The challenges we face are in many ways no different to the national picture, experiencing marked pressure and challenges in urgent care, finances, workforce and the burden of an ageing population with multi-morbidity. As the scale of the challenge increases so does the need for innovative solutions, particularly to meet the constitutional requirement of 18 weeks from referral to treatment.
The challenges we face are in many ways no different to the national picture, experiencing marked pressure and challenges in urgent care, finances, workforce and the burden of an ageing population with multi-morbidity. As the scale of the challenge increases so does the need for innovative solutions, particularly to meet the constitutional requirement of 18 weeks from referral to treatment.
Our response to this challenge was the emergence of a strong coalition for integrated care across the local health and social care system framed by the Better Care Together five-year strategic plan. For our community based elective services we decided to try a new contracting mechanism that involves collaborative working through an alliance rather than the traditional individual provider contracts which historically have been characterised by disputes, requiring separate contracts and a difficulty in achieving change.
What is alliance contracting?
Alliance contracting is relatively new in the health sector and there is positive but limited experience of its use. There is more experience in the commercial sector such as the oil industry. The main idea behind alliance contracting is that multiple providers work together under one performance framework for the common good of the project. There is a shared risk and reward framework, which encourages a high level of trust and collaborative working. This is through aligned objectives and collective accountability. In this way, there is an increased chance of integration. A key aspect of alliance contracting is that decisions need to be ‘best for project’ and unanimous. The other two options for contracting for commissioners include the ‘prime contractor’ and traditional NHS contracting with separate arrangements with a wide range of providers.
Our alliance
Our alliance contract was established in April 2014, as an innovative and pioneering solution to overcome barriers to integration across the local health economy. The contract requires the participants (three providers and two commissioners) to share both risk and reward in delivering a number of strategic outcomes. Uniquely, the alliance included a GP provider organisation, which has previously been formed by the local medical committee.
The strategic outcomes included improved service integration, better value for money, increased use of community settings, the removal of unnecessary or duplicate steps in patient pathways, and enabling the introduction of enhanced models of primary care. The community based elective care, as a bundle of activity, was chosen as it offered the ideal opportunity for testing this model of collaborative working. Reasons for this included:
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Discrete bundle of activity.
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Existing community based services.
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Strategic intent to drive ‘left shift’ of activity from acute hospital into community hospitals and primary care.
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Appetite from both primary care and consultant clinicians to drive shift.
A vision was developed for community based elective care services:
“Offer all patients a choice which includes end-to-end integrated care pathways for routine elective care…delivered within the health economy”.
Quality estate and services exist across the district but their deployment is fragmented across organisations. The Alliance opens access to these facilities
for service providers to bring care closer
to home.
How is the LLR Alliance governed?
The Alliance is a collaborative working arrangement between organisations working towards a common purpose. Although legal contracts exist in terms of delivering an NHS clinical service, the focus is a working relationship built on trust and shared values. It is directed by a leadership board, which brings together the best of each organisation in order to achieve the desired outcomes for patients.
Alliance governance model figure
It is not a legal entity and as such a partner organisation from the Alliance must host the activity, CQC registration and employer responsibility of staff. Currently University Hospitals Leicester hosts CQC registration, NHS counted and coded activity and is the legal employing trust of the Alliance’s staff.
Risk management
All surplus generated by the shift of activity into the Alliance is ring-fenced by the Alliance for further investment into community based elective care. Its unique financial model ensures funds are ring-fenced for the project. This creates a real drive to deliver efficiency as savings directly unlock the finances required to invest in new services.
Business risks are incorporated into the Alliance’s risk register. The Alliance employs a lead nurse and a senior medical lead who take joint responsibility for the quality and safety agenda for the elective care activity. A quality schedule and commissioning for quality and innovation (CQUIN) arrangements are tailored to the Alliance and its unique contract.
Patient involvement
The Alliance patient and public partnership group (PPPG) is an active and integral part of the governance structure. It provides a vital role to help innovate, test and challenge Alliance service developments.
Achievements to date
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Development of hernia hubs in GP practices to undertake local anaesthetic hernia repairs.
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Movement of ophthalmology activity from the acute trust into community hospitals.
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Movement of endoscopy activity to community facilities.
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GP led ENT pilot in three community/practice locations.
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Business case under development to move pain management services out from the acute trust into community hospitals and GP practices.
What has gone well
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The Alliance has brought together GPs, consultants, managers and other clinical staff in a monthly clinical reference group that drives the agenda for the Alliance with shared goals.
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We transferred a service including TUPE of 300-plus staff within a six-week window with no disruption to the service.
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Successful negotiation of sub-contracts resulting in improved efficiency and reduced cost using the knowledge and gentle challenge of all partners.
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Concentrating on “best for project” principles has facilitated a different working arrangement, helping to break down barriers, which have existed between organisations in the past.
Challenges experienced and lessons learnt
The main challenge has been the communication and understanding of what the Alliance is and how it is different for the staff working directly within it as well as the partner organisations. The main lesson has been not to underestimate the amount and style of communication and messaging required when you need behaviours to be different. We ran some Listening into Action (LiA) events for staff which were very well attended and provided us with a clear action plan. A newsletter has also been developed.
Top tips for considering this approach
Be clear on the goals, objectives and KPIs and do not underestimate the organisational development required for operating “best for project” principles. General practice engagement is crucial and continues to be challenging as the structure and organisations of primary care continues to change with GPs belonging to an increasing range of organisations such as federations, networks, localities and/or GP provider companies.
Not all practices are members of the GP provider company. An enhanced policy on conflicts of interest is needed by CCGs in such cases where GPs belong to both provider and commissioner segments.
Conclusion and future developments
As yet – in its first year of operation – it is too early to judge the success of this model of commissioning as data on patient outcomes and integration is collected. Certainly relationships have improved and there is a different ‘feel’ to this work and it is less adversarial.
There have been several successes with shifting activity and fewer cancellations. Future clinical areas for ‘left shift’ have been identified as musculoskeletal, ENT, urology, general surgery and gastroenterology.
Although the Alliance contract is a seven-year contract set up for elective care services, the model could be applicable to other services. The Alliance Agreement, which underpins the contract, allows for other partners to join the Alliance by mutual agreement of existing partners. This is important with the development of GP Federations and networks that may seek to benefit from the Alliance Contract.
Debra Mitchell is interim director of the Alliance and Professor Mayur Lakhani is Chairman, West Leicestershire CCG.
