1 Community Adult Health Services: Procurement
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- Angelina Blake
- 5 years ago
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Transcription
1 Forward View for Community Services Contents Introduction... 2 CAHS Progress to date... 3 Benefits of further partnership working with SGUHFT... 7 Managing financial risks... 8 Procurement requirements... 8 Risks related to a competitive tender Managing risk of staying with the existing provider Summary & Recommendations
2 Introduction The vision of the Five Year Forward View is for integrated working between primary care, community services, social care, mental health and the voluntary sector: local commissioners and providers are asked to work together with patients and other stakeholders to develop new models of care which will improve the quality and effectiveness of service delivery in the community and deliver better outcomes for patients. The planning guidance for the Five Year Forward View 1 suggests that commissioners: should be looking afresh at their medium-term strategies and choosing to take actions in 15/16 that create the conditions for rapid and early adoption. For example rather than proceed with stand-alone procurement of community services one option CCGs may want to consider is how best to integrate these with a new MCP model. In June 2015 the Wandsworth Clinical Commissioning Group (CCG) Board approved a strategy to develop a Multispecialty Community Provider (MCP) model to be commissioned by The MCP is being taken forward as a driver for local integration of care and a means to deliver improved outcomes for patients through collaborative working. Against this backdrop, a decision is now due on the procurement approach for Community Adult Health Services (CAHS) from April This decision requires consideration in the context of both national and local direction of travel, as well as being tested against the requirements of the 2013 NHS procurement regulations and associated Monitor guidance. The key objective in this decision is delivering the best outcomes for those patients currently receiving community services and also ensuring that even greater benefit can be delivered in future through greater integration, best use of resources and patient centred approaches. In 2012 Wandsworth commissioners began a re-design of Community Adult Health Services (CAHS) working with St George's University Hospitals NHS Foundation Trust (SGUHFT) as the incumbent provider and with wider stakeholders over a 12 month period. The key stakeholders included community services staff, social services, the voluntary sector, mental health and patient representatives. The feedback received during the workshop sessions was carefully considered and used to help shape the vision for community services in Wandsworth. A strong element of this vision was for a patient centred approach with strong alignment between multi-agency providers 2, with a very clear message that this is what would make the greatest difference to patients and their families. As a result of this work a new specification 3 was signed off by the CCG Board in October 2013 and a decision taken to remain with the existing provider to support full implementation of the new model over a two year period beginning April By the end of this period it was expected that all the newly designed functions of care would be fully operationalised Wandsworth Community Adult Health Services (CAHS) The Patient and Carer Engagement Process 3 Wandsworth Community Adult Health services Specification 4 Wandsworth Community Adult Health Services Business case (part 1) 2
3 and would be delivering improved patient outcomes. It was noted that a further decision would be taken on the procurement approach at the end of the two year period. In line with the CCG Procurement Policy, the Commissioning Directorate has undertaken a full SWOT analysis of the options coming to the end of this two year period, including remaining with the current provider beyond the original two year period and undertaking a full market testing exercise. The SWOT analysis is attached as Appendix 1. This paper sets out the case for continuing to work with our existing provider for up two years to support development of the integrated model described in the Five Year Forward View and locally in our Forward View for Primary Care 5 In considering this decision, four key questions are posed: 1. What benefit has been delivered to patients so far through working with the existing provider? 2. How confident are we of continued improvement to patient outcomes through this approach? 3. How will we manage any risk to service delivery as a result of the financial position at SGUHFT? 