Agenda item

JOINT COMMISSIONING WITH THE CLINICAL COMMISSIONING GROUP

Minutes:

CEO 01636

 

A report was presented to the Sub-Committee to provide an update on joint commissioning with the Clinical Commissioning Group. The update had been requested by the Contracts Sub-Committee at its meeting on 21st September 2017.

 

Members were informed that some of the joint commissioning was undertaken under Section 75 of the NHS Act (as amended by the Health and Social Care Act 2010), whilst other joint commissioning activities were funded through the BCF (Better Care Fund). 

 

The Sub-Committee was briefed that whilst the JSNA was the key data set from which local needs were defined, outcome based commissioning was also important in that it would impact on the health and wellbeing of Bromley residents.

 

The Deputy Chief Executive and Executive Director of Education, Care and Health explained that at the previous meeting of the Contracts Sub Committee (CSC) in September, a micro economic account had been provided with respect to commissioning; the intention for this meeting was to provide a macro economic outlook. He explained that by 2020 it was necessary that LBB and the CCG formulate a joint business plan. He stated that LBB could not solve health and social care needs in isolation, and so had to work in close partnership with the CCG. Efficient leadership would be required if good and effective services were going to be delivered to Bromley residents.

 

The Deputy Chief Executive referred to the 4 main elements of the report which were:

 

·  An overview of joint commissioning

·  Outcome based approaches

·  Previous good practice

·  Future priorities

 

The Sub Committee heard that the integration process had started with the Better Care Fund and was then furthered by the Improved Better Care Fund. The idea was to join resources together and to develop joint strategies. The Deputy Chief Executive and Executive Director of Education, Care and Health stated that there was a joint consensus that LBB and the CCG were on the right direction of travel together.

 

Mr Paul Feven (LBB Head of Programmes) stated that lots of discussions had taken place between LBB and the CCG on key issues. The discussions had then moved into agreement on key issues such as delayed transfers of care. Out of the agreement, a strategy had then been formulated. Joint posts had been set up, and working together would see the benefits of economies of scale in terms of spending power. Both organisations were able to purchase in the nursing care market. Trajectories needed to be joined, and an integrated joint mode of delivery was required.

Mr Feven referenced the good work undertaken by ICNs (Integrated Care Networks). The CCG website defines an ICN as:

 

‘An integrated care network (ICN) is a model of care that brings together a range of health and care services to work in a more joined up way to provide care for patients. This model enables services to be more responsive to the needs of patients and is focused on preventing ill health and proactively managing of patients with complex or long term health conditions’.

 

Mr Feven expressed the view that it was important to raise the profile of ICNs in Bromley. Another successful joint project was the ‘Discharge to Assess’ project which was designed to get hospital patients into a re-ablement setting as soon as possible. Similarly, a joint strategy and a joint health and social care offer had been developed for Care Homes.

 

Mr Feven stated that it was important to work out unified quality definitions, as opposed to several different quality strands. As part of the 2020 plan, strategies would be the ground work for effective delivery models, and systems and leadership would have to be looked at.  

 

A Member expressed concerns that outcomes should not be nebulous or difficult to quantify, but it was important to be able to see that outcomes were being actualised. He felt that it was essential to develop and use innovation and technology. The Chairman agreed that it was important to be able to measure outcomes, and this had historically been difficult.

 

A Member expressed support for the 2020 integration programme, but was also cautious due to issues and challenges that had emerged in the past. Previously, there had been issues related to cultural differences between LBB and the CCG, and differences of opinion with respect to key issues and key outcomes. He stated that there needed to be a guarantee of clear understanding between both parties with respect to outcomes, VFM, management and governance. These matters had to be made clear, as well as the need for clarity around decision makers.

 

Three services were cited as examples of existing good practice and good examples of joint working; these were the Dementia Hub, Bromley Well and the Transfer of Care Bureau (ToCB).

 

Members heard that the Council was the lead commissioner for the Dementia Hub, and that the Hub worked closely with the Memory Clinic from which most of the referrals originated.  Members noted the key strategic outcomes for the Dementia Hub, along with specific outputs and KPIs.

 

Members were informed that Bromley had a larger number of older people than any other London Borough, and it was also the case that the number of people with physical disabilities and sensory impairment had also continued to rise. 

 

Alicia Munday (Head of Programme Design for Commissioning) briefed the Sub-Committee around the Bromley Well Project. 

 

Bromley Well was a new service formed to help support local residents to maintain their health, wellbeing and independence, the Bromley Well service launched on 2nd October 2017. The service was delivered by a partnership of local voluntary sector organisations called Bromley Third Sector Enterprise CIC (BTSE) which brought together many years of expertise to provide a range of services for local people.

