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REPORT OF
Assistant Mayor for Adult and Older People Services
Assistant Mayor Health and Wellbeing
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TO
City Issues – 16.9.2013
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TITLE:Salford Integrated Care Programme – Memorandum of Understanding in
relation to the development of an Alliance Agreement
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RECOMMENDATIONS:
City Mayor alongside each of the proposed parties to the Alliance Agreement is asked to:
- Note the amendments proposed to the scope of the Alliance, following feedback from each of the parties in July and further review by the Integrated Care Board in August;
- Consider and approve the enclosed Memorandum of Understanding in relation to the development of the Alliance Agreement;
- Once approved, provide authority to the Assistant Mayor for Adults and Older People to sign the final MOU; and
- Provide delegated authority to the Councils nominated representatives of the Integrated Care Board (and its Subgroups) to develop the new legally-binding agreement.
EXECUTIVE SUMMARY
In February this year, as part of Salford’s Integrated Care Programme, it was agreed to develop proposals for new contractual and payment arrangements to support integrated care. The Integrated Care Board subsequently determined that an Alliance Agreement would be the most appropriate vehicle for bringing together commissioners and providers; enabling the provision of more integrated care and services and supporting risk sharing[1]
In June and July, a joint proposal was submitted to the four existing statutory partners to the Integrated Care Programme (Salford City Council, Salford CCG, Salford Royal NHS FT and Greater Manchester West NHS FT). This recommended the phased implementation of an Alliance Agreement from 2014/15. Each organisation was asked to:-
- Support the proposed implementation of an Alliance Contract, encompassing health and social care services for older people in Salford, and
- Comment on the proposed scope of the Alliance.
In August 2013, the Integrated Care Board considered formal feedback from each of the four partners. It was noted that the proposal had been supported, in principle, by the statutory partners, with broad consensus on scope and phasing. The phrase ‘Alliance Agreement’ was favoured by most partners and has therefore been used henceforth.[2]
The Integrated Care Board approved a set of proposed amendments to the Alliance Agreement and it was agreed that a Memorandum of Understanding would be produced, confirming the intended scope of the Alliance Agreement and the responsibilities to be delegated to it.
BACKGROUND DOCUMENTS:
Assistant Mayor Briefing Report: Proposed implementation of an Alliance Contract to support Integrated Care for Older People – 24.7.2013
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KEY DECISION:Yes (Decision 16.9.2013)
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DETAILS:
- Memorandum of Understanding
A Memorandum of Understanding (MOU)is being presented to the nominated committees of the existing four partners to Salford’s Integrated Care Programme inSeptember. The MOU has been developed with the support ofWragge & Co, whichhas been commissioned to provide advice on the development of the Alliance Agreement.
It is proposed that the four partners, with the addition of General Practice, form a legally binding Alliance Agreement, to support and enable the provision of integrated care and services to older people and other segments of the adult population.
The intention is that the Alliance Agreement commences on 1 April 2014, and is implemented on a phased basis. It is proposed that the agreement has an initial duration of five years, but with a break clause after 12 months and an option for a further three year extension.[3]
A clear commitment has been made to securing the engagement of General Practice, preferably as a “strategic partner”(if a collective federated body with authority and legitimacy to make binding decisions can be formed) or subcontracted (individually) to provide services on behalf of the Alliance.
The MOU sets out the proposed population focus, service content, aims and improvement measures to be adopted by the Alliance. It is recognising, however, that these will need to be reviewed as Salford’s Integrated Care model is further developed and refined (a timetable for completing this work is included with the MOU).
It is proposed that the Integrated Care Board is reformulated as an Alliance Board for Integrated Care, from April 2014. The intention is to operate shadow management arrangements in year 1 but to move towards a single management arrangement within a defined time period. Incorporating learning from section 75 arrangements, a review is to be undertaken of international evidence and best practice for the joint management of integrated care services.
The City Mayor alongside the other partners is asked to approve the MOU and provide delegated authority to the Assistant Mayor, Adults and Older People’s Services and the Strategic Director for Community Health and Social Care, to develop the new legally-binding agreement. Whilst Greater Manchester have committed in principle to join the Alliance Agreement they have requested more time to consider the content of the MOU and the implications for their organisation.
