Governance and Accountability in New Care Models The King's fund 8/2/17

Session 1: Ben Collins (Project Director, The King’s Fund)

In an ACO, Commissioners will take on a more strategic role, focussed on overall performance.

The system design will be key in helping to deliver results:

Given variation in systems currently, how this will look will be very variable across the country and contexts

How will Commissioners influence this? Many choices will need to be made.

Harder incentives require stronger/more worked-up contracts.

Risks identified from ‘uniting care’ and disrupting partnerships.

What’s the end-point? Should be to create learning systems, to be creative with finding solutions to the problems of the system. Should create opportunities for improvement:

Session 2: Saffron Cordery (NHS Providers)

We ignore accountability and governance at our peril, but given the pace, it has often been left as a lower priority.

State of NHS Providers Survey:

Dire pressures and dreadful recruitment/workforce concerns.

+ves Many feel engaged in STP process.

New models seem to be focussed on arranging services around the patient, however integration around a patient has been the focus for 20yrs + and will continue to be focussed so.

Good corporate governance is:

Indespensible (ambitious, effective, prudent, direction)

About strong dynamic leadership (directs and controls all board-led organistations)

The business of the board and responsibility of every director (NED and exec)

About success (effective strategies, ethical leadership, meaningful challenge, real accountability)

Accountability:

Ownership: owners must benefit, public are moral owners, so public need to hold in law to account for this formally.

Line of sight: critical. Able to see, access and engage with what we are holding to account.

Local accountability: nature of relationship with local people is critical. Formalised via members and governers for FTs. Openness, transparency, responsiveness, new care models mean multiple local accountabilities.

NHS providers perspective: Need to focus on role of individual organisations. Institutions, localities and systems are not a zero sum game: do not have to lose individual identities, can still be part of a wider system built to collaborate, but shouldn’t lose a sense of being an ‘individual’ organisation.

Leadership, control and STPs: getting the governance right.

STPs have no legal status currently: this is delivered through the individual organisations within this. Cannot pool sovereignty (individual responsibilities remain). How far can individual institutions go in journey to organisational altruism?

Governance in STPs: The MOU:

Scope and clarity of purpose, agreed principles, gov for decision making. How manage disagreements and disputes, how to organise opting-out. Decision-making subsidiarity, do the board decide everything? Risk and assurance. Who gives external advice, collectively or those of the individual organisations. Non-exec perspectives. How to ensure transparency, communications and consultation.

Summary:

Governance and accountability is key to delivering potential benefits (and risk if poorly carried-out). Therefore change to approach and pace warranted: should be thoughtfully and slowly defined, challenging as pressure is to move forward ASAP. Culture that this defines (and vice-versa) will drive the behaviours and results.

Critical tension: How can an FT legitimately be expected to sign-up to plans that may limit their future sustainability?

Mistakes they have seen: Mismatch between what’s happening on the ground, and what central agencies view and are enforcing. Process has held them back from consulting more with communities. Central agencies defining the process are not appreciating that individuals have to respect and meet their local accountability responsibilities primarily.

Session 3: Robert Breedon (legal perspectives)

Legal framework is key to defining results, given complexity of new care models relationships.

Start with the aim and objective, then define form in accordance with this (numerous structural options give different results). The structural models are complex in practice, but look simple on paper.

Prime contractor model: Commissioner to prime contractor (integrator) to multiple subcontractors.

Provider collaboration / contractual joint venture: Key difference is that all have a say in how to make decisions and define the terms. Share risk of benefits.

SPV :Provides come together to form a new corporate vehicle. E.g limited company LLP. Holds a contract with the commissioner. ‘fat’ or ‘thin’ variations depending on if owns assets and staff or not.

Alliancing: Shared risks and benefits. Collective accountability. ‘your problem is my problem’ held together by a single alliance contract, with individual service contracts below.

Can have multiples/combinations of these.

Advise: Do an options appraisal, following identifying the overall aim to find the ‘best fit’

Opportunities: All can deal with a single capitated budget. All can be used to incentivise outcomes. All can share risks and rewards. All can utilise NHS standard contract.

Challenges: How define decision making and delegated authority, likely best to define groups to take forward elements, individuals need to delegate decision making to representatives (cannot take each decision back to base: very slowing).

