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GREATER MANCHESTER HEALTH AND SOCIAL CARE

STRATEGIC PARTNERSHIP BOARD

Date: 28 October 2016

Subject: Delivering Theme 3: Standardising Acute and Specialised Services

Report of: Rob Bellingham

PURPOSE OF REPORT:

The attached report was presented to the Strategic Partnership Board Executive on 10th

October and the Joint Commissioning Board on 18th October. Its purpose is to outline the

arrangements for the development of the Theme 3 governance and programme to ensure

that it is fit for purpose to drive the delivery of Theme 3 priorities.

Detailed recommendations are covered within the body of this paper. In summary this paper:

Makes recommendations to reset the governance of Theme 3 (outlined in Section 2).

Outlines how Theme 3 proposes to deliver (outlined in Section 3).

Highlights and makes recommendations to resolve some key issues (outlined in

Section 4).

In supporting the paper the SPB Executive raised a number of issues where further work will

be required as the programme moves forward, notably with regard to:

Delivery and implementation arrangements.

Inter-connections to the other transformation themes including, but not limited to, the

need to more formally recognise the opportunity and requirement surrounding

digital/IT based solutions.

Connectivity and linkages to wider devolution governance, for example the Cancer

and Mental Health Boards.

Further work on the development of the system leadership arrangements to ensure

clarity on roles and responsibilities and underpinning the commitment to co-design

across the work programme.

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The JCB reviewed the paper on the 18th October together with the above comments and

have endorsed it.

RECOMMENDATIONS:

The Strategic Partnership Board is asked to:

Receive the paper, noting the support and feedback of the SPB Executive and the

Joint Commissioning Board.

Note the approaches suggested to resolve the issues outlined in section 4.0.

CONTACT OFFICERS:

Rob Bellingham

robbellingham@nhs.net

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1.0 Background

1.1. The Theme 3 Standardising Acute and Specialised Services Programme was set

up to deliver the commitments outlined in the Greater Manchester Strategic Plan,

Taking Charge specifically:

1. Improving the safety and quality of services and reducing variation

2. Improving productivity: hospitals are drawing up plans to achieve efficiency

savings of 2.5 per cent in 2016/17, and 2 per cent per annum in subsequent

years

3. Improving delivery and the interface with out of hospital models: hospitals are

working to introduce new care models to avoid emergency admissions and cut

very long lengths of acute hospital stays. Trusts are working to deliver the four

priority clinical standards for seven day working as part of the first phase of

implementation by 2017

4. Increasing collaboration: trusts have agreed to a programme of collaborative

efficiency and to joint working to achieve significant savings targets

Since then, the programme has been set a target financial contribution at GM level

of £140m.

1.2. The Greater Manchester Service Transformation Directorate, which became the

NHS Transformation Unit on the 1st April 2016, was asked in January 2106 to

deliver the first phase of work to agree and mobilise the programme governance,

provide a methodology for prioritising acute services, and use this to seek system

agreement to a shortlist of priority projects.

1.3. Governance arrangements for the programme were proposed and endorsed by the

Provider Federation Board in March 2016 and endorsed by the Joint

Commissioning Board in July 2016. The Theme 3 Clinical Reference Group was set

up in April to develop a clinical prioritisation matrix, and provide a recommendation

on which services should be prioritised. The Theme 3 Steering Group was fully

mobilised in July, reviewed the proposed Theme 3 priorities, and put forward a final

proposal which was endorsed by the AGG, the Provider Federation Board, and the

Strategic Partnership Board Executive in September.

1.4. With changes being made to the Governance of the Health and Social Care

Partnership; the new hosting arrangements of the NHS Transformation Unit coming

into effect on the 1st April 2016, and Theme 3 now entering a new delivery phase of

work, there is now a need to reset the governance to put the programme on a firmer

footing to deliver, and set out an approach to delivery that builds on what is in place

and is agile and flexible to quickly bring about change.

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2.0 Resetting the governance

2.1. Establishment of a ‘client function’

2.1.1. Recognising the NHS Transformation Unit’s new hosting arrangements and

operating as a supplier of the GM Health and Social Care Partnership, there is a

need to establish a ‘client function’ within the Partnership to manage the

relationship between the Partnership and the Transformation Unit, the delivery of

agreed work from the Transformation Unit and the commissioning of services for

the future delivery of Theme 3.

Recommendation: Client management function to be established within the

Population Health Transformation and Commissioning function to manage the

existing contract with the NHS Transformation Unit and the commissioning of

services to deliver Theme 3.

2.1.2. Similarly, there is also a need for clear separation between the strategic leadership

of Theme 3, and the commissioning of work to support Theme 3. As such, the

Theme Lead for Theme 3 should be a member of the Greater Manchester Health

and Social Care Partnership team.

