Enabling health and care transformation through devolution:

London Health and Care Devolution Enabling health and care transformation through devolution: Update and next steps 19 October 2016

Background This paper aims to update CCG governing bodies on the progress of the London Health and Care Devolution Programme as we move towards a second devolution agreement. Following the devolution agreements in December 2015, London partners have been working with five local and subregional pilots to support the development of business cases for devolution. When developing their proposals, pilots have been exploring what is possible within the current system and what explicit devolved powers are sought. It is clear that much can be done within existing powers, but that by overcoming some specific challenges, efforts to transform health and care could go further and faster. Pilots are setting out their transformation vision, offers by the local system to accelerate action and devolution asks to overcome identified barriers to progress. The emerging work of the pilots has reiterated the need for multi-level action, based on the foundational principle of subsidiarity. The devolution agreement last year described three levels for devolved powers: borough-level, STP-level and London, with aggregation only where necessary. This paper contains: A summary of current devolution proposals. This includes a description of the current thinking on the most appropriate approach for individual proposals (e.g. London level or voluntary draw-down by individual boroughs). These proposals continue to evolve as pilots finalise their business cases and with ongoing input from national bodies and central government and wider engagement. As such, the detail of proposals and spatial levels is still evolving. The proposals are therefore draft and work in progress. Timeline and process for the next steps 2

London already has a shared vision for better health and care New Models of Care Programme London Health Devolution Agreement National milestones Health and Social Care Act passed Better Care Fund Transformation in integrated health and social care Five Year Forward View the NHS strategy Greater Manchester s health and social care devolution deal Sustainability and transformation plans (STPs) announced 44 STPs under development 2012 2013 2014 2015 2016 London milestones London Health Board formed Better Health for London 64 recommendations for London Better Health for London: Next Steps First collaborative vision for London London Health and Care Collaboration Agreement Healthy London Partnership established London Health and Care Devolution Programme established Devolution pilots underway

Devolution aims to unlock barriers and enable transformation plans to go further and faster Transformation plans Devolution Improving the health and wellbeing of Londoners Learn more at: https://youtu.be/ir7okend9zs

The devolution journey Test how devolution could work in five areas of London Secure devolution based on robust business cases Devolution available across London

London s five pilots are exploring how devolution could work at different spatial levels Estates in Barnet, Camden, Enfield, Haringey and Islington ( North Central London ): making better use of health and care buildings and land Prevention in Haringey: exploring licensing and planning powers needed to ensure that local environments support health, and looking at early intervention to support those who have fallen out of work due to mental health issues Integration in Lewisham: creating One Lewisham Health and Social Care system by combining mental and physical health services and social care Integration in Hackney: Bringing together mental and physical health services, and health and social care budgets Key: type of pilot Sub-regional care integration Sub-regional estates Local care integration Integration across Barking & Dagenham, Havering and Redbridge: delivering a personalised health and care service focusing on self-care, prevention and local services that enable the sustainability of the health and care system Local prevention note that this borough is also part of the sub-regional estates pilot

01 Current status of proposals If you have any questions on the following please contact the programme team hcdevolution@london.gov.uk 7

Some asks are for the whole London system, others would be permissive, subject to local appetite and business cases The terms of application of each proposed ask are specified in the pages below. These broadly fall into two categories: - London level asks, which consist of the freedoms, powers and variations which, if granted, will apply to the London system as a whole; and - Local/multi-borough draw-down asks are the freedoms, powers and flexibilities which, if granted, will be made available to sub-regional and local health economies to adopt should they so wish, subject to robust business cases. 8

