Review of the Joint Commissioning Team: Jan 2005

Review of the Joint Commissioning Team: Jan 2005

1Background

1.1Purpose of Joint Commissioning in Hertfordshire

Joint commissioning structures, pooled budgets and the joint commissioning team have been established because of the benefits to service users of a countywide approach, and in recognition of the fact that splitting resources across eight PCT localities would not deliver consistent and cost-effective services to the level of quality that we are able to achieve through a joint approach.

1.2Purpose of Review

To identify the necessary areas of development for the Joint Commissioning Team and Joint Commissioning Arrangements.

To recommend appropriate developments and actions for discussion and agreement by the Partnership Board.

1.3Method

Report from Mark Jordan, Head of Joint Commissioning Team. Derived from Interviews, Documents, Observation and Analysis.

This final report will be discussed with the HCC Senior Officers (22/12/2004), Health and Social Care Chief Executives (06/01/2005) and JCPB (25/01/2005).

1.4Sources

Interviews and correspondence with JCPB members, and health and social care executives .

Discussions with JCT staff and a limited range of Professional Staff and User / Carer representatives.

JCPB papers:

• Sept 2002 Interim Report on Joint Commissioning Arrangements (E Peck / Kings College)
• April 2003 Review (S Pickup)
• July 2004 Draft Business Rules and Commissioning Framework (P Atkins)
• 2003 Audit Commission Recommendations on Partnership Arrangements

2Findings: Issues and Solutions

2.1Overall Strengths and Weaknesses

2.1.1There is Goodwill and Openness amongst the partners. They want to make to make the Partnership work and they recognise the Potential Benefits to be realised by making it work.

2.1.2There is a desire for a strong focussed commissioning body that firmly performance manages providers and that drives forward significant changes.

2.1.3Many of the issues and actions necessary to make things work better have been previously identified. Some of these have started to be acted on and others have not, but all need following through.

2.1.4The Joint Commissioning Team is staffed by well-respected, knowledgeable, hardworking staff.

2.1.5Joint Commissioning needs to become more proactive rather than reactive. It needs to promote a mixed economy of solutions (including private and voluntary) across various levels of care and agencies including primary care . It needs to better demonstrate the performance of both ACS, HPT and the other providers. JCT workload may therefore need some rebalancing from general strategy and service development work towards the standard strategic commissioning tasks.

2.1.6Basic systems, standards, and procedures in the Joint Commissioning Team are not yet sufficiently robust or consistent to ensure efficient planning and monitoring of commissioned services. Some systems work well in some parts of JCT, but overall there is a need for standardisation and application of the core commissioning processes.

2.1.7The remits and responsibilities of the Joint Commissioning Team in relation to those of the partners needs clarifying and focussing

2.1.8 Tensions can arise in the partnership resulting from cultural differences and differences in approach to budgetary and other processes. These tensions need addressing as they arise so that the partnership can continue to move forward.

2.1.9Local Annual Planning and Prioritisation processes are not clear enough yet to support effective management of service demand and supply, or the development of creative and innovative enough service solutions in the context of national frameworks and priorities.

2.1.10Consultation, Communication and Decision Making structures and processes are not effective enough yet to deliver the full benefits of Partnership working.

2.2Governance: JCPB / Consultation and Decision Making.

2.2.1Because the JCPB has to ensure there is a voice for each PCT and an equal voice for the county council, decision making can prove unwieldy. JCPB can get drawn into detail beyond its expertise. Its greatest value is as the high level strategic group that can oversee services and resolve differences if they arise.

2.2.2The climate of JCPB meetings is sometimes experienced as being shaped by formal county council approaches with a leaning towards oppositional type discussions. There is limited opportunity for exploratory discussion or involvement of executive officers and the pre-JCPB briefing sessions are tending to become business meetings themselves. There also needs to be a place for JCPB discussion apart from service suppliers and other non-JCPB members.

2.2.3Representation on JCPB of the County Council Director of Children’s Services as commissioner of CAMHS social care services needs reviewing in the light of the new Children’s Act.

2.2.4The involvement of users and carers in JCPB consultation and decision making has not been systematic enough and has proved unsatisfactory to both Users, Carers and Partners. Consideration should be given to improving the current approach, so as to enable greater openness and improved representation of the public in the business of JCPB.

