a meeting of the governing body of nhs bromley clinical ... - integrated care... · communication,...

A meeting of the Governing Body of NHS Bromley Clinical Commissioning Group

16 November 2017

ENCLOSURE 10

INTEGRATED CARE NETWORK UPDATE SUMMARY: The purpose of this paper is to provide an update on progress with the implementation of Integrated Care networks (ICNs) in Bromley. Proactive Care Pathway The first pathway to mobilse was the Proactive Care Pathway, with a core element of this pathway being a multidisciplinary meeting (MDT), where professionals discuss and plan integrated care for adult patients with complex long term conditions. The first MDT meeting was held one year ago in October 2016. Since that time there have been over 1,000 referrals in to the service, with full capacity achieved in February 2017 and demand reaching the required level in May 2017. A formative independent evaluation was commissioned from the Health Innovation Network (HIN). A report was delivered to the ICN Board by HIN in September 2017 (Appendix A). The Provider Joint Operating Group is studying the recommendations and developing an improvement plan. It must be noted that HIN were sharing their findings as they were identified throughout the evaluation phase which enabled many early implementation issues to be addressed, with continuous improvements made to the operating model.

Summary of Key Findings: • The small number of patients and their families / carers who were interviewed

reported a very positive experience, with one carer saying that “my life, and that of my mother, has been transformed”

• Professionals directly involved in the operational delivery also report that the ICNs and new pathways are having a positive impact on patient care, and are improving communication, understanding, and relationships between partner organisations

• When it has been possible to obtain input from social care into the MDT process this has been seen as enormously valuable. The absence of social care from the MoU, and also the very limited ‘on the ground’ engagement with the new pathways has been raised many times by professionals as a key issue throughout the evaluation. Many professionals stated that their consistent presence would add significant value, and that with them involved “the MDT would be a truly one-stop shop for patients”.

Clinical Chair: Dr Andrew Parson 1 Chief Officer: Dr Angela Bhan

• Overall, this early evaluation indicates that a positive start has been made with the

implementation of the ICNs and care pathways, with some initial signs that there is potential for a significant positive impact on health outcomes for a complex and vulnerable group of patients in Bromley.

Governance issues relating to the Data Sharing Agreement resulted in a delay in receiving activity data from all providers. Full data was received in September with initial findings shared with a joint ICN Steering Group and Board in October. This early analysis was encouraging, however, with a caveat that the majority of patients went through the pathway quite recently so long term outcomes are yet to be established. Further analysis and additional financial data are required before findings can be shared with confidence.

For patients where there has been a change in the number of hospital admissions, those that had a reduction (19.3% and 8.2%) compares favorably to those that had seen an increase (5.2% and 8.5%) at a ratio of approximately 2:1. The caveat is the nature of these patients would have been on a downward trajectory and there is no equivalent control group.

19.3%

8.2%

6.3%

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52.6%

Analysis of Hospital Admissions before and after MDT

ED admissions prior to MDT butno admissions after

Decrease in admissionsfollowing MDT

ED admissions prior and afterMDT the same

Increase in ED admissionsfollowing MDT

No ED admissions prior to MDTbut admissions after

No ED admissions both priorand after MDT


Referrals by ICN (as at 27/10/2017)

Referrals by Practice (as at 27/10/2017)

A Social Prescribing portal was commissioned as part of the ICN model and this is now in place. Work is being undertaken to explore the best approach to opening up access to the portal more widely, with an opportunity for this also to be aligned through the new ‘Bromley Well’ contract. Frailty Pathway The second ICN pathway to mobilise was the NEW frailty pathway, the hospital end of the

Network Plan Actual VarianceBeckenham 441 319 (122)Bromley 427 405 (22)Orpington 410 314 (96)Other Referrals 0 20 20 TOTAL - Bromley CCG 1,278 1,058 (220)

