Huge cuts-driven changes to NHS and social care commissioning in Isle of Wight

Huge changes to the Isle of Wight’s NHS and social care commissioning are underway, following a PWC “capability and capacity review”.

However, a recent study found that management consultants make things worse.

Today is a good day to look at the “new commissioning model” for the Isle of Wight, as it is the first day of the #JR4NHS Judicial Review of the effects of the Accountable Care Organisation contract on NHS commissioning, and the lack of transparency and openness on the part of NHS England and the Dept of Health in introducing the Accountable Care Organisation contract.

Major changes to the Isle of Wight Clinical Commissioning Group’s powers and responsibilities have come as a surprise to Protect the NHS campaigners. These changes include:

  • Joining the Hampshire Clinical Commissioning Groups Partnership
  • Joining the Maternity and Children’s Commissioning Collaborative
  • Commissioning so-called New Models of Care – in particular the Isle of Wight Integrated Care System (formerly known as Accountable Care Systems but rebranded by NHS England to avoid connotations of the USA’s health care system).

All these changes are summed up in the expression “ Developing a new commissioning model for the Isle of Wight”. This new commissioning model breaks down into two elements:

  • Commissioning at scale (ie across the whole of Hampshire and Isle of Wight Sustainability and Transformation Partnership) and
  • Integrated Place Based Commissioning (ie for the Isle of Wight Integrated Care System).

Why?

This is a cuts-driven set of measures.

Last December, NHS England put the Isle of WIght Clinical Commissioning Group under legal directions, after the Clinical Commissioning Group reported it couldn’t see how it was going to make all the spending cuts NHS England required and was likely to be £2.2m short of the NHS England target.

The legal directions required the CCG to commission a capability and capacity review within six weeks, and then submit an “organisational plan” within four weeks to deliver on the findings.

The sustainability plan had to show how the CCG will operate within its budget for 2018-19 and “subsequent financial years”.

As a result, PWC – one of the notorious Big 4 accountancy companies recently lambasted in connection with the Carillion scandal – was commissioned to do the capability and capacity review. You can find this review on p34 of the 24th May 2018 IoW CCG Governing Body papers.

It becomes clear, reading it, that PWC told Isle of Wight  Clinical Commissioning Group to join the Hampshire Clinical Commissioning Groups Partnership as a condition of being taken out of legal directions.

“Joining the Hampshire Partnership is an opportunity for the CCG to evolve the way it delivers its business and develop new approaches to address issues.”

And p 38 Next Steps spells out:

“1. The CCG should develop an action plan to respond to our findings which should reflect the opportunities flowing from integration with the Hampshire Parnership.[sic]
2. The action plan should articulate how the CCG’s leadership, governance structures, processes and behaviours will develop in the short and medium term.
3. Alongside this action plan, the CCG must produce its Clinical and Financial Sustainability plan, showing how the CCG will be financially sustainable in 2018/19 and beyond.
4. Developing and delivering on actions against these plans will demonstrate to NHS England the CCG’s readiness to have its legal directions removed.”

The Operational Plan 2018/19 Exec summary (p 35 in the April 26th CCG Governing Body papers)  summarises the situation:

“The CCG is in legal directions and the need to transform how the CCG does business is recognised and will be implemented. As a first step, on the 1st April 2018 the CCG joined the Hampshire CCG Partnership (Fareham and Gosport CCG, North Hampshire CCG, North East Hampshire and Farnham CCG and South Eastern Hampshire CCG).

This will support our internal development as an organisation while also helping how we move forward as a commissioning organisation to develop more local, place based integrated commissioning with the IOW Council and also work more effectively at scale with other CCGs.”

Developing a new commissioning model for the Isle of Wight – Future of IoW Clinical Commissioning Group

As already mentioned, this new commissioning model has two elements:

  • Commissioning at scale (ie across the whole of Hampshire and Isle of Wight) and
  • Integrated Place Based Commissioning (ie for the Isle of Wight Integrated Care System).

This slide from the IoW Clinical Commissioning Group Governing body papers for the Extraordinary Meeting on 26 April 2018 purports to show what the future of the Isle of Wight  Clinical Commissioning Group will be.

There is a bit of information about the New Commissioning Model in a paper presented to the Governing Body Meeting on 29 March 2018: “Welcoming the Isle of Wight CCG to join the Hampshire CCG Partnership”:

“As the Isle of Wight CCG joins the Partnership on 1 April 2018, the Isle of Wight CCG, Isle of Wight Council and the Hampshire CCG Partnership have also agreed to work together to develop, agree and implement a new commissioning model for the Isle of Wight.

The objectives of this work are to:

1) Agree the CCG commissioning functions and responsibilities that in future should be undertaken by the NHS with the Isle of Wight Council, (local, place based commissioning), and the CCG commissioning functions and responsibilities which should be undertaken by the Isle of Wight CCG working at scale with the Hampshire CCG Partnership.
2) Review the operation of the Local Care Board and strengthen the existing governance arrangements, with the aim of developing the Isle of Wight health and care system as an exemplar Integrated Care System.
3) Agree the governance mechanisms, leadership, financial and workforce arrangements that will be put in place to enable the new commissioning model to be successful.”

The April 26th extraordinary meeting of the CCG Governing Body approved the Operational Plan 2018/19. The Exec Summary p 46 includes more information about New Commissioning Models:

“Collaboration across five Hampshire CCGs and the establishment of single leadership across four CCGs, strengthened integration with Hampshire County Council, increasing the ability to unlock savings and reducing unaffordable infrastructure.

Single approach and shared infrastructure for the commissioning of hyper-acute and specialised physical and mental health services for the population of HIOW -driving improved outcomes, service resilience and delivering organisational inefficiencies.[sic]

Capitated outcomes based contracts procured for at least three places by 2019/20.