Salford CCG /- Executive Team 04.09.13 or 18.09.13
- Programme Management Group 18.09.13
- Governing Body 25.09.13
Salford City Council /
- City Issues 1st Briefing 02.09.13
- City Issues 2nd Briefing 16.09.13
- City Issues Key Decision 23.09.13
Salford Royal /
- Executive Board 16.09.13
Greater Manchester West /
- Strategic Network Board TBC
- Executive Management Team TBC
- Trust Board TBC
Table 1: Timetable for MOU Approval
- Next Steps
It may be necessary to amend some clauses within the MOU, based on feedback from the parties. It is proposed that any such changes are ratified by the Integrated Care Board.
Subject to the finalisation and approval of the MOU, a legally binding Alliance Agreement will be developed.This work will be overseen by the Integrated Care Board.
In parallel to the development of the Alliance Agreement, work is continuing to refine Salford’s integrated care model and to develop plans for rolling it out on a city-wide basis. A Cost Benefit Analysis (CBA) is also being undertaken, using a Greater Manchester template. This work should be substantially completed by January 2014 and will help inform the financial envelope of the Alliance, target cost savings and transitional funding requirements.
The Alliance Agreement and the associated CBA will also be critical in developing Salford’s response to the Government’s recently announced £3.8 billion ‘Integration Transformation Fund’, as the indicative timetable requires pooled budget proposals to be developed during December-January.[4]
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KEY COUNCIL POLICIES:
- Personalisation
- Promoting Independence Agenda
- Social Inclusion
- Supporting People
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EQUALITY IMPACT ASSESSMENT AND IMPLICATIONS:-
A Community Impact Assessment is being completed as part of the overall Integrated Care Programme. The Assessment will be informed by data from ‘The Case for Change’ document alongside service redesign and development options resulting from the ‘tests of change’ in each of the pilot neighbourhoods. Further iterations will be applied where changes are ‘roll out’ across the City.
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ASSESSMENT OF RISK: Medium
The Alliance Agreement has potential to help transform the way partners deliver care to older people, aligning services and financial resources within a single contractual framework, with shared standards and performance indicators agreed for all parties. It also provides a vehicle to implement different payment regimes, thereby facilitating financial risk and benefit sharing.
However, whilst the limitations of existing contractual arrangements and associated payment mechanisms have been recognised, it should be emphasised that there are numerous risks associated with moving towards different contracting and payment models. The materiality of these should not be underestimated nor should the difficulty of resolving them.
- The level of trust and commitment to joint working between partner organisations will be key to the success of the proposed changes.
- General Practice is a strong partner in a commissioning role but there is not presently a vehicle to engage them, collectively, as a provider group. Primary care is commissioned at a Greater Manchester level using nationally determined contract mechanisms.
- The potential partners within the Alliance have different organisational size, levels of resilience and roles within the system. They will have different externally determined funding sources based upon either place of registration or place of residence. They have different forms of regulation e.g. Monitor, Care Quality Commission etc.
- Organisations within the Alliance have different business models and organisational objectives. There will inevitably, at times, be a tension between the Alliance’s aims and those of the parties within it. Hence the importance of having effective collective leadership, principles to work to and development of mechanisms to manage risk where these tensions emerge.
- Issues related to choice, competition and procurement.
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SOURCE OF FUNDING: Salford City Council (Community Health & Social Care and Supporting People), NHS Salford CCG
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LEGAL IMPLICATIONS: Supplied by Nicky Smith, Solicitor, telephone 0161 219 6286
Under the Health and Social Care Act, the key new duty for local authorities is to take appropriate steps to improve the health of their population, obviously in Salford's case including improving health and social care for older people in Salford.. CCG's and NHS England also have statutory duties to promote and encourage the delivery and advancement of integration within their local areas. NHS England's guidance to CCG's requires integration including the pooling of budgets to reflect local need, and requires CCG's to work with local authorities to agree the allocation of funds to benefit health outcomes in the local population. It is clear from Government guidance that the Government is committed to the concept of integrated care and support, and it is important that the Council and its statutory partners agree the most appropriate vehicle to deliver this. It seems reasonable to proceed on the phased basis suggested, giving sufficient opportunity for all of the partners to consider the possibility of the Alliance contract in principle, and then to consider the proposed scope of the contract if it is approved in principle. As stated in the report, it is important that detailed consideration be given at the appropriate time to the competition, patient choice and procurement implications of proceeding with the proposal, especially since there is a need to comply with the procurement rules and contractual standing orders affecting the Council as well as those procurement rules affecting the NHS. Legal services and Procurement will be able to comment on such issues as required shouldthe in principle proposal be supported.