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pathway, namely the opening of Churchill and Elizabeth Wards in Orpington, these were operational between January and April 2017. At the request of King’s College Hospital, the remaining parts of the pathway (i.e. direct step up from community) were to be delivered on a ‘best endeavors’ basis allowing time for the end-to-end acute pathways to be reviewed. Commissioners agreed to stand down the frailty programme group over the summer with a view to ensure the full pathway was in place for the winter. Over the summer, King’s have joined the Acute Frailty Network (AFN) to facilitate their improvement in end-to-end care. Commissioners have been included in the process and supporting the work. Memorandum of Understanding (MOU) The MOU that was a key enabler to delivering the integrated care required in the ICN Model expired on 30 September 2017. In its place providers have signed a new Alliance Agreement for Virtual Multispecialty Community Providers (Appendix B). This agreement achieves several outcomes:

• Moves the local MOU agreement on to a national template that wasn’t available previously

• Secures the funding for the new posts that are delivering the Proactive Care and Frailty pathways

• Introduces a new governance structure that enables steps towards the development of an Accountable Care System for Bromley

• Brings in the London Borough of Bromley on a more formal basis as a signed member of the agreement

Next steps workstreams As part of discussions and agreement with system leaders work has commenced to explore additional areas to include within the ICNs. Progress against these areas is described below:

• Integrated Heart Failure

Ahead of the System Leaders Programme meeting in June 2017, an aspirational model for rapid diagnostics in primary and secondary care along with an integrated community maintenance pathway for patients diagnosed with Heart Failure was presented. The project group was tasked with developing this in to a robust case for change starting with a full service review. As such, over the summer, a data collection exercise was undertaken to include an audit of echocardiography at PRUH (a key diagnostic tool used to diagnose patients with heart failure), a patient survey and search for national good practice. This data collection is being reviewed ahead of presentation back to a system wide workshop to


include all stakeholders.

• Respiratory Services

Early discussion in the Heart Failure project recognized the need for a pathway to allow more effective diagnosis of ‘breathless’ patients that are found to be negative for Heart Failure. At the same time an offer has been received from Respiratory Medicine physicians at King’s College Hospital to develop virtual clinics which have been successful in Lambeth and Southwark. A service specification is being developed with the aim to pilot the service.

• End of Life

The project group has reviewed the findings from the audit of 100 deaths that occurred in the Acute Medical Unit at PRUH between November 2016 and January 2017. This included an in-depth review of medical notes for twelve of these patients to identify indicators of the patients being end of life and whether that had been previously identified and if advanced care plans were in place. A further review of the patients’ primary care notes is being undertaken before conclusions are drawn fully. However, early indications are that awareness and application of advance care plans can improve patient outcomes. Also under consideration is a service to deliver first dose IV antibiotics in the community. A service model that is in place for residents of Lambeth and Southwark, delivered by Guy’s and St Thomas’, is being reviewed. The intention is to create a workshop on how this model could potentially benefit the Bromley population.

• Integrated Therapy Services

In conjunction with the joint Transfer of Care Bureau programme of work, therapies services are being reviewed to allow greater integration of services and seamless patient care. The key areas of work identified are the acute to community interface, mobilizing the community therapy service, development of a trusted assessor model including a ‘Discharge to Assess’ model, aligning the Disability Facilities Grant to equipment access policies and the review of the fracture pathway.

• Care Homes

Discussions are ongoing to scope the current and future service model required to best meet the needs of residents in care homes. A new care homes programme group is being established under the leadership of the Director of transformation and integration.


The focus now will be as follows:

1. To review the recommendations from the Proactive Care pathway evaluation and the development of an improvement plan.

2. To restart the Frailty Programme to put in place the remaining elements of the pathway i.e. Step Up

3. To review options available for an Accountable Care System for Bromley. 4. To develop a new Model of Care for a more integrated Heart Failure service. 5. To develop a pilot Integrated Respiratory Service. 6. To develop the community IV antibiotic service to include first dose that would avoid a

hospital admission. 7. To continue the work on the ‘Trusted Assessor’ model to avoid duplication and reduce

delayed discharges from hospital. 8. To develop the “offer” for Care Homes.

