Solihull ICASS and Vanguard governance...

Solihull ICASS and Vanguard governance review Final Report

A programme from the Good Governance Institute (GGI)

June 2016

www.good-governance.org.uk

GoodGovernanceInstitute

Good Governance Institute


2

GGI exists to help create a fairer, better world. Our part in this is to support those who run the organisations that will affect how humanity uses resources, cares for the sick, educates future generations, develops our professionals, creates wealth, nurtures sporting excellence, inspires through the arts, communicates the news, ensures all have decent homes, transports people and goods, administers justice and the law, designs and introduces new technologies, produces and sells the food we eat - in short, all aspects of being human. We work to make sure that organisations are run by the most talented, skilled and ethical leaders possible and work to fair systems that consider all, use evidence, are guided by ethics and thereby take the best decisions. Good governance of all organisations, from the smallest charity to the greatest public institution, benefits society as a whole. It enables organisations to play their part in building a sustainable, better future for all.



Solihull ICASS and Vanguard governance review

Final Report

Client: Solihull Metropolitan Borough Council Project name: Solihull ICASS and Vanguard governance reviewDocument name: Solihull ICASS and Vanguard governance review – a report from the Good Governance InstituteReference: GGI-ICASS-GR-Report-2206-vDraft.docVersion: Final ReportDate: June 2016Authors: Christopher Smith, Team Leader for Knowledge Management, GGI David Cockayne, Managing Director, GGIReviewed by: Andrew Corbett-Nolan, Chief Executive, GGI, Thomas Mytton, Team Leader for Programme Delivery, GGIDesigned by: Emiliano Rattin, Senior Communications Officer, GGI

This document has been prepared by GGI Limited. This report was commissioned by Solihull Metropolitan Borough

Council. The matters raised in this report are limited to those that came to our attention during this assignment and

are not necessarily a comprehensive statement of all the opportunities or weaknesses that may exist, nor of all the

improvements that may be required. GGI Limited has taken every care to ensure that the information provided in

this report is as accurate as possible, based on the information provided and documentation reviewed. However, no

complete guarantee or warranty can be given with regard to the advice and information contained herein. This work

does not provide absolute assurance that material errors, loss or fraud do not exist.

This report is prepared solely for the use by Solihull Metropolitan Borough Council. Details may be made available to

specified external agencies, including external auditors, but otherwise the report should not be quoted or referred to

in whole or in part without prior consent. No responsibility to any third party is accepted as the report has not been

prepared and is not intended for any other purpose.

© 2016 GGI Limited

GGI Limited, Old Horsmans, Sedlescombe, near Battle, East Sussex TN33 0RL is the trading entity of the Good Governance Institute

[email protected]


3

4


Contents

Executive Summary

• Context to our work • Limitations

• Acknowledgements

• Methodology

• The context to the current situation at ICASS and the Vanguard

• Review of governance

o Purpose and strategy o Systems and structures o Relationships o Accountability risk o Leadership o Stakeholder engagement

• Defining success

• Further work to better develop governance arrangements

• Conclusion and recommendations • Appendices


5

Executive SummaryIn May 2016 the Good Governance Institute (GGI) were commissioned to undertake a governance review of Integrated Care and Support Solihull (ICASS) and the Solihull Vanguard. In particular, we were asked to examine:

1. The scope of ICASS within the 2016/17 health, care and economic landscape, specifically distinguishing between operational activity that should be considered “business as usual” for commissioners and providers and that which is different, transformational and seeking to develop whole system service redesign. This includes identifying collaborative pilot activity and the governance mechanisms to shift this, where the evidence suggests it is appropriate, from innovation pilot to embedded business as usual;

2. The relationship and governance arrangements between the Solihull Urgent and Emergency Care Vanguard and ICASS. This will include system wide agreement of the core purpose, mission, benefits and outputs of the Vanguard to the patient population of Solihull;

3. The key success factors for ICASS (and, if appropriate Vanguard, recognising its parameters are set by NHS England nationally) and the optimum delivery architecture to achieve and measure success;

4. The governance and accountability arrangements between the four organisations to deliver and measure success.

Throughout June 2016 we have undertook interviews with stakeholders from each of the four most prominent partner organisations (Solihull Metropolitan Borough Council, NHS Solihull Clinical Commissioning Group (CCG), Heart of England NHS Foundation Trust, and Birmingham and Solihull Mental Health NHS Foundation Trust), observed the ICASS Programme Board and Information Systems Governance Board, and carried out a comprehensive document review. We further engaged with patient, third sector and advocacy groups as part of the wider triangulation of the report. We carried out detailed benchmarking against other Vanguard and collaborative working sites and used this to help inform our recommendations.

The review is clear that the original intentions of ICASS were sound and based on a broad desire to bring together the public sector bodies across the Solihull geography to solve issues of health and social care integration. Much has been done to invest in these relationships, create programmes that deliver improved care at the patient level and adapt to changing national policy. These efforts and energy are recognised and valued by all we interviewed.

However, ICASS finds itself at a pivotal moment in its development, both in terms of new and developing relationships (e.g. University Hospitals Birmingham/Heart of England NHS Foundation Trust), and new national drivers (Sustainability and Transformation Plans). At the same time, the context within which the ICASS is operating has changed to, with the publication in October 2014 of the NHS Five Year Forward View and subsequent introduction of central policies; most critically, the development of Sustainability and Transformation Plans (STPs) across England. It is therefore important that the programme re-defines its purpose, situating it within this context. With this background we identified the following issues:

• a lack of clarity around the purpose of ICASS (and Vanguard status) and the origins of its conception • the absence of concrete objectives and deliverables supporting governance structures • an over-reliance of the strength of relationships in the region to drive actions/the programme forward in the absence of robust governance • a need to define in documentation how each of the partner organisations will hold each other to account • a need to review terms of reference and membership of a number of committees • a lack of clarity around leadership of ICASS in general • a need to engage more widely with staff and stakeholders to share learning and increase awareness of the programmes

6


Ultimately, we have suggested four options for taking ICASS and Vanguard forward.

