Governing Body (public) meeting

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1 ENCLOSURE: F Agenda Item: 82/14 Governing Body (public) meeting DATE: 31 July 2014 Title Recommended action for the Governing Body Children & Young People Prime Contractor Commissioning Project That the Governing Body: APPROVE the redesign and procurement of children and young people services in partnership with London Borough of Bexley to deliver a new integrated care pathway and service, using a prime contractor model as set out in the attached Business Case. The re-procurement of health services for children and young people is included in BCCG s Commissioning Intentions 2014/15 and is part of the QIPP programme for 2015/16. The Integrated Commissioning Unit has produced the attached Business Case for the joint procurement of children s health services and preventative social services using an outcomes based model. Executive summary The proposal is to seek a prime contractor to lead on the provision of in-patient and outpatient paediatric services, child and adolescent mental health services, specialist children s community services, a range of smaller CCG commissioned services, London Borough of Bexley s (LBB s) Children s Centres and outreach services, LBB s prevention and early intervention commissioned services, and also LBB s public health services for children and young people. Discussions are also in progress with NHSE with regard to the options for the future commissioning of health visiting services and immunisation for school aged children. The Business Case sets out the proposed high level outcomes and advantages and disadvantages of the inclusion or exclusion of the different services. The recommendation is that the proposed procurement should include as wide a range of services as possible in order to maximise the preventative opportunities, positive outcomes for children and young people

2 and families, and the financial savings. Examples of proposed outcomes and KPIs are included Which objective does this paper support? Organisational implications Patients: Improve the health and wellbeing of people in Bexley in partnership with our key stakeholders People: Empower our staff to make NHS Bexley CCG the most successful CCG in (south) London Pounds: Delivering on all of our statutory duties and become an effective, efficient and economical organisation Process: Commission safe, sustainable and equitable services in line with the operating framework and which improves outcomes and patient experience Key risks (corporate and/or clinical) Equality and diversity The key risks are: That insufficient providers will come forward to ensure a valid competition That potential outcomes and benefits will be limited if less than the maximum range of services is included That the procurement will not realise the required savings That the providers will not adequately address all the outcomes resulting in the potential withdrawal of elements of service from the process That the process will exceed the planned timescales That the prime contractor will not adequately manage its subcontractors That, as this will be the largest joint procurement process undertaken by the Integrated Commissioning Unit, there may be unforeseen issues in fulfilling the procurement requirements of both organisations That there may be tensions between the commissioning partners in terms of the prioritisation of outcomes The proposal seeks to ensure the best health, educational and social outcomes for all children and young people and because it is preventative in focus will

3 Patient impact Financial contribute to reduce inequalities and close the gap between disadvantaged children and young people and their more advantaged peers. The integrated nature of the proposal will ensure more streamlined care pathways and will aim to provide intervention as early and as close to home as possible with a view to improving outcomes and minimise escalation to higher threshold services such as children s social care and inpatient/residential services. A programme budget is being developed. Indicative high level details are shown in the attached paper. The current maximum indicative budget is 19,104,559. This amount will continue to be adjusted as the project progresses. The programme budget is set on the 2014/15 budgets (2013/14 out turn) and bids against this for savings will be evaluated. The financial evaluations will need to take into account the level of proposed savings offered by a prime contractor, the dis-investment in existing provision, versus the investment in new services, and considered against the service elements and outcomes of the service offering. We will also consider the % of the total price based on actual outcomes that is therefore at risk to the prime contractor. Both commissioning partners will need to agree how any savings are distributed once investments and disinvestments by services are considered. Consultation (public, member or other) The service specification will form a Legal issues schedule of the Section 75 Agreement between LBB and BCCG. The CCG will be the lead commissioners. The proposal is in line with the principles of NHS constitution the NHS Constitution in particular principle 5 by working across organisational boundaries. The procurement process is engaging stakeholders, service users and potential providers in the design of the care pathways

4 Audit (considered/approved by other committees/groups) Communications plan Author and specification of outcomes. The Business Case has been approved by Finance Sub- Committee and Quality & Safety Sub-Committee. A communications plan is included in the Business Case. Sarah Valentine Director of Commissioning Alison Rogers Assistant Director for Integrated Commissioning Jacqueline Skinner Head of Integrated Commissioning for Children & Young People Clinical lead Dr Karen Upton Executive sponsor Sarah Valentine Date 21 July 2014

5 Business Case (Incorporating PID) Name of Proposal Integrated Children & Young People Prime Contractor Model (0 years to 18 years and 364 days) Version 16 Issue Status Date Last Updated 22 nd July 2014 Author(s) Alison Rogers Jacqueline Skinner Sarah Valentine Clinical Lead Dr Karen Upton Executive Champion Sarah Valentine Financial Signed Off Julie Witherall, through Project Group Finance Sub Committee Approval 10 th June

6 Main Section Issue / Amendment Record 1. Executive Summary 2. Services 3. Consultation & Communications Sub Section Status / Version / Release / Issue Date / Reason for Issue or changes made 1.1 Overview & Summary 1.2 Change implications 1.3 Financial & procurement headlines 1.4 Recommendation and approval required 2.1 Current Service Model 2.2 The case for change and impact on workforce, IG and ICT 2.3 Proposed new service model including option appraisal 2.4 Overview of current to new service model 2.5 Assumptions for new service model 2.6 Service specification for new model 2.7 Service KPIs for new model 2.8 Success criteria for new model 2.9 Clinical support for new service model 2.10 How the new model will be performance monitored in the "business as usual" mode 3.1 Patient council, patient groups engagement & support for new service model 3.2 Clinical engagement in primary care 3.3 Clinical engagement in secondary care/ other 3.4 Consultation with, and notices given to existing providers 3.5 Market Engagement 4. Equality Impact 4.1 Equality Impact Assessment completed details Assessment 4.2 Impact of proposed service on choice, access, equality 5. Quality Impact 5.1 Stage 1 Proforma Assessment 5.2 Expected Quality Metric Outcomes (success criteria) 6. Privacy Impact 6.1 Privacy Impact Assessment Screening Assessment 7. Economic, 7.1 Considerations to be made Social, Environmental Considerations (Social Value Act 2012) 8. Finance 8.1 Analysis of current activity & costs by provider 8.2 Analysis of proposed new model costs by provider 8.3 Proposed savings 13/14 and 14/15 & QIPP impact 8.4 Budget Requirements 9. Sensitivity 9.1 Details Growth Analysis 2

7 10. Procurement Implications 11. Timescales 12. Risks, Constraints, Dependencies 13. Approval Required 10.1 Model of service and type of contract recommended 10.2 Details of external procurement(s) required 10.3 Timescales for procurement 10.4 Market engagement & stimulation 11.1 Project plan timescales (from approval to go live) 11.2 Issues against planned programme time scales 12.1 Risks 12.2 Constraints 12.3 Dependencies 12.4 Opportunities 13.1 Approval required and from whom 3

8 Issue/Amendment Record Status Version Release Issue Date Reason For Issue/Changes Made Included Final amendments pre issue 4

9 1. Executive Summary 1.1 Overview & summary This Full Business Case seeks approval to redesign and re-procure health and some Local Authority commissioned services for children and young people into a new integrated service model. The proposal currently includes the following service areas (these are subject to finalisation with all commissioners): CCG commissioned services: In-patient paediatric services elective and non-elective Out-patient paediatric services - first, follow-up and procedures Specialist children s community services Child and adolescent mental health services End of life care for children Youth Offending Team Health service Local Authority: Youth work projects Diversionary and targeted youth programmes Youth support services Careers and Education Information, Advice and Guidance Family and parenting support services, including for early years Children s Centres and Outreach Service Child and adolescent mental health services and emotional wellbeing School nursing Substance Misuse Sexual health Youth justice liaison and diversion service (subject to confirmation of funding arrangements from NHSE) Speech, language and communication services NHSE: The intention is that these services will be included from September The Commissioners will negotiate with the Prime Contractor once the service transfer is finalised expected for March 2015 (all subject to technical guidance awaited from DH or agreement from NHS England to include if responsibility is not delegated): Health Visiting Health Visiting Growth Family Nurse Partnership Youth justice diversion and liaison (The intention is that this service will be included from April 2015, this will be subject to negotiation with prime contractor) It does not include children or young people s (including paediatric) unscheduled care services (i.e. A&E, Out of Hours GP Services or Urgent Care Centres), or specialist paediatric services commissioned by NHSE England. The intention of this innovative joint project between Bexley CCG (BCCG) and London Borough of Bexley (LBB) is to transform services for children and young people by commissioning a comprehensive range of services through one main integrated pathway 5

10 tailored to early identification and intervention to prevent escalation of health, educational and social problems and the associated poor outcomes. The key drivers for change are: The need for clear integrated pathways due to the increasing fragmentation of services for children following the change in commissioning arrangements under the Health and Social Care Act 2012 The need to ensure services work together effectively to safeguard children to ensure that Bexley is on a trajectory towards a judgement of Good at the next Ofsted inspection of arrangements for safeguarding and looked after children The need to weight service provision towards prevention in order to secure better outcomes and reduce the need for high cost placements in educational, social and hospital settings The need to secure the best possible value for money and the maximum health, social and educational gain for every pound of expenditure. The changing demography and need of the child population of Bexley Implementing the recommendations of the Report of the Children & Young People s Health Outcomes Forum (for the Secretary of State) July With a clear focus on their recommendations for: Putting children, young people and their families at the heart of what happens; Acting early and intervening at the right time; Integration and partnership; Safe & sustainable services; Workforce, education and training; Knowledge and evidence; Leadership, accountability and assurance; Incentives (outcomes orientated incentives). Services for children and young people in Bexley are provided by a multiplicity of statutory, voluntary and independent sector providers (see section 8 for details). Whilst commissioning is becoming increasingly joined up via the Integrated Commissioning Unit, and whilst service specifications do require organisations to work together, inevitably there is a risk of duplication and gaps between services and indeed a lack of accountability for shared outcomes where no single provider can influence the whole pathway. This leads to duplication between providers and patients not signposted to the right service first time. Whilst there is a shared commitment to care and education as close to home as possible, this new integrated approach will ensure there is a shared responsibility to develop local service provision for Bexley children. 6

11 The following chart demonstrates the multiplicity of the current services: Illustration of Currently Commissioned Services Specialist Services commissioned & funded by NHS England HIGH Youth Justice Out- Patient Care In-Patient Care Specialist CAMHS Foster Care Community Paediatrician Audiology CAMHS Youth Justice Liaison & Diversion Occupational Therapy Speech & Language Therapies Children s Nursing End of Life Care Physiotherapy MEDIUM Special Education Domestic Violence Eye clinic YOT Health Worker Substance misuse Family Key workers Family Nurse Partnership* Diversionary & Targeted youth work Emotional Health Parenting Counselling Children s Social Care THRIVING FAMILIES SERVICE Outreach and Early Help Health visiting Careers & Education IAG School nursing Sexual Health Young Carers Children s centres LOW UNIVERSAL AND COMMUNITY SERVICES Maternity Pre-school settings Primary Care Schools Youth Services All current commissioned services receives referrals from and interconnects with these services A financial overview of the services (shown in the following chart and then in detail at section 8) shows that the majority of these investments are focused in high end secondary care services. The learning from other projects (see section 2.3 of this document) shows that integrating services and changing the dynamics of investment patterns, to increase investments in services that focus on child and family health both in social and preventative out of hospital services can lead to significant improvements in child health, thereby decreasing the need for the higher end investments. The following chart displays the level of investments in the key areas of service provision. 7