Integration: Summary of potential devolution asks Commissioning levers and financial flows Regulation Workforce Other Delegation / devolution of NHS England functions including primary care commissioning, capital and transformation budgets Greater alignment between NHS England, NHS Improvement and CQC for regulatory functions in London Funding and governance to support workforce transformation (London/sub-regional) Supporting pilots to co-develop and adopt innovative payment models The ability for a joint local authority/ccg structure 2c to take on commissioning functions, with pooling of budgets* The ability for an integrated / single delivery system to be regulated as a whole, despite underlying distinct organisational operating units* Supporting greater integration of the health and care workforce and addressing recruitment/retention challenges (London, sub-regional/local) Freedoms and flexibilities during the development and initial implementation stage of the pilot Enabling the delivery of integrated care and more consistent mental health and acute care; strengthening primary and community care, reducing hospitalisation and improving outcomes. Thus, enabling people to live more independently and contributing to the financial sustainability of the system Draft scope of ask Local/multi-borough voluntary draw-down (with some functions initially devolved/ delegated from national to London) London level *Note: Spatial level will depend on the design of any integrated system and also on agreed assurance / governance framework for re-designed regulatory framework 9

Estates: Summary of potential devolution asks London governance and delivery Business case approval Capital Utilisation A London estates board comprising local health economies, London and national partners to ensure clarity on London s assets, projects and capital needs, building up from STP estates strategies. Delegation of capital business case review and approval functions (sub-regional or London, depending on the delegation limit) Adoption of a commissioner capital control total (London with sub-regional draw-down) Accountability within London for utilisation of existing health and care estates An estates delivery unit to consolidate existing 2c London-level and national expertise to support local areas to develop and deliver high-quality capital cases Retaining the capital receipts generated by the London system to enable investment in health and care in London Releasing capital from surplus estate to invest in primary, community and hospital estate Releasing surplus land for housing and wider public sector use Accelerating estate transformation by streamlining decision-making Draft scope of ask Local/multi-borough voluntary draw-down (with some functions initially devolved/ delegated from national to London) London level *Note: Spatial level will depend on the design of any integrated system and also on agreed assurance / governance framework for re-designed regulatory framework 10

An estates board for London London partners recognise significant opportunities to enable greater value for Londoners from the NHS estate. These form the basis of London s devolution proposals. An estates board aims to directly solve some of the challenges of NHS estates approvals and disposals, by providing a single forum for NHS estate discussions in London and through early involvement of London government partners and national bodies. As it matures, the Board would also provide a mechanism to administer devolved responsibilities, including delegated business case approvals. The Board aims to enable strategic and decision-making functions to enhance efficiency, quality and transparency of discussions and decisions that are currently taken nationally. These functions would be phased over time, with the Board commencing with strategic and advisory role. The Board would aim to operate according to key principles: Subsidiarity, with decisions taken at the lowest appropriate level, and only taken at the London level when needed. Transparency with all relevant discussions taking place at the London estates board All partners bringing the collective expertise of their constituent organisations to achieve the greatest value for Londoners. Decision-making will seek to achieve consensus so far as is possible, while respecting the views and statutory accountabilities of constituent organisations. The role and function of the board has significant interdependencies with wider devolution proposals. Detailed discussions continue to clarify the proposed nature and scope of such devolved powers, and the board in its initial phase will be a valuable vehicle to collate expertise and streamline decision-making in this respect, allowing proposals to be developed at pace. The board s ability to fulfil the desired objectives would therefore be contingent on these devolved or delegated powers and resources being granted. 11

Prevention: Summary of potential devolution asks Devolution asks focusing on prevention have been progressed across three themes: Tackling Obesity Healthier environments Health and Employment Planning, licensing and fiscal powers to encourage healthier high streets (London and local) Powers to address problem gambling Contractual variations to Fit for Work service Use sumptuary tax revenue to invest in London health priorities Health as a fifth licensing objective for alcohol (for local trial) Devolve part of health and work budget to trial initiatives tailored to local needs (London ask with funding devolved to local/multiborough level) Powers to reduce tobacco consumption, distribution and illicit circulation (some pan-london elements for illicit tobacco) Complement individual Londoners efforts on staying healthy in their daily lives. Using devolution as a means to create better environments in which people can flourish Draft scope of ask Local/multi-borough voluntary draw-down (commencing with Haringey prevention pilot) London level 12

