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Slide 1 - Walsall Primary Care Trust by fdshsdhs


									                                                          Appendix A

           Transforming Community Services

         Assurance Process for PCT Proposals on
                  Community Services
PCT Name: NHS Walsall
Name of Service Line/Pathway/Sector: Acute Services Closer to
Home, Children & Families, End of Life Care, long Term
Conditions, Health and Wellbeing, Rehabilitation
Proposed Option For Organisational Form: Vertical integration
with acute provider
    Overview: brief description:

    –What tests the SHA is looking for:
    The three crucial tests to be applied by the SHA as highlighted in Eamonn Kelly’s letter on each
    submission will be:

    • delivery of quality improvement and service integration
    • increased efficiency
    • sustainability of solution

    -Options for Organisational Form:

    • Integration with an acute or mental health provider;
    • Integration with another community-based provider;
    • Social Enterprise.

    Other options, exceptional in a few places are:
    • Community Foundation Trust;
    • Care Trust which includes provision;
    • Continued PCT direct provision.

    Any proposal on provider form will be tested against the criteria below, (set out in the Operating
    Framework 2010/11)
    • are needs and pathway-driven;
    • provide more integrated and sustainable primary, community and secondary care services, which have
      the support of primary and social care;
    • deliver improved quality, including better patient experience as well as increased productivity;
    • are affordable, reducing management costs and transaction costs;

    • help to manage the demand for services more effectively (for example, reducing acute admissions and
      lengths of stay);
    • demonstrate that potential providers have a track record of leadership capability, governance structures
      and culture to engage and empower staff to lead service transformation;
    • support a viable provider market across the local health economy in light of the drive for greater quality
      and productivity;
    • represent an appropriate level of contestability.

    22nd January 2010           SHA issued proforma based on the assurance tests set out in the draft
    19th February 2010          PCTs to submit draft by 9:00 a.m. Organisational Form Summary Sheet to
                                SHA for DH Peer review process (informal feedback to follow after the 24th
                                February 2010).
    12th March 2010             PCTs to submit completed proformas and final Organisational Form
                                Summary Sheet to SHA for assurance and approval in principle (by close of
    12th to 31st March 2010     SHA to review returns and feedback to PCTs.
    All returns to

    -NHS West Midlands assurance and approval:

    The SHA will either approve in principle the proposals for the future organisational structure or will where
    appropriate offer constructive challenge to the PCT for reconsideration.

    •   Quality Improvement
    •   Increased Efficiency of Solution
    •   Sustainability of Solution

    Quality Improvement

    Areas to be assured by the PCT in considering rationale for the

        Q.1 Improving Outcomes

    •   The fit with the PCT Commissioning Strategy and priority
        outcomes as identified in World Class Commissioning, including
        joint commissioning plans;
    •   That Choice is safeguarded by the proposals;
    •   That there are robust plans which show how patient experience
        for all groups will be significantly improved, and assess the
        impact on inequalities.

1. Please state how the proposed solution will improve outcomes?

Will it meet patient needs and deliver improved local health outcomes as identified in the PCT strategic commissioning plan and Local
Area Agreement (LAA), and significantly better patient experience (including Choice)?

Rationale for decision                                                                                           Implementation Plans and   Dependencies
                                                                                                                 Milestones                 and Risks