12 In 2011 the Secretary of State commissioned a working group to look at the services for children and young people as a result of this a report was produced Report of the Children & Young People s Health Outcomes Forum (for the Secretary of State) July A key finding from that report was that: The NHS and social care have been designed around the system, rather than the individual. To children, young people and their families, that system feels fragmented and often means they have to tell their story repeatedly, striving unsuccessfully to be heard and get the properly joined up care they need. Designing and planning health and healthcare round the needs of the individual child or young person, taking account of their changing needs over time, will improve their experience of the services and their health outcomes not just at a point in time, but for the longer terms and improve their lives enormously. The Forum then makes a number of key themed recommendations (these are shown in bold) in the following they are set out in key themes together with the main recommendation that would impact on this integrated care project: Putting children, young people and their families at the heart of what happens; All health organisations must demonstrate how they have listened to the voice of children and young people, and how this will improve their health outcomes. 8

13 Acting early and intervening at the right time; All organisations in the new health system should take a life-course approach, coherently addressing the different stages in life and the key transitions instead of tackling individual risk factors in isolation. Integration and partnership (not having to repeat myself thirty times to every different person or part of the system); The NHS Number should be used as the unique identifier to bring together health, education and social care data for all children & young people Safe & sustainable services; CCGs need to develop local networks and partnerships with providers to address and deliver the sustainable provision of local acute, surgical, mental health and community children s services & ensure both care closer to home and no gaps in provision. Workforce, education and training; The Royal College of General Practitioners proposal to extend GP training to allow for adequate training in paediatrics and physical and mental child health is supported. All GPs who care for children and young people should have appropriately validated CPD. All general practices that see children and young people should have a named medical and nursing lead. All general practice staff should be adequately trained to deal with children & young people. Knowledge and evidence; The NHS CB, with support from Health & Social Care Information Centre (HSCIC), should establish electronic child health records, accessible for both patients and professionals. Leadership, accountability and assurance; Local commissioners, including CCGs and local authorities, should identify a senior clinical lead for children and young people. Incentives. The NHS CB and Monitor should prioritise and promote the use of integrated care provision in their funding, regulatory and performance roles within the NHS, and DH should address this issue across government for those services that fall within the remit of local authorities, education, or other government departments. Monitor and the NHS CB should ensure that they continue with the outcome-orientated development of Payment by Results currencies and tariffs for child health related areas. The proposed model is to improve and integrate the services for children, young people and their families (in line with the above recommendations), with the specific aims of avoiding ill health and integrating services, disinvestment in high end secondary care services, with investment into community and social care services designed to avoid escalation and prevent the need for high end secondary care services. To integrate the model we would seek a prime contractor to take the lead on the majority of commissioned services for Bexley children and young people. That contractor would take responsibility for integrating services across a range of sub-contractors and the delivery of new integrated pathways and outcomes for children and young people. The prime contractor does not need to be the prime provider of the services. The proposed approach will put a prime contractor in the position of driving integration and innovation, of understanding and being accountable for a wide range of agreed outcomes for local children and families to the CCG and the LBB. This will represent a positive development of the existing strong partnership working which exists in children s services in Bexley, including public health services. It will be expected that the successful prime contractor will align with the LBB Children s Services Front Door single point of entry into the children s services system. This team takes 9

14 responsibility for ensuring that children and families access the right pathway or pathways to ensure the desired, sustainable and improved outcomes. 1.2 Change implications including impact on life expectancy & health inequalities It will be difficult to demonstrate or quantify any impact on the life expectancy of Bexley s children & young people, however the preventative model of service is designed to impact on health, social and educational inequalities by narrowing the gap between the advantaged and disadvantaged. 1.3 Financial and procurement headlines The project team will be set a savings stretch target of achieving a level of savings through the integration of the services the stretch target is 20% (or in the region of 3,820,000 against the current budgeted costs of approximately 19,104,559) see Section 8 for details. The savings will be determined for each service after consideration of investments and dis-investments. 1.4 Recommendation and approval required The BCCG Finance Sub-committee, the BCCG Quality & Safety Group, the BCCG Governing Body, the LBB Management Board and Public Cabinet are therefore asked to approve the contents of this Business Case for the redesign of services, and the BCCG Governing Body are also asked to provide the approval to procure the services. 10

15 2. Service Integrated Children & Young People s Services Business Case 2.1 Current service model Services for children and young people in Bexley are provided by a multiplicity of statutory, voluntary and independent sector providers (see section 8 for financial details). Whilst commissioning is becoming increasingly joined up via the Integrated Commissioning Unit, and whilst service specifications do require organisations to work together, inevitably there is of duplication and gaps between services and indeed a lack of accountability for shared outcomes where no single provider can influence the whole pathway. This can lead to duplication between providers and patients not signposted to the right service first time. Whilst there is a shared commitment to care and education as close to home as possible, this integrated approach will ensure there is a shared responsibility to develop local service provision for Bexley children. The following chart demonstrates the multiplicity of services: Schematic of the current service model In the following sub sections we look at the range of commissioned services (by individual commissioners) and the multiplicity of providers. 11

16 2.1a BCCG currently commissions services for children and young people as shown below: Provider & Service Description Activity Oxleas NHS Foundation Trust Specialist children s community services Community paediatrics Speech & language therapy Occupational therapy Community pediatrics provide a clinical service by taking responsibility for all children in a community, providing preventive and curative services, and understanding the determinants and consequences of child health and illness, as well as the effectiveness of services provided. The community pediatrics concern is for all of the population those who remain well but need preventive services, those who have symptoms but do not receive effective care, and those who do seek medical care either with a GP or in a hospital. The outcomes include; maximising health, educational and social outcomes for children with complex needs by, early diagnosis and intervention thereby reducing late/more intensive treatment options and minimising family distress and contribute to statutory assessment of Special Educational Need (or Education, Health and Care Plan subject to passage of legislation) within statutory timescales. The aim of the Speech, Language and Communication service is to provide an effective whole system to prevent the development of SLC problems, to identify problems which do emerge, to provide timely assessments to inform intervention, to provide targeted interventions so that children with difficulties (could be delay or disorder) are enabled to catch up with their peers or reach their potential. To provide specialist interventions to improve communication skills, functional communication, access to education, social inclusion and/ or quality of life. The outcomes include; prevent, assess, diagnose and treat; delayed or disordered speech and language development eg: verbal dyspraxia, specific language impairment, voice or stammering disorders, Social communication disorders and communication difficulty associated with special needs including but not exclusively hearing loss, learning disability, physical disability, emotional and behavioural difficulty, autism. The OT service offers high quality, effective and equitable occupational therapy care for children registered with Bexley GP s. Improve quality of life and maximise outcomes for disabled children and those with acute or complex needs. Provide an integrated and flexible service which promotes and co-ordinates the care of children and young people and their families, and high quality, evidence-based information and support to enable children, young people and their families to be able to make informed choices and to actively participate in the care received. The outcomes include; ensuring children and young people with additional needs are supported to participate and use all mainstream and community Indicative Activity contacts (including overnight respite in the home) * *Included in the above figure *Included in the above figure *Included in the above figure Referrers Parents, health visitors, mainstream schools, special schools, GP s, social workers, school nurses, audiologists, CAMHS, acute paediatricians, educational psychologists Parents, health visitors, mainstream schools, special schools, GP s, social workers, audiologists, school nurses, CAMHS, OT s/physios, educational psychologists Mainstream schools, special schools, SLT s, physios, GPs, acute paediatricians, social workers Locations Child Development Centre QMH, Erith Hospital, Schools, community clinics Child Development Centre QMH, Erith Hospital, Woodside SLT Clinic, mainstream schools, special schools, community clinics, Children s Centres Child Development Centre QMH, Erith Hospital mainstream schools, special schools, paediatric wards 12

17 services and activities that they wish to use or experience. Disabled children and young people enjoy the highest quality of life possible and gain maximum life chance benefits from educational opportunities, health care and social care. Delivering high quality multi-agency transition services are delivered to disabled children and young people at important transition points. Integrated Children & Young People s Services Business Case Physiotherapy Secondary Audiology Children s community nursing As described above in conjunction with Occupational Therapy. Physiotherapy services provide children whose care plan includes a therapeutic programme (to be delivered in school or at home to improve or maintain mobility). This service identifies all children with a sensori-neural or conductive hearing impairment or deafness living in the Bexley area, early as possible. Those children with a congenital deafness and those with a deafness which is acquired after birth all require that their hearing difficulties are recognised when they are as young as possible. The service aims to improve the life chances of deaf and hearing impaired children identified in the Bexley area by giving them immediate access to excellent programmes of intervention with support for their families when they are as young as possible. The outcomes for this service include; provide a high quality programme reactive to parental and professional concerns about the child s hearing or the development of their speech and language, offering timely, safe, high quality age appropriate audiological assessments for those referred from both the newborn screen and the hearing surveillance and reactive programmes. The service works together with families and other agencies to deliver a high standard of care to children in various community settings. The objectives are; to facilitate timely discharge from hospital for children with complex health issues and long term conditions, provide care closer to home, support children with additional needs to attend school, provide teachers and carers with the skills to support children at school, provide preventative health interventions, enable children and their parents to manage their conditions, carry out assessments under the Framework for Children and Young People s Continuing Healthcare and co-ordinate children s continuing healthcare. The Children s community nursing provides assessments, care planning within 48hrs of referral to the service and continuing healthcare provided predominantly in the home but also school and respite shared care settings. This service will be provided 24 hours a day, 365 days per year with a senior paediatric nurse on call until 1700 hours on weekdays and 2200 hours at weekends to respond to changing requirements. *Included in the above figure *Included in the above figure *Included in the above figure Mainstream schools, special schools, SLT s, OTs, GPs, acute paediatricians, social workers Health visitors, school nurses, community paediatricians, ENT, GPs, Teacher of the Deaf, Acute paediatricians and paediatric nurses, GPs, community paediatricians, therapists, special schools Child Development Centre QMH, Erith Hospital mainstream schools, special schools, paediatric wards Murchison Clinic, Erith Health Centre Child Development Centre QMH, paediatric wards, special schools, mainstream schools, homes 13

18 Child & Adolescent Mental Health Services Tier 3 The service is organised so as to provide care pathways for different mental health needs as follows; generic (including under-fives), learning disability and neuro-developmental needs, Looked After and adopted children, specialist adolescent services including the community intensive outreach service. CAMHS Tier 3 Services provides specialist mental health assessment & treatment for children and adolescents from 0-18 years with significant, complex or enduring emotional or mental health difficulties Assessment & treatment is provided by a range of professional disciplines e.g. psychiatry, social work, nursing, child psychotherapy, clinical psychology, family therapy, mental health nurses. Treatment is provided by lone professionals or a combination of professions from the multi-disciplinary team. A mix of short and long term interventions are provided based on levels of complexity and chronicity, sometimes in conjunction with other agencies. The service aims are to promote the emotional health and well-being of children and young people by working in a 4 tiered model of care with other providers. Adolescent BCAMHS AAO service provides specialist mental assertive health assessment & treatment in the community for adolescents up to 18 years old who experience outreach significant and acute emotional and mental health (Tier 3.5) problems. During the last four years there has been a steady increase in the numbers of young people aged presenting to Bexley CAMHS with complex and significant mental health needs who require a psychiatric in-patient admission. In the main, these young people are admitted as inpatients because they are at risk and / or require intensive, highly specialist care which is not available within the community. The aim is to provide stepped care for young people who may be at risk of in-patient admission or postdischarge, with the aim of preventing, delaying or reducing the duration of admissions. The service provides intensive, outreach care to young people within the community, providing a rapid, responsive YOT Health worker LAC Nurse service when a crisis first emerges. Pro-active health assessment service for young people in the Youth Justice System. Sign-posting, referral and active follow up to ensure take up and outcomes Statutory health assessments: Every child who enters care has a holistic health assessment within 28 days of entering care. The initial health assessment is conducted by a registered medical practitioner with an interest in the needs of vulnerable children with the production of a comprehensive health care plan. A review health assessment takes place at six-monthly intervals for children under five, and annually for children over five GP s, schools, social workers, health visitors, school nurses, acute and community paediatricians, therapists, educational psychologists, special schools Included in figure above 131 young people GP s, social workers, acute paediatricians, internal CAMHS YOT Highpoint House, Child Development Centre QMH, schools, acute settings. Community settings 180 contacts Social workers Community settings 14

