1. Summary of Report
This report summarises the findings of work recently undertaken to explore the potential benefits of greater integration of health and social care services and recommends that support is given to the principle of establishing a North Somerset Integrated Care Organisation by April 2013.
Further integration will support the aim of being more responsive to individual needs and will help to eliminate unnecessary organisational and professional barriers.
The report also recommends that a combined directorate responsible for retained services for children, families and adults is established and that further work is undertaken to look into a potential transfer of appropriate housing services to the Development & Environment directorate and the options for managing the local authority Public Health function from April 2013.
The council’s Corporate Plan promotes greater integration of health and social care services, in line with Government policy. Working in partnership is also highlighted as a key feature of the Council’s organisational approach.
The recent formation of the Council’s statutory Health and Well-being Board (People and Communities Board) has provided a forum for key leaders of health and social care to promote the integration of services, both amongst commissioners and providers of services. In this context, an integrated service provider organisation sits well with this initiative and government policy.
The transfer of services to an Integrated Care Organisation will not impact on the council’s key role as a community leader, articulating the needs of the local area and influencing other organisations to adapt their plans and direct their commissioning resources to meet those needs.
The proposals in this report support the council’s stated direction of travel to become a smaller, more efficient and responsive strategic organisation which is focussed on service redesign as a mechanism to reduce costs.
They also give the best possible opportunity of retaining
clinically safe and financially viable acute health services and sustainable
community health services run from within
The Employment Committee has a responsibility to
oversee the arrangements for establishing and recruiting to senior roles.
3.1 Wider Context
The National Health Service is undergoing significant change. In relation to its work with local authorities, the most significant aspects are:
a) Through the Health and Social Care Act the coalition government is introducing a series of wide-reaching modernising changes to NHS structures and systems, including:
· The abolition of Primary Care Trusts and Strategic Health Authorities and the transfer of power to Clinical Commissioning Groups (made up of GPs and other health professionals) working within a framework set by a NHS Commissioning Board.
The transfer of public health responsibilities
to local authorities and a new organisation, Public Health
· The formation of Health and Wellbeing Boards, led by local authorities, to bring together local authority and clinical commissioning within a local area.
b) Under previous legislation:
· Primary Care Trusts were required to divest their provider functions, either through transfer to other provider bodies or through creation of new social enterprises (these include services such as District Nursing, Children’s Community Nursing, Therapy services and Specialist services supporting people in their own homes).
· Hospitals are required to achieve new organisational forms, with an expectation that all would become Foundation Trusts by a specified date (currently the expectation is April 2014).
c) While the NHS has been allocated continued real terms budget growth under the Comprehensive Spending Review, this is at a much lower level than in recent years and means that the Service will need to absorb the cost of demographic growth; through the national QIPP (Quality, Innovation, Productivity and Prevention) programme it has set ambitious targets for cash efficiency savings.
In addition, the changes provide a greater role for local authorities within the future planning, commissioning and provision of health services. The main aspects are:
· Coordinating the new Health and Wellbeing Board, based upon a joined-up approach through the Joint Strategic Needs Assessment for the area, a health and wellbeing strategy, and alignment of health, social care (both children and adults) and public health commissioning plans.
· Leading joined-up commissioning across health and adult social care and children’s services.
· Providing the health overview and scrutiny function.
· Leading health improvement.
· Engaging with Clinical Commissioning Groups, which are expected to be aligned with local authority boundaries and which also have a duty to promote integrated services.
· Commissioning the local HealthWatch service.
Locally, the implications of the national changes are very significant, and fast-moving:
· Ahead of the planned abolition on 31 March 2013, both the regional Strategic Health Authority and the local Primary Care Trust have been “clustered”; the SHA now forms part of NHS South of England and, while it remains a legal entity, the Primary Care Trust is now managed within Bristol, North Somerset and South Gloucestershire (BNSSG) under a single Board and Chief Executive.
