note the need to make and submit the necessary Board statements in May 2016. Recommendation q): Note the new Integrated Care System governance arrangements, recognising that these are subject to a parallel approvals process. Recommendation r): Note and support the content of the Commissioning workstream. Recommendation s): With respect of the ICO Implementation workstream:
Note commencement of shadow governance arrangements
Approve the Post Transaction Integration Plan (attached at Appendix 1 Part A)
Approve the Quality Governance Plan (attached at Appendix 1 Part A)
Recommendation t): Note the support required for change management and programme resources and dependency on Vanguard funding. Recommendation u): Note and support the development of a Benefits Realisation Framework and the Post Project Evaluation approach.
All SRFT All All SRFT and SCC All All
2016 04 12 ICO FBC PUBLIC 4.2 Section 10. Appendices