Key issues/Questions:

How manage Inherent conflicts of interest: esp local accountability responsibilities versus responsibilities to the vehicle/alliance?

Can commissioners delegate commissioning? Should retain duties, but contracting out some of these roles to provider groups.

GMS/PMS in or out?

Beware of sharing all commercially sensitive information: may violate competition law.

Be mindful of procurement law at outset and at any service redesign.

For Non-FTs, there are issues around powers to form corporate vehicles: they have no power to take shares in a company.

There are VAT implications for corporate vehicle: LLPs and companies are not ‘NHS’ organisations.

Need for guarantees or other assurances for corporate vehicles.

No real legal barriers to local authorities joining and being critical partners in these collaboratives, however perhaps more challenging for them to delegate authority to a group like this (?due to cultural history).

Procurement law is now more ‘light-touch’ and should allow more creativity.

An independent provider can opt-in to NHS pension system.

Caution of being too distracted by legal concerns, rather than remembering the bigger picture and goals/responsibilities, especially since change is happening so quickly.

Session 4: Ed Waller and Miranda Carter (NHSi/NHSe)

National contracts being devised co-developed with vanguards. The full vision will require a single provider to operate under a new contract.

Overview of contracting and implementation:

Contracts should be longer than are currently (10-15yrs)

Should be held by range of NHS and non-NHS providers

Three broad contractual options for MCPs/PACS: Virtual; partially integrated and fully integrated.

This will have an impact on the role of commissioners:

NHSi and Assurance:

ISAP created to supporting and assuring novel procurements, to ask the right questions early. NHSi will then be assessing using the same frameworks/questions.

Has 3 stages to process: Strategy; procurement; mobilisation; service delivery. Information discussed at 4 stages: Early engagement meeting, with 3 subsequent checkpoints.

‘Organisational form support’ through modelling how organisational forms will emerge.

Potential form scenarios currently imagined are varying.

Payment mechanisms. They are creating a handbook on how to create a whole Pop. Budget; improvement Scheme and (critically) set gain/loss agreement to set financial incentives.

Key Points identified:

Advise do not set too much of budget into ‘incentive’ payments, as puts overall financial sustainability of individuals (and therefore system) at Risk.

Be careful not to change a system so much that individuals may fail and add more cost to the control total of that system. The changes have to be gradual/tolerated by providers and not add to the system control total.

Control totals for providers and the local system do not stack up and are unaffordable: mismatch between analyses by NHSi and NHSe.

CQC (Janet Williamson: deputy chief inspector)

CQC will need to adapt to new landscape, e.g Inspecting multiple sites and organisations. Currenty defining and working this through. Inspection regimes will likely follow a patient pathway.

Current Strategy (to 2021): Encourage improvement, Innovation and sustainability.

Deliver an intelligence-driven approach (targeted to poorer areas, and stronger areas being inspected every 5 years).

Promote single shared view of culture and quality.

Aim to reduce duplication of other agencies assurance processes.

Improve efficiency and effectiveness.

Strengthen and simplify key lines of enquiry: separate for social care and healthcare providers.

Don’t want to obstruct innovation. Currently (until Sept) developing this approach.

Key representatives at CQC happy to support and advise on how to build to meet new requirements.

Consultation finishing at the end of this month: results out at spring/summer 2017.

Key principles: ensure accountability is crystal clear. Well-led will be critical part of new care models assessment. Do not want to discourage providers from taking over challenging services because they want to improve them.

Session 5: Dudley MCP

Session 6: Developing local systems of governance and accountability (Panel Discussion: NHS providers, NHSi, Dudley MCP)

NHS Providers again highlight risks of proceeding too quickly and individuals putting their individual responsibilities at risk.

NHSi stress that not to get bogged-down on transactional costs and taking time to ensure all parties are signed-up to changes. They feel control totals will help in achieving this.

Dudley MCP admit initial response to STP 1yr ago was ‘oh god….can we avoid this’ (as already had vanguard and MCP strategy). Reluctantly engaged. 1 yr on, it has helped enable a wider view and to facilitate making progress in their work. Work is complex and takes time, so beg for patience. All about relationships and collaboration, takes time to build this. Make patients and frontline staff the core.

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