London borough hounslowdemocraticservices.hounslow.gov.uk › documents › s107689 › Item... · 2014-08-22 · To reaffirm the ADASS statutory responsibilities and ensure that

LONDON BOROUGH HOUNSLOW COMMISSIONING INTENTIONS REVIEW

Susan Anderson‐Carr LLB (hons), MA, DipSW, MIBC, MCIPS, CMgr FCMI Health & Social Care Integration Consultant

January 2014

CONTENTS

Page

1. Background and Purpose of the Review 3 2. Methodology 3 3. Summary of Conclusions and Recommendations 4 4. Introduction 13 5. Integrated Commissioning Model of Delivery 13 6. Safeguarding 15 7. Contract Management 15 8. Market Development 15 9. Governance 15 10. Options 16

Appendix A Appendix B Appendix C Appendix D Appendix E

Page 2 of 18 January 2014 version 5

1. Background and Purpose of the Review 1.1 The London Borough of Hounslow (LBH) and Hounslow Clinical Commissioning Group

(HCCG) are committed to partnership working which is inclusive of establishing joint commissioning intentions across Children’s, Adults, Health and Public Health functions. Prior to the review commencing, senior managers within the Council had already identified that the baseline position is that there are no defined functions and limited capacity to fulfil the undertaking to deliver against the partners shared objectives. A change programme to implement a new approach to LBH’s supply chain management was underway whereby procurement and supplier performance are being centralised within the Resources Directorate. A review of the commissioning functions, dependencies, structure and governance arrangements across partners will support decision makers in the formation and implementation of a model that will deliver against the joint commissioning intentions and financial challenges that both organisations face.

1.2 The review deliverables were defined as:‐

a) To design a Joint Commissioning Intentions Function; to lead on strategy and policy for LBH and the CCG (with an aligned structure and job descriptions)

b) To reaffirm the ADASS statutory responsibilities and ensure that the future model compliments the undertaking of these.

c) To reaffirm respective roles in terms of safeguarding across the Joint Commissioning Intentions Function, Adults, Supplier Performance and Procurement in line with best practice.

2. Approach and Methodology for the Review

The approach for the review is outlined at Appendix A which is inclusive of a schedule of people who have been interviewed in the process. The composite elements are captured below:‐

• Collation of information surrounding current functions/job descriptions and structures


• Analysing the strategic framework inclusive of documents, processes and interdependencies between functions and teams

• A review of aligned implementation plans to strategies and recommendations from previous audit reports.

• Evaluation of needs identification and market analysis • Review of the contract monitoring methodology and safeguarding protocols. • Review of benchmarking and best practice information • Conducting a series of interviews with internal and external stakeholders

(Appendix A refers) • The formation and circulation of a questionnaire and information schedule

(Appendix E refers) • The formation and circulation of a supplementary questionnaire based on the

findings of the initial responses (particularly where there were inconsistent responses)

• Review of findings, evidence base and theory.


3. Summary of Conclusions and Recommendations

Recommendation 1 – Joint Strategic Commissioning Function and Structure


Recommendations A joint strategic commissioning structure should be implemented (Appendix B) which should be 50/50 funded between LBH and HCCG. The finance evaluation of the structure (Appendix C) indicates that the LBH contribution to a Joint Commissioning Structure is cost neutral however there may be a budget deficit for HCCG. It is recommended that any projected deficit is funded via the Better Care Fund. If the above recommendation is accepted, the Job Descriptions and Person Specifications for the integrated roles should be developed in conjunction with HCCG and staff consulted on the process. Observations The commissioning review has highlighted the strengths and weaknesses of the current function and structure. There is an urgent requirement to implement a structure in order to develop the joint commissioning intentions and to ensure that these are underpinned by joint strategies. There is minimal evidence available to indicate that a strategic approach is being taken to needs identification, market analysis and the development, implementation and monitoring of strategies. It should be noted that the recommendations outlined in the Internal Audit Adult Commissioning Final Report dated June 2013 are in the main outstanding which provides further evidence that the joint commissioning structure in its current form is not delivering the expected outcomes. Historically, and for a variety of reasons, the Joint Commissioning Team has failed to deliver an integrated function as generally staff within the team have minimal insight into whole system working and the benefits of delivering an integrated model. There are currently insufficient commissioning managers in the structure to ensure that the needs of all client groups are being met; the recommended minimum structure has taken this deficit into consideration and will provide a function that can plan and commission services for people from birth to death. Commissioning Managers should hold responsibility for facilitating, informing and monitoring the outcomes for their respective Boards/Partnership Groups as this will strengthen the governance arrangements under the Joint Commissioning and Health and Wellbeing Boards. Commissioning Managers should also lead on communication and engagement with internal and external stakeholders with particular reference to