The PCT’s provider community health services for
· Weston Area Health Trust is required to work towards a new organisational form and has to date been unable to apply to become a NHS Foundation Trust because of its underlying financial challenges. The Interim Chief Executive appointed with effect from 1st September 2011 was given the key task is to work with the health and social care organisations in North Somerset to develop truly integrated services for the people of the area.
3.2 Establishing an Integrated Care Organisation
At the Executive meeting in December 2011, Members endorsed the proposal to explore further opportunities for service integration between front-line social care, acute and community health services given the importance of the relationship between the local authority and health services and the need to ensure that services are delivered in the most efficient and effective manner.
The work undertaken to further explore this initiative builds upon a number of examples of successful joint working and integrated working initiatives already in place, such as:
· Joint management structures for locality services.
· A joint learning disabilities services.
· A co-located disabled children’s service.
· A single point of access (SPA) for older people’s services.
· Jointly agreed plans for use of additional NHS funding for “adult social care services that benefit health”, building on established joint commissioning strategies.
All parties acknowledge that this approach to joint working and integration of services has helped to secure improved outcomes for patients and service users and has also led to positive feedback from external assessors following service inspections.
Considerable work has, therefore, been undertaken to
investigate the opportunities of further integration of social care, acute and community health services including the
organisational arrangements to support and govern the delivery of
integrated work. Officers investigating
the potential for further integration have also undertaken visits to
The outcome of this further work is that a cross-organisational
group comprising senior representatives from NHS North Somerset, North Somerset
Community Partnership, Weston Area Health NHS Trust (
Such an arrangement would help respond to the huge demographic pressures impacting on social care and health services as well as ensuring that duplication is minimised and limited resources are targeted towards addressing agreed joint priorities.
Further detailed work needs to be undertaken to agree the most appropriate range of services to be provided through an Integrated Care Organisation and detailed plans will need to be developed in respect of key issues such as the TUPE transfer and other important aspects of the project including the governance arrangements, the physical location of staff, the impact on existing contracts and future tendering requirements for NHS and other work. This further work would be overseen by a Transition Board comprising senior representatives from NHS North Somerset, North Somerset Community Partnership, Weston Area Health NHS Trust and North Somerset Council and it is proposed that our representatives on this Board would be the Leader of Council and the Chief Executive Officer, supported by the Director of CYPS and the Director of ASS&H.
3.3 Further Senior Management Restructuring
Alongside the need to consider the organisational impact of transferring front-line social care functions to a new Integrated Care Organisation, late in 2011 the Employment Committee requested the Chief Executive Officer to bring forward further changes to directorate structures and senior management roles to achieve further management savings and a further potential reorganisation of Council services – specifically Adult Social Services and Children and Young People’s Services.
This request was confirmed in the Council’s Medium Term Financial Plan, which includes a commitment to undertake a review of organisational structures aimed at reducing the number of directorates to achieve management savings and ensure that senior management arrangements are ‘fit for the future’.
The developments highlighted in this report provide an opportunity to further streamline directorate structures and further reduce senior management costs in line with Members’ requests by combining the role of the Director of Children & Young People’s Services with the role of Director of Adult Social Services. This model has been successfully introduced in a number of other local authorities and reflects the changing role of the local authority following a significant increase in the number of Academy Schools and the developing role of the council as a strategic commissioning organisation, rather than a direct provider of services.
In response to the ‘Munro Report’ regarding child protection, the Government has confirmed that it is legally permissible for the role of Director of Children’s Services to be combined with other local authority functions providing that due consideration is given to protecting the discrete roles and responsibilities of both the Director of Adult Social Services and the Director of Children’s Services when allocating any further functions to the individuals performing these roles. In undertaking this local test of assurance Members will, of course, need to be satisfied that the focus on outcomes for children and vulnerable adults will not be weakened or diluted as a result of combining these responsibilities.
The Corporate Management Team has carefully considered this important issue and is satisfied that the proposed merger of the Director of Children & Young People’s Services and Director of Adult Social Services roles will continue to allow sufficient focus on outcomes for children, young people and vulnerable adults in the context that:
· Some education responsibilities are transferring to an increasing number of academies
· Day-to day management of a number of appropriate front-line social care services will be the responsibility of the new Integrated Care Organisation
· Senior management and leadership capacity is being maintained in children and family services by recruiting into the role of Assistant Director Support and Safeguarding; and
· Safeguarding roles will be retained within the council’s staffing structures to oversee safeguarding work.