Recommendation: Theme 3 Leadership should transfer to the Executive Lead for

Population Health Transformation and Commissioning, to be fulfilled by the Director

of Commissioning, Rob Bellingham in the interim.

2.2. Simplification and alignment of the governance

2.2.1. The Theme 3 programme governance was set up with reporting lines from the

Executive Team and Steering Group directly into the wider GM Health and Social

Care Partnership Governance, through The Provider Federation Board and the

Joint Commissioning Board. The Steering Group is jointly chaired by Ann Barnes

and Dr Chris Brookes while the Theme 3 Clinical Reference Group currently

provides an advisory function to Theme 3 and is chaired by Dr Chris Brookes. The

Theme 3 programme governance and co-ordination management is currently

provided by the NHS Transformation Unit.

Recommendation: Simplify the governance so that the Theme 3 Steering Group

becomes a Delivery Board, responsible for the oversight of all Theme 3

programmes. The Delivery Board will form part of the GM Health and Social Care

Partnership’s governance, reporting into the newly created GM Transformation

Portfolio Board, and serviced by the Partnership.

Recommendation: Work to confirm preferred option for chairing of the Delivery

Board. Current options are for the lead of the client management function to

assume the chair or to appoint an independent chair. In either case, the need to

maintain close working arrangements with the above name clinical and

management leads will be paramount.

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2.2.2. Healthier Together, which is part of Theme 3, and is in implementation, currently

has separate governance arrangements which pre-date the establishment of the

GM Health and Social Care Partnership. Healthier Together is a critical priority for

Theme 3, to deliver on commitments made to the public to improve the quality,

safety and effectiveness of general surgery, A&E and acute medicine; estimated to

save 300 lives per year. However, the governance now needs to be fully aligned to

Theme 3 and the GM Health and Social Care Partnership. Full details of proposed

changes are outlined in a separate paper and are being overseen by the Chief

Officer in his role as Programme Sponsor for Healthier Toghether; those relevant to

Theme 3 are noted below.

Recommendation: As one of the programmes in implementation under Theme 3

Healthier Together should report into Theme 3. The detailed implementation of the

new model of care for general surgery, acute medicine and A&E is currently

overseen by the monthly Healthier Together Programme Board. It is proposed that

this group shifts its reporting arrangements to report directly into the Theme Three

Delivery Board, and changes its name in line with other equivalent sub-groups. It

will retain its working arrangements to ensure continuity and momentum with

implementation.

2.3. Delivery through co-design and partnership

2.3.1. The principle of co-design and partnership working, in particular between providers

and commissioners has been the driving force behind the mobilisation of the Theme

3 Steering Group, and Clinical Reference Group in their current forms, and has

provided direction and input to shape proposals before they are put to the wider

system. Membership of the Steering Group is currently drawn from providers,

commissioners and AGMA, while membership of the Clinical Reference Group is

currently drawn from providers, commissioners, and NHS England, with medical

and nursing representation. With the shift in focus now to delivery, membership of

the Delivery Board and Clinical Reference Group will need to be revised to cover

the agreed priority projects, and co-partnership needs to be supported by specific

system leadership roles to drive implementation.

Recommendation: Co-design and partnership working should be recognised as a

vital principle for the successful delivery of Theme 3. Membership of the Theme 3

Delivery Board and Clinical Reference Group should be reviewed in the light of the

agreed priority projects for Theme 3 and supported by specific system leadership

roles; these are outlined below.

2.4. System Leadership

2.4.1. Taking the learning from previous reconfigurations in GM, there are a number of

system leadership roles that will be critical to the successful delivery of Theme 3.

The leadership required will need to reflect the scale of the programme; drive the

rapid delivery of benefits; and deliver the longer term strategic changes required to

unlock the system. Three roles are proposed: System Clinical Sponsor, System

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Provider Sponsor and System Commissioner Sponsor. These three roles would

provide leadership in each of the four areas of delivery in Theme 3:

Women’s and Children’s

Medicine (Cardiology and respiratory)

Consolidation of surgery

Specialised Services

2.4.2. System Clinical Sponsor – role outline

This role will provide GM-wide clinical leadership, within the relevant area, to

identify and drive the implementation of immediate interventions to improve the

quality, safety and efficiency of patient care;

articulate and promote the vision for change with clinical colleagues and

champion the sharing of innovation and standardisation of hospital care across

GM

develop agreed GM clinical standards, and models of care to inform new

service specifications

act as a key clinical advisor to the Delivery Board through the Theme 3 Clinical

Reference Group, and is a member of the clinical alliance

This would need to be a paid role (1-2 sessions per week) for a period of 12

months with review after 6 months. A formal recruitment process (job description

and expression of interest followed by interview) will be required. This could be

completed within six weeks once a full role specification and EOI has been

finalised.