These are:

1. Disband the ICASS and Vanguard programmes, subsuming programmes into organisational delivery;

2. Continue with the ICASS and Vanguard programmes, but rapidly slim down the governance and programme structures;

3. Tailor the ICASS and Vanguard programmes as the Solihull response to the wide-ranging West Midlands STP, with a more appropriate governance structure;

4. Revise the scope of the ICASS programme so that it functions as a tactical and troubleshooting pan-organisation body.

Our recommendation is for Option 3 to be pursued, with the ICASS and Vanguard programme improved and continuing in the short-term.

To support this we make the following recommendations:

1. Empower the ICASS Programme Board to be the sole decision-making body, point of resolution and implementation;

2. Refine and clarify the objectives of ICASS and Vanguard and subsequently re-issue a joint statement on organisational purpose;

3. Define expectations for each of the partner organisations and create a mechanism through which a partner can be held to account for non-delivery;

4. Rapidly engage with the emerging West Midlands STP to scope the positioning of ICASS as the ‘Solihull offer’;

5. Update the ICASS Programme’s risk register, and consistently review and maintain this at the Programme Board to ensure proper oversight of risk;

6. Review the Terms of Reference (ToRs) for the various working groups, with a particular emphasis on purpose and membership;

7. Consider streamlining the governance structure, removing superfluous meetings wherever possible;

8. Define deliverables for ICASS as a whole in terms of patient outcomes rather than project milestones and then evaluate performance against these;

9. Ensure that project management documents are clear, completed and maintained to avoid confusion over expectations and deliverables;

10. Ensure effective communication across working groups to avoid duplication of work;

11. Continue the communications work to ensure that staff both internally, and externally are aware of the activity that is taking place, including the strategic direction and are able to learn from good practice.


7

Context to our workIn the light of projected financial, population and health pressures, the Integrated Care and Support Solihull (ICASS) programme was formed in 2013 to bring together local organisations to create a more integrated system of care that delivered better outcomes, is reduce inequality and put the people of Solihull at the centre of its design.

Subsequently, in August 2015, Solihull was awarded Vanguard status by NHS England for its work to create an integrated system that combines preventative services with rapid access to primary, social and specialist care both in and out of hospital, enabling people to take better control of their lives.

Since then, progress towards achieving the vision of ICASS and the Vanguard has been slow, hampered by a variety of issues including the churn and effectiveness of leadership at Heart of England NHS Foundation Trust, and subsequent regulator intervention. The need for effective governance of, and consistent enthusiasm for ICASS is crucial in ensuring that is strategic ambitions are achieved, and that all partners and stakeholders are appropriately assured as plans develop.

The Solihull region also now falls under the Birmingham-wide STP, and so the continuation of ICASS and Vanguard must be seen in the context of this larger collaborative piece of work.

Following discussions with Chief Executive Officer, Nick Page, Dr Stephen Munday, Director of Public Health, and Paul Johnson, Deputy CEO and Director of Resources at Solihull Metropolitan Borough Council, the Good Governance Institute (GGI) were commissioned to conduct a governance review of ICASS and its links to the Solihull Urgent and Emergency Care Vanguard.

The immediate actions have been to identify:

1. The scope of ICASS within the 2016/17 health, care and economic landscape, specifically distinguishing between operational activity that should be considered “business as usual” for commissioners and providers and that which is different, transformational and seeking to develop whole system service redesign. This includes identifying collaborative pilot activity and the governance mechanisms to shift this, where the evidence suggests it is appropriate, from innovation pilot to embedded business as usual;

2. The relationship and governance arrangements between the Solihull Urgent and Emergency Care Vanguard and ICASS. This includes a system-wide agreement of the core purpose, mission, benefits and outputs of the Vanguard to the patient population of Solihull;

3. The key success factors for ICASS (and if appropriate the Vanguard, recognising its parameters are set by NHS England nationally) and the optimum delivery architecture to achieve and measure success;

4. The governance and accountability arrangements between the four organisations to deliver and measure success.

This report contains the findings of our evaluation and sets out recommendations for how best to take the ICASS and Vanguard programmes forward.

Limitations

The timeline for this review was limited to a five week review period late May to June 2016. This review is limited to the documentation that was provided to GGI during the time period of the review process and confined to the information provided to us by those who were available for interview as part of this process. The focus of this work is the governance of the ICASS, and not the delivery success of the ICASS.

8


Acknowledgements

The reviewers would like to thank everyone who has so willingly made themselves available for interviews and to those who provided project support and documentation for review.

We would particularly like to thank our key sponsors.

Methodology

GGI held a project launch in late May 2016. Work began immediately with interviews with the various stakeholders (Solihull Metropolitan Borough Council, Solihull Clinical Commissioning Group, Heart of England NHS Foundation Trust, and Birmingham and Solihull Mental Health NHS Foundation Trust) commencing on 1 June 2016 and concluding on 21 June 2016. Regular, weekly, highlight reports were provided for the project sponsors.

The outputs of this review are intended to support the leadership of ICASS and its partner organisations to identify issues within its governance arrangements, to better situate the programme within the health, care and economic landscape, and to identify key success measures for the programme.

To carry out this review, GGI have used a very specific methodology. This includes a variety of review techniques including interviews, focus groups and a comprehensive document review. Our review reflects this and represents the views of the various stakeholders and from various levels within the organisation.

In particular, we have:

• conducted a comprehensive document review • held interviews with the leadership of each of the partnership organisations, and with staff involved with ICASS and the Vanguard more broadly • held a focus group with patient representatives • observed the ICASS Programme Board and Information Systems Governance Board • conducted desk-top benchmarking against best practice and national guidance


9

The context to the current situation at ICASSThe ICASS programme is the result of an enduring legacy of integration of health and social care in Solihull prior to the existence of the former Solihull Primary Care Trust (PCT). It brings together members of a variety of partner organisations (Solihull CCG, Heart of England NHS Foundation Trust, Solihull Metropolitan Borough Council, Birmingham and Solihull Mental Health NHS Foundation Trust, and Age UK) to better integrate services in the provision of care for an increasingly frail and elderly population.