19 MASH Health Health visitor to work as part of Multi-agency New Service Social workers Civic Offices Visitor Assessment Hub which is the central point for referrals for all vulnerable children and the decision maker regarding which agency should take action St Georges Healthcare (sub-contracted to Oxleas NHS FT) Tertiary Murchison audiology Clinic Assessment and diagnosis of babies referred from National Neo-natal Hearing Screening Programme and on-going hearing aid management and review Lewisham & Greenwich Healthcare Trust Elective and The provision of paediatric secondary care non-elective Inpatient care across all clinical specialisms referred from services for both acute and non-acute referrals primary care, community settings and A&E Out-patient care The provision of paediatric out-patient services for both acute and non-acute services including the provision of out-patient clinics for clinical follow-up. Provision of A&E services Dartford and Gravesham Health Care Trust Elective and non-elective Inpatient care Out-patient care Ellenor Lyons The provision of paediatric secondary care services for both acute and non-acute referrals across all clinical specialisms referred from primary care, community settings and A&E The provision of paediatric out-patient services for both acute and non-acute services including the provision of out-patient clinics for clinical follow-up. Provision of A&E services This service offers effective and equitable care closer to home / at home for children living in the London Borough of Bexley. Provide specialist care for children and young people aged 0 19 with lifethreatening and life-limiting conditions, including acute oncology from diagnosis. Reduce emergency admissions and to facilitate as early a discharge as possible from acute care and specialist tertiary centres. Provide an integrated and flexible service which promotes and co-ordinates the care of children and young people and their families and offer children and young people and their families access to 24/7 specialist support. The outcomes include; providing children and young people with care which meets their identified needs and enable them to return to their home quicker or remain in their home for longer and deliver an informed choice about end of life care to children and young people in their own homes. 632 appointments 1557 (Bexley, Bromley & Greenwich) Hearing screening coordinator, audiologists, Teacher of the Deaf, ENT 844 spells GP s, A&E, UUC Queen Elizabeth Hospital, Lewisham Hospital 2368 spells GP s, acute paediatricians Queen Elizabeth Hospital, Lewisham Hospital 1407 spells GP s, A&E, UUC Darent Valley Hospital 2474 first & follow up appointments 120 children not including siblings supported GP s, acute paediatricians Children s community nurses, oncologists, acute paediatricians Darent Valley Hospital, Queen Marys Hospital Schools and homes 15

20 2.1b LBB currently commissions (and in some cases provides) services as shown in the table below Provider Service Description Indicative Activity Women's Aid Domestic Violence Services: Domestic Violence Liaison Worker to work across two social care teams; community based services for victims or potential victims of domestic abuse which includes the outreach service in schools and community settings. To assess children and families in need using the Common Assessment Framework (CAF) and provide a range of groups and individual support to victims or potential victims of domestic violence. They include home visits, advice clinics or recognised group work in this area e.g. FREEDOM programme. The service aims are to reduce the need for intensive support from the social care teams by providing timely support and intervention to lower level referrals. To reduce the cost of services in the long run to families with multiple problems and increased their knowledge on the impact that domestic abuse has had on their children and family relationships. Referrers 1,695 Social Workers; children centres; thriving families service Locations Children's Centres, Community Centres, schools and across the Borough ( via Outreach) Oxleas NHS Foundation The LBB Speech and language therapy services are concerned with the management of Speech, Language and Communication Needs (SLCN) in children aged 0-5. The service consists of 2x full time qualified Speech and Language therapists and 2 x Speech and Language assistants supporting targeted families, either referred or self-referred. Provide co-ordinated care packages that include drop in services, one to one support either at home or in the community. Improving children to thresholds set out in the EYFS in the areas of learning for communication, language, personal, social and emotional development, Reducing the number of inappropriate referrals made by the HV team to the Clinic based service. 3,597 includes contacts and caseloads Mainstream schools Mainstream schools The outreach team consists of 8 WTE Band 4 nursery nurse/outreach workers and 0.8 WTE Band 7 Lead H.V. 1.0 WTE in addition supporting the parenting programme; positive steps. The focus is supporting families referred in to access early intervention support from the children s centre and other organisations including courses for parents, childcare for the over two s and support for young parents. The aims include; increase Breastfeeding prevalence & provide support & information to parents using formula & starting solid foods in the targeted families within the children s centre reach, contribute to the development of Healthy Start and contribute to the development of an integrated Under 5 s Healthy weight pathway. Improving the take up of Breastfeeding in new mothers, improve maternal & infant nutrition, particularly in most at risk groups and deliver a care packages for children over 1 at risk of child obesity contributing to the lowering the risk of obesity. 3,276 GPs, schools, social workers, health visitors, school nurses, acute and community paediatricians, therapists, educational psychologists, special schools Highpoint house, schools, other community settings 16

21 Provider Service Description Indicative Activity CAMHS will provide Specialist treatments for PTSD 1128 jointly and Attachment Disorders, as a part of a multi-agency commissioned approach for children under the age of 5. More with the CCG generally, there is a significant body of evidence for the efficacy of interventions for infants, young children and their parents / caregivers; even short term interventions are known to produce very good developmental outcomes for children and to reduce risk. It is because of the evidence base for efficacy that early intervention is seen as cost effective; avoiding costs to the child and their family and to the public purse, of emotional difficulties remaining untreated and developing into more complex, difficult to treat problems as the child grows. The positive steps service is delivered by 15 trained health and social care staff across the borough of Bexley. This service includes a lead health visitor practitioner who coordinates and develops the service across education, health and social care. The lead practitioner (0.8 wte Band 7) and external supervision are fully funded by the London Borough of Bexley and oversees all training and service development. Management and administrative support is within the Specialist Children s Services contract. Positive Steps services promote positives parenting for local families, providing evidenced based parenting programmes which is focused on managing their children s behaviour. The services aims to increase the parent s confidence to deal with their children s behaviour and for parents see fewer problem behaviours with their children. Integrated Children & Young People s Services Business Case Referrers Health Visitors, CAMHS, social workers 240 families Schools, selfreferral, parents, GPs Locations Community settings, Children's Centres and in the community Mainstream schools Substance misuse: Tier 3 substance misuse treatment service for young people referred via Tier 2 service (YES) including those in the Youth Justice System 56 young people completing treatment Schools, GPs, social workers, YOT, A&E, UCC, vol orgs Highpoint House, Bexley's Youth Advice Sexual Health: The Young People s sexual health service provided offers young people the opportunity to access services at times and locations convenient to them. The service is complimentary to a range young people focussed services including sexual health services provided in GP practices, pharmacy, services by community groups, as well as services offered in the school setting through the School Nurse team. This whole systems approach enabling young people to have the information, knowledge and skills to enable them to look after their sexual health. The young people s service provides pregnancy testing, emergency hormone contraception, LARC, condoms, Chlamydia testing kits, advice and information Self-referral Bexley Youth Advice, Erith Health Centre, Lakeside Health Centre, Oval Clinic 17

22 Provider Service Description Indicative Activity Charlton The CACT Consortium service provides diverse, 7,348 youth Athletic varied, accessible and flexible youth projects and engagements Consortium alternative curriculum for 8-18 year olds across the borough, in particular for Y/P in need of targeted provision or support and during times of most need eg school holidays, after school youth clubs, antisocial behaviour hotspots, evenings and weekends. The service ensure that Y/P are engaged in positive activities on a regular basis, improve the number of YP engaged in employment, education and training, ensure the contribution to a reduction in the number of first time entrants entering the criminal justice system and to a reduction in the number of young offenders re-offending. London Borough of Bexley BYS; Bexley Moorings; YADT Youth Inclusion Project (YIP) are bespoke and evidenced based programmes aimed at preventing Y/P identified / referred in need or who are becoming involved in crime and anti-social behaviour. YIPs are located in a policing and neighbourhood service cluster at times to reflect need and or issues of antisocial behaviour and disorder. To provide a flexible approach and provision, this is tailored according to need and location. The service supports areas experiencing hotspots of disorder, to areas of high levels of deprivation. Reductions in the number of first time entrants entering the criminal justice, increase in the number of at risk Y/P engaged in YIP provision across the borough and reduce in the number of first time entrants entering the criminal justice system. Integrated Children & Young People s Services Business Case 584 north YIP and 6,384 south YIP Referrers Social workers, YOT Social workers, YOT, schools Locations Youth Centres, Community Centres and Parks/Open Spaces Youth Centres, Community Centres and Parks/Open Spaces Prospects Careers and Education Information, advice and guidance: Careers and education advice in schools and resources plus. Service to be offers within a context of the integration of services to support young people. The services plays an active or lead role in the delivery of integrated services and outcomes for eligible young people, including local structures and systems to provide multi-agency and cross-agency support; to deliver a lead professional role for the most vulnerable young people needing intensive support; to ensure that young people have ready access to information on and opportunities for positive activities; and to provide expert knowledge of the labour market and career options available. The outcomes include; providing preventative elements of the corporate and national objectives to reduce the numbers of young people Not in Education, Employment or Training (NEET) and to increase levels of participation and achievement, to work with partners to seek to ensure that all eligible young people covered by this contract aged Are assisted to develop clear aspirations and make sustainable decisions for their future. Eligible young people will need to be supported to enable them to work to achieve social and economic well-being through personal development that will enable them to access appropriate education, employment and training through support programmes in schools, Academies, free schools, work-based learning providers, specialist agencies and in the community. 10,215 including young people with disabilities of which 604 are from target groups Schools, Social Workers, YOT Bexley Youth Advice, Broadway. Schools 18

23 Provider Service Description Indicative Activity Homestart Bexley Moorings Children's centres are a community resource at the heart of Bexley's neighbourhoods. The Children's Centre will be required to provide the Services and required to reach children under the age of five years old through the Core Offer : Early education (integrated with childcare for crèche s etc), Family support service, Child and family health services, Community outreach and signposting to local provisions for Childcare. Home visiting and volunteer family support: Outreach support and early intervention service for targeted and vulnerable families with children aged 0-4 years. The service improves confidence of parents using evidenced based assessment, increases take up of children s centre services particularly from the most disadvantaged areas and contribute to narrowing the gap in outcomes for disadvantaged children based on EYFSP scores. The service supports 80 families per year, improved support as identified at initial assessment as having mental health issues to be prevented from escalation to statutory mental health services resulting in cost savings and preventing escalating to children s social care. The service provides befriending for young people experiencing problems at home, school or in the community that gives extra support and regular positive adult attention. The be-friender provides activities and support which will help the young person tackle difficulties before they get out of control. Develop strategies to support and proactively engage young carers into targeted and group activities to develop confidence, socialisation and self-esteem. 80 of children and young people engaged to improve socialisation, self esteem and behaviour. Engaged and trained 60 young volunteer and improved transition pathways for young people in particular through the education system to ensure they have the opportunity to achieve their full potential. Integrated Children & Young People s Services Business Case 6, children and families engaged 876 young people engaged Referrers Health Visitors, nurseries, social workers, CAMHS Social workers Schools, social workers, YOT, police, CAMHS, GP's, EWOs Locations Crayford, Danson, Falconwood & St Michaels (Hillgrove), Greenmead, Normandy, North Cray, Northend, Northumberland Heath, St Augustine's, Sidcup, West Street Homes and Children's Centres Community Centres and based at Danson Youth Centre Danson Youth Trust and Uniformed Groups Uniformed groups and targeted youth groups. Universal and community youth services: Activities for young people and small grants to community organisations supporting young people. Universal youth opportunities include physical activities improving health and well-being of Bexley young people, engaged YP and reported improved confidence through learning new skills, engaged YP to feel empowered, confident, understand presentation skills and in readiness for employment, training or further education and engaged in a new social experience broadening their attitudes, encouraging family cohesion. 15,000 young people engaged Schools, social workers, school nurses, police, YOT Danson Youth Centre and community settings *Full details of the LBB Children s Centre estate are provided at Annex 1. 19