4. In making this decision are we meeting our responsibilities in relation to procurement rules and related Monitor guidance? No procurement approach is risk free, so there is also consideration of risks related to an external procurement and how risks related to staying with the existing provider will be managed. CAHS Progress to date The new CAHS model is now early in year two of implementation and it is clear that significant progress has been made by SGUHFT to ensure that the new way of working is firmly embedded and to achieve the target for all community staff to be working in integrated teams to deliver the specified functions of care by April The complexity of taking all staff through consultation and restructuring over the last year has been significant and suggests a strong level of commitment to the new model by the provider. Implementation of the CAHS service was overseen in 2014/2015 by a monthly CAHS steering group chaired by Dr Angelique Edwards. Board level meetings to review implementation have also taken place regularly through the last year. Progress with implementation has been on track and is outlined below in Table 1.0. The most significant risk to delivery remains the difficulty in recruiting key clinical staff. This is recognised as a national problem but it is essential that during 2015/2016 SGUHFT focus sufficient time and resources on recruiting into unfilled posts and also identify innovative and sustainable ways of resolving staff shortages, including; greater use of appropriate skill mix, maximising administrative support for clinical staff, growing their own workforce and making CAHS an employer of choice for existing and potential staff. 5 Five year Forward view for Primary Care 3
4 Recruitment levels and plans are monitored monthly by the CAHS mobilisation group and any issues impacting on service delivery and Key Performance Indicators (KPIs) will be escalated contractually. Table 1.0 CAHS Implementation Progress Outcome Deliverable Achievement in 2014/2015 Planned for delivery in year 2015/2016 Commission er assurance New functions of care integrated around the patient to improve outcomes Staff working in an integrated way to improve patient care Implementation plan fully delivered by March 2015 Staff consultation to transfer all community staff into new roles aligned to the redesigned model of care New structure fully recruited by April 2015 Fully delivered Fully delivered by March 2015 Implementation completed All staff now working to new operational hours and Job Descriptions Vacancy levels remain high due largely to national shortages within some staff groups Provider has continued to run ongoing recruitment campaigns advertising posts, Implementati on KPIs Financial penalty CAHS Steering group CAHS steering group Mystery shopping exercises Monthly CAHS mobilisation meeting Clinical Quality Review Group Participation in national recruitment fairs. Regular advertisements Alternative skill mix solutions Care closer to home with multidisciplinary teams working closely together Estates Plan Review completed Provider-owned Locality hubs were identified Estates plan fully committed by SGUHFT for delivery by March 2016 CAHS mobilisation Group 4
5 Structural completed survey Phase 1 to be delivered summer 2015 Social Services and health working together to improve experience and outcomes for service users Integrated care plans to improve ongoing care and achieve outcomes that matter to the patient. Patients and professionals understand how to access the CAHS services and what it provides Colocation of Social Services and the Voluntary Sector staff with CAHS team to support integration Develop a universal care planning approach and pilot joint delivery between GPs and CAHS Communication plan developed and delivered Phased approach to delivery due to financial constraints Universal care plan developed Extensive work has been undertaken over the past year to ensure patients are engaged in the process of implementation and that their views are heard and considered. A regular meeting was established and occurred every eight weeks. CAHS Managers attended this meeting with CCG Commissioners. 12 month pilot for colocation of social care teams in each locality 6 Pilot of shared care planning approach supported by Local Development Improvement plan (LDIP) Care planning training for GPs To continue in Year 2: Health and Social Care Integration group Quarterly audits of patient outcomes against plans Patient discovery interviews CAHS mobilisation meeting All patients registered with a To review Clinical Teams and Patient representatives attended the meeting and were updated on the implementation process. Resource allocation The Provider is currently working with Mobilisation Group 6 PACT/Social work specification 5
6 Wandsworth GP have equitable access to care. Patients admitted to hospital are supported to leave hospital in a timely way with the right support Records can be shared with consent to support better care. Patients over 75 with extra support needs are managed proactively by a multi-agency team develop the functions of care within each of the four localities of Wandsworth, basing the staffing establishments on demographic need across the borough To review and agree arrangement for managing patients living out of borough In reach CQUIN The Provider was required to use an inter-operable IT system that could interface between Primary and Social Care Full engagement of community provider in coproduction of a frailty pathway for Wandsworth completed and implemented by SGUHFT in year. Single point of access implemented in year Out of borough contracts amended This was completed successfully at the end of Year one and the Provider have established effective working relationships with staff in the acute setting. This has resulted in a more proactive approach to discharge Development of interoperability solution Support for the Rapid Response pilot to ensure patients needing home care have rapid access to avoid hospital admissions Primary Care and Community Services to analyse the high risk frail and elderly patient group that requires regular admissions due to complex long term conditions. Community Services will work with Primary Care to develop a proactive care plan with an escalation process to manage this high risk patient cohort safely at home with an extensive care package to avoid unnecessary admissions where possible Business as usual Further development as part of the Frailty Pathway integration SGUHFT I.T plan includes deliverability of phase 1 interoperability of clinical systems by July 2015 and fully delivered by year end. Provider staff from both the acute and Community Services have participated in a series of workshops to devise the Frailty pathway between Primary Care, Community Services (CAHS) Acute Contract monitoring meetings Contract monitoring meetings Service Development improvement plan in SGUHFT with agreed delivery trajectory Integrated Health and Social Care Group 6