The ICASS programme is accountable to the leadership of Solihull Health and Wellbeing Board (HWB), and has, at all times, been managed in line with national guidance. In particular, the National Voices definition of integration has been at its core:

“I can plan my care with people who work together to understand me and my carers, allowing me control and bringing together services to achieve the outcomes important to me.” 1

There are number of health, economic, and population pressures that, although not unique to Solihull, have driven the development and focus of ICASS. These include:

• an increasingly elderly population. Currently, 20.3% of the population are aged over 65, compared with 17.2% in England and 17.7% in the West Midlands, and an above average proportion of people are approaching retirement. Between 2012 and 2022 the proportion of those over the age of 85 will increase by 43%. The implications of an aging population are well documented and include an increasing likelihood of co-morbidities and resultant heightened health and social care costs• the existence of significant areas of deprivation and inequality to the north and west of Solihull• increasing health and social care costs. Between 2015/16 and 2020/21, if organisations in the area do nothing, costs are forecast to increase by 11.5%, from £339m to £383m

To address these issues, the ICASS programme has focused its resources on three core workstreams:

• Prevention and early intervention • Out of hospital care • Hospital transformation

Although the formation of ICASS pre-dates NHS England’s Five Year Forward View2 the programme as outlined above does reflect the outcomes described in this document, notably the need for the NHS to take decisive steps to break down the barriers in how care is provided. In a very real way, Solihull anticipated policy changes and started working on effective integration as an early pioneer before this became national and mandated policy.

Thus the local context of ICASS and integration in the region put the area in good stead for a Vanguard bid and consequently in August 2015 it was one of eight areas awarded Vanguard status by NHS England as part of the Urgent and Emergency Care stream. The Vanguard proposition for 2016/17 outlines how the Solihull system for urgent and emergency care will be transformed through four key service offerings. These are closely aligned to the ICASS programme, namely:

1. Community Wellbeing Service - empowering people with the confidence and information to look after themselves when they can, and access care when they need to, giving people greater control of their own health and encouraging behaviours that help prevent ill health in the long-term. 2. Integrated Primary and Community Care Service - transformation and integration of primary and community teams into one service that ‘wraps around’ the needs of the patient.3. Integrated Urgent Care Service – the systematic implementation of best practice standards that will reduce variation and improve outcomes and efficiency.4. ‘Solihull Connected’ - Population Health Information System – learning from international models implementing a population health information system that will deliver an integrated care record, information and analysis to support flow, decision making and real time information for performance and outcome monitoring.

1) Redding D, ‘The narrative for person-centred coordinated care’ (2013) 21(6) Journal of Integrated Care <https://www.england.nhs.uk/wp-content/uploads/2013/05/nv-narrative-cc.pdf> accessed 21 June 2016 315–3252) Timmins N and NHS, ‘FIVE YEAR FORWARD VIEW’ (2014) <https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf> accessed 16 June 2016

10


The Vanguard programme’s membership is made up of Heart of England NHS Foundation Trust, Birmingham and Solihull Mental Health NHS Foundation Trust, Solihull Metropolitan Borough Council, Solihull Clinical Commissioning Group, primary care, and lay members representative of the Solihull population.

Because of the closeness of the objectives of the Vanguard to that of the ICASS programme, as well as a congruence between the memberships of each, there is a need to define clear governance arrangements, work plans and deliverables to ensure that organisations are able to hold each other to account for non-delivery and to ensure the avoidance of duplication of work.

The delivery of the ICASS and the Vanguard must also be viewed in the context of a change of leadership at Heart of England NHS Foundation Trust and also, to an extent, at the Council. In recent years, the trust has experienced a significant turnover of senior executives, and, notably, has witnessed four chief executives since 2014. The new leadership is bringing much needed stability to the organisation but there can be no doubt that each of the previous leadership changes has had a detrimental impact on the programme as new leadership were brought on board and up to speed. As one interviewee expressed, “we had to reset the clock with them [HEFT].”

The new leadership of HEFT, whilst retaining its own board and management team, operates to a significant degree in common with University Hospitals Birmingham NHS Foundation Trust (UHB). The Chair, Chief Executive, Medical Director and Director of Operations are members of both the HEFT and UHB boards. Other senior executives at UHB, such as their Director of Corporate Affairs, are overseeing key functions at HEFT during this period of recovery.

Vanguard workstreams

Community Wellbeing ServiceIntegrated Primary and Community Care ServiceIntegrated Urgent Care Service‘Solihull Connected’ - Population Health Information System

Vanguard outcomes

Better quality and outcomes for peopleSeven day access to health and care servicesImproved performance productivity and flow through the systemCommunities strengthened to enable people to improve their health and wellbeingReduced inequalityFinancial sustainability

ICASS workstreams

Prevention and early interventionOut of hospitalHospital transformation

ICASS pledges

We will develop communities to ensure that everyone feels they belong and are valuedWe will ensure people have the information, help and advice they need to help them have the best quality of lifeWe will ensure people only tell their story once and their support will feel like it comes from one teamWe will transform our hospital to become a vibrant hub of an integrated care system


11

The introduction of a new divisional, rather than site-based, management structure at HEFT will potentially, impact on how ICASS and Vanguard is delivered into the future. Solihull Hospital is one of three hospital sites within HEFT. Under this new management structure the hospital is part of two divisions (3 and 4). In regards to HEFT, it should be noted that the intention remains to develop Solihull Hospital. However this will be as part of a wider network of care in recognition that, for many services used by the people of Solihull, the local acute hospital is in fact Heartlands Hospital and not Solihull Hospital. This must be recognised in the on-going management of ICASS and Vanguard. Finally, we understand that the ICASS programme and Vanguard working has been posed awaiting the conclusions of this governance review. This provides a good opportunity to situate the work within the broader development of the STP. The Birmingham and Solihull footprint, including Solihull Metropolitan Borough Council, Solihull CCG, Heart of England NHS Foundation Trust, Birmingham & Solihull Mental Health Foundation Trust, and wider partners across Birmingham have been asked to put forward a plan for radical transformation to help ensure sustainability within their region. Amongst those we spoke to, there was a lack of clarity around how ICASS fits into the STP and what this meant for its continuation. This is an understandable issue, given that ICASS was ahead of its time and set up before STPs were envisaged.

Certainly, the guidance for STPs places emphasis on ensuring that plans “support the accelerated delivery of new care models in existing Vanguard sites”3 and as such it is likely that the STP will build on, rather than do away with improvements made under the ICASS programme. However, from 2017/18 onwards, the continuation of the programme must be seen in the context of STPs becoming the ‘single application and approval process for being accepted onto programmes with transformational funding’.4

It is important to note that the ICASS programme has delivered some notable success especially around integrated discharge and relationships. Regardless of what form ICASS continues in the future, the lessons learned from the experience of ICASS and Vanguard to date must be carried forward. Many we spoke to felt that the ICASS had created a useful Solihull focus to the planning and delivery of care services between health and social care.