service users, patients, carers and representative organisations as this is currently an area of weakness. Significant progress has been made in recent months in the development of strong relationships with HCCG and this has facilitated the development of joint commissioning intentions and joint working on the re‐modelling of care pathways and services. Discussions are currently taking place to strengthen the monitoring of Providers and safeguarding protocols between health and social care which will reduce the aligned risk and ensure that in circumstances where risk has been identified, that appropriate action is taken within an endorsed governance framework. A Joint Strategic Commissioning Team will provide assurance to senior managers within LBH and HCCG surrounding roles, responsibilities and accountability. A Joint Strategic Commissioning Team based on the initial structure recommendations will facilitate the transfer of other functions into it at a later date should there be a requirement (for example functions currently delivered by the Commissioning Support Service on behalf of HCCG).

Recommendation 2 – Disaggregation of Commissioning and Care Management Functions


Recommendation There should be a disaggregation of the commissioning and care management functions held within the Assistant Director, Adult Safeguarding, Social Care and Health role. Observations Former Primary Care Trusts were required to disaggregate the purchaser/provider functions and become commissioning organisations as it was recognised that there is a conflict between the respective roles and responsibilities. HCCG is a commissioning organisation and it will be difficult to implement a joint strategic commissioning function without a clear demarcation between the respective functions. The skills, knowledge and experience of staff required for the two functions are significantly different. All benchmarking carried out with other LA’s including Torbay, Kent, Medway, Essex, Lancashire, Birmingham City Council, Waltham Forest, Brent, Hackney, East Sussex, Sandwell and Oldham ( all with strong integrated commissioning outcomes) have a disaggregation between the roles and responsibilities. The disaggregation provides the checks and balances required in the

system to ensure safe practice and effective and measurable outcomes. In order to facilitate this it should be stated within the respective Assistant Director’s job descriptions and key work objectives that effective relationship building is a fundamental requirement for senior managers where there are strong inter‐dependencies requiring joint working. As more Local Authorities move towards a matrix management approach to care management, commissioning, category management and procurement greater emphasis will be placed upon senior managers delivering against this requirement.

Recommendation 3 – Supply Chain Management (Brokerage, Category Management, Monitoring and Procurement)


Recommendations The respective functions should remain within Supply Chain Management with a caveat that further work is required on the governance surrounding the functions with particular reference to safeguarding. The role of staff within the brokerage function should be reviewed to ensure that they are being utilised to best effect. Confirmation is required with regard to the composite elements purchased within CONTRoC as the software includes functionality with regard to contract management and alert systems when thresholds are exceeded for commissioned services such as safeguarding and factors that can affect quality outcomes for service users (i.e. the number of support workers assigned to a service user has been exceeded – information collated from ECM). The contract monitoring function for domiciliary care and Care Homes (Nursing and Residential) and Voluntary Sector contracts should be merged with the Commissioning Support Unit’s resources and be hosted by either LBH or the CSU. A communication and reporting protocol should be implemented as a priority. Performance management information of the supply chain should be available to senior managers and the HCCG as a priority. A contract monitoring framework should be implemented as a priority using a balanced scorecard, provider self‐audit and formal monitoring visit based on the Chartered Institute of Purchasing and Supply best practice. The contract monitoring process should ensure that service users, carers,