The Governing Body is asked to note the information within this report. KEY ISSUES:

Background In May 2016, a Memorandum of Understanding (MOU) was signed between Bromley Clinical Commissioning Group and local providers – King’s College Hospital NHS Foundation Trust, Bromley Healthcare Community Interest Company, Oxleas NHS Foundation Trust, Bromley GP Alliance, Age UK Bromley and Greenwich, St Christopher’s Hospice and the newly formed Bromley Third Sector Enterprise. Following development of the Proactive Care Pathway, the first MDT meeting was held in October 2016. Since then, over 1,000 patients have been referred to the pathway. Between January and April 2017, new Frailty wards were added to Orpington Hospital as part of a co-designed Frailty Pathway. In October 2017, a new Alliance Agreement for Virtual MCPs was signed by provider members to replace the expiring MOU, with the addition of London Borough of Bromley as a full member. The Alliance agreement outlines changes to the governance structure for ICNs, and also provides a springboard for developing an Accountable Care System in Bromley. Four ‘Next Steps’ projects were highlighted and agreed the System Leaders’ Programme, namely:

• Integrated Heart Failure • End of Life • Integrated Therapy Services • Care Homes

An additional fifth workstream was added – as an opportunity to more effectively manage the patient with breathlessness arose, along with the opportunity to develop an integrated respiratory service.


Summary of issues / risks and actions / mitigations taken to minimise these There is continued pressure on services at PRUH which could delay the delivery of the full Frailty pathway including ‘Stepping Up’ of patients from the community who may need additional support to avoid a crisis admission. Reconvening the Frailty Steering Group will ensure all partners can support the hospital in implementing the full pathway. The Heart Failure and Respiratory projects require senior clinical consultant and GP involvement for delivery whilst maintaining the current capacity to deliver increasing demand in patient care. This is being achieved through a managed approach to avoid unnecessary meetings. Projects are likely to require investment in the short term which is difficult in the current NHS financial environment. Whilst performance Funds from the MOU have been ring-fenced and other national funding such as Social Prescribing is being sought, any additional funding gaps will be identified, and form part of full business case development, as the work progresses. Reason for timeliness / submission now The ICN Board wish to share the findings from the independent evaluation commissioned from the HIN, and update the Governing Body on the signing of the Alliance Agreement which replaces the expired MOU. Finance considerations Extending the funding of the MOU to the end of the financial year has identified a cost pressure of £95k. For 2018/19, funding gap of £606k has been identified. Any new requirements for funding will be identified in separate business case development. Legal considerations The development of the Alliance Agreement for Virtual MCPs for Bromley is based on the NHS England New Care Models template agreement Version 2, September 2017. It is acknowledged that this agreement does not replace or surpass rights of parties that are signed up in individual service contracts using the national NHS Standard Contract. Any changes proposed under the Alliance Agreement for Virtual MCPs must be unanimous amongst parties with an interest through a service contract in place. Staffing & Equalities considerations All posts introduced to support the Proactive Care and Frailty pathways are now recurrent. PROFESSIONAL INVOLVEMENT:

• Dr Andrew Parson, CCG Clinical Chair and Bromley GP • Dr Ruchira Paranjape, CCG Clinical Lead and Bromley GP • Dr Mark Essop, CCG Clinical Lead and Bromley GP • Dr Jon Doyle, CCG Clinical Lead and Bromley GP • Dr Atol Arora, CCG Clinical Lead and Bromley GP • Dr Chris Fatoyinbo, CCG Clinical Lead and Bromley GP • Dr Miranda Selby, CCG Clinical Lead and Bromley GP • Mary Currie, Interim Director of Transformation, Bromley CCG • Dr Hasib Rub, Clare Ross (GP Alliance)


