The journey so far

The devolution journey so far

Steve Wilson, Executive Lead – Finance & Investment

The journey so far

• Me!

• The National Context

• What is Different about Greater Manchester?

• The Devolution Journey – Myths and Realities

• Payment Reform in GM

• The Future

Agenda

The journey so far

• 22 Years career in NHS Finance

• Director of Finance experience in Provider and Commissioner NHS Bodies

• Previous role as Director of Financial Control for NHS England

• Took up GM role in October 2016

• Married to NHS CFO!

Me

The journey so far

The National Context

The journey so far

• UK NHS

• £136bn annual spend

• 1.6m employees

• NHS in England

• 1.2 million employees• 150,000 doctors

• 41,000 GPs)

• 315,000- nurses and health visitors

• Fourth biggest employer in world

• Annual budget £107bn

• 98.8% funding from tax

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Devolution – The context

The journey so far

NHS Structure in England

The journey so far

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• Receive funding based on allocation formula

• Formula sets target allocation for CCG

• Size of the population

• Age and sex profile of the population

• Health needs of the population

• Unmet health needs & health inequalities

• Market forces adjustment

• Remoteness adjustment

• CCGs moved toward target allocation through “pace of change” policy

Clinical Commissioning Groups

The journey so far

• 236 NHS Providers (155 NHS Foundation Trusts)• 137 acute non-specialist trusts• 17 acute specialist trusts• 55 mental health & community trusts• 17 community providers• 10 ambulance trust

• Regulated by NHS Improvement• Foundation Trust Regime launched in 2004• FTs had financial and other freedoms• Accountable to local population through council of

governors• Differences between NHS Trusts and FTs significantly

eroded by 2016

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NHS Providers

The journey so far

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• CCGs & NHS England commission healthcare from a variety of providers

• Primary care services• Medical services national GP contract (GMS) or local variant (PMS)

• Further contracts for dental, optom and pharmacy services

• Community & Secondary Care• National NHS Standard Contract

• How are service paid for?• Block Contracts

• Payment by Results (PbR)/Cost per Case

• Capitation payments

• Outcome based payments

• Hybrid approaches

Commissioning & Contracting

The journey so far

What is Different about Greater Manchester?

The journey so far

Greater Manchester

The journey so far

Greater Manchester: a snapshot picture

The journey so far

Our Devolution Journey

The journey so far

What is Devolution?

• Devolution of powers from central to local government emerged as flagship policy 2014

• Two mutually reinforcing objectives

– Drive local economic growth

– Maximise contribution of and values derived from public services, inc health & social care

• Move towards place-based commissioning & decision making

• Drives integration of Health & Social care

The journey so far

The Reality of Devolution?

• What does all this mean for GM?

• Unique partnership governance structure

• Place based approach

• Integration of Health and Social Care

• Some limited freedoms from national oversight

• £450m 5 year transformation fund

The journey so far

• Greater Manchester Health & Social Care Partnership– NHS organisations and councils

– Primary care

– NHS England

– Voluntary, community and social enterprise sector

– Healthwatch

– Greater Manchester Combined Authority

– Greater Manchester Police

– Greater Manchester Fire and Rescue Service

Who we are?

The journey so far

Our vision

To deliver the greatest and fastest possible improvement to the health and wellbeing of the2.8m people ofGreater Manchester

The journey so far

• Transform the health and social care system to help more people stay well and take better care of those who are ill

• Align our health and social care system to wider public services such as education, skills, work and housing

• Create a financially balanced and sustainable system

• Make sure our services are clinically safe throughout

Four objectives…

The journey so far

Our Governance

GM Combined Authority and GM Mayor

GM Reform BoardGM Health and Care

Board

Association of Governance Groups

Joint Commissioning Board

Provider Federation Board

Primary Care Advisory Board

LCO Network

Finance Executive Director

Performance and Delivery Board

Urgent and Emergency Care

Board

Quality BoardProgramme

Co-ordination Group*

*previously Transformation Portfolio Board

Programme Governance

Children’s Health and Wellbeing Baord

Health Innovation Manchester

Digital Collaborative

Workforce Collaborative

Strategic Estates Board

GM HSC Partnership(previously SPBE)

The journey so far

• Quarterly assurance process

• Locality/Place based

• All locality attends

– CCG

– Local Authority (Council)

– Acute Provider, Mental Health & Community Providers

• NHS Improvement sit on Panel

• Single locality response

– Performance

– Finance

– Quality

Place Based Assurance

The journey so far

STANDARDISING ACUTE HOSPITAL CARE

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2 TRANSFORMING COMMUNITY BASED CARE & SUPPORT

RADICAL UPGRADE IN POPULATION HEALTH PREVENTION

STANDARDISING CLINICAL SUPPORT AND BACK OFFICE SERVICES

4

5 ENABLING BETTER CARE

Our transformation themes

The journey so far

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The Implementation Reality!