representative organisations, care management and commissioners are included and afforded the opportunity to influence the outcomes. The procurement for Children, Adults and Health services should include service users and carers in the evaluation process. The responsibility for monitoring the Healthwatch contract should be transferred to Supply Chain Management to ensure consistency and to facilitate the engagement of relevant stakeholders. Observations The Supply Chain Management and matrix management model is being implemented by a number of Local Authorities across the UK. The model focuses on ensuring that staff with the required skills can consistently deliver functions to the required standards (Appendix D refers) In the LBH the model has recently been implemented however there is a significant amount of work to be undertaken surrounding governance in order to ensure clarity with regard to roles, responsibilities, inter‐dependencies and accountability. A substantial amount of work is required on the protocols and inter‐dependency with safeguarding. The introduction of a contract monitoring framework will also require escalation procedures to mitigate against risks to vulnerable people. Trend analysis of safeguarding outcomes should be factored into the governance arrangements as this will result in proactive monitoring of Providers with quality issues. The most effective brokerage operating model would be for brokerage staff to be involved in attending safeguarding case conferences and dealing with low level quality issues in addition to the allocation of packages to Providers. It is important that staff carrying out the brokerage function are fully conversant with the day to day issues with Providers in their respective areas of responsibility and that systems are developed to support and communicate issues; risks; capacity; trends and performance to care management and commissioners (health and social care); this will facilitate a shift from the current reactive approach to a proactive model of monitoring of services and forward planning to meet increased demand and develop Providers to meet the needs of people with a range of needs living in the community. In order for the model to work effectively it is important that strategic commissioners and care management staff are actively involved in the functions aligned to Supply Chain Management. Strategic commissioners should be involved in market development and Provider events as the responsibility for developing the integrated vision, joint commissioning intentions and the identification of needs and commissioning of services to meet the same is the overall responsibility of Strategic Commissioning albeit that this is in conjunction with a range of internal and external stakeholders. The current position in LBH with regard to

market development is poor with only limited evidence available to indicate that Providers in the locality are regularly briefed with regard to the vision surrounding commissioning intentions; there has been limited engagement to prepare organisations for new business and operating models required for Self Directed Support which has impacted on LBH’s national performance indicators for personal budgets and direct payments. It should be noted that staff within Supply Chain Management have been working with commissioners to develop a Provider Embargo Policy and a Contract Monitoring Balanced Scorecard both of which are in draft form and awaiting endorsement through the internal governance process. The re‐modelled Personal Care Framework is a prime example of effective working between care management, commissioners, supply chain management and HCCG. All stakeholders have been involved in the scoping and testing of the model in preparation for an integrated service which incorporates quality initiatives that will strengthen the safeguarding of vulnerable people such as mandatory electric call monitoring; the introduction of a balanced scorecard monitoring methodology leading to a quality assurance score whereby Providers with the highest score will be initially selected for new services therefore fostering a culture of continuous improvement; enhanced monitoring for those identified as being at high risk; daily Provider exception reporting. The re‐modelled recovery pathway (incorporating rapid response, reablement, domiciliary care and falls) is a key component of the Joint Hounslow submission for the Better Care Fund and is on track to deliver improved outcomes within an innovative model of delivery. Staff are to be congratulated on the collaborative work that has taken place to date which is evidence that a matrix management model can work effectively when staff have clear direction and leadership surrounding their roles, responsibility and accountability. It is positive that staff are actively developing robust and effective working relationships and are eager to ensure that processes and protocols are developed and implemented to mitigate against any risks.


Recommendation 4 – Children and Early Years

Recommendations Consideration should be given to implementing the recommended structure (inclusive of the Children’s Strategic Commissioner & Short Breaks Co‐ordinators) and after a period of consolidation a review of commissioning and supply chain management functions within Children and Early Years should take place to ensure consistency. Children and Early Years should implement the recommended monitoring framework. Observations Children and Early Years services would benefit from a consistent approach to contract monitoring and supply chain management however it is acknowledged that due to the specialist nature of some of the commissioned services it will not be possible to transfer all of the functions. Despite this it is important that governance protocols are developed with regard to the inter‐dependencies and models of good practice.

Recommendation 5 – Public Health

Recommendations The recommended contract monitoring framework should be implemented in Public Health to ensure consistency. A review of the contracts commissioned by Public Health should take place to ensure a whole system approach to commissioning which should include Children, Adults and Health input in order to ensure the best use of resources and avoid duplication. The governance surrounding Public Health and the inter‐dependencies with Children, Adults and Health should be reviewed as a priority. Public Health should be included in all working groups aligned to the development of strategies.


