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Towards a Local Integrated Care Partnership (LICP) in Rushcliffe

1. Introduction

The MCP Governance Group considered and endorsed a paper in October 2017 seeking support for developing an ‘offer’ to the emerging ICS in Greater Nottingham as to how we could develop the MCP model in Rushcliffe beyond April 2018. The Governance Group supported the ambition for a ‘partially integrated’ model, under which GP Practices continue with existing contracts for core services and in which the key provider partners were PartnersHealth and Nottinghamshire Healthcare. This paper seeks a discussion and approval for the next steps.

2. Update

Since the last MCP Governance Group and initial Governing Body discussion: • Further engagement with Robert Breedon of Gowling WLG to consider the contractual

framework and development of an Integration Agreement – the legal advice note is attached (Appendix A)

• Progress in developing the detail around ‘in scope’ services and identifying the financial envelope for those

• NHSE and NHSI have published planning guidance ‘Refreshing NHS Plans for 2018/19’, confirming the priorities of Next Steps on the Five Year Forward View. The guidance places emphasis on integrated working across systems:

o STPs will take an increasingly prominent role in planning and managing system-wide efforts to improve services.

o The term ‘Accountable Care System’ (ACS) has been replaced with ‘Integrated Care System (ICS)’. The move towards systems working in 2018/19 will continue through STPs and the voluntary roll-out of ICSs.

RCCG/GB/18/056

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• Locally, the STP is developing its approach to integrated systems working – its current thinking is illustrated at Appendix B.

• The Greater Nottingham CCGs have commenced an internal change management process to reconfigure the CCGs’ management structures – currently being consulted on.

• A confirm and challenge process has been completed to determine future commissioning intentions for MCP schemes beyond March 2018, with most being spread or having the potential to spread across the STP footprint

• Final NHSE Assurance meeting held to formally close the Vanguard programme and signal proposed future arrangements for delivering a whole population health approach for Rushcliffe

3. Developing the local model

The diagram below shows how we have updated our initial thinking to reflect the emerging framework and tiered approach for the Integrated Care System. The Governing Body is asked to discuss this and what governance framework we should develop for the Local Integrated Care Partnership model beyond March 2018.

4. Next steps

In our last discussion at the MCP Governance Group, we agreed the following key milestones for the phased development of the Principia Local Integrated Care Partnership (LICP):

Jan - March 2018: Pre-mobilisation phase - concluding the formal overall MCP evaluation; confirming future commissioning intentions; seeking legal advice; finalising the future service model and ‘prospectus’

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April to Sep 2018: Establish the shadow LICP - develop the Integration Agreement; mobilise next stages of service improvement; focus on workforce development

Oct 2018 to March 2019: Formalise the LICP through appropriate contract framework; develop proposals for next phases of in-scope services; agree scope of tactical commissioning and associated support/resources

April 2019 onwards: Extend scope of services – including social care, third sector and specialist provision

A proposed programme high level work plan has been developed and is attached Appendix 4 together with proposed governance, workstream and workgroup arrangements Appendix 5 Key actions include: • Finalise the Integration Agreement, including the work on scope and financial values –

with the aim of approval by the Boards of Nottinghamshire Healthcare and PartnersHealth by the end of Q1 2018/19

• Develop a ‘prospectus’ to describe the new care model • Articulate how we would define ‘tactical commissioning’ for out of hospital care and the

likely associated resource requirements • Actively seek dialogue and support from the STP / ICS to continue developing the place-

based local care model in Rushcliffe – as a ‘pathfinder’ within the STP to help shape the future model and share our learning

5. Recommendation

The Governing Body is asked to: • Note this update • Discuss the proposed programme plan, governance and work groups

Sharon Creber

April 2018

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Appendix A

Rushcliffe MCP

Summary of Proposed Contractual Structure

1. Background:

1.1. The two main providers of NHS funded out of hospital care in Rushcliffe are Nottinghamshire Healthcare NHS Foundation Trust (Notts Healthcare) and PartnersHealth LLP (PartnersHealth). There is already a successful model of collaborative working across primary care in Rushcliffe and these two providers have developed strong relationships.

1.2. As part of the development of a wider Integrated Care System (ICS) across Nottinghamshire, the two providers have been considering how they can develop a local integrated care model in Rushcliffe which will form part of the wider ICS in due course.

1.3. Notts Healthcare and PartnersHealth have reviewed and considered the guidance and surrounding documentation in relation to multispecialty community providers (MCPs) and are attracted by the collaborative models described in the MCP guidance. Indeed Rushcliffe was identified by NHS England as one of the New Care Model Vanguards for the MCP model of care.