Ongoing activity Iterating proposals Workshops with central government, national bodies, London partners and pilots to align objectives and test the appropriate devolution levers to bring about intended health outcomes Maximising opportunities for alignment with STPs Supporting pilots to develop business cases by late October Discussions re: legislative change In partnership with DH, DCLG, NHSE and NHSI. London is examining amendments to existing legislation and considering additional legislative requirements Engagement on devolution asks and offers Engagement on and iteration of devolution offers and asks with the wider London system Exploring governance and accountability To be developed based on emerging pilot governance proposals and engagement with constituent organisations and London partners. Phased approach based on devolution requirements e.g. need for financial accountability Sharing learning Including shared learning from the pilots and development of a support package for non-pilot areas 13

01 02 Shaping final asks and the December agreement 14

15 CCG involvement in shaping devolved health powers in London Engagement has been key to developing the current set of asks and proposals. The high level proposals are subject to ongoing discussions with borough leaders, CCG Chairs and Chief Officers, LHCOG, BCF leads, London Prevention Board, LRET, HWBB chairs and the ADPH network. These opportunities for engagement with the developing devolution propositions will be critical, but they will not by themselves offer the mechanism for propositions to be explored comprehensively in detail, nor will these opportunities allow for the detailed and ongoing engagement likely to be required in the run up to December. For example, as pilot areas develop asks and discussions with London partners refine the detail, London s health and care system leaders may wish to be able to offer engagement which can respond flexibly and in an iterative way. The strategy for reaching agreement on London s December asks will require an approach which recognises that decision making will be necessary for different asks at different spatial levels. For example, where asks are emerging which would not of themselves affect all of London if granted (i.e. they are permissive and discrete to local or sub-regional footprints) then the appetite and support from a pan-london level would be beneficial but may not be essential to the case being made by the pilot area. However, where asks are emerging which would affect the whole of London if granted (i.e. where a pilot is making the case for devolution which would impact on all boroughs), then broad agreement of the London system would be needed. We are keen to ensure the asks are coproduced and are reflective of the London-wide system s thinking. As we draft the final agreement and shape our final asks, CCG governing bodies are asked to: 1. Note progress and the forward timescales to the next Devolution agreement for London, building on the commitments and priorities agreed in December 2015. 2. Review and provide any comments on the current proposals as they support specific Devolution Pilot requests and enable the potential to devolve certain powers across London partners, including CCGs. 3. Support the development of the final Devolution agreement(s) and delegate authority to a named individual (e.g. CCG Chair) to agree and sign off the agreement on behalf of the CCG.

Engagement with local government Local councils are engaged in discussions about health and care devolution. Illustrative engagement undertaken to date is described below: Month June July September September October November December Meeting or event Healthwatch Hackney London Councils and HSCIC Meeting Chief Executives (of local councils) of London Committee (CELC) Health and Wellbeing Board Chairs CELC CELC (TBC) Health and Wellbeing Board Chairs (TBC) In addition, significant engagement is underway at local level within pilots, among all stakeholders and political leadership. 16

Current programme and engagement timeline 2016 2017 2018 June July Aug Sept Oct Nov Dec Jan Feb Mar April April Key dates LHB STPs submitted STP operational plans submitted Pilot OBCs developed (TBC) Further devolution announcement CCG engagement 12 14 27 CCG Chief chairs officers meeting LTG London Prevention Board 14 15 LTG Themes, processes, timelines CCG CCG CFO 19 Chief CFO 17 Chief officers 14 Chief officers officers & Chairs Excerpts of draft agreement and emerging proposals LTG Updated agreement and proposals 29 20 LTG Final agreement Pilots Develop business cases and clarify asks and offers Iterate business cases and negotiate devolution Develop new working arrangements with phased implementation of activities within current powers Implement shadow arrangements Implement devolved arrangements Non-pilot areas Sharing learning from pilots Engagement on devolution asks and offers Develop business cases for devolution if locally desirable Implement shadow arrangements Londonwide activity Menus of devolution developed for London Develop London-level proposals Develop new working arrangements with phased implementation of activities within current powers Implement shadow arrangements Implement devolved arrangements Spreading learning

