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West Norfolk's CCG alliance

West Norfolk's CCG alliance

Clinical commissioning groups in West Norfolk are working in alliance to help co-ordinate care across the patient population and create a sustainable service
West Norfolk is a small rural health economy with one clinical commissioning group almost co-terminus with the borough council, served by one district general hospital (DGH) and two large providers of community and mental health services. 
The locality has a history of moving between county-wide and local commissioning arrangements and the current NHS West Norfolk CCG boundary matches previous incarnations as both a primary care trust (PCT) and local health authority. Health needs are influenced by rural deprivation, poor transport and lifestyle choices - such as smoking, diet and alcohol - leading to higher than England average levels of diabetes and chronic respiratory conditions. The demographic trend is of a rapidly increasing ageing population with multiple co-morbidities. 
The local DGH, The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust, is in special measures with Monitor and is in financial deficit, a picture which is set to worsen without radical intervention. The whole-system local health economy financial challenge is projected to be a cumulative funding gap of £100m by 2020, split 50:50 between providers and the commissioner.
Our key challenges are that:
 - We know that if we continue to deliver health and social care in the way that we currently do, it will be unaffordable in the future.
 - Patients tell us that care is often delivered in an un-coordinated, fragmented way and it is not clear who they should ask for help.
In the run-up to the introduction of clinical commissioning, the practice-based commissioning group established a local forum comprising CEO representation from health and social care commissioners and providers as well as the voluntary

sector, with the aim of tackling common problems at a locality level, using the existing very strong partnerships across public sector organisations.

This group has developed into a very effective alliance, with an agenda that has become increasingly challenging, with inherent inevitable tensions arising periodically between the partners. This has been ameliorated by the continuity in relationships and a set of common goals and values, cemented in a Memorandum of Understanding. The alliance is now exploring innovative finance and contracting models to support taking forward the integration agenda. Figure 1 describes the key challenges facing the alliance.

The West Norfolk Alliance, which is a participant in the national ‘Integration Pioneer’ programme, was formally launched in April 2014, by Norman Lamb MP, Minister for Care and Support. 
The key principles of the West Norfolk Alliance
The aim of the West Norfolk Alliance is to create sustainable, coordinated care with patients in control.
The four key principles underpinning this are:
 - Independence, choice and quality.
 - One assessment, one care plan.
 - No organisational boundaries.
 - Shared information and decision-making.
The four big challenges for the West Norfolk Alliance are firmly aligned with those identified by the national pioneers, these being:
 - Transforming health and social care services through the incentives offered by the Better Care Fund in order to enable people to maintain independence for as long as possible and then be cared for in their local community wherever they can. The big driver nationally is moving away from a ‘payment-by-results’ model towards a model incentivised by positive patient outcomes with greater focus on prevention rather than activity generated. 
 - Placing the individual at the centre of planning their care in order to empower them to make informed decisions about how the health and care services they need should be delivered. 
 - Moving from the existing fragmented system of institutional separation of services. Organisations will recognise and accept each other’s assessments, be able to initiate packages of care in other organisations and behave as ‘one’. The West Norfolk Alliance will create more joint appointments across organisations and pools of shared bank staff with honorary contracts so that they can move around the locality to support the areas of greatest need.
 - The sharing of information across health and social care is paramount for effective integration and the ‘Integration Pioneers’ are spearheading a draft information governance agreement to inform the national direction. The West Norfolk Alliance is developing an exciting ‘Smartcard’ system to safely share key health information across partners with patients’ consent, which will reduce errors and improve coordination. 
Building on success
The West Norfolk Alliance is taking forward a whole-scale transformation and integration programme that is informed by both ‘top-down’ design and identifying groundbreaking ways of working at operational frontline level. The alliance has a legacy of working together to deliver integration that includes:
 - An integrated commissioning team, comprising West Norfolk CCG and Norfolk County Council (West) commissioning locality team.

