NHS Kirklees Commissioning Intentions for Community Services 1. Background 1.1
The Department of Health programme, Transforming Community Services, challenges Primary Care Trusts to divest themselves of provider services, whilst at the same time, transforming the way services are delivered to improve quality, deliver efficiencies and offer more choice in line with the public’s expectations. PCTs will be abolished in 2013, as indicated in The White Paper, ‘Liberating the NHS’ (DH 2010), which means the option to remain as part of a commissioning organisation is no longer an option. The White paper also reiterated the commitment by the Government to the development of social enterprises as a way forward for both Foundation Trusts and community services.
Transforming Community Services should be seen as the catalyst to delivering transformational change which will improve the quality of services whilst reducing costs through innovation and increased productivity. This will only be achieved through integration of services, through formal partnership agreements, rather than ad hoc arrangements.
As commissioners we require any proposal to provide community services in Kirklees to have a strategy in place, including timescales, for providers to move through formal partnerships to the eventual formation of a fully integrated care organisation that will deliver our declared commissioning intentions.
This is a challenging and ambitious agenda that will require commitment and leadership across the health and social care economy to achieve the transformation. The new organisation must demonstrate this leadership and commitment from partners.
2. Challenges 2.1
The existing contract with Kirklees Community Health Services (KCHS) includes some excellent services that have been commissioned over the last three years. ‘The Commissioning Strategy for Community Services’, a supporting document to the five year strategic plan: ‘Realising Our Ambition’ (NHS Kirklees 2010) sets out NHS Kirklees commitment to commission high quality community services and was approved by the Board on 28 October 2009.
Highlighted is the need for a radical shift of care away from acute settings, a focus on outcomes, cost reductions through greater efficiencies, and a focus on technology and innovation.
The challenge in delivering World Class Commissioning outcomes, meeting financial targets through Quality, Innovation, Productivity and Prevention (QIPP) and delivering care closer to home, can only be achieved if there is an alignment of commissioning and provider strategies.
NHS Kirklees five year strategic plan 2010 - 2015, â€˜Realising Our Ambitionsâ€™ sets out our commitment to achieving the following goals: Goal 1 Raise male and female life expectancy at birth so that it is not significantly below the national average in any part of Kirklees. Goal 2 Improve health outcomes for children and young people, working in partnership to improve life chances and safeguard children. Goal 3 Target individuals and populations to tackle health and well being inequalities, focusing on the priority issues identified locally. Provide advice, support and care to these individuals, families and communities in the form of high quality targeted interventions known to work, to increase the control they have over their own health and wellbeing. Goal 4 Empower those people in Kirklees with a long term condition to exercise control over their own lives and be central to the decision making about their own care, so preventing problems arising or worsening and enabling them to independently manage their own health and well being.
To achieve these goals we need community services that can demonstrate the ability to innovate, to deliver services that are outcome focused, and transform the dynamic between professional and user, empowering individuals to self care and self manage and support the implementation of individual budgets.
3. Transforming Community Services 3.1
The Department of Health has not defined community services in their Transforming Community Services policy document. For the purposes of this paper we will be defining community services to include those services already commissioned through the NHS Standard Community Contract.
NHS Kirklees will continue to commission community services across Kirklees with providers that can deliver services that are equitable and take advantage of economies of scale.
Here there is evidence of achievement and where services have been successfully redesigned and specifications agreed, services will continue. We require that providers build on the best practice examples, for example, the route to a solution work and continue to support innovation.
Any future services that are commissioned will be subject to the existing procurement processes. The new organisation will have any willing provider status and be in a position to bid for new services.
We expect future providers of community services to demonstrate that they are responsive to needs within localities and working with commissioners, the Local Authority and other key partners to contribute to reducing health inequalities and improving health outcomes.
4. Delivering Excellence in Community Services As commissioner of local NHS Services NHS Kirklees intends build on the significant improvements that have been secured in the provision of community services over recent years. The environment within which health care is being delivered is changing rapidly and we need to keep pace with these changes. In order to meet this challenge future provision of community services in Kirklees will need to: 4.1
Be person centred in delivering quality care, with a focus on outcomes for patients, carers and families. This also means co-creation by involving patients and their carers in the shaping and delivery of services at both population and individual levels.
Demonstrate that patients are involved in their care, supported to self care and work with staff that are skilled to support patients through their health journey.
Ensure improved patient experience of services and that those services are high quality, accessible and safe. People should only attend hospital if the care they need cannot be safely provided in a community setting or in their own home.