2.4.3. System Provider Sponsor and System Commissioner Sponsor– role outline

This role will provide GM-wide executive leadership, within the relevant area, to

Articulate and promote the vision for change

Provide direction to support delivery within agreed timescales, and advise on

the resolution of issues blocking the progress of delivery

Lead the reporting and stakeholder management with the Provider Federation

Board and Joint Commissioning Board

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Oversee and drive the implementation of immediate interventions to improve

the quality, safety and efficiency of patient care; and longer term strategic

changes

Advise on strategic issues affecting the delivery of the change

Represent and champion the project within the wider GM Health and Social

Care Partnership key stakeholders and groups

This role would be provided from within the system with nominations received

through an expression of interest for decision by the Partnership.

Recommendation: it is recommended that the processes to fill the above roles are

initiated as soon as possible to ensure that leadership is in place for when the

scope and specification of work (PIDs) is agreed by the Partnership.

3.0 How will Theme 3 deliver its work?

3.1. Theme 3 priorities

3.1.1. The following Theme 3 priorities received system endorsement from the AGG, The

Provider Federation Board, and the Strategic Partnership Board in September, with

agreement to start work on the scope and specification of work (PIDs) immediately:

Paediatrics (including specialised children’s services)

Maternity and obstetrics

Respiratory and cardiology

Benign urology

MSK and Orthopaedics

Breast services

Neuro-rehabilitation

Vascular

Ophthalmology and HIV were also endorsed to commence PID work as part of a

second phase of work.

3.2. The challenge

3.2.1. With the pressures faced by acute hospital services to deliver high quality care

against increasing demand, workforce shortages and a significant financial shortfall

across GM, there is need for Theme 3 to accelerate the pace of change and be

agile, flexible and task focused to successfully bring about the required benefits.

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3.2.2. For larger-scale service changes where a GM decision is required, there is a need

to understand and learn the lessons from previous reconfigurations to design

decision making processes that deliver robust decisions able to withstand

challenge. There is also a need to build on recent successes such as the approach

developed by the NHS Transformation Unit for the commissioning of “world class”

OG and Urology cancer services for Greater Manchester (and East Cheshire) that

previously has been undeliverable for nearly a decade, despite many previous

attempts.

3.2.3. To effectively deliver change that releases the expected benefits requires:

1. Design and implementation of an effective model of care through a

detailed commissioning specification that resolves the issues identified and

improves the service for patients. Key considerations include:

What clinical issues are we trying to resolve?

What is the best model of care to resolve these issues?

How do we standardize and ensure every patient receives a high standard of

care?

How do we ensure clinical services are as efficient as possible?

How do we ensure the required interfaces and expected integration with the out

of models are put in place to deliver the expected service benefits?

2. Execution of a robust decision making process that can withstand

challenge (as appropriate for the change in question). Key considerations

include:

What decision making process is relevant for each project? (e.g. procurement,

option appraisal etc.)

What governance is appropriate for each project?

What is the likelihood of challenge for each project? What actions and

governance is required to ensure a robust decision that withstands challenge?

How will the statutory requirements be met? How will the Four Tests for Service

Reconfiguration be met?

How will patients and the wider population be involved and engaged in the co-

design of changes? Is formal consultation required?

How will clinicians be engaged? What scale of clinical engagement and

consensus is needed?

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How will the Greater Manchester JHSC be engaged?

What level of strategic service change assurance is required? NHS England /

Clinical Senate / Gateway review?

3. Strategic coordination at the system level to deliver a clinically coherent

future configuration of services across Greater Manchester that:

makes best use of all estate;

releases cost from the system (both short term cashable savings and medium

term savings) and contributes towards the financial savings position across

Greater Manchester;

improves performance;

engages with other themes and enablers in a coordinated way, and;

is delivered efficiently.

3.3. Clinically-led standardisation and innovation at pace

3.3.1. The Clinical Alliance has been a key asset in the delivery of Healthier Together with

a number of leading clinicians employed in clinical leadership roles to drive change.

It is a pan-GM group with a strong sense of ‘team’ and is well respected in the

clinical community. The agenda is based on exploring clinical themes that are

specific to the operationalisation of Healthier Together, for example enhanced

recovery for patients prior to surgery (ERAS+), ambulatory care models etc.

3.3.2. The model is one which could be adopted for Theme 3 to drive standardisation and

the implementation of immediate interventions to improve the quality, safety and

efficiency of patient care through the sharing of data, evidence-based changes and

innovations. At the same time it also provides a forum for the development / testing

of pan-GM clinical standards and models of care as part of any required clinical

redesign work.

3.3.3. This model could be adopted, building upon existing structures where relevant,

such as strategic clinical service networks but widening their multi–disciplinary

membership and using them as part of a Theme 3 task and finish group

Recommendation: Adopt the Clinical Alliance model to accelerate the delivery of

‘quick win’ improvements, starting implementation immediately.