•       Key Strategic Plan Outcomes impacted:                                                                    Not yet agreed             See question 8 for an
           –      Patient Experience                                                                                                              initial
           –      % patients spending greater than 90% of their time on a stroke unit                                                             assessment of
           –      Infant Mortality Rates
           –      Teenage conceptions
           –      Smoking quitters
           –      CVD Mortality
           –      Obesity
           –      Life Expectancy
           –      Health Inequalities
•       The inclusion of the section 75 arrangements for the Children & Families and Health and Wellbeing
        pathways is reflective of the need to maximise integration across all health and social care
        organisations in order to be able to deliver targets covering lifestyle, health promotion, prevention
        and health inequalities. Integration with an acute provider without a section 75 agreement may not
        have contributed to the delivery of these outcomes.
•       As part of our Strategic Plan, the PCT has identified 3 Strategic goals – reduce inequality, invest in
        prevention and improve the quality of services. We have specifically selected patient experience as
        a key outcome in order to identify quality improvement. We have therefore built on the 2009/10
        CQUIN schemes by adding further patient experience indicators into the 2010/11 schemes. These
        will be monitored through the contracting process and performance reported through our
        programme management structure. Patient experience indicators feature strongly throughout our
        strategic initiatives and programme management monitoring mechanisms.
•       Choice is safeguarded through our commissioning processes and procedures and is not adversely
        affected by this change. The delivery of our service transformation agenda will be driven by our
        programme management structure. In redesigning pathways, our programme commissioners are
        tasked with ensuring that patients receive the appropriate choice at each key point on their
        treatment pathway. We are also introducing market assessment and management methodologies
        to support the provision of choice for patients.

    Quality Improvement

    Areas to be assured by the PCT in considering rationale for the

        Q.2 Improving Quality

    •   That there are identified improvements in quality of service
        outcomes to be delivered;
    •   That there is a clear plan and capability to shift from acute to out
        of hospital care;
    •   That the improvements in quality will be sustained.

2. How would the proposed changes improve Quality?

Will it deliver significant improvements in quality of service and outcomes delivered?

Rationale for decision                                                                                                  Implementation Plans and   Dependencies
                                                                                                                        Milestones                 and Risks

•       The rationale for seeking to integrate with our acute provider for these (TCS) pathways is that they            Not yet agreed             See question 8
        are predominantly treatment focussed services, relying traditionally on healthcare interventions.
        One of the key vehicles identified in our Strategic Plan to deliver quality improvement is the
        integration of pathways across tiers of care and current work being undertaken on COPD,
        Diabetes and Frail Elderly pathways suggest the following positive impact on outcomes through
        better integration of treatment and tiers of care:
          –      Reduced hospital admissions
          –      Lower mortality rates and enhanced quality of care as many complications such as healthcare acquired
                 infections, delirium, pressure sores, malnutrition, dehydration, side-effects of medication will be
          –      Reduced admissions to a nursing or residential home.
          –      Better managed discharge
          –      Improved experience for older people, families and carers with less risk of loss of dignity.
          –      Maintains the independence of the individual
          –      Reduced length of stay in hospital
          –      Seamless care
          –      Simplification of systems/less organisational barriers
          –      Improved pathway management

•       NHS Walsall’s Strategic Plan sets out an agenda of achieving improvements in the quality of
        services through the development of integrated pathways which provide healthcare interventions in
        the most appropriate settings. The impact of this approach will be to move activity from a traditional
        hospital setting into the community. We have developed a programme management delivery
        mechanism in order to achieve these aims and each of our programmes are developing
        commissioning plans to deliver our strategic initiatives. The integration of these, predominantly,
        treatment pathways within a single provider will help to facilitate this process but our programme
        management approach is the main vehicle for delivering our strategy.
•       As a commissioning organisation NHS Walsall seeks to gain sustainable quality improvements
        through the strength of its commissioning and contracting processes. Our Strategic and
        Organisational Development plans place emphasis on the development of programme
        commissioning to deliver improvements in health and the quality of services. We intend to embed
        the commissioning cycle within our business planning processes and combine that with robust
        procurement, contracting and performance management processes. This will be the main vehicle
        that will ensure that we sustain improvements in quality. Working with a single organisation along
        pathways and through tiers of care will allow us to concentrate our efforts on a single provider of
        services and therefore will help to sustain quality improvement.
    Quality Improvement

    Areas to be assured by the PCT in considering rationale for the

        Q.3 Service Integration

    •   The proposals demonstrate at patient and pathway level how
        service integration will be enhanced to improve care;
    •   Show how the proposal supports primary, community, secondary,
        children’s services and social care partners to increase
        prevention through more integrated approaches.