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FINANCIAL IMPLICATIONS: Supplied by Dianne Blamire, Principal Group Accountant
This report is proposing a phased implementation of an Alliance Agreement to support integrated health and social care developments. This is a form of partnership agreement and would involve the City Council and 3 key partners as shown in Table 1, with the proposed addition of General Practice.The Alliance Agreement will commence on 1st April 2014 and involve shadow management arrangements for the first year. A Memorandum of Understanding has been prepared to acknowledge commitment from the partners to progress the work of the Integrated Care Programme, and develop and implement the Alliance Agreement.
Integrated Care is included in the Council’s Public Sector reform programme and partnership arrangements with health are therefore fundamental to the longer term strategy in this area.
In respect of the financial implications, initial baseline estimates have been calculated to determine the level of financial resources within scope and for the City Council, the level is approximately £37M. This figure has increased by approximately £7M since the previous reported figure due to the inclusion of additional services, mainly under category (b). There will be no change to the accounting arrangements of this funding, at least in the first year of the agreement. During this time shadow management arrangements will apply and costs will be monitored by each partner and information shared. The financial arrangements from April 2015 will need to be considered alongside the development of the new care model.
In line with Public Sector reform principles, a Cost Benefit Analysis is in progress and should be completed by January 2014. This should identify the projected financial benefits of the programme over the next few years. Any specific financial risks and implications for the Council will need to be determined as further information becomes available and the partnership arrangements develop.
The aims of the programme include reducing costs and securing best value and should therefore contribute to the Council’s overall budget strategy. The majority of this expenditure falls within the “Specialist/Acute” theme and the principles and commitments to an Alliance Agreement will need to be acknowledged and incorporated within the Think Reform proposals.
As mentioned in the report, the Government have recently announced the creation of an Integration Transformation Fund of £3.8bn to ensure closer integration between health and social care, joint proposals between the NHS and the local authority to be developed between December 2013 and January 2014. Further information relating to this allocation is available in a separate report.
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HUMAN RESOURCE: Supplied by Joanne Finnerty, Human Resource Consultant
The report describes the collaborative arrangement under which parties will work together to deliver an Integrated Care Programme for Older People, and sets the framework for this. The report does not at this stage include any specific service provision recommendations.
If any proposals are to be subsequently considered that will incorporate a service redesign, or will constitute a service provision change proposal, this will be subject to Salford City Council’s usual full consultation arrangements with the recognised Trade Unions. Any such changes would require a collaborative consultation and engagement approach involving all the relevant organisations.
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PROCUREMENT IMPLICATIONS: Provided by Mark Griffiths, Procurement Manager, Tel: 0161 686 6292
This is a high level strategic report that outlines a completely new andinnovative way of working in the area of commissioning adult social care services for older people. From the content of the report it is difficult to provide any specific procurement comments at this stage. However, once the legal advice from Wragge and Co has provided further clarity on the issues of procurement and competition, there will be a requirement to further examine the procurement implications for the City Council of moving to an integrated care approach underpinned by the proposed Alliance Partnership agreement outlined in the report.
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OTHER DIRECTORATES CONSULTED: N/A
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CONTACT OFFICER: Jennifer McGovernTEL. NO.0161 212 5632
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WARD(S) TO WHICH REPORT RELATE(S): All wards
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Appendices
- Appendix A: Alliance Agreement – Memorandum of Understanding [separate enclosure]
- Appendix B: Summary of Feedback from Parties and Amendments agreed at the Integrated Care Board on 20 August 2013
- Appendix C: Organisational feedback on initial proposal
Appendix B
Summary of Feedback from Parties and Amendments agreed at the Integrated Care Board on 20 August 2013
Feedback / Agreed Amendments- Population /
client focus
- Consensus that the initial focus should remain on the 65+ population but proposed (by most partners) that solutions should benefit other age cohorts.
- Retain focus on 65+ population for design of model and approach.
- Develop more sophisticated approaches to stratify all-adult population.
- Consider (and be explicit) which service solutions should be extended to other cohorts within the adult population.
- Review whether outcomes criteria need to be adjusted as a result.
- Terms of Reference for the Alliance Board to reflect the dual focus.
- Proposed strategic partners
- Dual commissioning / provider focus supported, though some separation of functions proposed in terms of allocating resources.
- Consensus that the existing four statutory partners should be included from the outset.
- Consistent view that General Practice, as providers, should be included in the Alliance.
- View that other Primary Care contractors should be engaged through the partnership.