1.4. The MCP Guidance from NHS England1 envisages the following:

1.4.1. an MCP combines the delivery of primary care and community-based health and care services – not just about planning and budgets;

1.4.2. an MCP is a placed based model of care – serving a whole population. It should be based upon the sum of registered lists of the participating general practices;

1.4.3. in its most integrated form, an MCP holds a single, whole population budget for all the services it provides;

1.4.4. an MCP should be able to deploy budgets flexibly and reshape the local care delivery system around what really works best for different groups of patients; and

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1.4.5. ultimately an MCP will need to be commissioned – to be established on a sound legal footing under contract: so that money-flows, contracts and organisational structure all help the MCP to do the right thing.

1.5. The current thinking in Rushcliffe is that the providers will not create a new single entity by way of merger, acquisition or otherwise (as envisaged by the fully integrated MCP model). Instead, Notts Healthcare and PartnersHealth will remain separate entities and the option being pursued, in the first instance, is the 'virtual MCP' model described in the NHS England Guidance. However, there is an appetite to borrow and replicate some of the features of a partially-integrated model where possible – see section 4 below.

1.6. We have met with NHS Rushcliffe CCG, Notts Healthcare and PartnersHealth on two occasions to discuss the emerging model of collaboration, integrated working and risk/reward sharing. This paper describes the proposed scope and structure for the Rushcliffe MCP. 1 The multispecialty community provider (MCP) emerging care model and contract framework: July 2016

2. Scope and structure of the MCP

2.1. The scope of services for the Rushcliffe MCP is out of hospital services. These comprise the current community and mental health services provided by Notts Healthcare and the various enhanced primary care services provided by practices within PartnersHealth. There should be scope to add in social care and pharmacy services in due course.

2.2. Under the proposed collaboration, GP practices will continue to deliver core primary care services under existing GMS/PMS contracts – although their engagement through PartnersHealth should nonetheless ensure that there is some alignment with the work of the MCP. The arrangements should be flexible enough to allow core primary care services to come within the scope of the MCP but that is not planned in the short term.

2.3. It is envisaged that some functions currently sitting with the CCG would also transfer to the Rushcliffe MCP: these could include matters such as medicines management and/or service re-design responsibility.

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2.4. Under the proposed model, the existing services contracts held by Notts Healthcare and PartnersHealth and its practices will remain in place and are un-affected. The proposed collaboration, integrated working and risk/reward sharing are achieved by an over-arching Integration Agreement between the two providers. Under the proposed model in Rushcliffe, the CCG is not a party to the Integration Agreement.

2.5. In December 2017, we advised that, in light of the fact that the underlying service contracts (NHS Standard Contract and GP enhanced primary care contracts) are not being altered or varied, the agreement of an Integration Agreement between the providers does not, of itself, raise any procurement concerns. The position will, of course, need to be kept under review and procurement law considerations may arise if the service delivery responsibilities for the providers change and where those changes involve variations/modifications to the underlying services contracts;

2.6. The arrangement is illustrated below:

NHS Standard Contract/GP Contract for enhanced services

Integration Agreement

3. Alignment with the Greater Nottinghamshire ICS

Joint Integration Board

Notts

HC

Partners

Health

CCG

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3.1. Adopting the language of the Nottinghamshire ICS, the above arrangements would comprise one of the Local Care Organisations (LCO).

3.2. It is envisaged that the Rushcliffe MCP can be accommodated within whatever Integrated Care Partnerships (ICP) emerge from the current ICS planning and the procurement for a system integrator to be undertaken by the Greater Nottinghamshire health and care commissioners.

3.3. The proposed arrangements for the Rushcliffe MCP will be designed so as to permit flexibility to work within the ICP.

4. The Integration Agreement

4.1. As described above, the Integration Agreement forms an overarching 'relationship contract' between Notts Healthcare and PartnersHealth. The Integration Agreement will covers matters such as:

4.1.1. Shared governance arrangements and decision making – through a Joint Integration Board;

4.1.2. The collective management of available budgets – even where those budgets may be changed by commissioners;

4.1.3. The service responsibilities for each of the providers in ensuring effective integration across out of hospital services.

4.1.4. The collective management of available resources; 4.1.5. The management of service re-design and the implementation

of new initiatives (e.g. Primary Care Psychological Medicine); 4.1.6. Any collective risk/reward arrangements and incentive schemes –

whilst there will not be a single budget, there will be aligned risks/rewards in the event of over / under performance against the available budgets;

4.1.7. The objectives of the collaboration and the agreed principles and behaviours; 4.1.8. The resolution of differences of opinion or disputes; and 4.1.9. Joint contract management.