Focus resources according to need, so providing a universal service as well as specific focused care available to those with greater, more complex needs, so narrowing inequalities and reversing the inverse care law.
Promote positive health and wellbeing â€“ so support people in opting for healthy behaviours, self care and access to support for the wider consequences of their ill health by, eg income, housing. This means close involvement across the Council.
Deliver measurable evidence of improved patient experience and delivery of safe and effective services.
Secure, retain and develop a high quality skilled workforce through the delivery of a leadership framework; professional development reviews all underpinned by training and development programmes.
Reduce costs through delivering integrated care, less reliance on secondary care beds and ensuring that people only attend hospital if the care they need cannot be safely provided in a community setting or in their own home.
Become more productive meeting QIPP challenges
Grasp the freedom and opportunity to innovate and provide new approaches to service delivery that secure high quality evidenced based care.
Continue development of technology solutions to assist care, reduce duplication and improve productivity.
Integrate health and social care teams and build on the model of “practice units” with devolved operational and budgetary responsibility.
5. Partnerships 5.1
In a time of growing demand and reduced resources, the focus on partnership working is paramount. Working together to improve efficiency, effectiveness and reduce costs requires a greater focus on joining up services and securing more formal partnership arrangements than the informal partnerships we have relied on in the past. This has been largely through co-operation across organisations and has improved the quality of services but is often dependent on the commitment of local teams.
There is a growing body of evidence which indicates that the way to transform the dynamic is through integrated care organisations. To achieve the potential cost and quality efficiencies, there needs to be an accelerated process towards integration with all partners.
NHS Kirklees will commission community services that can demonstrate success in partnership working and how they will meet the challenge of formal integration with partners across a number of health, social care and voluntary sector settings.
Partnerships are essential to the commissioning of the Healthy Child Programme, the development of Children’s Centres and extended services around schools and local communities. This allows for the delivery of services in a variety of locations to ensure provision of locally based accessible services. GP surgeries, schools and the child/young persons’ home, will also be available to provide primary care, urgent care services and a range of planned care services for children and young people.
6. Integrated Care Models 6.1
Integrated care is essential for the delivery of services that are safe, effective and efficient. There are several models that support integrated care but it is recognised that formal mechanisms are needed to deliver improved health and social care outcomes and sustain integrated care services.
Formal mechanisms for partnership that bring organisations together to deliver integrated care working, include joint ventures, organisational mergers and principal provider models.
The degree of formality and the pace of integration will vary according to need but the aim is both to reduce duplication, perverse incentives and increase efficiency through reduced costs.
Integration can only be achieved through the development of integrated care pathways that break down professional and organisational barriers and care delivery is based on competence.
Resources will be released when handoffs are reduced, a single point of access is in place and the skills of a generic workforce across health and social care is realised and utilised.
For both adult and children and young peopleâ€™s services, closer integration across heath and social care is essential. As commissioners, we will require providers to demonstrate that they have plans in place to move towards formal partnerships and integration.
The delivery of integrated frontline services to improve outcomes for children and young people will require robust governance arrangements for inter-agency cooperation which set the framework of accountability for the improvement and delivery of effective services.
Improving outcomes for children and young people involves changing the behaviour of those working with children, young people and families, so that they experience more joined up and responsive services, with specialist support embedded in and accessed through universal services.
The Government have an expectation of all partners to deliver this model of care. This will require provider organisations to work closely with the Director of Childrenâ€™s Services as the new model is embedded.
We will expect future providers to demonstrate how they will deliver this model of care provision and where possible provide timescales and show evidence of partnersâ€™ intentions.
7. Stakeholders The new provider must show that there has been and will be, stakeholder involvement in the development of the organisation. This will include: 7.1
Public We expect community services to strengthen relationships with local communities, both to inform the way health care is delivered and to support the contribution the public can make to positive health and wellbeing.
A stakeholder engagement strategy and action plan would be expected as part of the business case. 7.2
Patients Care planning, co-creation and supported decision making are innovations in partnership working with patients that have a strong body of evidence that links these tools to improved patient outcomes. This is a cultural and behavioural change for patients and professionals that results in improved quality and cost efficiencies. This is relevant both for individual care planning and planning on a population basis. The commissioner will require evidence within the business plan of how this will be taken forward within the organisation.
The expectation of the commissioner is that all members of the provider organisation are consulted and part of the process in taking forward a new organisation to deliver high quality care for the population of Kirklees.