Review of governance

During our review several issues came to light that are worth extrapolating. These have been organised under six headings as below:

• Purpose and strategy • Systems and structures • Relationships • Accountability and risk • Leadership • Stakeholder engagement

3) ‘Gateway reference: 04820’, (2016) <https://www.england.nhs.uk/wp-content/uploads/2016/02/sustainability-transformation-plan-letter-160216.pdf> accessed 21 June 20164) Ibid.

12


Purpose and strategyClarity of purpose

The Good Governance Handbook states that:

“Board or governing bodies of organisations need to ask themselves one fundamental questions: ‘what is the point of this organisation?’ The purpose of the organisation and the vision set by those that govern it to support the achievement of the purpose, is the starting point for any system of governance”.5

On numerous occasions we heard that the governance of ICASS was confused and not well communicated. There does not appear to be a uniform understanding of what ICASS has been set up to achieve, nor how it relates to the Vanguard and vice-versa. Indeed, as one interviewee summarised:

“It wasn’t a case of right, this is Vanguard, that’s ICASS, they’re two separate programmes, this is the delivery, this is the reporting mechanism, all of the simple stuff: it’s never been defined.”

Further, we heard variously that:

• Vanguard gives “short-term relief to the fact that a lot of these projects aren’t funded” • Vanguard has been ‘shoehorned’ into an integrated care proposition because there was additional money attached • Vanguard and ICASS are in effect one and the same, and there is a lack of clarity around how they differ • that the ICASS is in fact a much bigger programme of which the Vanguard is one workstream • ICASS has been set up to facilitate and support the development and delivery of integrated care services within Solihull • there is a lack of communication across the programmes and understanding of what each has set up to achieve

Although understanding and awareness of the programme tended to increase with seniority, too often this remained at a superficial level. It is important that staff throughout understand what both the Vanguard and ICASS have been set up to achieve and how their work fits into this.

Shifting to an outcome, rather than milestone, based approach could help provide clarity here, as could re-issuing a statement on organisational purpose.

Indeed, we were told:

“The challenge then is the measures. So again, are there a clear set of measures in place which people can judge the success or otherwise of whatever it is you’re re-designing.”

Drilling down further, too often we heard that working groups or sub-committees lacked terms of reference and that project leads and Chairs were unclear on their roles, responsibilities and deliverables. Certainly, we have only seen ToRs for the Programme Board itself, and the Finance Group. Whilst useful, the Finance Group ToR would benefit from greater clarity around its accountability, responsibility and authority.

It is important that, if the programme continues, clarity is provided for the remaining groups in the form of ToR and concise and clear Project Initiation Documents (PIDs).

5) ‘Good governance handbook’, (2015) <http://www.good-governance.org.uk/wp-content/uploads/2015/01/GGH-Main-.pdf> accessed 21 June 2016


13

The PIDs reviewed as part of this review were at varying stages of completion and of a varying quality. We found that:

• none of the PIDs in the prevention and early intervention workstream had been fully completed. Whilst some contained detail around the objectives and had a high-level project plan, none were clear on the implementation strategy nor contained an assessment of risk, and very few contained any analysis on resource. This is a significant gap and one that must be rapidly addressed going forward • the PIDs in the out of hospital workstream were largely incomplete and to a varying quality. It is telling that the D2A Combined Pathway PID had been comprehensively completed as this is a notable area of success for the organisation. Many documents lacked clarity over objectives, implementation plans and schedule, and risk. • the PIDs for hospital transformation had overall been completed to a higher standard though many still lacked clarity across a number of elements

The PID should be recognised as the core document for programme management, providing clarity and ensuring staff and stakeholders understand why the project is taking place, who is responsible for delivering it, what the deliverables are, when they will be delivered and any risk that is involved. We remain concerned that the programme approach and structure are distant from the outcomes they are designed to achieve.

Reporting

The absence of real clarity of purpose has potentially led to blurred lines of reporting and accountability. The perception exists, confounded by the confusion over deliverables, that the wrong things are being reported up to the Programme Board and in turn cascaded out to the workstreams.

We were told that:

“The tendency is to want to report positive progress positively rather than to share where things aren’t going so well. The Boards tend to have their role in that as well. They tend to encourage that sort of behaviour.”

And that:

“To be perfectly honest, there was very, very limited discussion around anything being escalated to that Programme Board.”

To ensure clear line of sight from front line service to the board there must be an explicit framework for:

• delivering and demonstrating accountability • quality improvement activity • measuring improvement and compliance • reporting, recording and escalating risk • monitoring and evaluating performance6

Similarly, there appears a general lack of awareness around ICASS and Vanguard amongst staff and leaders working outside the programme, particularly in HEFT. This has the potential to hinder the progress of work, as other work takes priority internally. It is important that any external reporting on the work of ICASS is of a sufficient quality to ensure that the activity, and potential benefit of it to each of the parent bodies, is adequately understood and that staff are not behaving in a disruptive way.

Within all this, it is unclear what role the Health and Wellbeing Board is fulfilling, with many describing its involvement as non-existent. The governance structure provided to us (see below image), and also described in the Vanguard value proposition document, illustrates the Programme Board as reporting into the Solihull Health and Wellbeing Board. We understand that the form this takes is a simple verbal update, and would question therefore whether the programme is coming under a sufficient level of scrutiny.

6) ‘Good governance handbook’, (2015) <http://www.good-governance.org.uk/wp-content/uploads/2015/01/GGH-Main-.pdf> accessed 21 June 2016

14


ICASS Programme Governance:


15

Meeting arrangements

On a number of occasions it was mentioned to us that the frequency of meetings was an issue, with one interviewee arguing that: “the answer to everything was another meeting, it wasn’t decision making” and that, “there was a philosophy of system leadership that was about having lots and lots of meetings and engaging everybody but without any clarity about why we were engaging people.”

Staff involved in the ICASS programme need to be empowered to take decisions, and a culture fostered where people are proactive in capturing and acting on issues.

It was also described to us that those in many of the workstreams were unsure as to who was meant to be attending from each partner organisation and that this was adding to the lack of performance. Clarity over deliverables, as well as the creation of robust terms of reference for each group should help resolve this situation.