Efficiencies of £36m in CHC [Continuing Health Care], £58m in prescribing costs and reduced system infrastructure costs by £10m.”

The bit about capitated outcomes based contracts for places is about Objective 2 in the paper Welcoming the Isle of Wight CCG to join the Hampshire CCG Partnership (above):

“Review the operation of the Local Care Board and strengthen the existing governance arrangements, with the aim of developing the Isle of Wight health and care system as an exemplar Integrated Care System.”

My guess is that the 3 capitated outcomes based contracts for places would be for the 3 multidisciplinary locality services.

The Operational Plan 2018/19 Exec Summary p91 elaborates a bit on Future of CCG – Integrated Place Based Commissioning and Commissioning at Scale

“The complexity and demands on commissioning are increasing and changing as part of wider changes in the NHS, and organisations have to continually review their capacity and capability.

The IOW CCG, as one of the smallest CCGs in the country is also reflecting on how it continues to effectively function in future, and has agreed that it needs to work in a more integrated way both to further develop integrated place -based commissioning on the IOW and commissioning at scale with other CCGs. We are exploring how we can further integrate local place based commissioning with the IOW Council, and at scale with the Hampshire CCG Partnership (Fareham & Gosport CCG, North East Hampshire & Farnham CCG, North Hampshire CCG and South East Hampshire CCG) and eventually across the STP.

The IOW CCG, with its commissioning partners, is considering what is best done at scale and what is best undertaken locally. In April 2018 the IOW CCG joined the Hampshire CCG Partnership, and agreed to join the Maternity and Children’s Health Commissioning Collaborative (MACH), which already includes the Hampshire CCG Partnership and West Hampshire CCG, with a view to implementation in mid – 2018.”

Arrangements for the Isle of Wight CCG as a member of the Hampshire and Isle of Wight CCG Partnership

(Does anyone know if the Hampshire CCGs Partnership is a statutory body and what the legal implications are of the Isle of Wight CCG joining it?)

In the paper “Welcoming the Isle of Wight CCG to join the CCG Partnership,” the following arrangements are proposed, from 1April 2018:

“1) Maggie MacIsaac is the Accountable Officer for NHS Isle of Wight CCG
2) NHS Isle of Wight CCG becomes a member of the CCG Partnership
3) The clinical chair of the Isle of Wight CCG (Dr Michele Legg) becomes a member of the Partnership Board, the group established to provide strategic leadership to the
Partnership and to manage the collective business of its members. The Partner
ship Board meets on a monthly basis.
4) One Isle of Wight CCG lay member is invited to join the Partnership Audit Committee and Remuneration Committee. This provides an opportunity for the Isle of Wight CCG to observe these committees in action (the committees are at an early stage of their development), and to determine the level of input and involvement of the Isle of Wight CCG. Initially the Isle of Wight audit and remuneration committees will remain in place, and the future arrangements will be determined jointly.
The Chief Executive will determine the appropriate executive and management structure for the Partnership and its members”

Joining Hampshire collaborative commissioning for Children’s and Maternity services

The Minutes of the March 2018 meeting (Section 5.4) of the IoW Clinical Commissioning Group Governing Body show that it was joining Hampshire collaborative commissioning for Children’s and Maternity services

“The Governing Body received paper GB17-103 The Future of Children’s Commissioning… The Clinical Executive recommended to the Governing Body the
proposal for the IOW CCG to join the collaborative commissioning arrangement for Children and Maternity Services which already exists across five of the Hampshire CCG’s.
The IOW CCG has diseconomies of scale and doesn’t have the capacity, breadth
and depth of commissioning expertise, including in Continuing Healthcare and Specialist placements to commission effectively in this area. There is a well-established and effective team of people within the Hampshire Children’s and Maternity Collaborative.
It was noted that this will be an opportunity to test out commissioning at scale from an IOW perspective. The cost for the service is £89k.
It was highlighted that accountability and decision making would remain on the Island with the IOW CCG. It was noted that subject to recruitment, the aim is for full implementation by July 2018. MD congratulated the ambition of getting this in place quickly.
MR commented on the importance of having a resilient, expert team in place in terms of quality and safety.
Clarity was requested regarding how the new post holder’s role would work. It was
confirmed they would be the link to the Island and work both on the Island and with the collaborative team on the mainland. Members of the mainland team would also spend time working on the Island. They would also have the support from the mainland team.
It was noted that the team are also the lead for the Hampshire and Isle of Wight STP transformation work on Children’s and Maternity Services.
The Governing Body approved the proposal for the IOW CCG to join the collaborative commissioning arrangement for Children and Maternity Services.”

Local, place based commissioning

This seems to be about commissioning an Isle of Wight Integrated Care System (aka Local Care Plan) by “implementing a New Models of Care commissioning framework approach.”

This baffling slide is from the CCG Governing Body papers for the 24 April 2018 Extraordinary Meeting. It begs MANY questions.

Such as where and what is the Alliance Agreement for ratifying into contract? And who approved it and where is the record of the discussion? Plus what actually is covered by each of the dark blue boxes? Where is all that info – like who is party to the Alliance Agreement and what are its main functions? What are the agreed arrangements relating to services contracts for delivery of the Services? What services does this Alliance Agreement and Contract cover? What are the contractual terms? Where are the outcomes/products of all the Activities to ensure readiness to launch the Alliance. What are the financials?

All this is totally OPAQUE and it should be clear and available to the public.

The CCG and the Council need to answer a lot of questions about this new Commissioning Model.

I will add some later but I’m sure you will have plenty of your own.

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