If Members approve the principle of establishing a North Somerset Integrated Care Organisation, the Director of Adult Social Services & Housing, working closely with the Director of Children and Young People’s Services, will be asked to oversee the transfer of services and staff to the new organisation and ensure that appropriate steps are taken to mitigate any risks.
3.4 Future Commissioning of Health & Social Care services
A key feature of the NHS reforms is that Clinical Commissioning Groups will, from April 2013, hold the budget for commissioning around 75% of health services for local residents.
GP Practices in
The GP Commissioning Group is currently developing proposals for its own workforce, which is likely to be about 30 people.
Commissioning support will include a range of services including information analysis, procurement, negotiating and managing contracts and other support services such as HR and Legal.
In the context of the council’s increased focus on commissioning, Members are asked to endorse the recommendation that the Chief Executive Officer actively engages with the North Somerset Clinical Commissioning Group to explore the opportunities of integrating, where appropriate, the council’s health and social care commissioning functions with those of the new GP led Clinical Commissioning Group.
3.5 New Public Health Responsibilities
The NHS changes include a reformed public health system
From April 2013 local authorities will have a new statutory duty to improve the health of the local population and public health staff and budgets will transfer to the council from the North Somerset Primary Care Trust. The staff transfer will follow the requirements of the TUPE legislation. The transfer of public health funds will be via a local ring-fenced public health budget and the new arrangements will also see the introduction of new ‘health premium’ payments to reward organisations which make progress against nationally determined health indicators.
Local authorities will be supported in their new role by a
new national organisation Public Health
Employees potentially affected by these proposals will be fully consulted over the implementation arrangements. Trade unions will also be fully consulted.
The Corporate Management Team has been consulted over the principle of establishing a new Integrated Care Organisation and further streamlining the organisational structure of the council and is supportive of the proposals.
5. Financial Implications
Achieving benefits for patients and service users and their families are the key drivers of this work. It is, however, also anticipated that financial benefits will also be achieved through the establishment of an Integrated Care Organisation by reducing duplication and streamlining processes and procedures.
Further work is needed to ensure the detailed business case for establishing an Integrated Care Organisation includes arrangements for, at the very least, maintaining levels of funding for social care services similar to that which would be available if the services remained under the direct management of the council. The detailed business case also needs to ensure that the proposed model is able to deliver a sustainable financial position for health services over both the short and long term.
There is an active dialogue with the Strategic Health Authority and other Government departments to identify potential funding arrangement from April 2013 to ensure that the funding of health and social care services are not adversely impacted by the establishment of an Integrated Care Organisation.
6. RISK MANAGEMENT
In pursuing further integration of health and social care, a number of risks are being actively managed and mitigated. The most significant ones include:
· Securing a financially sustainable model – mitigated by the actions described above
· Staff uncertainty – mitigated by TUPE, communications and engagement
· Organisational resistance – mitigated by strong leadership through CMT
· Failure to deliver benefits – mitigated by effective project management
· TUPE and pensions – mitigated by obtaining a good understanding of requirements and effective forward planning.
· Impact on support services – mitigated by the council’s support services contract with Agilisys.
7. Equality Implications
The Transition Board will oversee the development of an outline Equality Impact Assessment to help ensure that these proposals do not have an adverse impact on diverse or more vulnerable groups within our communities.
Implementation of these proposals will be in accordance with
council policies and practice, and legislative requirements.
8. Corporate Implications
The proposal to reduce the number of council directorates supports
the council’s stated direction of travel to become a smaller, more efficient
and responsive strategic organisation and the further reduction in senior
management costs will make a significant contribution towards addressing the
Council’s financial challenge. Further
integration of services will also make a positive impact towards the financial
challenge for the area’s health services.
9. Options considered
Not working closely
with the emerging North Somerset Clinical Commissioning Group,