Finally, whilst we recognise that the need to support the power and insight of external stakeholders, we would question the necessity of having ICASS specific stakeholder panels, clinical networks and communications groups. It appears to further add to confusion and creating repetition in the programme architecture.

We believe that ICASS could make better use of existing forums available to it through the parent bodies, with information sourced and reported on a regular task and project based approach. The new leadership at HEFT and the consequent stability and continuity this brings will also make delegated decision making more possible.

16


Systems and structuresICASS Programme Board

Attendance

The ICASS Programme Board we observed was well attended, although HEFT were unable to attend the meeting. We felt the meeting was well chaired, held in good nature and with equal contribution across partner organisations. In particular, there was a good debate and understanding of the relationship between the various statutory bodies (ICASS, BCF, Vanguard and STP) and the extent of the synergy with the STP in priorities, themes and workstreams.

However, perhaps inhibited by the status of ICASS given this governance review, there was a lack of challenge and it was unclear whether all attendees had the responsibility, delegated or otherwise, to take decisions on behalf of the organisations they were representing. Interviewees confi rmed that the Programme Board was more often a meeting in which partners were updated on progress, with the resolution of issues and principle decision-making taking place outside of this at the informal, non-minuted, meeting of Chief Executives:

“We’d hold them to account initially through the…ICASS Board; we’d raise it with them. I think if they were unable to resolve that then we would probably escalate it up to the leaders group or over into the ICE group where it’s a bit more of a closed session”.

The terms of reference for the Programme Board state that decisions can be taken “outside meetings…but records of these must be kept as part of the Board records for audit purposes.” As such, the existence of the Chief Executive meeting as a space for resolving issues and taking decisions is problematic. We would suggest either that the Chief Executive meeting become a formal part of the governance structure or that the Programme Board become the principle decision-making body and be enabled to resolve issues rather than escalating them further. In the latter case, the attendees at the Programme Board would need to be empowered to take binding decisions on behalf of their own organisations. Additionally, as the STP becomes the focus for collaborative working the feasibility of senior executives attending multiple forums engaged in similar collaborative exercises becomes diffi cult to justify.

A review of the minutes of the Programme Board, dating back to August 2015, demonstrate that, of the core membership, no organisation, or one person, markedly attended fewer Board meetings than others. However, the minutes do characterise a meeting with mixed or poor attendance generally and that enthusiasm for attendance is weakening.

MonthAugust 2015September 2015November 2015December 2015January 2016March 2016May 2016June 2016

Number of apologies4778111074 (observed meeting)

ICASS Programme Board attendance

This would appear to support the need to radically review the purpose and function of the Programme Board.


17

Content

Although risks were discussed at the meeting we observed, the risk register was not reviewed and it was suggested to us that it had ceased to be updated awaiting the conclusion of this review. The risk register supports the Programme Board in having oversight of all risks, ensuring that any decisions that are taken are properly considered, and as such should be a standing item on the agenda. In the context of system transformation, the risk register should be seen as a tool that can support behavioural change, aligning partners’ understanding of their roles and responsibilities, and their impact on other stakeholders. Not routinely reviewing the risk register presents a sizeable risk in itself.

The Schedule of Actions presented at the Programme Board is a useful document and helps clarify activity and responsibilities. However, the document from May 2016 includes no deadlines for delivery and appears to place more emphasis on the achievement of milestones rather than outcomes. The document would benefit from a focus on patient outcomes, with clear timescales for delivery, to ensure the Programme Board is properly sighted on the benefits and usefulness of any activity taking place.

We were also told that:

“The business was all exciting stuff to start with. It’s got diluted as the time has gone on.”

This is perhaps demonstrated by the seeming lack of focus on risk and deliverables at the Programme Board.

Finally, it was felt that the agenda could be streamlined slightly. For example, it is unclear what benefit there was in hearing the presentation on the Re-admissions Audit. This was a comprehensive presentation that failed to focus succinctly on highlights and would perhaps have been served better as a report to the Programme Board. The composition of the agenda should be reviewed with a view to consistency and ensuring that focus is placed on the right issues.

Other committees

More broadly, we received mixed feedback on the functioning of the various sub-committees.

The Finance Directors’ Group, was, near-universally, viewed as a positive development bringing together the finance directors from each partner organisation to make joint decisions around joint investment. However, we did observe that attendance was variable from HEFT and, at times, the Mental Health Trust and often not of the right seniority, nor with delegated authority to take decisions. It is important that if ICASS is maintained in its current form, attendance is improved and attendees empowered to take decisions. Interestingly, the finance directors reported the most valuable part of ICASS being the fact that they had quality time together as peers, and that they could demonstrate the wider value of finance directors to the system, beyond that of the traditional accountancy model.

Whilst this denotes a good use of time for those attendees it is a microcosm of how the parties involved in ICASS have transformed their own working groups and committees into a purpose that they can derive value from. No doubt a meeting of finance directors across Solihull can add enormous value and should be promoted and continued. We would question, however, whether this is part of ICASS itself and a good example of how the ‘relationships’ in Solihull are both valued and stressed as important to future success.

We have not seen terms of reference for the remaining groups and from interviews are unsure the extent to which these are complete, or even exist. This lack of written formality perhaps generally characterises the way that ICASS has been governed since its inception.

We were informed that the Quality Board, although well attended and with equal representation from each of the partner organisations, had not delivered on its anticipated workstreams. Discussion has focused on individual quality issues from the partnership organisations around discharge to assess, rather than the strategic vision of the outcomes. There is a need to define the system metrics that the Quality Board will examine in order to provide more focus in meetings, and greater clarity and detail in reports to the Programme Board – this depends on what option on continuation of ICASS is considered.

18


Communication across workstreams

It was commented to us that the governance arrangements and structure of ICASS and the Vanguard did not readily allow for communication across workstreams. The absence of adequate mechanisms for communication across working bodies leaves the programme exposed to duplication of work and a lack of awareness amongst staff of work that could potentially impact on other services. As one interviewee stated “you have to keep your wits about you,” and the region “doesn’t have a history of planning for delivery.”

This suggests a system in which there is a dependence on personal relationships and connections as the mechanism for alerting people to activity and risks rather than the governance arrangements doing this, and is something that should be examined further.