7 settings and Social Care, focusing on delivering care to frail elderly patients over 75yrs old in an aligned and integrated way The original proposal to place a two year decision point related to CAHS was to be able to test commitment and progress to implementation of the CAHS vision and service: on the basis of the progress to date, it is considered that the provider is committed and delivering a significant change programme against a challenging timetable and financial backdrop. Benefits of further partnership working with SGUHFT It is also important to note that the community service transformation is not taking place in isolation of other changes in the health and social care economy, and related transformation and integration plans. In February 2015, Wandsworth CCG and Wandsworth Borough Council (WBC) launched a joint programme to develop a multi-agency pathway of care to meet the additional needs of frail older adults with complex needs 7. The pathway of care builds on the functions of care designed locally for CAHS with the aim of establishing a shared way of working to deliver joined up care and prevention for a cohort of older people with the greatest need (see Appendix 2 attached). This pathway will be commissioned across providers in 2016/2017 with the aim of improving wellbeing through providing a range of timely community based support services to further reduce, among other things, the need for acute hospital and care home admissions. This integrated model is being co-produced by a wide range of stakeholders including patients, carers, service providers and commissioners. CAHS is a central element in the development of the model and the CAHS leadership team have been fully engaged in all stages of the design process and are committed to the integrated pathway as a means of delivering improved outcomes for older people they manage. There is strong commitment from commissioners and providers alike to move at pace and ensure that the frailty pathway is reflected in contracts for 2016/2017. The objective of this will be to hold providers jointly to account for delivering a common set of outcomes for this cohort of patients over 75 with complex needs. The level of local ambition in relation to the frailty pathway presents a real opportunity for making rapid change and delivering improved outcomes. Embedding this model as the standard way of working in Wandsworth relies on strong inter-organisational relationships and trust in terms of working differently and with more flexibility. PPI engagement shows that patients and the wider public want and expect care providers to work in this way in order to deliver effective care. In order to ensure that effective relationships continue moving forward, the Community Services contract will be strengthened by the insertion of a Memorandum of Understanding 7 Frailty Pathway Paper to Management Team 7
8 (MoU). This MoU will be a pre-requisite for any decision to extend the contract further with the incumbent Provider. This MoU will focus on key deliverables over the next two years which will ensure stronger and more cohesive relationships are developed between Primary Care and Community Services. The MoU will focus specifically on joint care planning and extensive multi-disciplinary team working with regular attendance by Primary care colleagues. This MoU will be the vehicle to support the delivery and development of the MCP model as outlined in the Five Year Forward View. Managing financial risks The potential impact of the recent deterioration in the SGUHFT financial position is a significant factor in making the decision about CAHS procurement. Community services are funded under a block arrangement as opposed to an activity based contract. This is the case for the majority of community service contracts but as CAHS is provided by an acute provider, it means that there is a risk of the community funding not being ring fenced and of additional funding to expand the service being diverted to support turnaround plans. SGUHFT have given assurance at Board level that this will not happen and that as a trust they are committed to strengthening their community services to reduce pressure on acute provision. They have also given assurance to the Wandsworth CCG Board that funding committed to their Community Service Division has been increased for 2015/2016. While this is reassuring, commissioners are clear that the risk remains and a number of measures are needed in mitigation, these include: Commissioner approval of community Cost Improvement Plans (CIPs); assurance that the % CIP is proportional, alongside clinical review of CIP plans relating to CAHS. Monitoring of vacancy levels and agency cover levels Close monitoring of service KPIs and appropriate escalation Close monitoring of quality indicators and soft intelligence Procurement requirements Whilst CCG s do not have an obligation to go out to tender for health services, they do have