24 2.1c NHSE currently commissions the following services: These will not be included at the tendering stage with the prime contractor, although the impact on their future inclusion will be considered. It is commissioners intention that these services will be include from October 2015, subject to negotiation with the prime contractor March Provider Service description Activity Referrers Locations Oxleas NHS Foundation Trust The health visiting team, working in partnership with families delivers the Healthy Child Programme to all children registered with a GP in the borough of Bexley. Health visitors initially visit the homes of families with newborns to do a hearing test on the baby, provide feeding advice, undertake a family health needs assessment and provide support. Ongoing advice and support is provided until your child is five years old. The health visiting team provide advice on issues such as immunisations, minor ailments, sleep, parenting, behaviour, special needs, postnatal depression and your child s general development. 45,760 Maternity services, GPs Homes, Children's Centres and community settings including GP surgeries Bromley Healthcare Immunisation programmes for school age children Liaison and Diversion Service: The Liaison and diversion services is intended to improve the health and justice outcomes for adults and children who come into contact with the youth and criminal justice systems where a range of complex needs are identified as factors in their offending behaviour. The Liaison and diversion is a process whereby people of all ages with mental health problems, a learning disability, substance misuse problems and other vulnerabilities are identified and assessed as early as possible as they pass through the youth and criminal justice systems. Family Nurse Partnership; Voluntary home visiting programme will support first time young mothers, aged 19 or under (and partners) who are from 12 weeks and 6 days up to 26 weeks pregnant. Two specially trained family nurses with a caseload of up to 25 young mothers will visit them regularly, from early pregnancy until the child is two. All school children in targeted age and gender groups 159 young people received at least one engagement (most receive more) 50 Maternity services, social workers, health visitors Schools, GP practices 20

25 2.2 The case for change and impact on workforce, IG and ICT Quite rightly and appropriately services for children and young people are, as shown above, largely embedded in community settings and places which are familiar for children and families. But as the chart below demonstrates there are still high levels of spend and also services focused in secondary care: In 2011 the Secretary of State commissioned a working group to look at the services for children and young people as a result of this a report was produced Report of the Children & Young People s Health Outcomes Forum (for the Secretary of State) July A key finding from that report was that: The NHS and social care have been designed around the system, rather than the individual. To children, young people and their families, that system feels fragmented and often means they have to tell their story repeatedly, striving unsuccessfully to be heard and get the properly joined up care they need. Designing and planning health and healthcare round the needs of the individual child or young person, taking account of their changing needs over time, will improve their experience of the services and their health outcomes not just at a point in time, but for the longer terms and improve their lives enormously. The Forum then makes a number of key themed recommendations (these are shown in bold) in the following they are set out in key themes together with the main recommendation that would impact on this integrated care project: 21

26 Putting children, young people and their families at the heart of what happens; All health organisations must demonstrate how they have listened to the voice of children and young people, and how this will improve their health outcomes. Acting early and intervening at the right time; All organisations in the new health system should take a life-course approach, coherently addressing the different stages in life and the key transitions instead of tackling individual risk factors in isolation. Integration and partnership (not having to repeat myself thirty times to every different person or part of the system); The NHS Number should be used as the unique identifier to bring together health, education and social care data for all children & young people Safe & sustainable services; CCGs need to develop local networks and partnerships with providers to address and deliver the sustainable provision of local acute, surgical, mental health and community children s services & ensure both care closer to home and no gaps in provision. Workforce, education and training; The Royal College of General Practitioners proposal to extend GP training to allow for adequate training in paediatrics and physical and mental child health is supported. All GPs who care for children and young people should have appropriately validated CPD. All general practices that see children and young people should have a named medical and nursing lead. All general practice staff should be adequately trained to deal with children & young people. Knowledge and evidence; The NHS CB, with support from Health & Social Care Information Centre (HSCIC), should establish electronic child health records, accessible for both patients and professionals. Leadership, accountability and assurance; Local commissioners, including CCGs and local authorities, should identify a senior clinical lead for children and young people. Incentives. The NHS CB and Monitor should prioritise and promote the use of integrated care provision in their funding, regulatory and performance roles within the NHS, and DH should address this issue across government for those services that fall within the remit of local authorities, education, or other government departments. Monitor and the NHS CB should ensure that they continue with the outcome-orientated development of Payment by Results currencies and tariffs for child health related areas. When our model of commissioning (across multiple commissioning organisations and also multiple service providers is reviewed it is clearly that there are opportunities to fully integrate the services to deliver a population based approach to need and the services delivered, and to also include into this the recommendations from the above report. There is an opportunity of changing the overall dynamics of the system to focus more on maintaining the child or adolescent s good health, rather than a system that is financially incentivised to respond to poor health. There is the opportunity of redesigning & integrating the services, to respond to the voice of the population with services delivered close to home, in support of the child and family s needs, and to reduce wastage and duplication. There is an opportunity of designing and rewarding providers based on outcomes rather than delivering activities. There is scope for a prime contractor to take a strategic overview of both the geographical distribution of services and the range of services that input to the same settings to potentially deliver more coherent and efficiently joined up services based around the needs for our populations. This commissioning approach seeks to ensure that the prime contractor thinks in terms of delivering care pathways and outcomes rather that services which are labelled by the name of the profession providing them. Most outcomes require a multi-disciplinary team approach and the provider will have the freedom to configure cross cutting teams to achieve joint outcomes. 22

27 Therefore in summary the change proposed change is to a model where one organisation uses the resources outlined above to achieve the new specified outcomes and an integrated care service. As shown above there is potentially a wide range of providers and employers affected by the proposal. The exact impact on their respective workforces will depend on how the prime contractor decides to sub-contract for the full range of outcomes. It is proposed that within this new model the services currently provided by the LBB in-house provider team i.e. Children s Centre services, will be transferred to the new prime contractor, and that the workforce (which is currently employed by LBB) will be subject to a TUPE transfer. It is not anticipated (or desired) that the prime contractor will be the sole provider of services, it is expected that they will sub-contract services to other providers, but retain overall responsibility for the integration and the outcomes for the sub-contracted services. On this basis the commissioners (BCCG and also LBB) will need to consider with the bidders the potential TUPE implications for this contract based on these services and the workforce. The full TUPE implications will then be identified within the Invitation to Tender (ITT) documents. With respect to Information Governance and ICT appropriate information sharing between professionals and organisations is a crucial of effective intervention for children and young people and most especially in relation to safeguarding. The prime contractor will be encouraged via the service specification to look at and offer to the commissioner s innovative solutions to enable information to be shared more effectively between itself, its sub-contractors and GP s. A Privacy Impact Assessment screening is shown at Section 6 below. 23

28 2.3 Proposed new service model including option appraisal As described above the proposed approach is to seek a prime contractor to take the lead for the majority of commissioned services for Bexley children and young people. That prime contractor would take holistic responsibility for delivering an integrated pathway with sustainable improved outcomes for children and young people. These outcomes, which are for further refinement with potential stakeholders and providers throughout the procurement process, are broadly: Pathways Acute and Long term condition pathways Complex and additional needs pathways including end of life Emotional and mental health pathways Pathways for young people Pathways for children in need and looked after children Universal and targeted early help pathways including young carers Outcome Children and young people who are ill or experience acute exacerbation of long term conditions are diagnosed and treated quickly and their parents carers supported to look after them at home Children and young people who have long term conditions and their parents/carers are supported to keep healthy and live normal lives including the management of their condition in school Children who are diagnosed with a terminal or life limiting illness or condition are supported with all their associated needs and enable to die in their place of choice Children who have sensory impairment are diagnosed as early as possible and supported to achieve their maximum potential Children and young people who may have ADHD or be on the autism spectrum are diagnosed as early as possible and enabled to access appropriate services Children with additional needs (e.g. speech and language) and complex disabilities are diagnosed and their needs assessed as early as possible to achieve their maximum potential Children who have or are at risk of mental health problems are supported/treated and prevented from needing high cost interventions such as residential or in-patient care Young people who are at risk in relation to crime, teenage pregnancy, substance misuse, sexual health are prevented from becoming pregnant, and/or contracting sexually transmitted infections and supported to achieve their maximum potential Children in need are supported to achieve their maximum potential and prevented from needing high cost interventions such as residential/foster care/mental health admission All children in Bexley are supported to be healthy and ready/prepared to maximise their opportunities from education and their contribution to society. Young carers are supported to achieve their maximum potential ensuring early intervention and prevention strategies are in place when the level of care giving and responsibility to the cared for person becomes excessive or inappropriate for that child, risking impacting on their emotional or physical wellbeing or educational achievement and life chances 24

29 A stakeholder consultation took place on the 16 th June at which a wide range of local stakeholders and potential providers were engaged in commenting on and refining these local outcomes. Analysis of the outputs from this event is currently in progress and will be incorporated into the final service specifications and outcomes where appropriate. The proposed approach will put a prime contractor in the position of understanding and being accountable for a wide range of integrated services with agreed and sustainable outcomes for local children and families. This will represent a positive development of the existing strong partnership working which exists in front line of children s services in Bexley. The prime contractor may develop a single point of entry into the children s services system and will take responsibility for ensuring that children and families access the right pathway or pathways to ensure the desired outcomes. This single entry point would need to integrate with the LBB s key Thriving Families framework see Figure 1.and could be one of the most significant elements of the service redesign in which potential providers will be engaged. Figure 1 This project will also look to respond directly to the recommendations of a task force set up by the Secretary of State to look (and report on) the needs for Children & Young People: This report Meeting the health needs of children & young people (source: provides an in-depth analysis for children & young people s needs in London of those who are ill, as well as those with long term conditions, or complex health needs. It showed clearly how services were not meeting the health needs for this group, and the case for change clearly identified the following areas that are relevant to this project: Children s health & wellbeing in the UK is not as good as it should be. There are complex reasons for this but some explanation lies in the changing disease burden and the way medical services are provided. Too many children & young people present to A&E and are seen by paediatric specialists for illnesses that could be treated in primary care. For many children & young people hospital admission for stays of up to 1 day could be avoided by providing care in a different setting. Children & young people have to attend a hospital for out-patient appointments when often these could be provided in the local community by the primary care workforce. Children & young people with long term conditions or complex health needs are not getting the best possible care, with staff working in a disconnected way, and too much care being provided in hospitals when it could be delivered in the local community and in their homes. 25