 - Joint health and social care leadership of operational teams delivered by integrated management roles.

 - Community health and social care teams operating from three integrated locality sites supported by a central triage hub.

 - “Prevention First” partnership between health, social care, voluntary sector, district councils and county council to target prevention initiatives to maintain health and wellbeing of older people.
 - Living Independently in Later Years (LILY) initiative to support older people in navigating available services (
 - System-wide commissioning for quality and innovation (CQUIN) initiatives that have targeted the avoidance of emergency admissions to hospital.
 - Extension of the national integrated care organisation pilots, to promote multi-disciplinary team meetings at general practice level, to identify vulnerable patients that should receive integrated care planning.
Despite our best endeavours, patients tell us that care is often delivered in an uncoordinated and fragmented way and it is not clear who they should ask for help.To address the challenges and achieve the aims of the programme, the West Norfolk Alliance has embarked on a system sustainability programme to inform the shape and delivery of locally sustainable services in the future. 
Both Monitor and the NHS England area team support the alliance’s approach to system sustainability, which is being undertaken in a number of key work streams including:
 - Clinical reference group comprising some 18 senior clinical staff across organisations, with clinical pathway sub-groups.
 - Workforce transformation group, undertaking a detailed analysis of the current workforce across the alliance organisations, including general practices.
 - Integration group that identifies the opportunities to integrate the delivery of care.
 - Infrastructure group that is reviewing the IM&T architecture and associated organisations’ IM&T strategies to inform greater collaboration.
 - Communication and engagement that ensures both internal and external stakeholders are informed and engaged in order to inform the delivery of a sustainable health and care system.
Delivering a sustainable health and care system in West Norfolk
In order to achieve this, it is clear we cannot simply ‘tinker at the edges’; we need radical transformation. We need to develop innovative solutions and truly integrated multi-agency working so that local health and social care systems work as a whole to respond to and meet the needs of people who use these services.
This has to be achieved while also fulfilling the requirements of Monitor’s special measures Contingency Planning Team (CPT) programme. Ultimately it is our intention to work with partners to create a new DGH model that is fit for the future, and able to provide high quality care for our local population.
The West Norfolk Alliance vision for the provision of hospital care is that it must adopt an innovative model that encourages a joint approach to managing the care of patients across professions and health and social care teams. Future developments will be patient-centred and focus on services that are provided either as:
 - Hospital based with greater clinical co-ordination.

 - Delivered as a shared responsibility including intermediate care, enhanced discharge planning, and integrated health and care providing specialised care in the community and patients’ homes.

 - Community based between primary and community care, mental health, care homes, patients’ homes and community beds.
Fundamentally, the funding arrangements for such a transformation will need to be aligned and incentivised across the health and care economy in West Norfolk, so that providers are rewarded appropriately for individually and collectively achieving positive patient results. We will identify areas where systems can be streamlined and simplified, such as Continuing Health Care, and provide strategic leadership on maximising opportunities to further strengthen excellence in local integrated, cross-sector services for older people. 
Finally, the key to providing sustainable health and care services in West Norfolk is driven by the ability to attract and retain highly qualified and competent health and care professionals locally across primary, community, mental health and secondary care, working together in the West Norfolk Alliance, by developing exciting new roles and relationships between providers.
Through the system sustainability review and redesign, using an alliance model of commissioning for integrated care, West Norfolk will continue to implement the Alliance plan to deliver ‘sustainable coordinated care with patients in control’.
We will demonstrate:
 - People are more satisfied with their care.
 - Confirmed stakeholder and public support.

 - Reduced inappropriate admissions to hospital and to care/nursing homes.
 - Improved sharing of relevant information.
 - Reduced duplication of assessments.

 - Increased uptake of personal health budgets for social and health care.
Early findings will be shared in autumn 2014 to inform commissioning intentions for 2014/15 and the work will continue in conjunction with Monitor, NHS England and Alliance partners to develop long-term sustainable workforce and organisational transformation.

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