4.2. We have agreed with the CCG and the two MCP providers to commence work on the development of a draft Integration Agreement for consideration and review by the partners in early March. The draft Integration Agreement will build upon the principles set out in this paper

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and reflect our learning from other examples of provider collaboration.

Gowling WLG 1 March 2018

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TIER 1

Integrated Care System (ICS)

Strategic Commissioning

TIER 2

‘Integrated Care Partnership ‘(ICP)

Provider collaborations, network and alliances e.g

Greater Nottingham

Mid Nottinghamshire

Tactical Commissioning

TIER 3

Locality working

Primary Care Homes, GP Federations, Local Authorities and District Councils,

Voluntary sector, neighboroud populations

Tactical Commissioning

Appendix B

Integrated system working – the STP’s emerging thinking

Tier 1: Nottinghamshire Integrated Care System:

Responsible for strategic commissioning

Planning for the future and production of the ‘single plan’.

Functions include: o Aligning commissioning o Integrating regulation o Managing performance

o Providing system leadership o Owning and resolving

system challenges Tier 2: ‘Integrated Care Partnerships’

Provider-led Partnerships

Responsible for ‘tactical commissioning’, supply chain management and local delivery

Functions include: o Tactical commissioning

devolved by the ICS o Patient navigation o Planning for delivery of

service change o Focus on defined population o Market management and

setting contracts Tier 3: Locality working

Integrated teams set up around the needs of 50-80,000 populations

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Appendix C

Principia Integrated Local Care Partnership (LCP) Delivery Plan Overview This high level plan sets out the key milestones for the phased development of the Principia Integrated Local Care Partnership. The detailed work programme will be fleshed out early during Q1 2018/19. The main phases of the plan are:

Jan - March 2018: Pre-mobilisation phase - concluding the formal overall evaluation; confirming future commissioning intention; seeking legal advice; finalising the future service model and ‘prospectus’

April to Sep 2018: Establish the shadow Integrated LCP - develop the Integration Agreement; mobilise next stages of service improvement; focus on workforce development

Oct 2018 to March 2019: Formalise the Integrated LCP through appropriate contract framework; develop proposals for next phases of in-scope services; agree scope of tactical commissioning and associated support/resources

April 2019 onwards: Extend scope of services – including social care, third sector and specialist provision

Reference Objective Type

[Activity / Milestone]

Forecast Start Date

Forecast End Date

On track (RAG)

1 Pre-Mobilisation

1.1 Gain approval from MCP Governance Group to proceed with scoping of model

Milestone 17-Oct-17 Green

1.2 Discussions and initial legal advice around partnership Activity Green

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options

1.3 Complete and sign off formal evaluation Activity 31 Jan 18 Green

1.4 Gain approval from CCG, PartnersHealth and NHCT Boards to progress with scoping the LICP

Activity 31 Jan 18 Green

1.5 Preparation for final NHSE Assurance meeting Activity 01-Jan-18 08-Mar-18

Green

1.6 Scope commissioning intentions through Confirm and Challenge process

Activity 01-Nov-17 15-Mar-18

Green

1.7 Formal close down of Principia MCP vanguard programme

Milestone 31-Mar-18

Green

1.8 PartnersHealth approval of Integration Agreement Milestone 29-Mar-18

Amber

1.9 Notts Healthcare approval of Integration Agreement Milestone 26-Apr-18 Amber

1.10 Rushcliffe CCG Governing Body approval of LICP and work programme

Milestone 19 Apr 18 Amber

2 Establish Programme Governance and Leadership

2.1 Agree governance for the programme leadership and ToR

Activity 30-Apr-18 Amber

2.2 Agree governance for programme management and ToR Activity 30-Apr-18 Amber

2.3 Take legal advice with regard to contracting arrangements

Activity 01-Jan-18 28-Feb-18 Green

2.4 Draft Integration Agreement between PartnersHealth, CCG and Nottinghamshire Healthcare Foundation Trust (NCHT) produced

Activity 01-Jan-18 08-Mar-18

Green

2.5 Develop communication and stakeholder plan Activity 01-Jan-18 30-Apr-18 Amber

2.6 Agree resources necessary for programme mobilisation Activity 01-Jan-18 30-Apr-18 Amber

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2.7 Develop Prospectus and description of model Activity 30-Apr-18