19

Relationships There is a strong legacy of joint-working and partnership in Solihull pre-dating ICASS. Consequently, there are well-established relationships amongst the senior leaders of the area, something that was highlighted as a key positive differentiator in the Vanguard pitch. The new leadership at HEFT are less-well known because some have been focused around UHB, and the residual members of the former HEFT executive team remaining on that board were fairly new in post.

Whilst the relationships in the region are an undoubted strength, it was mentioned, on several occasions, that rather than reinforcing effective working arrangements these had, at times, contributed to an absence of robust governance and programme functions as decisions were more easily taken outside of these and work driven forward informally. The existence and functioning of the Chief Executive meeting, which was invariably seen as the most important meeting that senior members attended, as a point of resolution outside of the ICASS governance structure is perhaps most illustrative of this. As mentioned previously, we would argue that the strong relationships in the region should work within the governance framework not as a reason to neglect it.

Perhaps because of the change in leadership at the organisation, the recent position of HEFT has variously been characterised as challenging, obstructive and an opportunity. However, this must be seen in the context of the historic relationships of the previous management regime.

There is, therefore, a need for the partner organisations to re-define their commitment to the programme and within this an understanding that the new HEFT leadership, in re-examining and defining their own internal governance, can no longer devote the same level of resource as previously. This is not necessarily indicative of a lack of willingness from the new regime, who have demonstrated intent by investing and instilling a knowledgeable and able senior executive to oversee ICASS, Vanguard and the STP.

That said, there is certainly room for increased sensitivity from the new HEFT in their dealings with the ICASS programme and the partner organisations, recognising the central position that ICASS has held/been portrayed in strategic planning for Solihull. Despite evidence to the contrary, there remains feeling and concern that the new leadership have taken a model, albeit a very successful one, from UHB and directly applied it to the situation at HEFT and in turn ICASS. We felt this was an unwarranted perception given the evidence.

This review therefore presents a renewed opportunity for the new leadership at HEFT to re-engage with partner organisations and fully demonstrate their understanding of the nuances at work across health and social care in Solihull.

More broadly, amongst those involved in the various ICASS workstreams at a service delivery level there is a sense both of frustration and regret that more has not been achieved, but also a view that the decision to halt the work is a mistake given the time and effort invested in the programme to date and the potential it presents for improved patient outcomes.

Indeed, this was aptly summarised by one interviewee who described how staff would view the abandoning of ICASS as being symptomatic of another re-organisation and “a waste of time and energy at a time when everyone is just finding their way with this.”

Alongside this, the potential impact that the discontinuation of the programme might have on morale, must be taken into consideration in any discussion around the future of ICASS/Vanguard within the broader STP and evidence of delivery and outcome improvement.

Similarly, those patient representatives that we spoke to expressed their frustration at the slow progress made by the ICASS Programme, but felt that a culture of partnership and integration was being fostered that should be protected and enhanced.

20


Accountability and risk System transformation work is challenging and complex, and we fully appreciate the pressures on individual organisations around national targets, workforce, and resources that might divert attention and focus away from ICASS.

That being said, we were not convinced that the documentation we had seen adequately described how the individual organisations would work together and hold each other to account for non-delivery.

Although for ICASS, each organisation has pledged to:

• develop communities to ensure that everyone feels they belong and are valued• ensure people have the information, help and advice they need to help them have the best possible quality of life• ensure people only tell their story once and their support will feel like it comes from one team• transform our hospital to become a vibrant hub of an integrated care system

in practice, it is unclear what this means to each individual organisation. The same could be said with regard to the Vanguard proposition documentation.

We were advised:

“The problem with ICASS is there’s no operating principles.”

Without adequate clarity over objectives it is difficult to determine each organisation’s accountability for compliance. As mentioned previously, the partner organisations would benefit from coming together to better define outcomes, workstream deliverables and project initiation documentation.

In terms of risk, we have had sight of a high-level risk register. This is a useful document that could be further improved by greater granularity around the risks themselves, due dates, and ownership. With regard to the operational risks, more detail should also be provided to the mitigating actions. We are not clear how some of the identified mitigating actions can offset the risks cited for example, the ICASS Programme Board have identified as a risk:

“Birmingham Social Services are facing significant financial difficulties”

With a mitigating action of:

“Invitations to appropriate meetings”.

Similarly, for the Out of Hospital workstream we have reviewed the Risk Register for April 2016. Although nine risks have been identified, seven are without owners, seven have not been scored in terms of the likelihood of the risk occurring and its possible impact, and there is no evidence that the document has been reviewed. It is important that this document is completed and maintained to ensure proper oversight of risk and clarity of role.

By not properly defining its objectives, the ICASS Programme, and Vanguard, have been unable to produce a BAF or similar objective based risk instrument, or set their risk appetite/tolerance. This has hindered the organisation’s ability to identify whether there is a mismatch between the ability to transform services in the various partner organisations, and perhaps added to confusion around risk sharing.

We would suggest that a mature organisation should discuss and agree their risk appetite in relation to their strategic objectives, and that this would be constantly updated in a document that reflected the situation of the individual organisations.


21

Leadership “Governance is about effective leadership”

The leadership of an organisation should provide clarity over strategic direction, and be held to account against the achievement of this.

As described earlier in this document, in the context of ICASS we would argue that the extent to which this is the case is limited.

Those we spoke to praised the commitment and resilience of the leadership team to the programme but our review finds that the team have not delivered a coherent strategy across the organisations involved.

We were advised that:

“As soon as we were awarded it, we didn’t all get round a room and go bang, what do we do here?”

That:

“There was a disconnect between the workstream leads and the Programme Director and accountabilities and responsibilities were blurred.”

And that:

“The programme leaders did not have a clear understanding of output.”

The leadership of the organisation should provide clear strategic direction, however without sufficient clarity around objectives and purpose this is impossible to achieve.

Part of this is a blurring of leadership and management roles. We observed that there were “too many of the same people going to too many of the same meetings.” We would argue the Programme Board and its members should fulfil a subsidiary function and that staff are empowered so that at “whatever level, the right decisions are being made at the right place.”

Finally, a lack of non-executive presence on the Programme Board was described to us as a ‘governance deficit’. This is something which could perhaps be explored to ensure further awareness and buy-in from each of the partner organisations but is not an immediate focus for attention.