The workforce should have the competence and leadership skills to lead and implement the changes needed to build a sustainable, high quality organisation.
We require the organisation to have in place a strategy for succession planning and developing future leaders.
Employees of KCHS will play a part in the formation and development of the organisation. Staff will have representation on the Board.
We require evidence of staff being consulted and engaged in the development of the vision and structure for the new organisation.
We require evidence of a coherent over-arching strategic approach to workforce to include the following elements: a) A commitment to staff health and well-being and how this will be delivered. b) Evidence of a robust approach to workforce planning and workforce development including recruitment and retention strategies, development strategies linked to individual and organisational objectives, including succession planning, talent management and equality issues. An approach to ensuring the collection and utilisation of workforce information. c) Evidence of employee involvement strategies both through formal recognition of staff representatives and partnership working at all levels and the organisationâ€™s intentions towards the development of reward structures that fit with organisational objectives, equality and
partnership working. d) The organisationâ€™s approach to maintaining a working environment that is safe and meets all statutory requirements. e) An understanding of the Transfer of Undertaking (Protection of Employment) Regulations and how this will be ensured during the change process, including the envisaged structure for the new organisation and any measures envisaged to be taken in relation to the workforce, eg reduction in numbers, relocation, redeployment, changes to terms and conditions. f) How staff will be paid 7.4
Acute Trusts The delivery of seamless integrated care is dependent on partnership working with acute and mental health providers working with community providers on pathways that deliver care closer to home. Patient safety and the quality of care are compromised by the number of handoffs and poor communication across care pathways. We require our providers to work with all health care providers to develop care pathways that reduce risk, improve the quality of care and are cost effective.
Local Authority Health and social care services in the community work closely together to provide care to the local population. There is a locality focus and services are designed to meet the needs of their local communities based on the needs outlined in the Joint Strategic Needs Assessment (JSNA). Whilst there are many examples of integration at locality level, there is potential for greater integration. People want fewer people involved in their care and a reduction in the duplication of services. This requires a more formal approach to the integration of health and social care services and we require providers to work with Local Authority partners to deliver this outcome.
General Practitioners We expect to see closer alignment with primary care practice units. This is essential to the delivery of integrated care and reduction in emergency admissions. Primary care practice units with community services and social care, engage with, support and maintain people in their local communities. It will require greater integration across the health and social care system to reduce demand on secondary care services. Reducing this demand and bed capacity will deliver the QIPP agenda and free up resources for investment in primary and community care.
Community services commissioned by NHS Kirklees will be expected to work with GPs and primary care practice units to reduce unnecessary hospital admissions. Integrated health and social care teams working in practice units and the delivery of the single point of access and intermediate care services will deliver a reduced demand for hospital admissions and impact positively on length of stay. We will require the provider to identify potential savings and future reduction in the bed base. Further development of intermediate care services and long term conditions pathway delivery will be strengthened to support this outcome. 8. Reducing Health Inequalities 8.1 The PCT strategic goals clearly describe the focus on inequalities. The JSNA for Kirklees shows wide differences in health status across different groups of people and localities, many avoidable. 8.1.1 To reduce such avoidable differences requires: 8.1.2 People being at the heart of everything that we do, so more people feel in control of managing their problems. 8.1.3 Focus on prevention across all 3 levels, ie preventing problems occurring, recurring, through prompt detection and treatment and helping people minimise the consequences of those problems. 8.1.4 Focus on needs, assets, what works and outcomes, so working with the assets of local communities in tackling their needs, use what works, so not reinventing the wheel or working innovatively if more appropriate. 8.1.5 Understanding what difference the service makes for whom, ie outcomes, especially across the gradient of need. 8.1.6 Focusing on outcomes requires services to work with other relevant services in tackling the factors affecting an individual in their functioning, so partnership is essential. 8.1.7 Resources are allocated according to need, with some universal services, reducing the inverse care, variation between resource and need. Specifically for the fourth goal: 8.2
People with long term conditions feel in control of managing their conditions through: 8.2.1 self managing their care 8.2.2 using personalised budgets for both health and social care 8.2.3 using electronic technology, be that care records, e-care, information
and assistive technologies 8.2.4 can manage the wider consequences of their condition, eg loss of work or breakdown of relationships 8.2.5 can opt for healthier behaviours 8.2.6 living at home longer with complex health needs 8.2.7 decision making about their care and end of life 8.2.8 improved management of chronic conditions, as shown by improved clinical and health functioning assessments Whilst there are many factors that lead to health inequalities, we expect provider organisations to focus attention on those more at risk of developing disease or illness as well as promoting health and wellbeing and promoting positive social, psychological and physical quality of life. The commissioners require the provider to demonstrate how this will be achieved through a partnership approach. 9. Technology There has been growth in the use of technology in health and social care, however, the success of the Government Whole System Demonstrator Pilots indicate that we have only touched the surface of what can be achieved. Predictive risk modelling, telemedicine, assistive technology and improved communication through IT solutions are now known to improve the quality of care, reduce admissions and generate cost savings. Technology is a tool that can be used to deliver care to those groups who do not traditionally access health services, to support self care and self management and for those who need additional support to access services. As commissioner, we want to see clear plans for implementation of technology solutions. We want to see how innovation and technology can be linked to the delivery of health outcomes and improving productivity. We require evidence of an organisation that has developed the cultures and behaviours that will lead to innovations in practice. 10. Innovation 10.1
The development of planned care services in community settings will allow progression of the care closer to home agenda and greater integration between clinicians in the primary and secondary care sectors.