Amber

3 Mobilising Local Care Model

3.1 Set up LICP Joint Leadership Board Activity 12-Mar-18 30 Apr-18 Amber

3.2 Set up LICP Management Board Activity 12-Mar-18 30 Apr-18 Amber

3.3 Project Initiation Document produced and approved by LICP Joint Leadership Board

Activity 30-Apr-18 31-May-18

Amber

3.4 Delivery of LICP core components matched to workstream activity

Activity 12-Mar-18 31-May-18

Amber

3.5 Alignment of transformation areas and STP priorities with LICP

Activity 12-Mar-18 30-Apr-18 Amber

3.6 Prioritise clinical workplans for each priority area Activity 12-Mar-18 01-May-18

Amber

3.7 Development of contractual mechanisms and relevant variations, associated legal frameworks with gain/risk sharing agreement and financial incentives

Activity 12-Mar-18 01-Oct-18 Amber

4 Outcomes Framework

4.1 Development of an Outcomes Framework of aligned phasing of in scope services to inform relevant contractual obligations

Milestone 01-Feb-18 30 Jun 18 Amber

4.2 Identification of budget lines to be included Milestone 01-Feb-18 30 Jun 18 Amber

5 Workforce Development

5.1 Taking recommendations from WSP analysis and developing a workforce plan

Activity 31-Jan-18 30 Jun 18 Amber

5.2 Engaging OD support for the transformation model Activity 31-Mar-18 01-May-18

Amber

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5.3 Interface with tactical commissioning Activity 31 Mar 18 01 May 18

Amber

6 Communications and Engagement

6.1 Develop and produce materials/resources to communicate the LICP vision and model of care

Activity 12-Mar-18 01-Jun-18 Amber

6.2 Produce Staff Engagement Plan Activity 01-Jan-18 30-Apr-18 Amber

6.3 Produce Patient Engagement Plan Activity 01-Jan-18 30-Apr-18 Amber

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Appendix D

Proposed Principia Local Integrated Care Partnership Governance Arrangements

Principia Local Integrated Care Partnership Board

Unplanned Care Mental Health

Planned Care Out of Hospital

Primary Care Community Whole

Population Health

Principia Programme Operational Group

Rushcliffe CCG Governing Body

Nottinghamshire Healthcare NHS Foundation Trust

Executive Board PartnersHealth Board

Greater Nottingham Joint Integration Committee Nottinghamshire ICS Out of Hospital Board

Core functions: Medicines Management, CAS, Service Improvement Supported by: Workforce and OD, Communications and Engagement, IT, Estates, Data and Performance Analysis

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Appendix E

Principia Local Integrated Care Partnership – Proposed Workstreams and Working Groups

Workstreams/Groups PartnersHealth/CCG Leads

NHCT Leads Local Authority Leads Meeting Frequency

Interface with Greater Notts

Organisational Groups

Principia LICP Partnership Board

Monthly

Ensure alignment of all organisations to the vision and objectives

Review performance and determine strategies to improve performance or rectify poor performance

Promote and encourage commitment to the Integration Principles and Integration Objectives amongst all Participants

Formulate, agree and implement strategies for achieving the Integration Objectives

Principia LICP Operations Group

Monthly

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Develop and implement project plan

Ensure delivery of key milestones/tasks

Produce strategic planning guidance for workstreams

Produce reports for Partnership Board

Clinical Workstreams:

Planned (services) Bi-weekly?

Elective Pathways

Community Clinics

CAS

Fracture Liaison Service

Out of Hospital(services)

Primary Care Sub Group

Social Prescribing

Long Term Condition Management

Frailty Pathway

Health Promotion

Population Health Sub Group

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Community Sub Group

Unplanned Care (services)

Case Management of Very High Service Users

Integrated Discharge inc Trusted Assessor

10 minute protocol

Enhanced Support to Care Homes (Including eMAR and dietitian)

End of Life Pathway

Mental Health (services)

Primary Care Psychological Medicine

Depression Advice Clinic

Integrated Mental Health Pathway

Reducing EA’s in patients with severe mental health issues

Reducing EA’s in Patients with LTCs

Enabling Task and Finish

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Groups

Communications and Engagement Working Group (key tasks)

Development of Comms materials/key messages

Development of a workforce Engagement plan

Development of a patient engagement plan

Workforce and Organisation Development Working Group

Produce and deliver Rushcliffe Workforce plan

Mapping of existing assets/skills/competencies

Develop and deliver leadership/training programmes

Integration of roles/skills/functions

Finance, Business

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Intelligence and Performance Monitoring

Contract finance identification of population budget

Contract negotiation/performance

IT Infrastructure

Electronic Shared Records

Further development of F12

Business Intelligence