30 This report provided a series of recommendations for a new and improved model of care, again those relevant have been extracted: Health services will be delivered locally, where this is clinically appropriate & delivers value for money Healthcare will be delivered in the home, or as close to home as possible, including school, thus avoiding or reducing the need to attend and/ or to be admitted to hospital Close working between tertiary, secondary and primary care services alongside partners, such as local authorities & children & adolescent mental health services (CAMHS), to provide more cohesive & better care for children & young people. There are examples of other areas that have re-focused their healthcare services into preventative models (rather than responding to ill health) and an example of this together with some of the key findings are given below: 26

31 Case Study 1: Improved Multi-Agency Working and Integrated Social Care Pathways (source: In Swindon between 60 and 100 families in the worst state of chronic crisis were surrounded by a crowd of public sector agencies, each with a different offer, a different approach, and different forms to fill in. For some families, these had little effect on their lives and were in fact stopping families taking full responsibility for their own lives. Recognising that the families themselves were the most informed about their own situations, and should therefore be at the centre of any efforts to help them, Swindon Borough Council and its partners on the local strategic partnership commissioned a new integrated social care pathway with a focus on early intervention and prevention. One of the principles of the program is that the team members themselves will be required to develop their own capabilities just as much as the families will be. They are learning to work in a radically different way. This has been so effective that one of the family members now works alongside the team. The core characteristics of the approach were prevention and early intervention as follows: 1. Assess the whole family; where appropriate including grandparents, family friends and other significant people to the family. 2. Family-centred; involving both adults and children in assessing the family situation and looking at the family's point of view. 3. Focus on strengths and potential: to build resilience and capacity. 4. Assessment as the basis of an integrated support plan: agreeing a contract, monitoring progress and working towards shared goals As well as the important benefits to the social resilience of families and the wider community, the program had by July 2013 achieved: measurably improved outcomes: an per cent reduction in police call-outs seven eviction orders being prevented 12 children no longer having a child protection plan a reduction in domestic violence a 90 per cent improvement in mental health conditions for those who reported this as a risk factor and 70 per cent of children re-engaged with education where this was an issue 70 per cent of family members building positive relationships between themselves. 720,000 of estimated savings in the second year ( 235,000 on actual, 485,000 on preventative) has been achieved. 27

32 Case Study 2: Integrated Pathway for Children with Asthma (Source: In North London a new Integrated Care Pathway (ICP) for Asthma in Children was established jointly between two acute providers and a commissioner their model focused on prevention and out of hospital services (including telephone follow ups). Their findings have been evidenced and reported on and showed: 18% reduction in A&E attendances 27% of admissions for asthma can be avoided Admissions reduced from 13.2% to 4.6% Complexity/ Severity of admissions also reduced Severe admissions non ICP was 93% - this reduced to 38% Moderate admissions non ICP was 27% - this reduced to 3% As part of this research post implementation they also took a patient journey and costed what happened prior to the project, and what then would happen the chart below demonstrates a significant variance in the attendances needed: Child with Asthma (age 2) Actual Example without ICP Cost ( ) With ICP Saving Saving ( ) 6 GP attendances GP attendance using Int. Care Pathway 5 GP attendances A&E attendances (with x-rays) A&E attendances Non Elective admissions 4,899 4 Non elective admissions -4,899 1 PICU admission PICU admission OP New (to wrong clinic) OP New OP New (to the right clinic) Op New OP Follow Up OP Follow Up Practice nurse appointments 24 1 community MDT assessment & training 3 practice visits 76 1 OP New (to allergy clinic) OP New MDT Allergy & Asthma Clinic replaced OP Follow Up (to allergy clinic) OP Follow Up MDT Allergy & Asthma Clinic replaced -3 1 x-ray (direct access) addt cost of 1 DA x-ray 25 7,476-6,983 Not only does this represent a significant investment in time for the family, both in attending the appointments, but also the time taken to nurse a sick child, or to attend hospital. The quality of life for this child and family should also be valued. In purely cost terms to the NHS this patient journey shows: Cost without ICP approx. 7,500 Cost using ICP approx. 600 A saving of approximately 6,900 (or 90%). 28

33 Options: Due to the size and complexity of this proposal the range of options are many and have a range of interdependencies. They are summarised as: Option High Level Description Detail of Action Option 1 Do Nothing All services to continue to be commissioned/provided as now Option 2 CCG only procurement CCG re-procures only health services Option 3 Option 4 Option 5 Integrated pathway for CCG and ESC procurement Integrated pathway for CCG and LBB Procurement Integrated pathway for CCG, and LBB NHSE and Procurement The options are assessed as follows: CCG and LBB procure only those services commissioned/provided by CCG and Education & Social Care CCG and LBB procure those services commissioned/provided by CCG and LBB including public health services CCG and LBB procure as in Option 4 but including reference to services commissioned by NHSE which will transfer to LBB in October 2015 subject to the forthcoming technical guidance on this. Option Advantages (including but not limited to) 1.Do Nothing Reduced uncertainty in provider market Avoidance of officer time spent on re-procurement 2.CCG-only procurement 3. Integrated CCG and ESC procurement Reduced complexity of procurement (for CCG) Reduced officer time spent on re-procurement (for LBB) Reduced complexity of procurement compared with options 4/5 Opportunity for innovation Opportunity to secure financial savings Opportunity to benefit from joint outcomes which align with Thriving Families Possibility of reduced commissioning costs Opportunity to benefit from estates maximisation/rationalisation e.g. through inclusion of children s centres Disadvantages (including but not limited to) Loss of opportunity for innovation Loss of opportunity for integration Loss of opportunity for QIPP Loss of opportunity for prevention of escalation to high cost services Loss of opportunity for efficiency savings Loss of opportunity for innovation Loss of opportunity for integration Loss of savings opportunity( for LBB) Loss of opportunity to specify joint outcomes Loss of opportunity to secure joint preventative outcomes through the inclusion of Public Health Services i.e. young people substance misuse, sexual health services and school nursing Reduced opportunity for innovation Reduced opportunity to make savings on public health services through loss of economies of scale 4. Integrated CCG and LBB Procurement Reduced complexity of procurement compared with option 5 Opportunity to for innovation including in the commissioning School nursing has only recently transferred to LBB and needs assessment not completed therefore uncertainty re required outcomes As above re sexual health 29

34 5. Integrated CCG, and LBB NHSE and Procurement Integrated Children & Young People s Services Business Case of public health outcomes Opportunity to secure financial savings including on public health services Opportunity to benefit from joint outcomes including public health outcomes especially for young people Maximum opportunity to achieve joint health and social care outcomes Maximum opportunity for safeguarding outcomes Maximum opportunity for innovation Maximum opportunity to secure financial savings (although see disadvantages) Possibility of reduced commissioning costs Maximum opportunity to benefit from estates utilisation ( health visitors and Children s Centres) Loss of opportunity to secure joint public health, safeguarding and prevention outcomes from inclusion of commission of health visiting, health visiting growth and Family Nurse Partnership (subject to technical guidance from DH) Increased complexity of procurement compared with option 3 Maximum complexity owing to timescale of health visitor transfer from NHSE to LBB and existing joint commissioning with Bromley for Family Nurse Partnership Maximum opportunity for financial savings although limited to management costs in respect of health visiting and health visitor growth (due to ring fencing expected to be prescribed in forthcoming technical guidance) Risk of reduction in public and provider confidence during the transition period and mobilisation of new prime contractor Recommendation: The recommended option is option 5 because it maximises the opportunity for integration and increased efficiency. 2.4 Overview of current to new service model The change of service model will be from: A fragmented commissioning and provider landscape where a range of providers are contracted to provide a discrete range of services An integrated landscape where all providers, whether the prime contractor or subcontractors, deliver the same set of outcomes and can see where their contribution whole fits into the big picture. Children s services lend themselves to this approach because integrated care is known to represent good practice. The proposed new model - we will be looking to invest in: Improving the health of the child and adolescent Improving preventative and supportive services for the children, adolescents and their family Improving services that support and avoid escalation Develop new and innovative service models (that respond to the changing needs of the population) Improving outcomes (clinical and patient) for the child or adolescent Rewarding for outcomes, rather than rewarding for activities Improving the health of our children and adolescents. We will be looking to disinvest in: Duplication caused by the lack of integration High cost services designed to respond to ill-health. 30

35 2.5 Assumptions for new service model The new service model is predicated on the following assumptions: That we proceed on the basis of Option 5 assuming, until there is any reason to do otherwise, that public health services commissioned by LBB are included in the model with NHSE to be negotiated into the contract at a later point. That the prime contractor is able to meet the outcomes required by the different commissioner stakeholders. The prime contractor may not be the main provider of services. Potential providers are involved in the development of the service model via the competitive dialogue process. That there are sufficient major providers with a sufficiently large turnover who express an interest in developing the model That those providers are credible as prime contractors capable of leading on the full range of care pathways from preventative to acute. 2.6 Service specification for new model All current services are contracted with detailed service specifications. Outcomes based service specifications for the new service are being developed by the Project Team. Eleven high level overarching outcomes have been developed. The validity and comprehensiveness of these will be tested at a market warming event with potential providers and a wide range of stakeholders in June These high level outcomes will then be further refined by the Project Team in to a full range of specific outcomes for each pathway. Providers will then be invited, through competitive dialogue, to develop a service model based on the programme budget available, to deliver those outcomes. The BCCG s Quality & Safety Group, the LBB team and the Project Team will need to approve the outcomes and services specifications for the contract. The Project Team comprises for the service specification and outcomes will be (this is subject to ongoing refinement): Director of Commissioning Assistant Director for Integrated Commissioning Head of Integrated Commissioning Children, Young People and Maternity Head of Procurement (Procurement lead for the project) Clinical Lead Governing Body Clinical and Locality Lead Designated Nurse Safeguarding Information Governance (& IT) Lead Project Finance Manager Clinical Quality Lead Deputy Director Family Youth and Employment Head of Social Care Placements Head of Children s Social Care Head of Prevention Strategy Procurement Manager Head of Procurement Manager ESC Service Manager Youth Crime and Prevention Public Health Consultant Head of Finance ESC BCCG BCCG/LBB BCCG/LBB BCCG BCCG BCCG BCCG BCCG BCCG BCCG LBB LBB LBB LBB LBB LBB LBB LBB LBB 31

36 Head of Legal Services Head of HR Services Project Manager Integrated Children & Young People s Services Business Case LBB LBB LBB A strategic group will then be extracted from the above to undertake the evaluation of the prequalification responses, undertake the competitive dialogue and evaluate the tenders received. We will also be including within that evaluation team a patient representative. 32