Community settings, given the correct estate and infrastructure, including staffing and equipment, are ideal environments for planned procedures. The scope of such planned procedures needs to be within the capability of the
community setting and focus on minor procedures and investigations where the back up of an acute hospital environment is not required. 10.3
Community planned care services can provide whole or part pathways of care with the focus being on the patient and accessibility, as well as safety and quality of care.
In Kirklees, we would want to see the development of planned care services in the community. This should be a long term strategy of a community provider. There should be a broad range of planned care services. The community provider would be expected to work with commissioners to option appraise the planned care services that could be provided in the community. There would then be an expectation that developing and implementing these services progresses. Ultimately the commissioner would expect a full and comprehensive range of appropriate planned care services available in the community. In addition, planned care pathways, where appropriate, should be integrated with other providers of health and social care giving a seamless experience to the patients and their family.
11. Finance 11.1
Providers should provide details about how they will manage the requirements of commissioners in a challenging financial environment for the NHS, the wider public sector and the national and local economy. Plans should show how services will be maintained under the following scenarios:
Implied efficiency requirements Base case Downside cases
4% 4.5% and 5%
4% 4.5% and 5%
4% 4.5% and 5%
4% 4.5% and 5%
Community services providers face a different set of risks to those in the acute sector. Historically during periods of financial pressure in the health care system, expenditure on community activity has fallen more rapidly than expenditure in other areas coupled with increasing demand that is not met through increased income. To reflect this risk, providers will be assessed against two downside cases of 4.5% and 5% efficiency requirement in each year.
NHS Kirklees recognises the scale of the productivity challenge that these efficiency requirements imply. However, it is important that the financial assumptions reflect the economic outlook and current policy framework. Whilst these assumptions reflect the national risks, we believe they face community providers nationally. We also recognise that providers in Kirklees may feel they face a specific individual set of circumstances. Providers are invited to comment on this and provide detailed justification for any alternative financial planning assumptions they put forward.
Providers will be expected to demonstrate the ability to deliver high quality care based on evidence. The organisation should have a strategy for audit and research that demonstrates implementation of evidence based practice and NICE guidelines.
We will expect a focus on improving patient experience by: • • • • • • • •
Improving patient choice. Delivering single sex accommodation Reducing HCAI Greater focus on informed choice. Single point of access and care coordination. Care planning and goal setting Patient held records A focus on safeguarding
Patient safety will be evident in the organisation strategy with evidence of quality reporting that includes patient safety, patient experience and evidence based practice.
Quality indicators in the community contract and in individual service specification will be vigorously monitored through existing processes. National and Regional CQUINS will be used as a benchmark for quality improvement.
13. Summary The commissioning intention is intended to set out for the provider, the strategy for delivering community services. It should be read alongside NHS Kirklees “The Transforming Community Services Strategy” and the five year strategic plan ‘Realising The Vision’. Commissioning a service for the community needs to focus on the challenges of the future, encouraging innovation and utilising technology to deliver services closer to people’s homes and to maximise the opportunity for greater efficiency and productivity in managing limited financial resources. We need to see significant progress towards delivering integrated care via integrated care organisations with evidence of partnership agreements to progress towards this outcome. The future is focused on delivery of services that are local, and meet the needs of the communities across Kirklees. They need to be equitable, personalised, focused on improved outcomes and reduce the inequalities that we know exist across Kirklees.
Recommendations The Board approves the commissioning intentions. The Board requires the provider to align the business case with the commissioning intentions.