- The two commissioning organisations (CCG, SCC) determine the value of the funding pool, with all partners then having equal decision-making on priorities and spending.
- Clear commitment to include General Practice within the Alliance, though further work required to identify the mechanisms for securing their engagement (which could include a mixed model and phased approach).
- Salford CCG to lead a workstream to engage with General Practice and other primary care contractors.
- Service content
- Recognition that service content should be driven by the integrated care model and may change over time.
- Balance required between a broad, inclusive and a more targeted approach.
- Distinction drawn between those services that:
(a) play a critical role in delivering the model or exclusively support ‘at risk’ cohorts,
(c) are unlikely to experience any material impact in the short or medium term
- Category (a) services to be included within the Alliance, with some form of coordinated management. Category (b) services to be monitored, with financial risk and benefit sharing. Category (c) services to be excluded.
- Relevant additional services to be identified that are outside the direct influence of the proposed partners (i.e. commissioned and/or provided by third parties).
- Included within the MOU is the potential configuration of health and social care services within these three categories. This will need to be reviewed as the model is refined and further developed.
- Consideration to be given to the Alliance undertaking a subcontracting role.
- Aims and improvement measures
- Consensus that the existing focus and priorities of the Integrated Care Programme is appropriate.
- Some suggestions as to other aims and measures that could be incorporated (service specific measures, role of primary care, ambition and aspirations for individuals and communities) and the role of social value.
- Retain principal focus on triple aim and 7 improvement measures.
- Revisit the question of supplementary measures once the service model has been further developed, the service content agreed and any additional partners (incl. General Practice) confirmed.
- Ensure any additional objectives are simple and measurable.
- Decision-making principles
- Consensus or unanimous decision-making supported and a recognition that it would be unworkable to escalate or reserve decisions for approval by each of the ‘parent’ organisations.
- Question regarding the role of Councillors and the Health & Wellbeing Board.
- Proposed that operational decision-making should be delegated to an agreed party / management body.
- Proposed principles[5] to be adopted, with the amendment that decision-making should be unanimous wherever possible, but majority decision-making to operate where a stalemate would otherwise occur.
- Clear scheme of delegation to be agreed, setting out responsibilities delegated from each party and any reserved decisions (e.g. relating to significant changes in strategy or disinvestment).
- Councillors to continue to have a scrutiny role, through the Health & Wellbeing Scrutiny Committee and the Community Adult Social Care Scrutiny Committee.
- The Alliance Board to act as the responsible body for integrated care, but to work alongside the Health & Wellbeing Board - recognising the latter’s role in setting city-wide strategy and promoting integrated care and partnerships.
- Separate arrangements to be agreed for operational decision-making (see below).
- Governance and management arrangements
- Support to establish an Alliance Board to oversee the achievement of agreed aims and improvement measures.
- Recognition that services incorporated within the Alliance will need to be managed as a single, virtual unit.
- Subject to sign-off of the MOU, the Integrated Care Board to be reformulated as an Alliance Board for Integrated Care, from April 2014.
- Shadow management arrangements to be established in year 1, building on section 75 arrangements, with in principle agreement to move towards a single management arrangement with a defined time period.
- Review to be undertaken of international evidence and best practice for joint management of integrated care services.
- Payment
options
- Recognition that different payment models will be required and that further work will need to be undertaken once the service model and final framework have been agreed.
- Payment options to be reviewed once the service model and financial framework have been agreed.
- Work to be developed by Finance Subgroup for ICB approval.
- Existing payment mechanisms to be retained in year 1 whilst alternative arrangements are developed and shadow monitoring (and costing) arrangements established.
- Commercial terms
- Three of the parties favour a longer term agreement, though GMW has advocated a 12 month agreement.
- Recognition that further work is required on risk and benefit sharing within the Alliance.
- 5 year legally binding agreement with a break clause after 12 months and an option for a further three year extension.[6]
- Risk and benefit sharing to be developed as part of phased approach to implementation of Alliance.
- Pace of change
- All parties support the proposal to commence the Alliance Agreement in 2014/15.
- Alliance Agreement to commence in 2014/15, on a phased basis.
- Subject to further refinement when model finalised, Year 1 to:
-Focus on alignment and some form of joint / single management for category (a) services.
-Develop alternative currencies / payment options and risk and benefit sharing mechanisms.
-A clear timetable for securing GP engagement as partner / subcontractor (if this is not secured from the outset).
Appendix C