37 Examples of more detailed outcomes are shown below: Integrated Children & Young People s Services Business Case Strategic Outcome High Level Outcomes Possible Service Provision End of Life Care Children who are diagnosed with a terminal or life limiting illness or condition, and their families, are supported with all of their associated needs and enabled to end their life in their place of choice Neuro-disability: Children and young people who may have ADHD or be on the autism spectrum are identified and diagnosed from the first symptoms and signposted to appropriate services Children and young people are enabled to access education Children and young people are enabled to access social activities and live lives as normally as possibly Children and their families are supported emotionally and spiritually Children and young people are kept free from pain Children and young people end their life in their place of choice Autism Spectrum Disorder and ADHD is differentiated from other potential causes of similar behaviours prior to commencement of a formal diagnostic process Families of children not engaged in formal diagnostic process but with ongoing problems at home and/or school are provided with or signposted to alternative pathways Children with ASD or ADHD are diagnosed as early as possible Children with complex co-morbidities associated with ASD or ADHD are identified Delivery of palliative nursing care for children in required settings Delivery of psychological support for children and families Co-ordination of complex care packages at and between home, school and respite care Delivery of pre-diagnostic screening of children who exhibit behaviours which may be indicative of ASD or ADHD Delivery of multi-disciplinary diagnostic pathways for ASD/ADHD Delivery of comprehensive ongoing mental health service for children with complex comorbidities Delivery of parenting programmes for families of children with mild to moderate ADHD in accordance with NICE guidelines Delivery of on-going management of children with severe ADHD in accordance with NICE guidelines Delivery of behaviour management programmes for children with ASD/ADHD and severe challenging behaviour (with and without mental health comorbidities Complex & Additional Needs: Children with complex disabilities and additional needs are diagnosed and their needs assessed as early and as possible to achieve their maximum potential Children with congenital conditions, developmental delay, disability as a result of illness/adverse event eg brain injury, meningitis are identified Families of children with the above are supported and trained to manage their clinical and behavioural needs Families and schools of children with the above are supported and trained to maximise their mobility, speech and language, gross and fine motor skills Children and young people have an up to date Education, Health and Care Plan Delivery of diagnosis, assessment and review of children with complex and additional needs Delivery of medical management of the above Delivery of speech and language therapy, occupational therapy, physiotherapy for the above including both direct input and provision of programmes to parents and educational settings in accordance with Education, Health & Care Plans Delivery of nursing advice, support and training for parents and educational settings Delivery of health assessments 33

38 Young people: Young people who are at risk in relation to crime, not being in education, employment and training (NEET),, teenage pregnancy, substance misuse, sexual health, poor emotional health and wellbeing are supported to engage, stay safe and health and achieve their maximum potential reduce the number of year olds not in education, employment or training; Diverting and supporting young people from offending and out of the youth criminal justice system Reduction in number of ASB incidents with children involved Significantly increasing access to physical, mental and substance misuse services including drug and alcohol prevention and drug and alcohol treatment programmes; and reassessments for Education, Health and Care plans for children aged 0-19 Delivery of Continuing Health Care Assessments Delivery of transition planning for children with EHC plans from age 14 Delivery of the school nursing service including sexual health clinics Delivery of evidenced based programmes for substance misuse Delivery of emotional health and wellbeing interventions Delivery of targeted issue based youth work Services to improve the physical and emotional health outcomes of young offenders Building on evidenced based models to promote sexual health and wellbeing Supported to achieve 5 A* to C s at GCSE Delivery of targeted intervention Programmes to prevent youth crime Delivery of careers information, advice and guidance Young Carers: Young carers are supported to achieve their maximum potential ensuring early intervention and prevention strategies and services are in place when the level of care-giving and responsibility to the person in need of care becomes excessive or inappropriate for that child, risking impacting on their emotional or physical well- being or educational achievement and life chances Universal Services and Targeted Early Help during the Early Years: All children and young people in Bexley are supported to be healthy and ready/prepared to maximise their opportunities from To reduce the number of teenage girls or young women Reduce the health inequalities of young offenders Reduction in number of ASB incidents with children involved Young carers are identified earlier and achieve all the outcomes below* and; support provided for families is more personalised, integrated and holistic; supported by tackling the underlying causes of inappropriate caring roles improving emotional and physical health; Young carers are lifted out of inappropriate caring roles. Improved readiness of children for school Improved consistent parenting Including improved behaviour management Improved speech, language and Raise awareness amongst professionals on the issues faced by young carers Provide interventions to support young carers to achieve their full potential Delivery of the children centre services across 3 localities including 10 children centres and 4 satellites Delivery of evidence based parenting courses 34

39 education and their contribution to society Integrated Children & Young People s Services Business Case communication skills Increase opportunities for adults to participate in activities that improve their personal skills, education and employability; Development of healthy lifestyles Improved parents understanding of their responsibilities for their children s safety and well-being. Improved services for perinatal women to reduce health inequalities (smoking during pregnancy/obesity) Patients and carers empowered and supported in the community Delivery of services that address the obesity agenda Delivery of targeted speech and language sessions Delivery of behaviour management and TMHS Delivery of integrated community midwifery and health visitor services Deliver opportunities to parents to engage them in employment, education or training Delivery of breast feeding support & infant feeding education across localities Delivery of family support and outreach services 2.7 Service KPIs for new model & monitoring arrangements A full set of KPIs will be developed when the outcomes have been defined. Examples by strategic outcome are: Universal Services and Targeted Early Help during the Early Years: All children and young people in Bexley are supported to be healthy and ready/prepared to maximise their opportunities from education and their contribution to society Young Carers: Young carers are supported to achieve their maximum potential ensuring early intervention and prevention strategies and services are in place when the level of care-giving and responsibility to the person in need of care becomes excessive or inappropriate for that child, risking impacting on their emotional or physical wellbeing or educational achievement and life chances Children in Need and Looked % increase initiation breastfeeding % increase exclusive breastfeeding % improved speech, language and communication skills Achieved level 2 UNICEF accreditation % improved parenting skills & behaviour management % children school ready % reduced smoking during pregnancy % reduced number of inappropriate referrals to Children s Social Care % decrease in tooth decay % improvement health and development outcomes for 2 year olds % improved health lifestyles reduced obesity Engagement to maternity services by 12weeks 6 days % reduced bullying% achieve 5 A*-C s at GCSE % improved school attendance % decrease of young carers in appropriate caring roles % improved emotional health of young carers % improved school attendance % reduction young people becoming LAC 35

40 after Children: Children in need are supported to achieve their maximum potential and prevented from needing high cost interventions such as residential/foster care/mental health admission Integrated Children & Young People s Services Business Case % step down and stay down from CSC % improved emotional well being % increase in diversion services from offending and out of the criminal justice system % reduced youth re-offending % increase in smoking cessation % decrease in substance misuse % decrease in teenage pregnancy Enrolled with EET (C&YP aged 16yrs +) Enrolled at school (under 16rs) Decrease in the number of fixed (short term) exclusions Decrease in the number of permanent exclusions Each child in the family has less than 3 fixed term exclusions in last 3 school terms 2.8 Success criteria for new model Success criteria for new model Potential for one point of entry to all of the services (e.g. aligned with the Childrens Services Front Door and Thriving families to deliver Right First Time ) Patient (and carer s) experience of services improved More appropriate and planned streamlined access Improved outcomes for clients and patients Services are delivered locally in the borough of Bexley wherever possible Prevention of poor and expensive outcomes Less duplication of services Reduced waiting times for services (where appropriate) Less gaps between services Meeting the national and local key performance criteria Improved efficiencies in terms of patient pathways and costs Managed integrated care pathways Information transmitted between services to facilitate care Young people who are on the border of transition to adult care receive services when needed and transition seamlessly into adult services in a planned way More investment and focus on prevention and self-management support services for patients Cost reductions 2.9 Clinical support for new service model Dr Karen Upton has been nominated as the GP clinical lead for Safeguarding and Paediatric Services by Bexley CCG and will be supporting the procurement process. BCCG s Governing Body will be asked to nominate a further locality GP clinical lead from the Governing Body to assist in the clinical design and evaluations How the new model will be performance monitored in Business as Usual mode The intention is to contract for the provision of these services using one contract with a single prime contractor (this may not necessarily be the main provider of the services). Clearly defined performance metrics will be developed for the services to be commissioned, including the National Quality Requirements and these will be monitored through the monthly contracts monitoring process. A Clinical Quality review meeting will also be put in place. The service will be commissioned using the NHS Standard Contract and subsequent amendments, which contains in the General Conditions, the contracts management clauses, 36

41 including performance reporting, performance management and dispute resolution measures. The BCCG will be the lead commissioner and the contract will be a schedule of the Section 75 agreement between BCCG and LBB. 3. Consultation & Communications Preparation and planning is paramount to the success of this programme. Early engagement is taking place with potential prime contractors to establish if a market will exist for this type of procurement. An event has been planned for providers and stakeholders to consult and engage on the outcomes and potential service model. The broad aims of the communications plan are: To communicate the right message, to the right people, at the right time To help keep stakeholders informed To respond to stakeholders queries To aid delivery of the new service through effective communication Our project-specific objectives are: To provide key messages explaining the work being undertaken To explain specific information about and build confidence in the new service model To ensure that patient groups are engaged To ensure that stakeholders are presented with a balanced view on changes being made To identify and support key spokespeople to deliver the key messages Dependencies The successful delivery of this communication and stakeholder engagement plan will be dependent on: LBB Public Cabinet approval is achieved BCCG Governing Body approval is achieved Acknowledgement and agreement by all partners that a consistent and transparent approach to communication and engagement with any audience is essential. Understanding that stakeholders have differing awareness, information needs and accessibility issues Engagement of the Bexley Voluntary Service Council to ensure the local voluntary sector is fully engaged in service design Patient group engagement in service redesign GP engagement & support Timely delivery of communications to stakeholders Ensuring commissioning communication channels are used effectively to ensure a wide pool of potential providers. Robust project management and reporting with clear deadlines to ensure the delivery of a whole system service redesign Key Messages These will be developed and refined to meet the plan s aims, but overall the messages will inform stakeholders that the development of an integrated children and young people s service will: Improve outcomes for children and young people Provide clearer care pathways which are integrated to ensure Right first time Improve stakeholder confidence in provision, Reduce duplication of services and unnecessary movement around the system 37

42 Reduce gaps between services Integrated Children & Young People s Services Business Case Communications networks The following communication channels are used to communicate with our stakeholders. Stakeholder group Channels CCG LBB Other NHS bodies Political Parents, Children and Young People and Patient representative groups Community Media Bexley GPs Bexley Practice Managers Governing body members CCG Executive Officers and staff involved with quality, safety and finance. Health and Well Being Board Integrated Commissioning Board Heads of Service Children centre staff Other local CCGs (especially Greenwich and Bromley) which jointly commission tertiary audiology) Neighbouring acute and community providers NHSE Leader LB Bexley Cabinet member for Children and Young People Peoples OSC Local MPs LMC Patient Council Bexley Healthwatch Relevant voluntary and self-help groups (tba) Patient participation groups Children in Care Council Youth inclusion Project Children Centres and parents forums Youth Council CE, Chair and Coordinator of BVSC Community forums Voluntary organisations Locals News Shopper, Bexley times, Mercury Letters, s, locality meetings, CCG Bulletin, monthly staff briefing,, intranet, secure extranet for GPs the GP zone, presentations, Q&As Reports and , written stakeholder briefing HWBB meetings Others: written stakeholder briefing, 1:1 briefing (as necessary) Written stakeholder briefing, presentations, Q&As, engagement meetings, agenda item at patient council ; 1:1 briefings, Written stakeholder briefing, Q&As, engagement meeting s with information to go in In PPG newsletters Some of the above, especially leaders of patient groups may require a 1:1 briefing Social media Written stakeholder briefing, Q&As Written stakeholder briefing Stakeholder Social media Reactive statement drafted Social media 38

43 3.1 Patient council, patient groups engagement and support for new service model No engagement with patient groups has taken place to date but the Patients Council, Healthwatch and relevant voluntary organisations were invited to take part in the stakeholder engagement event in June. This event also engaged with a wider audience within LBB children and young people services. We will also discuss this potential model with the Patient s Council to seek their input to the service specification. A specific patient focus group will be formed. 3.2 Clinical engagement in primary care A programme of engagement with localities took place in June. A GP clinical lead representing Bexley CCG will lead the project clinically (for the CCG) Dr K Upton. 3.3 Clinical Engagement in secondary care / other A wide range of professionals are involved in the delivery of children s services including: Acute and community paediatricians Therapists Psychiatrists, psychologists and psychotherapists Nurses Educational psychologists Social workers Specialist teachers Audiologists It is essential to harness their expertise and experience to ensure that we have defined the right outcomes and care pathways and this will be undertaken through the engagement event, the competitive dialogue process and through the membership of the project group. We also have the input and advice of Dr Jenny Selway, Consultant in Public Health Medicine (with a special interest in children s services) from Bromley CCG through LBB s Public Health contract with Bromley. 3.4 Consultation with, and notices given to current providers All current providers are aware of Bexley CCG s intention to re-procure the services, although formal notice has not yet been served. Formal notice will be served following CCG Governing Body and LBB Public Cabinet approval to proceed. 3.5 Market Engagement A market engagement exercise will be undertaken with potential bidders as part of the procurement process and is scheduled for 20 August. 39

