Clinical Commissioning Group (CCG) Board Date of Meeting: 18 TH May 2012 Agenda Item: Paper 12 Subject: Reporting Officer: Strategic Joint commissioning Options - Adult Care a discussion paper Sheila Downey- Executive Director - RMBC Purpose of the Paper: This paper proposes some options for future joint commissioning between the CCG and RMBC for adult care, and to request a steer from the CCG Board as to next steps Governance: Link to PCT Strategic Objectives S04: Building an effective and innovative commissioning infrastructure with staff, stakeholders and partners in line with the national policy Resolution: To approve To support Recommendation To provide in principle support to the general direction of travel. To authorise further detailed work to be progressed, ensuring all risks to the CCG are fully exposed and considered at the CCG Strategy /informal session in June. To request that an update paper is provided to the next CCG formal board in July 2012 Page 1 of 6
Subject: Development of Joint Commissioning Status: For circulation Report to: Clinical Commissioning Group Board Report of: Chris Duffy, Chair, Clinical Commissioning Group and Sheila Downey, Executive Director, Adult Social Care RMBC Date: 18 May 2012 1. PURPOSE OF REPORT 1.1 To update the board on the work of the joint commissioning sub group of the HWBB 1.2 To seek a steer from the board on the future direction of travel and agree the work needed to enable future decisions to be made. The board is not asked for any decisions at this point, but to agree the scope of future work and probable timescales. 2. BACKGROUND 2.1 The integration of health and adult social care, both in terms of joint provision and joint commissioning is now clearly signalled on the national agenda. 2.2 Over the years various attempts have been made at encouraging integration. Joint provision, particularly in mental health and intermediate care services has become common. In terms of joint commissioning many organisations established joint commissioner posts and jointly commissioned some specific services, for example learning disability or intermediate care services. There are a small number of examples where health and social care joint commissioning partnerships have encompassed a wider range of services, for example the Torbay Care Trust and the integrated adult social care and PCT in Knowsley. These examples of wider integration have tended to arise from the particular local circumstances and local leadership rather than from any national direction or requirement. 2.3 The introduction of the Health Act flexibilities enabled organisations to establish joint commissioning and pooled budgets. Arguably, pooled budgets underpin joint commissioning, with organisations jointly determining need, jointly investing in services to meet those needs, and jointly benefitting from the success or otherwise of those services. The issue of benefit from jointly commissioned services has been a thorny one, which the DH passed to local partnerships to resolve. (this was particularly in relation to intermediate care services where the benefit of successful intermediate care may be realised more in one organisation than another). These are the sort of issues that have bedevilled joint commissioning and have been a barrier to more integrated working. In many cases joint commissioning has not been accompanied by pooled budgets and where pooled budgets were in place they related only to specific services (for example learning disability). These partnerships typically become strained if the jointly commissioned service overspends and organisations then retreat to protecting their individual interests. Page 2 of 6
2.4 The new Health and Social Care Act, together with the financial pressures on both adult social care and NHS services, has now put the challenge of integration firmly back on the national agenda. There are clear examples of where under or disinvestment in adult social care has a serious negative impact on the NHS, and underinvestment in the NHS has a similarly negative impact on demand for adult social care services. 2.5 The new Health and Well Being Boards are seen as being ideally placed to both promote and oversee joint commissioning for the future. The HWBB has a responsibility to oversee health commissioning in our locality, to lead on the health and wellbeing of the population and provide local democratic accountability across the whole system of health and social care through elected members. This is designed to bring about greater accountability of health commissioning to local communities and provide a vehicle which can challenge the health and social care system to work better together. We have made a strong start to the development of our local HWBB. 2.6 Over recent months discussions have taken place in the HWBB and the joint commissioning subgroup about the potential scope for future joint commissioning of health and adult social care services. This report is based on those discussions and seeks a steer from the Clinical Commissioning Board; a similar steer is being sought from Council cabinet on the next steps. 3.0 THE LOCAL POSITION 3.1 In discussions over recent months it has become clear that we are united in our vision for health and social care services for the future. The CCG wants to further develop and improve care closer to home, improving patient outcomes and increasing best value through alternatives to hospital and challenge to providers. Adult Social Care is similarly working to increase support at home, reduce dependence on more expensive forms of care, increase independence and develop a wider more cost effective social care market. 