3. How would the proposed option deliver service integration?

Will it deliver significant improvements in service integration and quality of health and social care?

Rationale for decision                                                                                               Implementation Plans and   Dependencies
                                                                                                                     Milestones                 and Risks

•       We consider the following as key factors that integration will have on the                                   Not yet agreed             See question 8
        quality of care

         –    Minimise organisational barriers within pathways and between providers.
         –    Reducing the number of’ hand-offs’ within the system, allowing the patient journey to be quicker and
              more seamless
         –    Services focussed around the patient rather than vice versa
         –    Improved communication reducing errors and delays
         –    Maximum opportunity for the patient to become more involved with their care and to control events.

•       Evidence suggests that people are more likely to act on lifestyle
        advice/intervention when it is provided as part of an outpatient or
        treatment episode. Integration with an acute provider for these treatment
        pathways and the use of consistent approaches, methods and delivery
        along the whole pathway will help maximise the impact of both primary
        and secondary prevention.

     Quality Improvement

     Areas to be assured by the PCT in considering rationale for the

         Q.4 Stakeholder Engagement

     •   The extent of engagement to date with all key stakeholders
         including clinicians, workforce, SPF, patients, the public, OSCs,
         LINKs and local service partners and their relevant partnership
     •   Specific plans for workforce engagement to deliver transformed
     •   Specific plans which demonstrate how the proposals will bind in
         the support of primary and social care and children’s services;
     •   Evidence of robust planning involving all key stakeholders for:
          – future engagement and involvement;
          – any necessary consultation.
4. What stakeholder engagement has been sought for the proposed option?

Has it got engagement and support of key stakeholder groups?

Rationale for decision                                                                                        Implementation Plans and       Dependencies
                                                                                                              Milestones                     and Risks

The following engagement activity has been undertaken in order to specifically address the issue of           Not yet finalised for future   Not yet assessed
        organisational form:
Public Engagement
           –      Presented at NHS Walsall Public Board 28th January 2010
           –      Discussed at MyNHS Walsall Parliament meeting 28th January 2010
Stakeholder Engagement
           –      Listening Event for Walsall Local Health and Social Care economy 11th February 2010
           –      TCS Programme Board meetingd held on 10th February 2010 and 17th February 2010 to
                  discuss the proposals
Staff Engagement
•       Discussed at JNCC Agenda 17th February 2010
•       Presented at NHS Walsall Protected Learning Time Event 19th February 2010
Walsall Community Health staff consultation:
           –      18th February 2010
           –      4th March 2010
           –      5th March 201
Detailed plans for future workforce and wider stakeholder engagement have not yet been finalised but a
        full consultation process with staff will be undertaken.

In terms of general staff engagement on service transformation, our programme management
       mechanisms and business cycles dictate that all programme commissioning plans have a
       stakeholder engagement and communication plans before they move to implementation. These
       plans include staff engagement.

As highlighted within our Strategic Plan, the integration of care has become a key value and principle in
       the way that we are seeking to commission and procure services. To that end we have established
       an ‘Integrate to Improve’ programme which will work across the health and social care economies
       in order to steer through the transformation task required to deliver an integrated care economy. It
       has been identified that the Board will need to address issues concerning behaviour, culture and
       values as a priority in order to embed the concept of integration. The Integrate to Improve
       programme is currently being configured.

     •   Quality Improvement
     •   Increased Efficiency of Solution
     •   Sustainability of Solution

     Increased Efficiency of Solution

     Areas to be assured by the PCT in considering rationale for the

         Q.5 Efficiency Improvements

     •   The proposals will help deliver the efficiency improvements set
         out in the Operating Framework 2010 / 2011;
     •   The proposals explain how, and the extent to which, they will
         deliver technical efficiencies in 2010 / 2011 and 2011 / 2012;
     •   The proposals set out how allocative efficiencies will be delivered
         in 2011 / 2012 and thereafter;
     •   Identified reductions in fixed costs including management and
         transaction costs.