01 Annex Initial agreements published in 2015 The London Health and Care Collaboration Agreement The London Health Devolution Agreement 18

Two London agreements were signed in December 2015 The London Health and Care Collaboration Agreement Agreement to transform health and wellbeing outcomes and services, recognising: the need to shift from reactive care to prevention, early intervention, self-care and care closer to home the scale and complexity of the health and care system in London - transformation will be driven at three geographical levels the need to tailor solutions to the different needs of people and places and that locally shaped solutions will progress at different paces The importance of enablers, including estates The London Health Devolution Agreement Commitment by government and national bodies to work with London to explore: aligning capital programmes and removing barriers to make best use of the NHS estate flexibility of payment mechanisms developing place-based provider regulation workforce planning and delivery of education and training devolving transformation funding using planning & licensing to support prevention joint working on employment and health. Full report available here: https://www.london.gov.uk/sites/default/files/ london_health_and_care_collaboration_agreement_dec_201 5_signed.pdf Full report available here: https://www.gov.uk/government/publications/london-healthdevolution-agreement/london-health-devolutionagreement#parties 19

Summary of agreements The key elements of the agreement are: i) Multi-level action: Given the size of the London system three levels of action will be needed: borough (local); multi-borough (sub-regional); London-wide (regional). ii) Underpinned by the principle of subsidiarity: This means that decisions should always be taken at the most local appropriate level and aggregated up to multi-borough or London-wide only as needed. iii) London s health and care system is highly complex. We have a large number of health and care organisations and population and patient flows occur with frequency across local boundaries. For these reasons London will be running pilots to test different elements of health and care devolution at different spatial levels. iv) Focus on integration, prevention and estates What does it mean for London? Through Better Health for London, our city already has a plan making it fairly unique in England. All organisations have committed to delivering on the 10 aspirations to promote health and wellbeing set out in Better Health for London: Next Steps and in doing so, deliver on the NHS Five Year Forward View. If decisions about London are made within the London system, they will respond more closely to the challenges and opportunities of our city and population. We plan to test how this works in practice through devolution pilots with the ambition to scale up across the city. For Londoners we expect this to mean a more effective, streamlined health and care service, greater support to stay as healthy as possible for as long as possible and ensuring health and care resources are used most efficiently. 20

Aspirations and objectives of London devolution (from 2015 agreements) The parties have a shared commitment to deliver on the 10 aspirations to promote health and wellbeing set out in Better Health for London: Next Steps and, in doing so, deliver on the NHS Five Year Forward View and secure the sustainability of health services and social care. To meet these aspirations, the parties share the following objectives: To achieve improvement in the health and wellbeing of all Londoners through a stronger, collaborative focus on health promotion, the prevention of ill health and supporting self-care To make rapid progress on closing the health inequalities gaps in London To engage and involve Londoners in their health and care and in the health of their borough, sub-region and city including providing information so that people can understand how to help themselves and take responsibility for their own health To improve collaboration between health and other services to promote economic growth in the capital by addressing factors that affect both people s wellbeing and their wider economic and life opportunities, through stronger partnerships around housing, early years, employment and education To deliver integrated health and care that focuses on maximising people s health, wellbeing and independence and when they come to the end of their lives supports them with dignity and respect To deliver high quality, accessible, efficient and sustainable health and care services to meet current and future population needs, throughout London and on every day. To reduce hospitalisation through proactive, coordinated and personalised care that is effectively linked up with wider services to help people maintain their independence, dignity and wellbeing. To invest in fit for purpose facilities for the provision of health and care services and to unlock the potential in the health and care estate to support the overall sustainability and transformation of health and care in the capital To secure and support a world-class workforce across health and care To ensure that London s world-leading healthcare delivery, academic and entrepreneurial assets provide maximum benefit for London and the wider country and that health and care innovation is facilitated and adopted in London. 21