44 4. Equality Impact Assessment 4.1 Equality impact assessment completed details Equality Impact Assessment Does the scheme affect one of the following groups more or less favourably than another? Age Consider and detail (including the source of any evidence) across age ranges on old and younger people. This can include safeguarding, consent and child welfare. Disability Consider and detail (including the source of any evidence) on attitudinal, physical and social barriers. Sex Consider and detail (including the source of any evidence) on men and women (potential to link to carers below) Gender reassignment (including transgender) Consider and detail (including the source of any evidence) on transgender and transsexual people. This can include issues such as privacy of data and harassment. Marriage and civil partnership Consider and detail (including the source of any evidence) on people with different partnerships. Pregnancy and maternity Consider and detail (including the source of any evidence) on working arrangements, part-time working, infant caring responsibilities. Race Consider and detail (including the source of any evidence) on difference ethnic groups, nationalities, Roma gypsies, Irish travellers, language barriers. Religion or belief Consider and detail (including the source of any evidence) on people with different religions, beliefs or If yes, explain impact and any valid legal and/or justifiable exception The service model is for children and young people, young adults up to 19 in some provisions, and families. It is intended to improve services for this age group but without detriment to other age groups The proposed service will have a positive impact on children with complex needs as the referral pathway will be improved and waiting times to services reduced in particular to children with ASD. None identified None identified. None identified. The proposal will have a positive impact on the maternity pathway. Women will have access to a wide range of services and be well informed of the maternity pathway supported by the established maternity services liaison committee. Services will be community based to support improved caring responsibilities. None identified None identified 40

45 no belief. Integrated Children & Young People s Services Business Case Sexual orientation Consider and detail (including the source of any evidence) on heterosexual people as well as lesbian, gay and bi-sexual people. Carers Consider and detail (including the source of any evidence) on part-time working, shift-patterns, general caring responsibilities. Other identified groups Consider and detail and include the source of any evidence on different socio-economic groups, area inequality, income, resident status (migrants) and other groups experiencing disadvantage and barriers to access. Is the impact of the scheme likely to be negative? If so, can this be avoided? Can we reduce the impact by taking different action? None identified The service will have a positive impact on young carers. Children and young people will be assessed to ensure they are not undertaking inappropriate caring roles and interventions put in place to ensure improved learning, health and emotional wellbeing outcomes None identified. The impact of the programme will not be negative as the referral pathways will be improved, there will be a single plan in place preventing duplication, and interventions will be put in place considering a whole family approach. Hence ensuring improved family experience. 4.2 Impact of proposed service on choice, access, equality The prime contractor will be accountable for ensuring that services are accessible and delivered as close to home as possible. By working with a range of subcontractors the prime contractor will ensure that where possible families are offered a choice of services to deliver the required outcome. However the priority will be to ensure the achievement of equality in relation to ensuring early identification and intervention, to prevent disadvantaged children and young people suffering poorer outcomes. The project will also aim to maximise the range of services that are provided to patients from locations within the Borough of Bexley thereby increasing accessibility of services. A provider and stakeholder engagement day was held on the 16 th June 2014 to discuss the potential contract and to enable feedback on outcomes and pathways. A market stimulation event will be undertaken once the advert and PQQ is issued in July/August. This event will give providers the opportunity to be engaged in the procurement and to network with one and another to develop their supply models. Consultation: Due to the reconfiguration of some of the services a consultation exercise may need to take place with the public and staff as the procurement and programme develops. 41

46 5. Quality Impact Assessment 5.1 Stage 1 Proforma Scheme Details: Scheme Title / Name Clinical Leads Management Lead Sponsor Integrated Children & Young People Prime Contractor Dr Karen Upton Dr Jenny Selway Alison Rogers Assistant Director for Integrated Commissioning BCCG/LBB Jacqueline Skinner Head of Integrated Commissioning for Children and Young People and Maternity LBB/BCCG Sarah Valentine Director of Commissioning BCCG Mark Charters Director of Education and Social Care LBB Answer positive/negative in each area. If Negative, score the impact, likelihood and total in the appropriate box. If score 10 insert Yes for full assessment (Please see Quality Impact Assessment Tool Stage 1 final for guidance on scoring and rag rating). Area of Quality Duty of Quality Patient Experience Impact question P/N Impact Likelihood Could the proposal impact positively or negatively on any of the following - compliance with the NHS Constitution, partnerships, safeguarding children or adults and the duty to promote equality? Could the proposal impact positively or negatively on any of the following - positive survey results from patients, patient choice, personalised & compassionate care? Does the business case include patient involvement or has it acted on patient/carer experience in its development? Which patient/carer groups have been consulted/ involved in development of this project? Monitoring of complaints to include numbers/themes/whether timeframes are met/whether upheld/action arising. Compliance with 2009 NHS Complaints Regulations +PHSO (Ombudsman) principles. Ensure audit of patient experience + evidence learning from feedback to be included. Proposed access and waiting times. P P Score Full Assessment required 42

47 Patient Safety Clinical Effectiveness Prevention Productivity and Innovation Safeguarding Adults and Children Note child safeguarding is also statutory for adult focused services. Could the proposal impact positively or negatively on any of the following safety, systems in place to safeguard patients to prevent harm, including infections? Could the proposal impact positively or negatively on evidence based practice, clinical leadership, clinical engagement and/or high quality standards? Has reference to up to date relevant national guidance and research been made in the design of this project? Clear demonstration that relevant NICE Quality Standards, Public Health Guidance and Clinical Guidelines are being taken into account / followed. Could the proposal impact positively or negatively on promotion of self-care and health inequality? Could the proposal impact positively or negatively on - the best setting to deliver best clinical and cost effective care; eliminating any resource inefficiencies; low carbon pathway; improved care pathway? Does the proposal comply with: 1. Policy/Guidance/Procedures Bexley Safeguarding Children and Adults Boards Guidance and CCG policy. Pan London Child Protection Procedures (2010). Working Together to Safeguarding Children (2013). Pan London Safeguarding Adults Procedures (2011) CQC Essential Standards of Quality and Safety Open Safeguarding Culture with being open guidance.-whistleblowing policy in place. Procedures for reporting of incident/concerns including feedback to staff and patients of actions taken and outcomes. Safer recruitment P P P P P 43

48 arrangements and procedure for dealing with allegations against staff including identification of a Senior Named Officer within their organisation to liaise with the Local Authority Designated Officer or Safeguarding Adult team. Staff training policy and compliance with this. Arrangements for staff supervision. 3. Compliance with Equality and Diversity Act Monitoring of compliance and reporting. Equality and Diversity performance indicator identified. Note: Safeguarding children and adults frameworks will need to be embedded within agreed contract and reporting arrangements. Integrated Children & Young People s Services Business Case Please describe your rationale in detail for your assessment of each positive impact here: The project is has clinical and professional leadership and engagement from health and social care led and the service specifications will be required to be approved by the Quality & Safety Working Group prior to formal Governing Body approval. The aims of the project of direct relevance to the Quality Impact Assessment are: Duty of Quality. The aim of the project is to secure the highest quality care pathways and interventions for children, young people and families Patient and Service User Experience the aim of the project is to increase integration between services and streamline care pathways, reducing duplication of referrals and preventing children falling into gaps between services. The introduction of a single point of access will improve the experience for service users Patient and Service User Safety the integrated system will have a positive impact on the safeguarding of children and young people by ensuring a single provider is accountable for safeguarding across the whole system. There is no reason for any negative impact on infection control Clinical Effectiveness and Evidence Based Practice the integrated model provides the opportunity for innovative models of clinical and professional leadership providing more joined up opportunities to implement national guidelines (including NICE) which frequently specify integrated care pathways Prevention prevention of poor outcomes and escalation to high cost services is one of the central aims of the project Productivity and Innovation the project seeks to ensure improved productivity by moving towards commissioning for outcomes and allowing the contractor the freedom to innovate by re-directing resources from across the system to target specific outcomes preventing duplication and repetition of assessment and intervention. Safeguarding Children safeguarding is one of the key high level outcomes of the which will be required of the prime contractor. The integration of the model with the LBB Thriving Families programme will ensure that resources are targeted as early as possible on children at risk of abuse and neglect. 44

49 5.2 Expected Quality Metric Outcomes (success criteria) Metric these need to be measurable Patients and carers empowered and supported in the community High quality, timely and appropriate referral from primary care, schools, social workers and other appropriate referrers Access and waiting times Clinical, social and educational outcomes Patient and service user experience Resilience and sustainability of new model including workforce planning issues Facilitation of inter-professional and inter-organisational working and shared learning Expected impact Positive. The preventative nature of the service will ensure that children and young people and their families are supported as far as possible without admission to in-patient care, out-borough education, foster care or residential care. Positive. The service will deliver a single point of access which ensure the experience for referrers and ensure that children are directed towards the right care pathways reducing the burden on the referrer to decide where to refer Positive. The new service will be subject to the waiting time targets. We will also seek to maximise the services offered from locations within the Borough of Bexley Positive. The new model will be based on delivery of jointly agreed outcomes recognising the interdependency of each upon the others Positive. The prime contractor will be responsible for a whole system increasing their ownership and accountability for the service user experience. In children s services where service users are frustrated it can often be because of delays in engaging different partners. This will be addressed by the new model. Positive. The model will have a positive impact on workforce planning with the provider better able to plan for the whole system and having the flexibility to develop skills and talents by providing wider opportunities across the system. Positive. As above plus the opportunity for innovative partnerships as the prime contractor develops new relationships with sub-contractors especially in the voluntary sector Signature: Alison Rogers Designation: AD Integrated Commissioning Date: 8 May Stage 2 Proforma This has not been completed as the outcomes from stage 1 indicate it is not required 45

50 6. Privacy Impact Assessment 6.1 Privacy Impact Assessment Screening PIA SCREENING QUESTIONNAIRE Project / Policy Lead: Project Outline - Set out a short summary of the intended project, policy or procedure. This does not need to be complex. If a PID or Terms of Reference for the project already exist please supply these. Environmental Scan - What is already out there? Do PIA's in this area already exist? Have any consultations (with professional associations or patient groups) already taken place? Stakeholder Analysis - Who might be affected? What is the purpose of this new process or system? Why is it required? Will the proposed new process or system gather, process or store person identifiable data or corporate sensitive information? Is the proposed new process or system likely to involve a new use or significantly change the way in which existing personal data is handled or processed? Is the proposed new process or system likely to allow personal information to be checked for relevancy, accuracy and validity? Is the proposed new process or system likely to incorporate a procedure to ensure that personal information is disposed of through archiving or destruction when it is no longer required? Is the proposed new process or system likely to have an adequate level of security to ensure that personal information is protected from unlawful or unauthorised access and from accidental loss, destruction or damage? Alison Rogers The project is the proposal to undertake an integrated procurement process between LBB and BCCG for children s acute, community, mental health services as well as Childrens Centres and services commissioned from the voluntary sector An internet search has not revealed any relevant examples. No consultations have taken place as yet The procurement will affect all children and young people and their families who use acute inpatient and outpatient services, CAMHS, specialist childrens community services, Children s Centres, and a range of preventative and early intervention services commissioned by LBB. It may also impact on users of health visiting, school nursing and substance misuse services The project is a QIPP scheme signalled in the CCGs commissioning intentions. LBB has agreed to explore the possibility of a joint procurement to secure joint improvements and efficiencies Yes This will depend of the provider(s) but it is likely that they will wish to further integrate information systems to secure service improvements and efficiencies Yes Yes Yes 46