an obligation to commission services in a way that delivers most benefit to patients, improves quality, efficiency and value for money. Commissioners also need to act in a way that is fair and transparent to all providers and potential providers. The requirements for health commissioners are set out in the NHS Procurement, Patient Choice and Competition (No.2) Regulations 2013 (the 2013 Regulations) and the UK Public Contracts Regulations 2006 (the 2006 Regulations ). There is an associated Monitor guidance document for commissioners produced in A SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis is provided in Appendix 1 which considers each of the following two options: Option 1 - remain with the incumbent Provider for a further period of time to allow the continuation of some crucial developments that are underway in order to optimise the opportunities to embed the model fully Option 2 - Undertake a full market exercise and if indicated proceed to a full tender process 8
9 Table 2.0 below sets out the requirements in relation to the CAHS procurement decision and provides an outline of the evidence used in reaching our preferred option of staying with the current provider for a further period. Table 2.0 CAHS Procurement requirements and response Procurement requirement Are you demonstrating that you are acting in the best interest of the patients to meet their needs and how? Justification for staying with the current provider Service users have been engaged fully in the design and consultation process for developing community services and the CAHS model puts the patient at the Centre of their care. Patients remain actively involved in monitoring service delivery and maintain an ongoing dialogue with providers through the Patient Experience Review Group. Patients are also involved in feedback meetings which are held monthly and the message is overwhelmingly positive with confidence in the new model and a belief that the changes are real and taking service delivery in the right direction. Extensive work has been carried out over the past 18 months to interview patients and gain an insight into their experience. Baseline interviews were undertaken and patients are invited to be re-interviewed a year later to assess whether the implementation of the model is supporting more integrated and seamless working. Health-Watch have been involved in this process and it will be rolled out further this year and next. Patient experience is reflected in service KPIs and will increasingly be used to measure the effectiveness and performance of the new service model and the payments to providers. Commissioners are confident that significant progress has been made by incumbent provider and that implementation and mobilization have remained on track. Risks to service delivery do exist and clear processes are in place to identify and address these. Dialogue with the provider happens on a regular basis and has ensured a level of transparency that supports quality improvement. Are you acting to improve the quality of the service The service is currently being monitored through a number of mediums including; KPI monitoring at regular contract meetings, through the delivery of CQUINS last year and this year through a local development improvement plan (LDIP). The improvement plan builds upon the work that was done last year to develop an Integrated Care Plan that is universally accessible to all providers across multi-agencies and developed in partnership with the patient and their carer where appropriate. The CCG is realistic about the challenges that large transformational change brings and has worked collaboratively with the Provider to set realistic but stretching goals. KPI targets for 2015/2016 are linked to positive patient outcomes and carry penalties of 2% of the contract value in any quarter. Commissioners have been clear that an increasing element of community service funding will be linked directly to achieving specified outcomes and contractual mechanisms to support this are being developed for 2016/
10 There is a general move away from using units of activity to establish the value of community services. It is not how many visits a patient has that determines the value of a service. There are a range of factors that contribute to effectiveness and in the Wandsworth model it is the patient focused, preventative joined up approach that will add value to the care of a patient and the positive outcomes achieved. There is work going on in South West London (Richmond and Croydon) and beyond to develop outcome based contracts for community services. In this model providers would receive baseline funding linked to the level of need in the population they care for and the remaining element of funding would be linked directly to delivering patient focused outcomes. Are you acting to improve efficiency and value for money? It is too early to confidently commission an outcomes based service, but we are working with providers to move towards this and to focus less on process related payment and more on evidencing positive patient outcomes. The integrated care plans with identify outcomes are the first stage of this journey and are a contractual requirement for the CAHS service in 2015/2016. In 2016/2017 the plan is to extend outcomes related payments to include a range of providers working together to support a Frail elderly cohort of patients. Although financial modeling is difficult at this stage there is a general assumption that strong integrated community services are likely to deliver efficiencies