Observations The Public Health interface with Adults Services is particularly weak and this is to the detriment of services commissioned and staff involved in the delivery of the functions. Awareness raising and staff development workshops should be scheduled to improve the interface.

Recommendation 6 – Safeguarding


Recommendations All staff, Providers and key stakeholders should ensure that they are fully conversant with the PAN London Safeguarding Procedures; this will require a series of workshops/training events in order to provide clarity with regard to roles, responsibilities and process. The LBH safeguarding procedures aligned to the PAN London procedures should be reviewed as a priority to ensure that all relevant stakeholders are captured and accountable in the process. It is important that a whole system approach to identifying, managing and addressing risk is adopted and co‐ordinated within an endorsed governance framework and that the Adults Safeguarding Board provides effective leadership. The protocols surrounding the co‐ordination of case conference meetings should include inviting commissioners and representatives from supply chain management in circumstances where a Provider of services is the subject of an alert. The service history of the Provider should be included in the process and in a written format. Trend analysis of safeguarding alerts should be incorporated into the safeguarding protocols and included within the responsibilities of Joint Commissioners and staff in Supply Chain Management responsible for the monitoring of services. Safeguarding should be a standing item within staff supervision to ensure that line managers are aware of any risks and that any escalating risk is managed by a person with the appropriate level of responsibility and accountability. Regular Provider Forums should be established with standing items including safeguarding. This is the opportunity for health and social care commissioners and providers to collectively review trend analysis, system failures, issues impacting on quality provision and how lessons can be learned to improve performance and deliver better outcomes.


Regular performance management reports of the supply chain should be formulated for health and social care senior managers to discuss at the SMT’s and the Joint Commissioning Board. This should include an analysis of safeguarding alerts together with the respective outcomes and details of any Provider embargo’s in place and progress made towards achieving the deliverables within the action plan. The draft Embargo Policy should be endorsed as a priority in order to provide staff and Providers with clarity surrounding the process and to reduce the current risk of subjective decisions being made that could result in a legal challenge for the Council. An information sharing protocol should be designed in conjunction with CQC to ensure that all parties are aware of quality issues that may impact on service delivery and the outcomes for individuals. This will enable any previously unidentified risk to be actively addressed and any escalating risk to be managed in a controlled and planned way. The contract monitoring function for domiciliary care and Care Homes (Nursing and Residential) and Voluntary Sector contracts should be merged with the Commissioning Support Unit’s resources and be hosted by either LBH or the CSU (recommendation 3 refers) A communication and reporting protocol should be implemented as a priority (recommendation 3 refers) This should include the framework for care managers to report to commissioners and supply chain management the outcome of reviews where Providers are delivering services as this should influence the monitoring process and the award of the Quality Assurance score. A contract monitoring framework should be implemented as a priority using a balanced scorecard, provider self‐audit and formal monitoring visit based on the Chartered Institute of Purchasing and Supply best practice (recommendation 3 refers) A review of the joint reporting to the Quality Surveillance Group should be reviewed as a priority to ensure that it is fit for purpose. All draft service specifications should be reviewed by an appropriate person holding safeguarding responsibility to ensure that they are fit for purpose. Observations The safeguarding process in Hounslow is currently disjointed and would benefit from re‐modelling to ensure that it is fit for purpose as there is no robust evidence available to indicate that there is a strategic overview and that effective planning and co‐ordinating is taking place in the locality. The review of the submissions from the respective questionnaires sent to key

stakeholders (Appendix A) reaffirms this position as generally there is a lack of understanding surrounding process and responsibility. Essex County Council commissioned John Dixon (May 2013) to carry out an independent review of the matrix management model proposal prior to adopting the same. It was concluded that the commissioning structure needed to include a direct line to the safeguarding boards and the partners and providers in order to offer a one team approach to safeguarding. Staff involved in the interview process are clearly focused on delivering better outcomes however they require advice and guidance on how to effectively facilitate this. Progress is being made on addressing the risks within the supply chain as evidenced in the observations aligned to recommendation 3 above (PCF Modelling) and the implementation of the recommendations will ensure that control measures are in place to mitigate against risk.