2.2.4.1Opportunities can be developed to better share performance and other information with users and carers, obtain their views, and then ensure that these views are represented at JCPB meetings.

2.2.5There are four strategic commissioning groups each of which oversees a particular care group. Their authority and the degree of PCT representation on these groups is variable. The role of these groups as taking the commissioning lead for each care group should be strengthened and formalised.

2.2.5.1PCT and ACS reps should ensure they have representatives on these groups who have delegated authority to speak on behalf of their organisations. The representatives should carry responsibility for ensuring that their organisation (and their JCPB member) is fully briefed on key issues. In this way the relevant strategic commissioning group will act as a clearing house for all matters going to JCPB, thus enabling JCPB to concentrate on overall monitoring, prioritising and dispute resolution across all pooled areas. A scheme of delegated authority can be drawn up on this basis.

2.2.6There is a tension between on the one hand ensuring sufficient direct PCT involvement in Joint Commissioning planning and on the other, the amount of PCT resource available. If the strategic groups in future meet quarterly and are run in a focussed way, furnished with clear and concise information, and delegating development work to subgroups, then this should optimise the use of these people. The involvement of further local groups (e.g. Mental Health LITs ) will then imply a similar trade-off between available time and local involvement. Additionally, if Pct’s are each able to identify a single director who holds the overview of all JCT areas for the PCT, this could also better focus resources.

2.2.7If these groups and their representatives perform successfully, then the function of the Chief Executives Group could in time shift from particular Joint Commissioning matters to a more strategic oversight of all areas of health and social care in Hertfordshire (including children’s services).

2.2.8A Consultation and Decision Making Structure: (It will take time for an improved consultation and decision making structure to bed down.)

2.3Governance: Annual Planning and Budgets.

2.3.1The processes by which annual plans are drawn up and budgets agreed between the health partners, have not been clear and methodical enough. For Joint Commissioning to succeed all partners must be clear about their obligations and adhere to them.

2.3.2JCT needs to be more closely involved with LDP processes so that firm commitments to budgets can be established. The evolving joint management arrangements between Pct’s may enable JCT to link with groups of Pct’s rather than with each one individually.

2.3.3Baseline health budgets have been set according to historical levels. Differences of priority between individual PCT agendas can work counter to aspirations of service equity across the county. Joint Commissioning will only be viable if principles of Capitation and Service Equity are adhered to, but historical differences cannot be ignored. We should therefore commit to a planning and budgeting structure where annual health budgets are determined according to principles of Capitation and Equity. A number of models can be explored including ones that provide countywide agreement while offering some flexibility to the two SHA quadrants.

2.3.4To make annual funding decisions, partners require clearer summaries of bids, including options and implications, prioritised across all pooled budgets.

2.3.5Partners should be protected from the risk of other partners insufficiently funding their own service areas. The proposed revisions to the s31 agreement have been designed to better manage this risk .

2.4Governance: Reporting and Communication,

2.4.1There is a range of performance and other information that partners require from JCT and other sources both for statutory reporting and internal planning purposes. It is not clear enough who collects what, checks what, signs off what and submits what information to whom. An exercise is therefore needed to establish the information needed and how it is best collected and distributed.

2.4.1.1There is a range of public information that JCT requires for comprehensive needs analyses. PCT and other sources will need linking as part of this exercise.

2.4.2It is not clear enough to partners and other stakeholders, what the Joint Commissioning team does nor is it clear enough to the Joint Commissioning team how well it is doing in the eyes of the partners and other stakeholders. There should be publication of a wide range of information on a JCT website and also an annual review of JCT including partners and stakeholders, resulting in an annual JCT development plan.

2.5JCT: General

2.5.1In addition to strategic commissioning and monitoring work, JCT is currently also engaged in project management, service development, policy development, case management and routine contract management.

2.5.2“JCT needs to ensure it gets the bread and butter stuff right and better demonstrate putting the theory into action.” The remit of the JCT needs to be more clearly defined and communicated. An increased focus is needed on the core strategic commissioning activities of Needs Analysis, Benchmarking and Gap analysis, Planning and Options, Specification and Contracting / Service Level Agreement with ensuing Monitoring and Reviewing and with an underlying drive of better value delivery.