across the health and care economy. Money spent on timely proactive care delivered around the clock in the community will save money elsewhere in reduced admissions and costly nursing home care. Integrated working between Health and Social Care is likely to provide benefits including a leaner service through the elimination of unnecessary duplications and patients who will better supported and safer at home. Have you considered whether competition or integration would work to drive up quality? Has the CCG acted transparently and proportionately and treated providers in a nondiscriminatory By 2018 it is anticipated that a population based funding mechanism will be more strongly established through the Five Year Forward View Vanguard work and we will be in a position to use this methodology to commission an MCP using a population outcome based approach. Wandsworth CCG supports a strategy of integration over the next five years, with an MCP model at the heart of this vision. The benefits of supporting the integration of local services are believed to be greater at this stage than the benefit achieved through procuring a new provider for community services. However innovative a new provider might be, they would still at this stage be commissioned to provide a standalone community service and as such would need to participate in the ongoing development of an MCP model for Wandsworth. It would be very likely that bringing a new provider into the local landscape at this stage might slow down the development of integrated working while effort was diverted to internal contract mobilization priorities. In October 2013 the CCG took the decision at CCG Board level that it intended to remain with the incumbent Provider for a two year period to allow the new model to be implemented. The CCG publicises its minutes on the CCG website and at various points since October 2013 the CCG has recorded its intention to re-consider procurement options in The procurement approaches of each SWL CCG have been shared as part of 10
11 way? the SWL strategic planning process and local providers who have approached the CCG to enquire about the potential procurement process have been informed that a decision will be taken by the CCG board in July The decision taken by the Board will be available within publicly available documentation. In addition the CCG has shared information with NHS England (NHSE) in terms of the timeline for reconsidering the tendering of Community Services. This information was shared with providers and other CCGs at London-wide workshops to support the development of community provision. The information has also been shared in commissioning intentions every year available on the CCG Website. Risks related to a competitive tender In considering the impact of each procurement options, the risks of a competitive tender at this stage have been carefully considered and the following issues identified: 1. An open tender process at this stage would be likely to delay cross borough integration. Providers would potentially be put into a process of direct competition with each other for the duration of the tender which would limit the opportunity for open dialogue and sharing information. 2. As the design of the integrated model is a co-production process, tendering at this stage would limit the type of community service commissioners could specify. The frailty pathway is the first phase of testing an integrated whole system approach and the vision and potential for this model is expected to continue to develop throughout 2016/2017 as provider collaboration becomes more embedded and understood locally. 3. By going out to tender now we would miss the opportunity to learn from the national MCP vanguards when scoping our local specification. 4. Patients and carers are positive about the progress in implementing a new more patient focused model and may not be supportive of a tendering process if it disrupt this early progress. 5. Provider staff have been through a difficult reconfiguration process to align their roles to the new service model. Further uncertainty could be unhelpful in terms of developing the workforce and providing continuity for patients. Managing risk of staying with the existing provider Staying with the existing community provider until 2018 will also pose some risks which will need to be managed along with clear expectations for the provider in terms of the requirement to integrate the service with primary care and other partners. It is suggested that these are described clearly to the provider and subsequently embedded within the 16/17 contract with appropriate timelines and outcome measures. 11
12 Year 2015/2016 Provider requirement 1. Full mobilisation of all aspects of the CAHS Model by October CCG approval and monitoring of the SGUHFT recruitment and retention plan for community services. 3. Continued engagement with development of the Frailty pathway to establish agreed pathways of care with primary, social care, Mental Health (MH), secondary care and the voluntary sector. 4. Establish a system for joint care planning with Primary Care for frail elderly patients. 5. Continue to strengthen working relationships with the local GPs through regular daily communication and sharing patient records where appropriate. 6. Establish a single frailty cohort using community services and primary care records and develop a shared methodology for identifying the level of need within this cohort (including MH and social need). 