4. Introduction

The report “Commissioning in Health, Education and Social Care” published by the Evidence for Policy and Practice Information and Co‐ordinating Centre (EPPI Centre) and the Social Science Research Unit (SSRU) (Report No 2007; September 2012) highlights the changes that have occurred with regard to the divide of functions into service purchasers (commissioners) and service providers.

The in‐depth review and findings provide academic guidance as to what factors will facilitate successful joint commissioning which are outlined below.


5. Integrated Commissioning Model of Delivery

The evidence about the factors that affect commissioning provide some useful indications for decision makers about what needs to be taken into consideration if any joint commissioning initiative is to be successful.

The findings highlight the importance of:

� Trusting relationships between commissioners, and how these are built up over time by continuity of staff;

� Clarity over responsibilities and legal frameworks, particularly in the context of any shared or pooled financial arrangements;

� The importance of co‐location.

� The development of clear structures, information systems and communications between stakeholders.

In the context of health and social care, ‘commissioning’ includes assessing needs, setting priorities, allocating resources, influencing providers, involving patients and the public, minimising transaction costs and managing financial risk (diagram below refers).

The demarcation between the respective functions and recommendations to facilitate a matrix management but collaborative approach to delivering a successful operating model is encompassed within 1‐6 of the recommendations in this report.

Department for Communities and Local Government, 2008 (P. 22)

Definition and stages of commissioning:


6. Safeguarding

The safeguarding of vulnerable people is the responsibility of the whole system engaged with the individual/s. The evidence available indicates that a whole system approach is not currently being co‐ordinated; and this represents a risk that should be addressed as a priority (recommendation 6 refers).

7. Contract Management

Contract management cannot take place in isolation of key stakeholders as the delivery of quality services is the responsibility of the whole system including service users, carers, patients and representative organisations. Supply Chain Management is the conduit for contract management and with governance, systems, processes and protocols in place effective outcomes can be achieved.

8. Market Development Market development is a key deliverable to ensure that there is a sufficient capacity of Providers in the locality to meet the changing needs of the health and social care economy. There is a substantial amount of national evidence available to indicate that people in receipt of personal and health budgets will opt for a direct payment rather than a virtual budget if the market has been stimulated and encouraged to diversify to offer flexible, responsive and quality services. It is important that Providers consider that they are integral to the redesign of services and partners in the delivery of integrated pathways. A successful outcome of functional and/or structural integration is dependent upon the whole system working in a unified and collaborative way which will be challenging given that historically Providers have worked in competition with each other. A market that is responsive to changing need must be informed with regard to the shared vision and included in the process of defining the “as is” and the “to be” pathways. This can be achieved within a matrix management model if Supply Chain Management and Strategic Commissioners work in partnership to facilitate it.


9. Governance A review of the submissions to the questionnaires and supplementary questionnaires has highlighted an urgent requirement to ensure that robust governance is in place as without it the operating model is not fit for purpose.

A new governance framework should also ensure that there are processes in place to monitor the impact of joint strategies and the outcomes aligned to implementation plans. It is recommended that Strategic Commissioning holds responsibility for ensuring that the relevant Boards and Partnership Groups fulfil their responsibilities by meeting regularly and actively and robustly monitoring progress and reporting on any identified risk. Consideration should be given to how the Boards will report to the Joint Commissioning Board and how this information is captured by the Health and Wellbeing Board.

10. Options Considered in the Scoping of the Recommendations for a Joint Strategic Commissioning Team

10.1 Options Appraisal

Option For consideration 1. Do nothing 2. Transfer the ASC functions currently within the responsibility of

Supply Chain Management back to Adult Social Care. 3. Transfer the Strategic Commissioning function to Supply Chain

Management with a recommendation that a Corporate Centre of Excellence for Commissioning is established.

4. Re‐model the current Joint Commissioning Team to establish an integrated Strategic Commissioning function for Children and Adults.