2.5.3In the medium term, a clearer delineation should be made around any work that sits outside this core remit of JCT:

2.5.3.1 Certain service development work is JCT core business . Other service development work may at times be best managed by service providers. Where significant service development and project management work is needed, this should be costed as part of any development proposal and provided outside of JCT if appropriate (but then with JCT still retaining overall oversight of development).

2.5.3.2Individual case management work and responsibility should be sited more in provider or other teams.

2.5.3.3Policy development could be derived from partner organisations.

2.5.3.4JCT resource needs identified here assume that any further resources required for service development will be obtained through development bids rather than through permanent JCT staffing.

2.5.4Some anomalies remain whereby pockets of LD and MH services are still commissioned directly by Pct’s. These need bringing within partnership arrangements.

2.5.5It has been recommended that the commissioning of mental health services for the elderly move to JCT. Resource requirements will be integrated into LDP bids and a full proposal produced for April JCPB.

2.5.6Adult Mental Health commissioning has been over-reliant on the Head of Joint Commissioning taking on specific adult mental health commissioning tasks: in future it needs to be sufficiently resourced so as to avoid this (see below).

2.5.7At present the Head of Joint Commissioning is required to spend significant time attending generic ACS meetings. This needs to be adjusted to enable an equitable balance of involvement with the other joint commissioning partners.

2.6JCT: Systems

2.6.1Adequate support systems for managing the routine business of the team are not in place. This results in reduced effectiveness in commissioning and less effectiveness in delivering improved value from providers. A central electronic repository of information needs to be established and maintained that fully supports annual planning, SLA and Contract monitoring and associated financial and performance management. Without an additional ‘systems co-ordinator’ post, we will be unable to adequately establish, oversee and maintain these essential cross care group systems. The new HCC ‘SHARP’ accounting and resources IT system should also be investigated as part of the solution.

2.6.2Quality Assurance and Performance Management and Development systems need to be fully applied. Adult Care Services structures can be used and consideration also given to the use of external quality accreditation (e.g. ISOQAR).

2.6.3Ongoing support will be required from Health Infomatics, Public Health and Social Care Information Management services.

2.7JCT: Adult Mental Health Commissioning

2.7.1This area of JCT has in the past been over-reliant on the involvement of the Head of Joint Commissioning and is in need of additional resource both to manage current needs safely and to support the future agenda.

2.7.2For the JCPB Mental Health Strategy and Investing In Your Mental Health recovery model to move forward there will need to be significant service reconfiguration work over the coming years. There is also a major commissioning development agenda to address in terms of forensic and secure services. An additional service development manager is therefore the minimum needed to support such developments, manage SLA’s and enable adequate links to local Pct’s and quadrants, particularly if we were to provide some flexibility of local planning in future. This will then also enable us to estimate any further support needed in longer term primary care provision.

2.7.3Proposed Adult Mental Health Commissioning Team structure.

2.8JCT: Contract / SLA Management

2.8.1JCT contract management staff currently work both on services for which the JCT pay directly and also services that are purchased by and invoiced to HPT or ACS teams (e.g. private residential care contracts). This has contributed to the difficulties in achieving the necessary standards in both areas. It is recommended that in future JCT contract management staff work only on the services that JCT pay directly for and that other arrangements are used for the other areas.

2.9JCT: Service Suppliers

2.9.1It is appropriate that there should be differences in JCT monitoring approaches to different suppliers but there needs to be a clearer rationale and greater consistency. At present there is no SLA with Adult Care Services (the provider of community learning disability services). Nor do the Pct’s receive sufficient evidence of the effectiveness and efficiency of our main provider, HPT . Equal focus needs to be given to cross boundary provider trusts.

2.9.2Clarification is needed about the arrangements for performance managing those services that are subcontracted by the main providers.

2.9.3The approach to the funding and monitoring of voluntary and private organisations is not clear and consistent and requires comprehensive review.

2.9.4The Joint Commissioning Team needs in future to be looking towards a wider economy of public, private and voluntary provision at both primary and secondary care levels.

2.10Conclusion:

Its all do-able if ………..