5. How would the proposed option deliver efficiency improvements?

Will it delivery substantial improvements in the technical and allocative efficiency of the services being delivered?

Rationale for decision                                                               Implementation Plans and           Dependencies
                                                                                     Milestones                         and Risks

We don’t have the specific detail worked through which will provide us with a        Not yet agreed                     See question 8
    quantified level of efficiency that can be released through this proposal.
    However, the rationale on which this proposal is based is that this
    approach would align provision with our programme approach and be
    consistent with ‘Integrate to Improve’ and the plan of delivering
    qualitative and efficiency gains through integration of services. If Walsall
    Community Health, currently a going concern, is substantially
    transferred as a whole (other than Learning Disability) to become part of
    the acute provider then we know that we will avoid significantly splitting
    the existing overhead across several organisations and therefore there
    is at the very least an initial efficiency to be made. Working with a single
    merged organisation NHS Walsall will then be well placed well
    positioned to discuss what efficiencies can be driven out of the system
    as a result of the vertical integration. This work is scheduled to take
    place over the next 3 months and will be supported by work that we
    have commissioned on programme budgeting and efficiency

     Increased Efficiency of Solution

     Areas to be assured by the PCT in considering rationale for the

         Q.6 Infrastructure Utilisation

     •   The proposals will identify steps to increase utilisation and
         efficiency of back office estate and other infrastructure. To
         identify scope to share use of assets more efficiently with other
         partners, including local authorities;
     •   How will the proposal improve the utilisation of all NHS owned or
         use estate and infrastructure?
     •   The proposals will identify any surplus assets and infrastructure
         that will be released by the proposals.

6. How would the proposed option maximise infrastructure utilisation?

Will it maximise utilisation of own (and any integration partners) estate and infrastructure?

Rationale for decision                                                         Implementation Plans and   Dependencies
                                                                               Milestones                 and Risks

NHS Walsall’s Strategic Plan, Capacity Plan and Strategic Services             Not yet agreed             See question 8
    Development Plan all identify a shift of activity from an acute to a
    community setting. This typically includes Outpatient and minor surgical
    activity. We currently have good quality community estate which will
    need to be fully utilised in order to accommodate the levels of activity
    that we have modelled as transferring. We are currently undertaking an
    analysis on Walsall Manor estate, particularly in the light of their new
    PFI development in order to understand how this can also be fully
    utilised in conjunction with community facilities. This work is still in

     •   Quality Improvement
     •   Increased Efficiency of Solution
     •   Sustainability of Solution

     Sustainability of Solution

     Areas to be assured by the PCT in considering rationale for the

         Q.7 Sustainability

     •   Show how proposals will be sustainable in the long and short
         term, clinically, financially and in terms of infrastructure;
     •   Show how the proposals will give PCTs with LA and PBC
         partners the leverage in the local health economy to deliver;
          – strategic commissioning plans;
          – continued service transformation and realignment;
          – continuing contestability and service innovation;
     •   Show how the proposals will ensure that the local health
         economy has and retains a sufficiently skilled workforce to lead,
         develop and deliver new service models.

7. How would the proposed option support sustainability? Note: If any proposal for continued direct provision is,
exceptionally, being considered, then the host PCTs would have to demonstrate very strong commissioning skills, including
performance in WCC assessments equal to the thresholds set in the Operating Framework 2010 / 2011. If those performance levels
were not sustained then the DH and SHAs would reserve the right to review any continued direct provision.