 

The Sub-Committee was briefed concerning the pathways, outcomes and KPIs for the Bromley Well Service. The Sub Committee noted that as part of the Bromley Well initiative, the Council and the CCG had set up a joint carers’ strategy. LBB was the lead commissioner for the Bromley Well project. LBB dealt with the procurement for the client and the contract side and reported back to the CCG via their internal commissioning board. The Bromley Well project was scrutinised by the Care Services PDS Committee, and most of the funding from the project came via the CCG from the Better Care Fund.

 

Fifteen per cent of the contract value for Bromley Well was retained to allow for innovation and change in the future. The length of the contract meant that it was likely that in the future, needs would change and so there would be a need for innovation and adaptability. The tender for Bromley Well had been led by LBB with a 60/40 split that had been endorsed by the CCG. There had been an engaged specification formulated with clinicians.

 

The Deputy Chief Executive and Executive Director of Education, Care and Health gave an example that previously there would have existed separate pathways for carers and for the CCG, and that there was a need to integrate pathways. Vulnerable users required simple processes. Previously, a situation could have existed where care for a person’s legs could have been split in terms of budgets. One leg could have been paid for by the Council, and one by the Primary Care Trust. There was therefore clearly a need to integrate pathways and to pull resources together, and for budget and efficiency challenges to be addressed.

 

Ms Munday informed the Sub Committee that as part of LBB’s commissioning activities in health and social care, LBB was collecting 100% of NHS numbers. This meant that patients could now be tracked across the system to see how their care impacted services. The CCG was not allowed to track NHS numbers.

 

Mr Feven pointed out that micro outcomes for individuals in many cases would add up to macro savings which would be created by generating independence. People would be doing new things as a result of being rehabilated. 

 

A Member raised the matter of insurance liability. He queried who would refer matters of insurance liability to the insurance companies. He stressed that it was important to determine where LBB’s insurance liabilities sat. He stated that as LBB would be involved in matters of statutory liability, LBB would need to draft tight contracts. There was also the generic issue that applied to all contracts that involved sub-contracting, which was to make sure that all such contracts were looked at from an insurance perspective.

 

The case of Woodland v Essex County Council [2013] UKSC 66was noted by the Deputy Chief Executive and Executive Director of Education, Care and Health and he assured that LBB’s modus operandi would be in line with this judgement. LBB had to ensure that contracted out services were of a high standard because the Council would still be liable for the statutory duty.

 

Ms Munday provided assurances that all contracts were scrutinised by the Insurance Team. With respect of Bromley Well, there were no medical implications.

 

The Director of Commissioning clarified that the main contractor was responsible for dealing with sub-contracting issues. Going forward the contracts database would detail insurance policies.

 

A Member referred back to the Woodland v Essex case and stated that in this case the sub-contractor did not have insurance, and he was not convinced that liability stood where it should in all cases. 

 

The Vice Chairman raised the issue of outcomes and outputs. He queried if a proper distinguishing would take place between outcomes and outputs, and asked if outcomes would be the most significant indicator. Ms Munday assured that effective monitoring would take place against both outputs and outcomes.

 

A Member drew attention to the fact that with the joint commissioning, there were two large organisations involved in making decisions for one service. She asked how decisions would get made when there was disagreement, and how could democratic accountability be ensured. The Deputy Chief Executive and Executive Director of Education, Care and Health responded that officers were mandated by the Council’s internal structure, and that delegated authority structures were in place. Both organisations were looking to serve the needs of the same local residents and people’s mind-sets were changing. A culture of trust needed to be nurtured. Integrated systems, leadership and processes were being developed and a Joint Leadership Board had been set up. If disagreements came, they could be worked through.

 

The Member continued by saying that if the CCG was not making a good job of a contract, where was the accountability to the public. It was noted that with respect to joint commissioning, LBB would have inputted into the specifications in the contract.

 

A Member advocated that ‘obligations’ be written into contracts so that contract managers knew exactly what they were measuring.

 

The Director of Commissioning explained that in some cases it may be necessary to build in extra capacity into a contract. Sometimes the extra resource could be derived from savings made by virtue of the commissioning process. 

 

The Work of the Transfer of Care Bureau (ToCB) was also noted. The aim of the ToCB was to facilitate a safe and timely discharge of hospital patients back into the community.

 

The Sub Committee noted that the CCG and LBB had formed the Integrated Commissioning Board as a result of a review of governance arrangements. Resultantly, a number of joint priorities had been established and were outlined in the report.

 

The Chairman was pleased with the progress that was being made with joint commissioning and asked for an update to come back to the Sub Committee in six months time.

 

RESOLVED that the report be noted and that an update be brought back to the Sub-Committee in six months time. 

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