• Jane Farrell, Paul Donohoe, Matthew Trainer, Dr David Smithard, Dr Wendy Hildick-Smith, Dr

Joble Joseph, Dr Jane Evans, Dr Nike Dare, Jill Solly, Janet Edmonds, Dr Ian Webb, Dr Mohamad Albarjas, Dr Madalina Garbi, Paran Govender, Janet Edmonds (PRUH)

• Amanda Mayo, Tracy Stocker, Fiona Christie, Andrew Hardman, Jacui Scott, Janet Ettridge (BHC)

• Estelle Frost, Helen Jones, Adrian Dorney (Oxleas) • Lorna Blackwood, Tricia Wennell, Ade Adetosoye (LBB) • Penny Hansford, Dr Rob George, Dr Caroline Nicholson (St Christopher’s) • Colin Maclean (Community Links Bromley) • Maureen Falloon, Mark Ellison (Age UK Greenwich & Bromley)

COMMITTEE INVOLVEMENT: Proactive Care is operationally managed by the Provider Joint Operating Group which reports to the ICN Board via the ICN Steering Committee. The development of the Frailty Pathway has involved weekly Frailty Clinical Interface Group meetings which include representatives from KCH, the CCG, Oxleas, BTSE, the GP Alliance, St Christopher’s, Bromley Healthcare and LBB. These meetings are now fortnightly to complete the rest of the pathway following the opening of the beds. The Frailty Clinical Interface Group, Beds Working Group and Programme Group were stood down in early April following the opening of the new Wards. A new Frailty Steering Group may be required to deliver the remaining elements of the pathway. ICNs will be part of the Alliance Agreement governance structure going forward, see below:


PUBLIC AND USER INVOLVEMENT:

Patient Advisory Group (“PAG”) members participated in a Frailty Workshop held at The Warren on 9 May 2016 where they had the opportunity to contribute to the initial thinking around the Frailty Pathway. In August 2016, a written update was provided to the PAG members to advise them of the ongoing work in developing a Frailty Pathway that is linked to the ICN model of care, and that helps to support the frail elderly population of Bromley in a more integrated and coordinated way, both in and out of hospital. A Patient Frailty Focus Group was held on 28 November 2016 and was attended by PAG and Healthwatch members. The purpose of this session was to discuss and test key aspects of the new Frailty Pathway to ensure the patient voice has been considered in the frailty pathway and that it is fit for purpose. Following the opening of the beds on the Orpington site, King’s held a Public Information event at Bromley Baptist church earlier this month, which was attended by more than 50 patients, carers and members of the public. Patients that are members of the Bromley Heart Support Programme were surveyed as part of the Heart Failure service review.


MANAGEMENT OF CONFLICTS OF INTEREST None identified. OUTCOME OF IMPACT ASSESSMENTS COMPLETED: Impact assessment previously completed for ICNs RECOMMENDATIONS: The Committee (s) is asked to note the content of the paper for information. ACRONYMS

• ACS: Accountable Care System • AFN: Acute Frailty Network • BHC: Bromley Healthcare • BTSE: Bromley Third Sector Enterprise • ICN: Integrated Care Networks • HIN: Health Innovation Network • JOG: Joint Operating Group • KCH: Kings College Hospital NHS Foundation Trust • LBB: London Borough of Bromley • MCP: Multispecialty Community Provider • OPAL: Older Person’s Assessment & Liaison Team • PAG: Patient Advisory Group • PRUH: Princess Royal University Hospital

DIRECTOR CONTACT: Name: Mary Currie Post: Interim Director of Transformation E-Mail: [email protected] Telephone: 07834 171387

AUTHOR CONTACT: Name: Daniel Knight Post: Interim Project Manager E-Mail: [email protected] Telephone: 07789553100