3.2 In terms of integrated working we agree the focus is on the person receiving the service. If one part of the care pathway is working fine, but the other is not connected or not available then the outcomes for that person are inevitably compromised. This must be highly frustrating from the patient/user point of view, and is a waste of resources from an organisational point of view. 3.3 In addition, health and social care commissioners and providers are committed to working across the system to redevelop health and wellbeing services in the borough, both generally and specifically as a response to the changes in provision at Rochdale Infirmary. There is a joint emerging vision for a community based network of services which would see Rochdale Infirmary developing as a community health and wellbeing hub, and investment shift to services to support people closer to home. There is work underway to add detail about what the service network would look like, and some early opportunities are already apparent, including developing dementia health and care support services. This latter piece of work is being developed by RMBC and Pennine Community NHS trust working to the leadership provided by the Rochdale Infirmary working group 3.4 Local partners are increasingly clear that primary, community and social care have a close interdependence. We have therefore concluded that, ideally, we would wish to make commissioning decisions together across the whole system so as to ensure that we make best use of the whole system resources. This, however, requires us to develop a joint commissioning partnership, and an initial view of the opportunities/options are outlined in this report 3.5 The imperative to do so is linked to the financial challenges faced by both the CCG and the council. In particular the council needs to make further savings of around 40m in 13/14 and 14/15, in addition to the savings already made. This equates to a further 20% reduction Page 3 of 6
in the council s controllable budget. Adult Social Care (including services contained in the previous Supporting People programme) spends 37% of the council s controllable budget hence further budget cuts are indicated of around 13-15m over these 2 years. Please note this is indicative only and not yet agreed. However, it is clear that adult care could be required to make significant cuts given its share of the council budget. 3.6 Adult Care has already made significant savings through changed ways of working, new commissioning and contracting arrangements (and costs of contracts) and cuts to some services. However, having already delivered significant reductions in costs the anticipated level of further budget cuts poses a real risk to the efficiency and demand on the whole system. There are further efficiencies (as opposed to cuts) possibly available, to the value of @ 6m, however beyond this reductions to services may be required. This could include reductions to personal homecare, day support, residential care placements, carer support, and enablement and intermediate care services, amongst others. The council may need to reduce the number of people who it supports. In addition adult care would seek more contributions from the NHS regarding people who are either eligible for Continuing Health Care or who have high level needs where a shared package of support might be appropriate. All of this would potentially have a detrimental impact on individuals and on the whole system. In the case of Continuing Health Care and shared packages much time and effort could go into simply moving costs around the system; which we would wish to avoid if possible. 3.7 The need for the council to potentially make significant reductions in adult care would inevitably impact on the CCG and the ambition to develop more care closer to home. 4. THE OPTIONS FOR JOINT COMMISSIONING Within the Joint commissioning sub group we have identified 3 options 4.1 Option One: Do nothing, continue as we are This is not recommended for the reasons outlined below: Advantages: Continue as we are No extra work at a time of change for the CCG No direct responsibility on the CCG budget in relation to the councils cuts in adult care Disadvantages : Continue as we are The council will, most probably, need to significantly reduce adult care and this will impact on the CCG Perceived Cost shunting is likely to be an increasing source of tension and affect partnership working The whole system will not be operating as one, the cuts the council would have to make will negatively impact on the CCG, resources across the system will not be used to best effect 4.2 Option Two : Jointly commission particular services This would involve a limited partnership where the council and the CCG agreed joint commissioning and investment in specific service areas. These would be those areas where there is a clear indication that both organisations have responsibilities in the specific service area, and the user and system would benefit from an integrated approach. This may or may not require use of pooled budgets 4.3 Option 3 : Jointly commission across the full remit of both the CCG and Adult Social care Page 4 of 6