1) The additional team resources identified above are made available at the earliest opportunity (as delay in so doing will delay improvement)

2) The partners maintain their resolve and continue to structure and conduct themselves accordingly

And then a prospective development timetable would be ………..

Draw up capitation models for agreement at Apr JCPB : Feb / Mar 2005

Draw up scheme of delegated authority for agreement at Apr JCPB agreement: Feb 2005

Produce Annual Planning Calendar for agreement at Apr Chief Execs: Feb 2005

Produce JCT Annual Workplan: Feb 2005

Establish JCT SLA / Contract monitoring standards and approach for subcontracted and county border services: Mar 2005

Establish internal management systems: Jan / Apr 2005

Plan integration of EMI commissioning (for agreement at Apr JCPB): Jan / Apr 2005

Develop Information Sets and Systems and Information Flows: Feb / May 2005

Relinquish non - JCT contract management work: Mar 2005

Agree NHS and HCC SLA’s: Mar / Apr 2005

Recruit Additional JCT Admin and MH (adult and elderly) Staff: Apr 2005

Complete website : Apr / May 2005

Review private and voluntary sector commissioning arrangements: May / July 2005

Review user / carer involvement in JCPB processes: May / July 2005

Revision of partnership agreement and constitution : July / October 2005

3Summary of Issues and Solutions.

Refs. / Issues / Solutions
JCPB / Consultation and Decision Making.
2.2 / Unwieldiness of JCPB
Expertise and Climate of JCPB
User and Carer Involvement on JCPB
Purpose of Chief Executives Meetings
Need for ‘JCPB only’ discussion
Status of CSF representation / 1. Formalise the 4 strategic groups below JCPB to formally represent Pct’s and become the ‘clearing house’ for all reports to JCPB.
2. Provide more interactive briefing and monitoring events for JCPB and for Users and Carers.
3. Over time, expand the brief of Chief Executive’s meeting into a broader multi-agency strategic forum.
4. Clarify structure of public involvement in JCPB meetings
5. Review CSF representation
2.2.6 / PCT involvement and time pressures / 1. Convene strategic groups quarterly and delegate development work to subgroups.
Annual Planning and Budgets
2.3 / Lack of clarity around Budget planning.
Lack of clarity around joint commissioning priorities.
Differences of Priorities between Pct’s. / 1. Formalise links between JCT and LDP processes and improve bidding information.
2. Agree budgets prior to financial year
3. Design a range of potential capitation based approaches including an East – West ‘Quadrant Based’ model
reporting and communication
2.4 / Partners and stakeholders are not getting a clear picture of the things they need to know about.
JCT needs better access to public health and other info.
JCT is not clear enough about how well it is meeting the needs of partners and stakeholders. / 1. Establish key information sets, systems and information flows including PCT public health information sources.
2. Establish JCT website for regularly publishing key information
3. Conduct annual JCT review including annual visits to partners’ executive committees.
Joint commissioning team
2.5 / Multiple JCT activities diluting key commissioning functions
Some MH and LD commissioning still in Pct’s / 1. Clarify remit with partners and providers.
2. Delineate project / service development work etc.
3.Bring all MH and LD commissioning within partnership arrangements.
2.5.7 / Disproportionate attendance required at ACS meetings. / 1. Adjust obligations so as to strike a balance of involvement with all partners.
2.6 / Lack of robust management systems and information sets. / 1. Create JCT systems co-ordinator post to establish and maintain core management systems
2. Investigate use of HCC SHARP system
3. Investigate external quality assurance accreditation
2.7 / Insufficient Mental Health Commissioning Resource. / 1. Create an additional Mental Health Service Development Manager post.
2. Review grading and terms and conditions of the overall Mental Health planning and commissioning manager.
2.8 / JCT staff currently covering routine Contract Management tasks for HPT. / 1. JCT contracts staff in future only work on contracts / agreements with providers that invoice JCT.
service suppliers
2.9 / Need for consistency and transparency of approach with the range of service suppliers
Rationalisation of use of private and voluntary sectors / 1. Develop an SLA with Adult Care L D Services
2. Establish consistent SLA / Contract monitoring standards and processes, with equal focus on cross border and sub contracted providers.
3. Share improved HPT perf information with partners
4. Review approach to and management of private and voluntary sector organisations.

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