Integrated Urgent Care Procurement in North West London 1. Executive summary North West London currently have two 111 and out of hours providers (across multiple contracts). The current contracts cease for both 111 and Out of Hours opted out contracts on 1 st April 2018. A new integrated urgent care service that meets the NHSE requirements must be mobilised by this time across the North West London footprint. Colleagues across the patch have been working towards a procurement plan and specification to meet this requirement for two years. Local views on the success of our current 111 service as well as eight different local CCG urgent care strategies and approaches to primary and community urgent care provision agreeing a specification has been a challenge. North West London now requires a clear decision as to the procurement strategy to ensure a safe, affordable, credible service can be delivered by April 2018. This paper is recommending to the IUC Board, the CWHHE Investment Committee (with Hillingdon CCG invited) and the CWHHE Chairs group (incl Hillingdon) that in order to progress this procurement at pace following substantial delays a market event is held at end of May outlining the plan to make a direct award to our incumbent providers on the basis of a two year pilot which will be fully evaluated and purchased through an open transparent procurement by April 2020. The incumbent providers, LCW and Care UK, would be provided with the minimum specification required to meet the NHSE standards with the ability to bolt on additional add-ons of activity work over the first year to further integrate the NWL urgent care services. Each module would be on an open book basis and enable NWL to understand the full costs of the services both in activity and development to be procured for April 2020. 2. Introduction The North West London (NWL) Collaboration of Clinical Commissioning Groups (CWHHE and BHH) have been working together with the aim of commissioning an Integrated Urgent and Emergency Care Service, including OOH and associated Urgent Care pathways with NHS 111 as the single point of access. Patients requiring urgent help will also be able to access this through their GP. Five year forward view outlined an urgent and emergency care strategy that requires a patient journey that starts with 111 and NHS 111 on line and calls are the first two columns of the NHSE Urgent and Emergency Care strategy (see appendix 1). The project mandate agreed by the Collaborative Board was to deliver an Integrated Urgent Care Service across NWL (8 CCGs); incorporating 111, Clinical Telephone advice and Out of Hours services. Linking into extended hour primary care hubs and primary care transformation, as well as Integrated Care Services and Rapid Response. The following core principles reflect the ambition for the Integrated Urgent Care Service. As the service evolves these core principles are likely to develop further. People contacting NHS 111 for urgent care needs expect the service to:
Be always available, 24 hours a day, 365 days a year Be accessible, personalised and based on their individual needs Have knowledge of when they have previously contacted NHS 111 so they do not need to repeat their story Be able to connect them to a clinician with access to important health records and notes Be safe and give the right advice based on the best and most up to date clinical and medical knowledge available Definitively resolve health concerns without the need to go anywhere else if appropriate Book appointments with the urgent care provider they need To dispatch an ambulance without delay if necessary Be able to access the service through digital or online channels both to give better access to information and to meet specific needs people have Make sure that specific health needs, such as palliative care, mental health and long term conditions are properly catered for. NHS 111 should provide a consistently high quality service irrespective of the geographic area. Our current service provides a number of these services but the largest barriers are the lack of interoperability and digital access and direct booking into urgent care services (incl GPs in hours across all our practices). In addition the NHSE guidance requires the development of clinical assessment and treatment services (CATS) across North West London. Currently patients are offered clinical advice by 111 clinicians supported by a directory of service. A new CATs would include providing patients who require it access to a range of hear and treat response from both generalist or specialist clinicians 24/7. CATS will provide support directly to patients who access North West London NHS 111 by receiving appropriate calls directly from NHS 111 health advisers (non clinical) and clinicians. The service will also be accessible by health professionals in the community and within the acute sector (if required) so that no decision needs to be taken in isolation. 3. Specification There is a final specification available which meets the minimum requirements of NHSE guidance as well as maintains what is good about the current service. There remains an outstanding debate regarding the role of the Clinical Advice and Treatment service in hours which is currently being worked through. Currently 111 (Care UK and LCW) provides non clinical call answering using an algorithm and clinical advice through nurses and paramedics with GP capacity currently piloted with NHSE support. The providers also triage Out of Hours calls for both Opted In and Out practices using the algorithm. The largest barrier to NWL agreeing a specification is how and where the clinical advice is provided. CWHHE and Hillingdon CCGs have a view that there should not be a separate service in hours but that the clinical advice should continue to provided by the 111 provider but should be bolstered to meet the minimum NHSE requirements (incl GP advice in and out of hours). The majority of hear and treat advice will then be provided by the 111 clinicians or sent directly