51 Is the proposed new process or system likely to enable the timely location and retrieval of personal information to meet subject access requests? Is the proposed new process or system dependant on a third party to supply the system, undertake processing or provide support/maintenance? Is the proposed new process or system likely to create new data flows and will they be internal, external or both? Has this new process or system been added to the CCG s Information Asset Register? Integrated Children & Young People s Services Business Case Yes Possibly Yes they will be external to the CCG but may be internal to LBB No Name: Alison Rogers Signature: Job Role: Assistant Director for Integrated Commissioning Department: Integrated Commissioning Unit Date: 12 May 2014 Date submitted to IG Department: 12 May 2014 Submit Form to: Information Governance Department, NHS Bexley Clinical Commissioning Group 47

52 7. Economic, Social, Environmental Considerations (Social Value Act 2012) 7.1 Considerations to be made The current service providers are predominantly locally based healthcare providers and as such, current service provision may be deemed to promote the economic well-being of the local area. Certain services are provided outside of the Borough of Bexley and we will look to bring those back into Bexley wherever possible and safe to do so. The new service will seek provision from a prime contractor and this would enable local service providers to bid on their own or in partnership with other providers to provide the service. Local third sector organisations will be involved from the outset enabling them to contribute to service design and be part of the potential solution. This will be key to the evolution of the preventative model and will enable the development of social capital linking to TUPE will apply to the commissioning of this service and as such, it is likely that the new service will not necessarily lead to a loss of skills locally. BCCG and LBB will facilitate the TUPE process between the incumbent providers and appointed prime contractor to ensure that there are no undue delays in the process and that locally available skills are retained where possible. Service providers will be required to demonstrate how their proposals meet the requirements of the Social Value Act

53 8. Finance Integrated Children & Young People s Services Business Case 8.1 Analysis of current activity and costs by provider The parameters for the final programme budgets are as follows: Children & Young People s Integrated Care Commissioning Organisation Programme Budget CCG funded 14,600,059 LBB Education, Families, Youth & Employment & Social Care 3,718,500 LBB Public Health 786,000 Total 19,104,559 The NHS England budget for services of 2,994,000 has been excluded from the initial programme budget but will be considered within the negotiations with the prime contractor Bexley Clinical Commissioning Group High Level Analysis Provider Service Current Indicative Actual Budget Activity Oxleas NHS Specialist Children s contacts 3,590,860 Foundation Trust (FT) Community Services (including overnight respite in the home) YOT Health service 131 young people 36,000 LAC Service 180 contacts 56,000 MASH Service New Service 49,606 St Georges Healthcare (subcontracted to Oxleas NHS FT) Oxleas NHS FT *Lewisham & Greenwich HCT Dartford & Gravesham HCT Other acute providers incs. Guys & St Thomas, Kings, GOSH etc. Tertiary audiology (Bexley, Bromley and Greenwich) Child and Adolescent Mental Health Services Elective & non elective in-patient care Outpatient care Elective & non elective in-patient care Outpatient care Elective & non elective in-patient care Outpatient care 632 appointments (across BBG) 1,800, spells 3,529, first & follow up 1,363,585 appointments 1407 spells 1,562, first & follow up 422,068 appointments 844 spells 1,682, first & follow up appointments 378,002 Looked after Children 50 10,000 Assessments Ellenor lyons Palliative care 120 children not 40,707 including siblings supported CAMHS cost per case 79,955 Total 14,600,059 *Lewisham & SLHT activity combined to reflect anticipated patient flows 49

54 London Borough of Bexley Education & Social Care Spend Analysis: Provider Service Indicative Activity Current Budget Bexley Women s aid Domestic violence 1,695 professionals, 105,500 project young people and mothers engaged Oxleas NHS FT Parenting programmes 240 families engaged 45,000 Charlton Athletic London Borough of Bexley/Bexley Moorings London Borough of Bexley/YADT YIP targeted youth service Youth Inclusion projects North Youth Inclusion projects South 7,348 youth engagements 584 youth engagements 6,384 youth engagements 85,500 37,000 49,500 Homestart Home visiting service 652 children and 59,500 families engaged Bexley Moorings Befriending service 876 young people 101,500 engaged Oxleas NHS FT Outreach service 3,276 engagements 316,000 London Borough of Children s Centres 32,000 attendances 1,700,000 Bexley/five externally commissioned GLSCE Youth, uniformed and 7,105 young people 54,000 sports groups small grants accessed groups that have been funded from this grant Danson Youth Trust Universal youth service 8,356 young people 94,000 engaged Oxleas NHS FT CAMHS 329,000 Prospects Careers, Education Information, Advice and Guidance 10,215 inc YP with disabilities of which 604 are from target groups 545,000 Oxleas NHS FT Joint communication team 3,597 includes contacts and caseloads 197,000 Total 3,718, London Borough of Bexley Public Health Spend Analysis Provider Service Indicative Activity Current Budget Oxleas NHS FT Substance Misuse 77,000 School nursing 308,000 Sexual health lead 40,000 School nursing youth advisory 361,000 Total 786,000 Notes & Assumptions within table 1. Potential budget is indicative only and all parties/partners will need to confirm their contribution as the process proceeds and decisions are made about the final scope of the project. 2. Current health budgets are primarily based on block contracts for activity. 3. NHSE budget of 2,994,000 is ring-fenced and therefore not included in the savings projections. 50

55 8.2 Analysis of proposed new model costs by provider The new model will be a prime contractor model and the CCG/LBB are setting a stretch target which will be to reduce expenditure by 20% from the total programme budget 19,104,559 (this figure excludes any NHS England services which may be included at a later date). This will be achieved through involving the providers in competitive dialogue to re-design and deliver an integrated future model of service that reduces duplication and increases front line patient management. See section 2.3 on savings made in other projects. 8.3 Proposed savings current financial year and next financial year and QIPP impact BCCG and LBB are in discussion about the budget from both parties which would form the basis of a programme budget for the children and young people procurement. BCCG has analysed the budgets which are either specific to children or comprise an element of children s provision. LBB has outlined the budget lines from the Education & Social Care Directorate which it is considering including and BCCG financial information from the 2013 Public Health Transfer has been used to estimate potential public health elements. It should be emphasised that at this stage the potential budget is indicative only and all parties/partners will need to confirm their contribution as the process proceeds and decisions are made about the final scope of the project before the procurement is initiated. Early discussions have taken place between BCCG and LBB finance colleagues to develop a set of working assumptions to underpin the financial relationship for the procurement. These are: The programme budget is set on the 2014/15 budgets (2013/14 out turn) and bids against this for savings will be evaluated. The financial evaluations will need to take into account the level of proposed savings offered by a prime contractor, the dis-investment in existing provision, versus the investment in new services, and considered against the service elements and outcomes the service offering (value for money and MEAT (most economically advantageous tender). We will also consider the % of the total price based on actual outcomes that is therefore at risk to the prime contractor. Both parties will need to agree how any savings are distributed. Once investments and disinvestments by services are considered. We will look for a contract duration of say 5 years to develop a partnership relationship and for the prime contractor to be able to invest in services this will be part of the competitive dialogue process However this assumes the agreement of a block/capped contract, or a reduced contract value that will not be subject to significant variations in year (or in future years) If NHSE projects are able to be included in the programme it may need to be protected from the 20% top slice because of the requirements of the national Health Visitor Implementation Plan (we are therefore in the previous tables excluding this budget) The procurement will focus on an element of the payment being linked to clinical and service user outcomes to incentivise performance of the provider (the % of this will be negotiated with providers but the negotiation will seek to maximise this element) We will be seeking a cumulative cost, rather than a cost per activity across the total contract to minimise the financial exposure via activity based contracting. We will look to link this to population needs Further discussion is needed to establish how to manage the different organisational boundaries and different definitions of a child aged 0-19 years. 51

56 It is recognised that both parties may have to decommission elements of the service going forward, but that we may be investing in alternative services that assist patients/service users in accessing the right first time pathways, and also look to increase self-management and support improved health and wellbeing. The table in section 8.1 shows the potential budgets for inclusion. It should be emphasised that acute figures are a full year projection based on month /14 and are therefore subject to change. Benchmarking is underway to further understand the potential scoping for the savings. The programme budget (shown below) for the procurement is the existing service costs. The CCG/LBB have set a stretch target of 20% savings at this stage however until full financial analysis is completed and bids are received this will not be able to be substantiated. It will also be necessary for the project to consider the dis-investment and reinvestment between the constituent parts of the services. Ascertaining the likely level of savings will be achieved through involving the providers in competitive dialogue to re-design and deliver an integrated future model of service that reduces duplication and increases front line patient management. Children and Young People Integrated Care Savings scenarios Commissioning Organisation Programme Budget 5% 10% 15% 20% 25% CCG funded 14,600, ,003-1,460,006-2,190,009-2,920,012-3,650,014 LBB Education & Social 3,718, , , , , ,625 Care LBB Public Health 786,000-39,300-78, , , ,500 Total 19,104,559 Savings will only be considered once the investments and dis-investments between individual services are first accounted for. 52

57 9. Sensitivity Growth Analysis Integrated Children & Young People s Services Business Case 9.1 Details Sensitivity Growth Analysis Details Analysis of population growth (via the Joint Strategic Needs Assessment) shows that whilst there will be a growth in the number of children in the Bexley area, this growth will not be as great as for other areas of the population. Bexley currently has 57,600 under 19s and this number is forecast to increase by 4.0% (cum.) over the next 5 years. The project seeks via the use of the following to offset the costs of the growth in the service needs for the population by: Reducing duplication between services Ensuring that the patient is directed to the correct service right time first time Improved efficiency of services (inc. productivity) Increased support to improve health Avoiding exacerbations or deterioration Improved self-management and advisory services Increased use of innovative technologies (tele medicine, tele health, patient support, selfmanagement) Investing in preventing ill-health Disinvesting in services (as appropriate) that are designed to respond to ill-health as the preventative model of provision advances. 53

58 10. Procurement Implications Integrated Children & Young People s Services Business Case 10.1 Procurement & Model of service and type of contract recommended Consideration is given as to whether the service outcomes of integration and also improved efficiency can be delivered without the need to revert to a formal procurement. The impact from the procurement regulations also is considered. The current expenditure is distributed across a range of providers the chart below shows the distribution of the 17.6m (and excludes Health Visiting) this is shown in two ways. It is clear from this that no one provider could be seen to hold a clear majority for the market and that the potential for competition could exist. In addition in a prime contractor arrangement the prime contractor does not need to be the prime (or main) provider of the services therefore another provider may be interested (and capable) of delivering on the prime contractor role. Analysis of the above Provider Current % of total spend Oxleas 37.72% Lewisham & Greenwich Trust 25.61% Dartford & Gravesham Trust 10.39% Other NHS Acute Trusts 11.47% Inspire 0.00% Bexley Women's Aid 0.55% Other social service providers 1.77% London Borough of Bexley (in-house) 12.50% 54