All parties agreed to the following principles Improving the health and wellbeing of Londoners will be the overriding driver for reform and devolution. We will work to secure a significant shift from reactive care to prevention, early intervention, self-care and care close to home that supports and enables people to maximise their independence and wellbeing. London will remain part of the NHS and social care system, upholding national standards and continuing to meet and be accountable for statutory requirements and duties, including the NHS Constitution. Joint working will improve local accountability for services and public expenditure. Where there is local agreement to change accountability arrangements, accountability to NHS England will be maintained in relation to issues including delivery of financial requirements, national standards and the NHS Constitution. Changes to current accountabilities and responsibilities will be agreed with government and national bodies as necessary and may be phased to balance the pace of progress with ensuring a safe transition and strong governance. We commit to fulfil the legal requirements for making significant changes to commissioning arrangements. Decision-making will be underpinned by transparency and the open sharing of information between partners and with the public. Transformation will be locally owned and led and will aim to get the widest possible local support. We will ensure that commissioners, providers, AHSNs, patients, carers, the health and care workforce, the voluntary sector and wider partners are able to work together from development to implementation to shape the future of London s health and care. All decisions about London will be taken in or at least with London. Our goal is to work towards resources and control being devolved to and within London as far as possible, certainly in relation to outcomes and services for Londoners. Collaboration and new ways of working will be needed between commissioners, providers, patients, carers, staff and wider partners at multiple levels. Recognising that the London system is large and complex, commissioning and delivery will take place at three levels: local, sub-regional or pan-london. A principle of subsidiarity will underpin our approach, with decisions being made at the lowest appropriate level. Given London s complexity we recognise that progress will happen at different paces and in different orders across the different spatial levels. We will ensure that learning, best practice and new models for delivery and governance are shared to support and accelerate progress in all areas. Subsidiarity as a principle will extend to the adoption of ideas piloted in other areas to allow flexibility and adaptation to local conditions. The people that work in health, health care and social care are critical to achieving London s transformation goals. We will build on London s position as the home of popular and world-class health education, to develop new roles, secure the workforce we need and support current and future staff to forge successful and satisfying careers in a world-class London health and care system. We recognise that considerable progress can be made, building on existing foundations, with existing powers and funding and we are committed to doing so. But devolution is sought to support and accelerate improvements. A series of devolution pilots will be established through which detailed business cases for devolution of powers, resources and decision-making can be developed in partnership with government and national bodies. Through these, devolution may be secured both for the pilots themselves and also for other parts of London, contingent on these areas also developing suitable plans, delivery and governance arrangements. 22

Continued While embedding subsidiarity, we will ensure the strategic coherence and maximise the financial sustainability of the future health and care system across London. Political support for jointly agreed change will be an important feature of the arrangements. New London-level arrangements, including governance and political oversight, will be established to secure this. We commit to minimising bureaucracy as much as possible to enable delivery of local innovation. In 2016/17 - and drawing from the experiences of the pilots - sustainability and transformation plans for health and care will be developed as part of NHS and local authorities planning arrangements. These will draw on learning from the devolution pilots, other transformation initiatives including the Vanguard programme and any London-wide initiatives. A London-level picture, drawn from sub-regional health economy plans, will enable oversight of the impact on health outcomes and financial sustainability of the system across the capital. We recognise that London provides expertise and services for people who live outside the capital and that benefit the country more widely. London will work collaboratively with other regions and national bodies to consider and mitigate the impact of London decisions on surrounding populations reliant on London-based services. 23