The journey so far

• Local care organisations coordinate delivery of integrated care in each borough

• Boroughs are made up of smaller neighbourhoods -GP practices working with other health and care professionals

• Standardisation across hospital sites and more care in the community, closer to home

• A single local commissioning function in each borough plus a GM Commissioning Hub

The building blocks of transformation

The journey so far

• Creation of 10 Integrated health and social carecommissioning functions

• Responsible for strategic commissioning for locality

• Much tactical commissioning moves to local care organisations (LCOs)

• Standardisation of certain activities across GM

• Single GM commissioning hub, or

• Lead CCG commissioner

• Review of support functions across GM and within localities

The Future of Commissioning

The journey so far

• Some form of LCO will emerge in each locality

• Integrated health & social care provision

• Focus on delivering care outside hospital setting

• Based on neighbourhood mode 30k – 50k population

• Will include primary care, community services, social care, urgent care and some acute services

• Will be a number of forms

• Single provider (could include acute)

• Lead provider

• Alliance contract

Local Care Organisations (LCOs)

The journey so far

LCO Core Features

Enable conditions to be managed at home & in

the community

Secure the contributions of the full range of public

service partners to providing early help and

prevention

Support individuals & communities to take

more control over their own health

Take responsibility for the management of the

health & wellbeing of a defined population

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• Enhanced 7 day primary care services

• Improved care in residential and nursing homes

• Improved patient flow

• Early diagnosis

• Prevention and early intervention

• Place based integration to maximise health benefit

• Independent living for older people, people with LD

• Extra care housing models

• Enabling people to take control of their own lives

• Asset based community support

• Social prescribing

• Personalised care/personal budgets

• Risk stratification, active case management

• Talent development and system leadership

• Capital and estates solutions

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3

4

The journey so far

Contracting and

Payment Reform

The journey so far

• Relationship between Strategic Commissioning Function (SCF) and LCO become key

• Creates 109 accountable care systems (ACS) across GM

• Move towards capital and outcomes contracting by SCF

• LCO will allocate resources between functions and move care out of hospital

• Incentives are aligned with opportunity to deliver care in a different way

• Different forms of LCO will use different tactical commissioning tools

Payment Reform in GM

The journey so far

Accountable Care Models

HGLCO

Primary Care

Social Care

SCF

Block

Capitation

LCO

Primary Care

Secondary Care

Tertiary Care

Social Care

SCF

Capitation

HGLCO

Primary Care

Social Care

SCF

BlockBlock

Fully Accountable system Partially Accountable System Basic System

The journey so far

Scope of services of covered

• SCFs decide what to include, exclude or potentially phase in at a later date. Generally, it is better to keep most things included to avoid reinforcing silos or fragmenting care.

• They should take into consideration which budgets (and associated services and care responsibility) they are pooling when deciding the scope of the arrangement.

Step 1 Step 2

£Budget, contract and duration

• Set capitated baseline using current commissioner spend

• Modify budget based on provider productivity improvements, regional costs and trends

• Determine contractual form and duration (multi-year contract recommended)

• Set payment amounts and frequency for the distribution of capitated budget

Risk share, shared savings and incentives

• Determine risk share between SCF and LCO with the potential for shared savings increasing as risk is assumed by the provider

• Set incentives such as quality measures for both physical and mental health that providers must meet in order to earn shared savings

• In order to ‘beat the target budget’ providers are encouraged to think creatively about how to delivery more efficient care (e.g. partnering with third sector organisations)

Population is defined by each

SCF

Define population • Identify

population through CCG registered list and Local Authority Resident List

• Determinepatient mix and risk adjust through looking at case mix, spend and utilisation

Source: NY DSRIP Roadmap – Year 1 Update June 2016 and Draft Whole population models of provision: Establishing Integrated Budgets March 2017

Contracting with LCOs

• LCOs may opt to pilot the contract in ‘shadow’ form initially

• SCF and LCOs should discuss risk mitigation strategies such as caps and collars or risk corridors

• SCF and LCOs can determine contracting monitoring frequency (if there is a need for reconciliation)

Step 3

SCF

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Capitation & Outcomes Budgets

The journey so far

• Beyond the Transformation Funding

• An enduring legacy

• Statutory Changes?

• Future organisational form

• Further devolution from central government

The Future?

The journey so far

For further detail go to:

www.gmhsc.org.uk

@GM_HSC