22


Stakeholder engagement As mentioned previously, based on our interviews we are not convinced that there is a universal understanding of ICASS and Vanguard among those directly involved centrally and in the workstreams. We did not have the opportunity to test this either more broadly across the STP.

When examined at a partner organisational level it is therefore likely that, while staff may have heard of ICASS or Vanguard, they would lack a sense of the nuance of what either programme is trying to achieve.

There has been some good engagement activity, notably the Solihull Together for Better Lives Awards, which we were told represented a good opportunity to celebrate the successes of staff and also a forum for sharing learning, and local media interaction and coverage in general, but overall we were told that communication within the partner organisations had been “fragmented.”

It is important that staff involved in the programme are able to act as effective ambassadors both internally, within their parent organisations, and externally, to the general public and more widely. Currently we are not convinced they would be able to do so.

There are valuable lessons to be drawn from the experience of ICASS and Vanguard to date, and also an engagement piece to be conducted to situate the programmes within the context of the new STPs. Indeed, we were told:

“Within the STP Programme, the three domains, STP, we’re going to be promoting the example of ICASS as a good example to the STP, within the wider West Midlands, or GBS economy, of how you actually should do some of these things.”

In order for ICASS and Vanguard to position themselves as learning organisations, and ones in which service users are integral to the design of they system, they must be more proactive in sharing their experiences, best practice and in seeking feedback.


23

Defining success The bringing together of a range of health and social care organisations to try and find joint solutions is arguably an indicator of success in itself, and ICASS and its partner organisations should be commended for this.

However, those we spoke to argued that the success of the ICASS programme should be defined in both concrete outcomes data and also less tangible measures such as patient experience and wellbeing.

We were advised:

“Some partners have a preference for process data. Whereas I think the longitudinal data is much better”

and that:

“I think it is that triple aim”

We would agree with all of these points and would argue that in order to do this, there is a need to properly define programmes by outcomes rather than project milestones. In particular, we would recommend monitoring:

• clinical outcome data across the Solihull region • indicators of health inequality including:

o smoking prevalence o amount of physical activity o cardiovascular, cancer and respiratory disease mortality o healthy life expectancy with a focus on enhancing the quality of life for people with long term conditions

• patient experience data • the financial health of the four organisations

These should be presented and reviewed regularly at the Programme Board, used to focus and drive improvements, and placed within the context of the ongoing STP work.

24


Options for the future and next steps We thank all colleagues involved in this short review for their input and contributions. All are clearly united by wanting to put the interests of patients and the local community first, and get the best benefits from time invested in collaboration. Based on our comprehensive document review, range of interviews, and knowledge of integrated working, we envisage for options for the future of the ICASS programme:

1. Disband the ICASS and Vanguard programme, subsuming programmes into organisational delivery.2. Continue with the ICASS and Vanguard programmes but rapidly slim down the governance and pro gramme structures. 3. Tailor the ICASS and Vanguard programmes as the Solihull response to wide-ranging West Midlands STP, with a more appropriate governance structure. 4. Revise the scope of the ICASS programme so that it functions as a pan-organisation tactical troubleshooting body.

Option 1

The partner organisations could decide to discontinue the ICASS programme and Vanguard altogether. This would be in recognition of impending work for STP and also the lack of progress that has arguably been made over the past two years.

This option is not without risk, and could arguably damage relationships in the region and have a negative impact on staff morale.

Option 2

The partner organisations could decide to continue with the ICASS and Vanguard programme in its current guise, recognising the work that staff and stakeholders have already invested in this endeavour and the conti-nued need to work collaboratively across the region in the pursuit of health, care and economic efficiencies.

This option would require re-examining and properly defining the role of ICASS and Vanguard, the makeup of the Programme Board and various sub-groups, and proper documentation including updated risk registers, PIDs and Terms of Reference.

Option 3

From 2017/18 the STP will be the principal source of transformation funding for health and social care. As such, it is likely that increased focus and resource will be devoted to the STP in the future, perhaps to the detriment of ICASS and Vanguard in the longer term.

There are valuable lessons that can be drawn from the experience of ICASS and Vanguard, and also a structu-re / programmes to build upon as the STP develops.

Another option, therefore, is for the ICASS and Vanguard to be positioned, and further built upon, by the STP. In the short-term this would mean the ICASS and Vanguard continuing and would help ensure some stability and, to an extent, counteract any duplication of work as the STP evolves.

ICASS will still be responsible for local delivery and as such require a programme structure to support this. We recommend that the workload of ICASS is limited to a small, highly defined set of projects that have clear and realistic goals and can be easily understood by all parties.

Option 4

One perception, is that the ICASS would be best served by becoming a troubleshooting body at which the senior leadership of the primary health and social care organisations could come together to jointly resolve issues. These, in practice, would be much like the Chief Executive meetings but with a more formal governan-ce architecture around them.

This option would be most suitable if a separate body, perhaps the STP, could be formed to drive forward the resolutions at a program level.


25

It is our belief that Option 3 presents the best possible solution for the ongoing functioning of the ICASS and Vanguard programmes. To ensure the success of this the programme board would need to be established with revised Terms of Reference, we would also make the following detailed recommendations:

1. Empower the ICASS Programme Board to be the sole decision-making body, point of resolution and accountable for implementation

Specific issues to address:

• a suggested tendency for decision making and resolution to take place informally, outside of the governance structure • a need to further empower the programme leadership to drive the programme • Terms of reference

2. RefineandclarifytheobjectivesofICASSandVanguardandsubsequentlyre-issueajoint statement on organisational purpose.


• variance in understanding of what ICASS and Vanguard have been set up to achieve across organisations, workstreams and levels of seniority • audit of unresolved ICASS and Vantguard decisions should be taken (e.g. future of the Discharge to Assess programme)

3. Defineexpectationsforeachofthepartnerorganisationsandcreateamechanismthrough which a partner can be held to account for non-delivery.


• weakly defined accountabilities for each partner organisation • a lack of clarity over ICASS’ role and expectations, in terms of responsibility, for individual organisations

4. Rapidly engage with the emerging West Midlands STP to scope the positioning of ICASS as the ‘Solihull offer’


• the STP will be the single application and approval process for being accepted onto programmes with transformational funding from 2017/18 and ICASS needs to be framed within in this

5. Update the ICASS Programme’s risk register, and consistently review and maintain this at the Programme Board to ensure proper oversight of risk.