7. Co-design of an in-reach nursing home team to ensure equity of access to CAHS by Develop SOPs with SGUHFT acute frailty pathway to ensure effective patient flow. 9. Develop RiO I.T systems to support care planning and reporting of patient outcomes. 10. Work with commissioners and other stakeholders to agree a sustainable estates plan (regardless of future MCP provider) 11. Delivery of an interoperable I.T system that allows Primary Care and Community Services to share relevant information about patients to enhance Care in the Community. 12. Patient engagement should be at the forefront of any development work and the Provider will be required to participate in Stakeholder engagement with the public promoting the ongoing development of the Community Service Model 13. Develop a Memorandum of Understanding between Primary Care and CAHS to develop ongoing initiatives associated with closer collaborative working as described on page 7 of this document. 2016/ Continue to embed 2015/2016 developments 2. Deliver requirements of the 2016/2017 frailty pathway specification (subject to appropriate contract negotiations) 3. The Provider will continue to support the development of Planned Care pathways within the Community and work with the CCG to identify opportunities for Specialist Consultants to out-reach into the Community, 12
13 including Consultant Geriatricians, Diabetologists, Respiratory and Heart Failure Consultants to lead clinics and work alongside GPs. 4. Deliver the requirements of the 2016/2017 frailty pathway contract as phase 1 of MCP development 5. Patient engagement should be at the forefront of any development work and the Provider will be required to lead and participate in Stakeholder engagement to the public promoting the ongoing development of the Community Service Model. 6. Monitor the ongoing work as described in the Memorandum of Understanding through regular three to six monthly Board to Board meetings. 2017/ Open tender for the Wandsworth MCP incorporating CAHS. 2. Business as usual delivery of all agreed integration throughout the tendering process. 3. Patient engagement should be at the forefront of any development work and the Provider will be required to participate in Stakeholder engagement to the public promoting the ongoing development of the Community Service Model 2018/ CAHS will form one part of the wider MCP to be delivered by the provider awarded the contract as a result of the 2017/2018 tendering process Summary & Recommendations Service integration is central to the Wandsworth CCG response to the Five Year Forward View and there is strong board level support for establishing a Multi-Specialty Community Provider. It is widely recognised that integration offers the greatest opportunity for improving the quality of care for patients, particularly for older people and those with the most complex needs. This view is shared by patients, providers and commissioners alike. It is in this context that the preferred option for CAHS procurement is to stay with the existing provider for up to two additional years from April This will give time for integrated working to become established and its full potential to be understood more clearly ahead of procuring an MCP in As described within this paper, timely progress has already been made in implementing the CAHS model during 2014/2015 and all community staff are now working to the patient centred functions of care described in the service specification. In 2015/2016 the emphasis is on full mobilisation of all aspects of the specification and developing stronger alliances between CAHS, primary care and social work teams and the development of joint working arrangements to deliver the frailty pathway. This work is progressing with momentum and there is significant engagement from stakeholders across the health, social, mental health and voluntary sector and this work will be pivotal to helping shape the MCP model of the future in Wandsworth. The Memorandum of Understanding, which will be a pre-requisite for 13
14 an on-going extension of the Community Services contract moving forwards, will drive the transformational changes required between Community Services and Primary Care. A change to the existing Community Services Provider at this stage in the development of the new integrated model runs a considerable risk of limiting progress, relationships and patient outcomes. It is however clear that remaining with the incumbent Provider does not come without a degree of risk. The risks associated with this have been clearly outlined in the paper and the means to mitigate these risks have also been described. On balance it is argued that there would be a greater risk to procuring the services at this stage whilst Wandsworth is undergoing such a crucial time of development and transformation in Primary Care, including CAHS. The board is therefore asked to: Approve the recommendation to retain the CAHS contract with the incumbent Provider until April 2018/2019 and for the Provider to work within an agreed contractual framework to develop a model for integrated working which will inform development of the MCP. 14