Will it be clinically and financially sustainable?
Rationale for decision                                                                               Implementation Plans and   Dependencies
                                                                                                     Milestones                 and Risks

In regards to long and short term sustainability, clinically, financially and in terms of            Not yet agreed             See question 8
       infrastructure, work is taking place over the next 3 months which will provide more detail
       regarding these issues. In the interim, our judgement is that, in line with our response in
       question 5, we believe that this proposal provides us with a good basic starting point for
       being able to address how vertical integration can help to sustain the quality and
       distribution of services.

NHS Walsall’s Strategic Plan identifies integration as the fundamental enabler required to
     address issues of unhealthy lifestyles, deprivation and general ill-health. As such, the
     greater integration of services that this proposal engenders will contribute directly to the
     delivery of our strategic commissioning plans and service transformation. We will
     continue to use our programme structures to drive forward redesign at a pathway level
     and we have plans to bring together the respective programme management offices and
     service transformation plans between NHS Walsall and Walsall Manor Hospital in order
     to maximise alignment and agree joint benefits realisation targets.

Vertical integration with NHS Walsall Hospitals Trust would provide the opportunity to
       overcome the organisational boundaries that can prevent seamless care and would
       support effective care pathway redesign. This will particularly benefit patients with long-
       term conditions and will provide an opportunity to deliver much more coordinated care.
       Working across acute and community settings will provide new opportunities for staff to
       work in different ways which will aid recruitment and retention, and will support
       innovation. There will also be the opportunity to plan and develop the workforce in an
       integrated way to ensure that we maximise productivity. In addition there will be a
       change in incentives in the system for the new organisation to deliver the right care in
       the most appropriate setting at the right time rather than retain patients in costly acute

     Sustainability of Solution

     Areas to be assured by the PCT in considering rationale for the

         Q.8 Whole System Fit

     •   Demonstrate how solution will deliver whole health economy
         effectiveness and efficiency;
     •   Show how the proposals will fit into current and future patterns of
         acute and out of hospital provision;
     •   Show how the proposals will contribute to delivering significant
         wider health system improvements in allocative efficiency;
     •   Have any potential adverse impacts of the proposals elsewhere
         in the local or wider health economy been identified and are
         there proposals for the management of those impacts?

8. How would the proposed option deliver whole system fit?

Will it fit into and enable delivery of wider health economy service transformation and shifts in care?

Rationale for decision                                                                                         Implementation Plans and   Dependencies
                                                                                                               Milestones                 and Risks

The work that we have undertaken on developing the Frail Older People’s pathway has demonstrated               Not yet agreed             See text
      that, with lower numbers of emergency admissions and patients being managed in the community
      in ‘virtual wards’, that a saving of £2.8m can be made on this pathway alone. Duplicating this
      approach across other pathways and building on the benefits of closer, more integrated working,
      better communication, less system hand-offs and shared values and goals will help to deliver our
      efficiency targets. The detail regarding the exact impact of proposal has not yet been generated
      but our Strategic Plan identifies significant savings based on demand management and service
      redesign and the development of an integrated care economy is a key vehicle in delivering this.

Potential adverse impacts of this proposal have been identified and further assessment and quantification
       will form part of the remit of the ‘Integrate to Improve’ Board. Risks and adverse impacts identified
           –     Speed of change of culture
           –     Acute culture - strong and will dominate
           –     Tension between models, especially medical us social
           –     Takeover not merger
           –     Asset Stripping
           –     Cynicism/here we go again
           –     Costs associated with transition
           –     Time frames (often national) and capacity to deliver
           –     Reduction in performance on targets
           –     Higher rate of staff attrition
           –     Disruption to services
           –     Inflexibility
           –     Professional boundaries
           –     Public perceptions
           –     Lack of shared vision
           –     Lack of resource to deliver
           –     Lack of strong commissioning/contract monitoring

We are currently working through financial issues with Walsall Manor but do not yet have finalised plans
       with regard to how these will be mitigated other than they will be the focus of the’ Integrate to
       Improve’ board.

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