10.2 Review of Options

10.2.1 Do Nothing

Doing nothing is not a viable option as currently there is no Strategic Commissioning function in Hounslow and the Better Care Fund submission and delivery of the projected outcomes is dependent upon the functions identified in Recommendation 1 (observations) being achieved.

10.2.2 Transfer the ASC Functions back from Supply Chain Management to ASC


The LBH Corporate Operating Model is to deliver an overarching Category Management and Supply Chain Function as outlined in Appendix D. A number of Local Authorities are adopting this approach including Essex CC, Medway Council, Brent Council with Enfield and Waltham Forest currently undertaking modelling to provide a central function. This is the best use of resources with the LBH rationale based on a bespoke version of the Price Waterhouse and Cooper model. The rationale underpinning the model is that by disaggregating the functions this ensures a consistent approach to the delivery of the

requirements aligned to contracting, procurement and monitoring with staff developed to undertake tasks to the required standard.

This review has taken into consideration the DASS statutory responsibilities of ensuring that services are in place to meet assessed need and that vulnerable people are safeguarded in the delivery of services. The current operating model is insufficiently developed with regard to governance, accountability, roles and responsibility however there is a significant amount of evidence available to indicate that this is achievable within three months (PCF modelling; Draft Embargo Policy; Draft Balanced Scorecard and Monitoring Methodology; collaborative working with the WLA and Supply Chain Events are all prime examples of positive and effective outcomes resulting from the matrix management model of delivery. The recommendations highlighted above, if endorsed, will provide the required control measures across the services commissioned by the Council and within the health and social care economy.

10.2.3 Transfer the Strategic Commissioning Function to Supply Chain Management

This was considered as an option in order to facilitate a corporate centre of excellence for commissioning. The option is not currently viable as there is a substantial amount of work to be undertaken to improve the baseline position surrounding safeguarding; governance; systems, processes and protocols; to deliver against the Medium Term Financial Strategy; Adult Transformation Programme; functional integration with health and delivery against the Best Care Fund submission.

10.2.4 Re‐model the Current Joint Commissioning Team to Establish an Integrated Strategic Commissioning Function for Children and Adults

This is the recommended option which will deliver against all of the priorities outlined in 10.2.3 above together with a Strategic Commissioning function as outlined in the diagram below (Diagram 1)

If this recommendation is endorsed there will be a requirement to raise awareness across the Council and with external stakeholders surrounding the model of delivery and how this inter‐relates with other functions. There is generally a lack of understanding amongst stakeholders as to what Strategic Commissioning is as historically this has not been available in LBH.

There is a need to have a common understanding amongst stakeholders that Strategic Commissioning represents the activity that ensures the vision and strategic objectives of the organisation are aligned and assessed against customer needs for the short and long term and that it also is responsible for a continuous cycle of :

• Analysing the need for change through joint strategic needs assessments (in conjunction with other stakeholders including Public Health)


• Planning the change

• Enabling and acting on the change • The ongoing review of progress against the required outcomes

Strategic Commissioning is differentiated from Supply Chain Management as it acts as the driver and initiator of service delivery and ensures that the voice of the customers is at the heart of defining and designing services. Supply Chain Management is responsible for procuring services upon needs being identified and subsequently monitoring the services (in conjunction with stakeholders) across the whole life cycle of the contract.

There will be a requirement to develop a new pictorial operating model encompassing Diagram 1 and Appendix D together with an operating manual which captures the role and responsibilities all of the stakeholders (internal and external) in the end to end process.


Plan Analyse

Enable Review

Strategic Commissioning Strategic Purpose

Needs Analysis Risks Analysis Service Reviews Options Appraisal

Gap Analysis Joint Commissioning Strategy Development Service Redesign Operational

Commissioning Resource need User Needs Current & possible p roviders

Service Spec. Procure‐ment / In‐house provision Plan

Change Management Budget and Market Management

Strategy Monitoring and Review

Contract / SLA Monitoring and Review

Tender and Contract SLA Mgt

Procure Perf. Mgt

Individual Commissioning

Business Need

Diagram 1.0

Business Objectives

Documents

London borough hounslowdemocraticservices.hounslow.gov.uk › documents › s107689 › Item... · 2014-08-22 · To reaffirm the ADASS statutory responsibilities and ensure that