3.4. Phases of work

3.4.1. The diagram below outlines the high-level phases of work and timescales starting

with the development of the scoping of work for each project (PIDs) which is already

underway:

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3.5. On the assumption the system will work at pace, it is proposed that by the end of

Quarter 3 all priority projects deliver an overall assessment and high-level proposals

for change that can be subject to a ‘Gateway’ style review by the system

governance groups and Theme 3 Delivery Board, early in Quarter 4. This would

include decisions to fast track any early implementation opportunities where

possible (i.e. not requiring option appraisal, formal consultation etc.).

3.6. It is also proposed that these proposals for change are reviewed against a GM

Acute Clinical Services Strategy framework.

High-level phases of work and timescales for delivering Theme 3 priorities

3.7. The proposals for change would include the following a combination of sub-

products, subject to the project:

Case for change and root cause analysis of issues

Vision and proposed approach (options, service model) to deliver the change

Summary of the opportunities and evidenced quality, safety and efficiency

benefits, including quantification and type of savings

An indicative assessment of any long-list options for change

Task and finish recommendations for immediate implementation.

3.8. For some of the priority services, clinical redesign work has already been done to

develop standards, and new models of care (for example Paediatrics), and in these

cases, work needs to build on previous work that has previously be done by the

system and in many cases, the NHS Transformation Unit.

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4.0 Issues to resolve

4.1. Interfaces with other parts of the GM system and Programme work streams

4.1.1. The standardisation of GM hospital services is one part of a much larger system

change driven by localities delivering improved primary, community and social care

services, with the interface between the two critical to delivering improved care;

illustrated below:

4.1.2. As part of the Theme 3 scoping of projects, links with other themes and Programme

work streams are already being made to identify and define the supporting pieces of

work that are needed from other parts of the GM system, to help bring about

change.

4.1.3. There will need to be clear understanding of the key priorities and deliverables from

other work streams. In addition, a number of these projects may be viewed as GM

cross-cutting work where inputs from other task and finish groups may be required

with overall co-ordination of work plans.

4.1.4. As part of this process of alignment, work will take place with the Strategic Clinical

Networks (SCN), to ensure appropriate levels of connectivity and support to the

Theme 3 work.

Recommendation: Assurance from the Partnership that the work programmes of

the Themes align, and interfaces are aligned to Theme 3’s delivery plan and vice

versa.

4.2. System ownership for cross-system changes (e.g. Children’s Services)

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4.2.1. There will need to be some thought given to system wide ownership (and

subsequent implementation arrangements) where multiple change proposals are

anticipated for one service area across tertiary, secondary, primary and community

care and local government. Children’s services would be one such area.

Recommendation: System leadership roles are clearly identified and work with the

relevant theme leads to provide overall direction and co-ordination.

4.3. Timescales for agreement of resourcing projects and use of Transformation

Unit and any other suppliers

4.3.1. The PIDs are currently being prepared for Theme 3 priority projects that will outline

the projected resource requirements to take the project thorough the initial gateway

review and subsequent phases of service re-design as outlined above.

4.3.2. Projected resource requirements will cover the following:

expected resource in kind - use of available organisational resource

(commissioners and providers)

proposed clinical leadership backfill

expected specialist expertise required to deliver the different phases of the

project over the next 18 months given the expected return on investment

specific project management inputs required.

In addition, the overall strategic and programme co-ordination of the proposed

projects will need to be resourced we propose that this is outlined in a separate

PID. Administrative support to the Theme 3 governance will need to be provided by

the Partnership. This is currently resourced by the NHS Transformation Unit.

4.3.3. There is a risk that Theme 3 projects will be subject to a delay as result of the need

to commission resources, whether this is from internal sources such as the NHS

Transformation Unit or other suppliers. A quick approval process, so that work can

commence off the back of gateway review points would resolve this.

Recommendation: Implementation of a quick and clear process to commission

resources thorough the Partnership’s client function off the back of agreed resource

budgets and work briefs.

4.4. Communication of the programme work

4.4.1. As projects progress, there will be an increasing need to keep the system well

briefed of progress, on major stakeholder and engagement events, and the overall

direction of service models as they are developed. This will need to be properly

resourced to facilitate the change process.

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Recommendation: Partnership Communication lead to assess and advise on the

communication and engagement programme budget required.

5.0 Summary recommendations

The Strategic Partnership Board is asked to:

1. approve the proposed governance changes as outlined in Section 2

2. endorse and provide feedback on the proposed approach and high-level

phasing of work and suggested gateway review points to deliver Theme 3

3. endorse or refine the approaches suggested to resolve the issues outlined in

section 4.0.