15 Appendix 1 SWOT Analysis Option 1 - remain with the incumbent Provider for a further period of time to allow the continuation of some crucial developments that are underway in order to optimise the opportunities to embed the model fully Strengths The incumbent Provider has developed strong cohesive working relationships with Social Care Colleagues and the Voluntary Sector over a period of time and these relationships are continuing to grow and develop through a joint working vision to deliver the Frailty Pathway Staff are beginning to understand this model of working and recognise the benefits of greater multi-disciplinary working with colleagues in Primary, Secondary and Social care Weaknesses Financial pressures may limit the incumbent Provider engagement in ongoing Service Development There is a risk that the current Provider could become too complacent if it believes that the Contract will remain with them for a further two year period and therefore not maintain attention to detail and prioritise the implementation of the CAHS model Over the past 18 months there have been regular Board to Board meetings between the Provider and the CCG. Both Boards are aware of the opportunities and potential threats to delivery and work together positively to address these to keep the implementation of the model on track Significant work is underway looking at a Frailty pathway for the high risk vulnerable patients with complex needs. The current Provider is committed to working with Primary Care, Social services and their Community Services to develop an Acute Pathway for managing these patients with a multi-disciplinary approach to reduce unnecessary non-elective admissions The Incumbent Provider's Board has given assurance that it fully supports the ongoing recruitment of Staff into the CAHS Model and will work with the Management Team to ensure that Staff time is released to focus on the development of this work 15
16 The Provider has fully engaged in a robust Patient and Public involvement process and continues to take on board and utilise the feedback which has been provided by Patients and Carers through patient interviews and review groups over the past year (2015/2016) The Incumbent Provider will be familiar with the Wandsworth Health and Social Care system which supports a more integrated approach to Patient Care. The current Provider is monitored at a variety of quality forums held between the CCG and Provider. There is nothing to suggest from the reporting that poor quality is in question. The complaints are monitored closely and are at an acceptable level. Staffing levels are closely monitored and workforce planning Strategy is shared openly with Commissioners Opportunities The CCGs Five year forward view focuses on the Multi-specialty Community Provider model (MCP). The CAHS model and approach to MDT working compliments the MCP model and a considerable amount of work has already been developed around multi-speciality working. The CAHS model will therefore act as a solid platform to build an MCP model upon. The CAHS model and functions of care will become more aligned to Social Services following a review of enablement posts. This review is due to be completed in September 2015 and will explore opportunities to share resources across Health and Social care enablement budgets to avoid unnecessary waste and duplication of services. The sharing of resources across the existing Health and Social Care system builds on existing precedents for joint-working; Threats Current Financial position and deficit could impact on the ambition to recruit into posts which are crucial to the ongoing implementation and success of the CAHS model National recruitment issue - This could prove detrimental to the productivity and success of the CAHS Model Workforce anxiety due to the unstable financial position of the Provider The development of IT as a key enabler may be hindered due to financial restraints however it is relevant to note that the Incumbent Provider has an IT strategy that has been shared with the CCG and is delivery is monitored closely against the strategy plan The development of the key Estates enabler may be hindered due to the financial restraints Joint working - CAHS are working with Primary Care to develop a process to contribute to joint care planning for patients in the Community. Also effective joint working with the 111/OOH provider is in place. The Provider has offered their staff mutually Agreed Resignation scheme (MARS), This has been offered to Community staff but the Provider has suggested it is unlikely any staff in Community services would qualify for the scheme based on the internal application 16
17 The current Provider is keen to develop their Community Services over the coming years and is looking at opportunities to work collaboratively with Primary Care Colleagues to improve Patient care. The Provider is making additional financial investment into Community Services review process and criteria that would need to be met The current Provider at Board level has confirmed that it is keen to demonstrate creativity moving forwards by building on the work that they have delivered since April 2014/2015 The Provider has openly expressed an interest to apply for the tender for Merton Community Services. This could create an opportunity to align Community Services throughout Wandsworth and Merton as there is a natural overlap with the delivery of services for some patients that sit across the Borough border. This could create economies of scale as well as providing opportunities to develop services in a positive way. Based on the ongoing developmental work that is being undertaken with the current Provider the CCG will aim to be in a position shortly to develop a set of comprehensive KPIs based on an Outcomes Framework for a fully functioning model that is integrated across the Health and Social Care Sector Option 2 - Undertake a full market exercise and if indicated proceed to a full tender process Strengths Market testing provides the CCG with an opportunity to identify whether there are alternative market providers who might be interested in and able to deliver community services in Wandsworth; Particularly if the Contract was outcomes based, A new Provider could look at developing the service and identifying Weaknesses The new Provider would be starting from naivety in terms of having to familiarise itself with the specification and the staff structure. A new Provider would not have the benefit of existing relationships across the Health and Social Care system to work with partner organisations to deliver the specification; 17
