Case study: older people’s services in Cambs Demography: an ageing population, rising cost Poorly funded CCG, need for savings Multiple providers, lack of integration Care centred around organisations, not the patient Too much care in acute settings, too little in community Too many emergency admissions The case for change

The aim CCG commissioning a radically integrated “seamless” service Integrating pathways for over 65s, so can provide more care “upstream” and in community, and less in acute settings Outcome-based contract Flexibility about service design as long as it delivers outcomes Lead provider (community services) 5-7 year contract, £800M over the whole period Single point of contact and rapid response 24/7 The Older People’s Programme is a landmark effort to deliver the deep integration of services necessary to cope with demographic and funding pressures.

What’s in the contract? Community health services for over 65s (District nursing and most community therapy services, specialist nursing teams and dieticians) Emergency hospital care for over 65s (Attendance at the A&E departments; avoiding emergency admissions where they can be safely avoided) Mental Health Services for over 65s End of Life Care including community specialist palliative care (in a patient’s home, or a community or hospice bed if needed) Social care is NOT in scope

Four bidders have reached the final stage: Uniting Care Partnership (Cambridgeshire and Peterborough NHS Foundation Trust with Cambridge University Hospitals NHS Foundation Trust) Accord Health (Interserve with Provide, formerly Central Essex Community Services, and North Essex Partnership Foundation Trust as Mental Health Lead) Care for Life (Care UK with Lincolnshire Community Health Services NHS Trust, and Norfolk Community Health & Care NHS Trust) Virgin Care Ltd. Who is bidding?

Scrutiny’s role CONTEXT OF MAJOR SYSTEM CHANGE Clinical Commissioning Groups new to this Health and Wellbeing Boards new also High risk environment NOT PARTY POLITICS Political ante high, biggest contract in UK Opposition is exclusively to private providers SCRUTINY Ensure commissioners held to account and process feels democratic Ensure service for our older people is a good one

1. An outcome-based contract: Align financial incentives with priorities across system End perverse incentives of block contracts / PBR Encourage innovation in service design 2. A competitive dialogue procurement: Contract worked up between commissioner and provider over multiple rounds of procurement: joint ownership of contract Encourages innovation BUT with an outcome-based contract nobody knows what the service will look like before contract is let. Full contract specification won’t exist until end of procurement  Makes meaningful consultation difficult  three challenges

3. Commercial confidentiality: NHS commissioning subject to procurement law Higher profile in context of Health & Social Care Act CCG lawyers extremely defensive Risk of being sued by bidders Wary of political campaigners and Judicial R Want a stable procurement three challenges

To the public the process appeared secretive and unaccountable. None of the key documents were publicly available Requests for information were rejected on grounds of “commercial confidentiality” Public consultation was to begin after the contract was awarded to the preferred bidder

Improving accountability Working group signed confidentiality agreements to reassure CCG and bidders about how we would use their information. We asked questions at our public scrutiny meetings. Knew our powers and its limits – FOI – duty to consult – commercial confidentiality Made a better-informed case for a more open approach Communicated our positions in the media

Results CCG agreed to publish the key procurement documents Consulted the public before the final bidding round Published summaries of the bids themselves Allowed us to shape the consultation document Co-operation and pressure needed Tension between public law and procurement law. CCGs can hide behind commercial confidentiality, or find ways to be creative and work within it

What should scrutiny try to achieve with outcome- based contracts? In terms of process, Scrutiny should press CCGs to ensure: Public accountability maximised Consultation is timely and meaningful – before final round Public are able to influence service design The contract should not simply be awarded to the lowest bidder: Credible, realistic and deliverable contracts NOT a predatory bid or a loss-leader Owned by commissioners & providers Evaluated on this basis, not just cost! Good commissioners can commission good services in the new system.

East Sussex experience Health scrutiny agreed these points with CCGs for early, open discussion on outcome based contracts: An explanation as to why change is needed Examples of possible changes to patient pathways to help scrutiny assess whether it is a substantial change – what it feels like as a patient How patients will be involved in the case for change and development of the service specification Procurement plan and timeframes and who is involved in the procurement process Early perspectives from the current provider of the service.