• the risk register doesn’t appear to be a standing item at the Programme Board • the risk register has ceased to be updated or reviewed as it is awaiting the outcome of the governance review

6. Review the Terms of Reference for the various working groups, with a particular emphasis on purpose and membership.


• a lack of clarity over attendance at meetings • a lack of clarity around individual roles and responsibility • a lack of clarity over purpose of meetings

26


7. Considerstreamliningthegovernancestructure,removingarguablysuperfluousmeetings.


• a need to ensure effective reporting lines • additional meetings are taking place that could be covered within individual organisations and fed back into the Programme Board

8. DefinedeliverablesforICASSasawholeintermsofpatientoutcomesratherthanproject milestones and then evaluate performance against these.


• the need to shift to an outcome rather than milestone based approach to ensure delivery and performance

9. Ensurethatprojectmanagementdocumentsareclear,completedandmaintainedtoavoid confusionoverexpectationsanddeliverables.


• a tendency for project initiation and management documents to be incomplete • a lack of clarity over project ownership and leadership

10. Ensure effective communication across working groups to avoid duplication of work.


• the lack of a mechanism for the various workstreams to communicate with each other • the suggestion that workstreams do not have sight of activity that might impact on, but sits outside of, their workstreams

11. Continuethecommunicationsworktoensurethatstaffbothinternallyandexternallyare aware of the activity that is taking place, the direction and are able to learn from good practice.


• there are lessons and best practice from the ICASS and Vanguard work to date that could be shared more broadly to support the development of the STP


27

AppendicesAppendix1–Interviewsheldwiththefollowing:

Solihull Metropolitan Borough Council

- Interview with James Millington, Head of PMO- Interview with Andy Shipway, Information Governance Manager- Interview with Paul Johnson, Deputy CEO and Finance Director- Interview with Councillor Bob Sleigh, Leader of the Council- Interview with Melanie Lockey, Head of Partnerships and Communities- Interview with Sara Rooney, Drug and Alcohol Manager- Phone interview with Karen Murphy, Assistant Director Commissioning- Interview with Dr Stephen Munday, Director for Public Health- Interview with Councillor Ken Meeson, Chair of H&WB - Interview with Sue Dale, Interim Director for Adult Care and Support- Interview with Cassie Simpson, ICASS Communications Lead

Solihull CCG

- Interview with Ian Woodall, Chief Finance Officer- Interview with Patrick Brooke, Accountable Officer- Interview with Helen Kelly, Director for ICASS- Interview with Chris Howell, Chief Officer Service Design- Interview with Doug Middleton, Chief Operating Officer- Interview with Sue Nicholls, Chief Nurse- Interview with Dr Anand Chitnis, Chair- Interview with Karen Middlemas, Chief Officer Organisation and Service Design- Phone interview with Dr Mike Baker, CCG Board Member- Interview with Carol Andrew, Manager

Heart of England NHS Foundation Trust

- Interview with Nikki Boileau/James Brindley, Senior Communications Officer- Interview with Adam Winstanley, Divisional Finance Manager- Interview with Sally Caren, Group Manager- Interview with Christine Van Bylevelt, Business and Project Manager- Interview with Dr Vijay Suresh, Deputy Medical Director- Interview with Ian Philp, Deputy Medical Director- Interview with Rachel Cashman, Interim Director of Projects- Interview with Dr Khalid Elfandi, Consultant Acute Med & Clinical Lead Acute Med – Solihull- Interview with Ben Richards, Deputy Head of Operations – Division 3- Interview with Andrew Clements, Head of Operations – Division 4- Interview with Karen Lewis, Therapy Lead- Interview with Kelly Smith, Programme Manager- Interview with Kevin Bolger, Interim Chief Operating Officer- Interview with Dame Julie Moore, Interim CEO- Phone interview with Suzanne Nicholl, Clinical Director- Phone interview with Jacqui Smith, Interim Chair

Birmingham and Solihull Mental Health NHS Foundation Trust

- Phone interview with Vanessa Devlin, Associate Director of Operations- Phone interview with Dr James Reed, Chief Clinical Information Officer- Interview with Fiona McGruer, Associate Director of Operations for Solihull, Older Adults and Youth Community, BSMHFT- Interview with Richard Sollars, Finance and Business Manager- Interview with John Short, CEO- Phone interview with Linda Playford, Clinical Director

28


Appendix2–Focusgroup:

- Anne Hastings, CEO, Age UK Solihull - Annette Brandstaetter, ICASS Lay Board member - Christine Logan, Carer/former Patient Representative

Appendix3–ICASSprogrammemeetingsobserved:

- Observation of ICASS Programme Board Meeting- ICASS Information System Governance Board

Appendix4–Documentationreview

- Urgent and emergency care Value Proposition 2015/2016- Appendix A Programme Plan for Vanguard- Appendix B Mental Health Vanguard information- Appendix C Vanguard financial information- Appendix E Vanguard Metrics framework- Appendix F Solihull Together: Value Generation Hypothesis Tree- ICASS Risk Register- ICASS Programme Board meeting and sub-board minutes and agenda from last three meetings - Terms of Reference for ICASS Programme Board and sub-boards- Project initiation Documents for Caradigm, HT UCS, OOH IPCCS and PEI CWB- ICASS organogram and governance documents- Selected communications materials


29

Appendix5–ICASSProgrammeBoardagendatimeline

ICASS Programme Board MeetingThursday, 09 June 2016

Time: 14:00pm to 16:30pm

Location: Sans Souci Training Centre, Tanworth Lane, Shirley B90 4DD

ITEM(S) 1 2 3 4 5 6 7 8 9 10 11 12 13

TIME

MINUTES

14:00

14:05

14.15

14.30

14.40

14.50

15.05

15.15

15.25

15.35

15.55

16.10

Meeting ends

16.25

5

10

15

Welcome and Apologies

10

10

15

10

10

10

10

20

15

ICASS Minutes/schedule of actions

Governance Review

Communication and Engagement

Sustainability and Transformation Plan

Solihull UEC Vanguard Programme Overview

Readmissions Audit

BCF

D2A

Work-stream Highlight Reports

Enabling Groups

ICASS System Measures

A.O.B



Date post:	19-Jun-2020
Category:	Documents
Upload:	others
View:	1 times
Download:	0 times