to other providers which NWL currently commission eg mental health the SPA or pharmacy to the pharmacy hub. Work would need to be undertaken during Q2-Q4 to ensure the availability and quality of these services to be able to receive warm transfer (ie live transfer or 10 min call back) and that they are listed appropriately in the directory of services. Brent and Harrow CCGs approach is that all clinical advice including that currently provided from 111 should be separately procured from the 111 call answering. Recent correspondence (13 th April from A.Mackintosh, Programme Director, Brent and Harrow CCGs) stated that following a meeting with Chairs and COOs For Brent and Harrow CCGs, the NHS 111 provision will have the clinical advisor elements removed from the specification. The Clinical Hub (CATS) for Brent and Harrow will not form part of the NHS 111 procurement and this will be led and commissioned locally. This approach is not supported by NHSE and would result in both Brent and Harrow as well as the rest of NWL failing the NHSE Integrated Urgent Care Gateway process. NHSE require any procurement to be NWL wide. Further work is required to bring the CCGs back into a NWL procurement. A meeting has been arranged in the next fortnight with NHSE to discuss the Brent and Harrow model as concerns have been raised that this will not meet the NHSE standards nor align to the following procurement approach recommended below. 4. Procurement North West London has recently had a number of issues resulting from large scale procurements particularly of new models of care. Procuring a radically new model has rarely delivered the large scale immediate change required or expected and mobilisation to the final benefits realisation has taken considerably longer than expected. This has resulted in not meeting our resident and service user expectations and has been costly for commissioners both in terms of the procurement costs as well as the management and clinical input from CCGs during mobilisation to reach the required service. As this procurement has to date been complicated the following process is now suggested. 4.1 A market engagement event is held by the end of May the likely participants would be LCW, Care UK, Vocare, PELC and LAS as the current London providers. 4.2 NWL Present their intention to run a pilot with the incumbent providers for two years with the minimum integrated care specification delivered from April 2018. The two incumbent providers, LCW and Care UK, would be offered this contract once they have agreed a lead provider. The lead provider would be responsible for both delivering the minimum specification within a block contract as well as agreeing any further add-ons NWL CCGs wish to procure during the two year period. 4.3 The pilot would be a transparent open book pilot for April 2018 March 2019 enabling a full evaluation of costs and activity. 4.4 The pilot would continue to run from April 2019 March 2020 however an full evaluation would be funded and undertaken in Q1 to inform a full business case to be presented to GBs in July 2019. An open procurement would then be run to the full market from August 2019 with the new service mobilised for April 2020.
4.5 Procurement advice provided by SBS is that the decision to direct award the pilot to the incumbent providers can be made by the CCGs. Following this award there is a 30 day period in which other providers to lodge a challenge to the direct award and the CCG would be expected to answer that challenge. 4.6 If it was felt the challenge could not be answered then a full procurement process would need to be entered into over the summer of 16/17 and a new service mobilised by 17/18. 4.7 A full procurement is a high risk approach at this stage as: 4.7.1 NWL does not have comprehensive activity predictions nor bottom up financial costings of the new model as this data is not available and would be collected during the pilot phase. This would mean any financial model to support the procurement could be of considerable risk. The procurement of the IUC service in SE London recently failed as the market was unable to respond to the cost envelope outlined in the tender. 4.7.2 The specification is still not finalised across NWL and without the opportunity to pilot a new service and to evaluate the impact there is a risk the NWL procurement will not meet the needs of all 8 CCGs. 4.7.3 The mobilisation phase of a full procurement would be significantly shorter than a direct award (potentially 3 months shorter) increasing the risk of full mobilisation by April 2018. 4.7.4 A large scale recruitment will be resource intensive whilst CCGs have other significant pressures that could put the focus required at risk. 4.7.5 The development of a competitive process between providers may not develop the partnership working required to successfully integrate the urgent care services across the STP footprint. 5. Issues/ Risks 5.1 There is a risk one of the incumbent providers is currently under investigation for a serious incident following a number of claims by a media outlet. An internal and concurrent independent investigation is underway to ensure lessons are learnt. However, it is important to note that this should not prevent a direct award. Other direct awards have been made to local providers whilst there are ongoing serious incident investigations (for example the Acute Trusts within NWL). Part of any contract award would stipulate that all lessons learnt following the investigations are fully implemented. 5.2 Risk of challenge to the procurement process and direct award. There is always a risk of challenge in any procurement. Here NWL is balancing the risk of challenge to the procurement process versus the risk of failing to procure and mobilise a new service that meets the benefits required of an integrated urgent care service. The mitigation is both work with the market to explain our approach and to be clear on our plans to enter a full procurement. Further mitigation is to consider what challenges may be made to the direct award and ensure that NWL has prepared appropriate responses. 5.3 There is a risk to the credibility of NWL CCGs with our residents that we are unable to progress our 111 services in to a fully integrated urgent care service. NWL staff and lay members have engaged with our community for over 2 years on this work and are yet to procure a new service for them. Whilst our current 111 and out of hours continue to
develop and learn it is vital that NWL now move to a new integrated specification and publicise it to our residents. 5.4 There is a risk a lead provider is not identified. Formal discussions have not started with the incumbent providers as this could have prejudiced an open procurement. 6. Conclusion 6.1 The committee is asked to support the procurement of a minimum integrated urgent care specification with add on modules that meets the requirements of NHSE. 6.2 Chairs and MDs have resolved the issues and concerns of Brent and Harrow CCGs to enable them to join the wider procurement and pass the NHSE Gateway process 6.3 The committees is asked to support the suggested procurement approach of market engagement, direct award, evaluation and full procurement for April 2020.