18 opportunities of delivery, growth and expansion with a fresh mind-set A new Provider may be in a stronger more stable financial position compared to the Incumbent Provider and may have more flexibility to implement key enablers at a quicker pace, for instance increasing the pace of delivery for the I.T strategy for Community services A new Provider may have a more developed I.T programme and software already in place that could be operated immediately Enable development of a new outcomes framework that is based around a fully functioning model. To introduce a new Provider would mean commencing the process all over again to allow time for the new Provider to truly understand the model and ambition. There is a risk that crucial momentum would be lost in this transitional period and this would risk the delivery and implementation of the current transformational work to date. It may seem detrimental to the Model's implementation to take it out to tender too prematurely whilst crucial work is still being undertaken: this work is still in development (part way through Year 2) and CAHS Staff and other allied Health & Social Care Professionals across multi-agencies need additional time to understand the Model and how they can continue to work with their Health and Social Care colleagues across Primary Care, Community Services and the acute setting There may consequently be a considerable delay in progressing the ongoing work which would hinder the impact of CAHS and the overall development of the MCP Model The Estate for the four selected Community hubs are owned by SGH: therefore new Locality hubs would need to be identified by a new Provider (or rental agreements put in place). This may be difficult as Estates space is limited in Wandsworth for Community Services There is a risk that the considerable work undertaken with Patients and Carers over the past year would lose momentum and pace whilst the new Provider familiarises itself with the Model and staffing structure. This could destabilise the relationships and trust built with the public, who have been involved in the designing of pathways, care plans and information leaflets around the new CAHS model. There is a risk that if the Service was to be tendered at this stage, as the services are not fully integrated properly, the service would therefore need to be tendered as is which will not be the final fully functioning Model for the future. This may be misleading for any new Provider and may have 18
19 significant cost implications if the work for the tender is under-costed by the time completion of the final Model is made. The four locality Hubs would probably need to be returned to the incumbent Provider and new estates would need to be sourced. It is essential that the MCP Estates Model reflects the requirements of delivery of the CAHS Estate plan. There should therefore be one Estate strategy. The Provider may not have experience of leading bring an innovative approach to delivering the CAHS model and how this will integrate with the MCP model Opportunities The new Provider may have prior experience in leading other organisations and could bring lessons learned and opportunities A new Provider may have experience and innovative new ideas that they can bring from outsider of the local area Cost efficiencies may be found which have not been previously identified by the incumbent Provider A new Provider may consider a more creative approach to workforce planning and ways to address the current vacancy factor within the establishment. This may include more creativity with skill mixing whilst ensuring the key outcomes continue to be met Depending on the Provider, it could provide economies of scale if delivering similar services in other local areas; Threats Staff may not feel confident being TUPED to a new Provider and this could result in staff resignations which could destabilise the workforce further within Community Services An unstable workforce within the Community could have significant impact on local acute Trusts and put them under increasing pressure impacting on increasing A&E attendances and unnecessary non-elective admissions for Wandsworth residents National recruitment issues could prove detrimental to the productivity and success of the CAHS Model, A new Provider is equally likely to encounter recruitment issues as this is something that all Community Providers have declared. There is a potential risk that if a new organisation led CAHS, some of the current Community staff would leave due to the change of management alone. This would destabilise the workforce which would be detrimental to both Acute and Community Services. The latter already have a 17% vacancy factor across the entire model of Care and this is 20% in Community Nursing alone. A new Provider may be unable to identify suitable Estates provision from which to operate the hubs. 19
20 Appendix 2 Frailty Pathway Structure FRAILTY PATHWAY STRUCTURE.docx 20
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