This option would effectively bring together the commissioning function and budgets of the CCG and the commissioning function and budgets of RMBC Adult Social Care. This would require the use of pooled budgets. This is a much wider partnership than option 4.2 and in effect brings the two systems into one. 4.4 We consider option 4.2 and 4.3 are both possible, and a more detailed analysis and assessment of the advantages and disadvantages of each is required. Some initial thinking regarding advantages and disadvantages is summarised below: Advantages of a Joint Commissioning Partnership It could be set up as a formal partnership; there would be no need for any changes to employment or organisational structures. The CCG is in development as a new organisation therefore this is an opportune time for a new partnership. The new partnership would ensure that resources were used to achieve joint priorities. It would enable commissioners to share best practice and expertise. It could provide new and innovative ways of working to solve key problems. It would avoid the need for difficult cuts to Adult Social Care services which would ultimately impact on NHS services. It would avoid duplication across the health and social care system. It would ensure value for money and efficiency. It would enable commissioners to work together to move resources into more preventative and early intervention services, thereby avoiding unnecessary admissions to hospital or residential or nursing home care. It would enable commissioners to work together to understand the implications of options for cost savings and the outcomes of these options. It could deliver cost savings which could be reinvested back in to services or shared between organisations. Disadvantages of a Joint Commissioning Partnership The new entity/partnership would take on the risks associated with the requirement for cost savings by adult social care. Difficulties in working practices between different organisational structures could cause some difficulties. As the CCG is in its early stages of development, it is still trying to understand the requirements of its role. CCG budget allocations are still unknown therefore the Partnership wouldn t be able to make an informed decision about the total budget available to them. There is potential for conflicts to arise between the two organisations, particularly in relation to decisions about joint savings or reinvestment. 4.4 Most of the advantages and disadvantages apply to both options 4.2 and 4.3, to a greater or lesser extent. The task now, subject to a positive steer from both the CCG board and the council, is to more fully explore the relative merits of each and propose a way forward. 5.0 GOVERNANCE AND FINANCIAL IMPLICATIONS 5.1 In option 4.2 the CCG could jointly commission some services which are currently commissioned and fully funded by the council. This would increase income for the council and enable the CCG to jointly commission these services with the council, agreeing joint outcomes and priorities. The value of these joint commissioning arrangements would potentially need to be in the order of a minimum of 4m (this is not confirmed and could be greater) to avoid other undesirable cuts in adult care services. Areas for joint Page 5 of 6
commissioning might include intermediate care; carers support services, and enablement services (these services are already jointly commissioned and jointly funded in some other health and social care systems). It could include other areas. 5.2 In option 4.3 the CCG and Council would make joint decisions about the use of the total adult care budget which would be reduced by an agreed level of savings. The CCG would in effect be entering a partnership which offers influence and flexibility but brings a potential budget deficit along with it. The opportunity is to make efficiencies through better use of resources which avoid undesirable cuts. 5.3 Both the above options need to be fully explored. Whilst this work will commence now it is not envisaged that it will be reported back until later in 2012. However, prior to this the council will need to consult on the full package of budget reductions/service cuts or changes for 13/14 onwards; hence it will be necessary to give an initial steer on the options in summer 2012, accepting that the decisions will not be made until later in the year. 5.4 Any decision to proceed with either of the above options would need formal agreement by the CCG Board, the council cabinet and HWBB. 5.5 Whichever option is pursued carries important risks, which need to fully and honestly explored and accepted should this partnership go forward. 5.6 If we do proceed there will need to be new governance arrangements for the partnership. So for example, there would be a commissioning plan which would include both health and adult social care and would need would need to be agreed across both `home` organisations. The role of the HWBB would be important as this could be the body that governs and signs off the plans of the partnership. 5.7 There would need to be a formal partnership agreement which would include strategic objectives and ensure that the partnership would work to deliver both the NHS and Adult Social care outcomes frameworks. 6.0 RECOMMENDATIONS 6.1 CCG Board notes the implications of both options for developing joint commissioning, and the financial risk associated 6.2 CCG Board commissions further work on both the options, with a view to working with the council cabinet and HWBB to indicate a preferred direction of travel during summer 2012. 6.3 CCG Board notes that a formal decision will be required as soon as practicable later in 2012, this will have implications for the business and financial plan for both organisations from April 2013 onwards 6.4 CCG begin to consider adult social care performance and financial information as part of the performance reporting for the new CCG, this will assist in developing good partnership working future whatever option is pursued. Page 6 of 6