CLINICAL LEAD: Dr Ruchira Paranjape, Principal Clinical Lead

Appendices available electronically Appendix A - Health Innovation Network formative evaluation of the ICN Proactive Care Pathway Appendix B – Bromley Alliance Agreement for Virtual MCPs (replacing the Memorandum of Understanding)


https://www.acutefrailtynetwork.org.uk/

https://healthinnovationnetwork.com/

Evaluation of Integrated Care Networks in Bromley: Final Report

25th September 2017

Prepared by the Health Innovation Network

for Bromley Clinical Commissioning Group

Written by: Donna Boreham-Downey, Programme Manager Zoe Lelliott, Director of Strategy and Performance Polly Sinclair, Project Manager Quality Assurance by: Dr Ros Blackwood, Innovation Fellow & Professor Michael Hurley, Clinical Director

www.healthinnovationnetwork.com

@HINSouthLondon


25 September 2017 Page 2

Contents

Contents .................................................................................................................................................. 2

1: Executive Summary .............................................................................................................................. 3

2: Introduction ......................................................................................................................................... 6

3: Background and Context ....................................................................................................................... 7

4: Methodology ....................................................................................................................................... 9

4.1 Data Collection ............................................................................................................................................ 9

4.2 Sampling and Response ............................................................................................................................ 11

4.3 Analysis of data ......................................................................................................................................... 14

4.4 Methodology - Strengths and limitations ................................................................................................. 16

5. Findings ............................................................................................................................................. 18

5.1 Evaluation Objectives ................................................................................................................................ 18

5.2 Evaluation Objective One - Are the ICNs Effective in Terms of Delivering Their Objective? .................... 18

5.3 Evaluation Objective Two - What is the Impact of the ICNs on their Stakeholders? ................................ 34

5.4 Discussion of findings – evaluation objectives one & two ........................................................................ 39

6: Recommendations for Further Evaluation ........................................................................................... 41

6.1 Third evaluation objective ........................................................................................................................ 41

6.2 Fourth evaluation objective - note the critical success factors that would support spread and adoption of the Bromley ICN model, to other localities. ............................................................................................... 43

7: Considerations for Improvement & Recommendations ........................................................................ 44

7.1 Summary of considerations for improvement: ......................................................................................... 44

7.2 Recommendations & next steps ............................................................................................................... 45

Glossary ................................................................................................................................................. 46



1: Executive Summary

Overview

In Summer 2016 Bromley CCG commissioned the Health Innovation Network (HIN) to conduct an independent evaluation of the impact of its three Integrated Care Networks (ICNs), focusing on the proactive care pathway , which includes the community en of the frailty pathway (the pathways), which are key elements of the Borough’s Out of Hospital Strategy. Implementation of these pathways begun in October 2016, with the overarching objective:

“To identify and work directly with the biggest users of NHS services, to deliver better health outcomes and have a measurable impact on reducing avoidable hospital attendances and

admissions”.

Bromley CCG has made considerable investment in the Out of Hospital Care Transformation Programme, and the commitment of local provider organisations to achieve joined up care has been demonstrated through a signed Memorandum of Understanding (MoU). All partners and stakeholders, including patient representatives, have been fully involved in the development and design of the pathways. Keen to understand the impact of this investment and their local transformation work, Bromley CCG commissioned the Health Innovation Network (HIN) to conduct an independent formative evaluation, to determine:

The effectiveness of the ICN model (specifically proactive care , which includes the community end of the new frailty pathway)

The impact of the ICN model on stakeholders (patients and healthcare professionals) It was important to the CCG, and to the Joint Operational Group overseeing the implementation, that the evaluation was conducted relatively rapidly after the implementation begun, so that the findings could be used to inform the continued implementation process and the on-going development of the pathways, to ensure optimal impact. Therefore, the HIN were also asked to make recommendations for a longer-term, summative evaluation, to be completed once the new pathways have been fully embedded in routine practice. The evaluation used a mixed-methods approach, which was developed by the HIN in partnership with colleagues from the evaluation sub-group. This included 3 main elements:

Qualitative interviews with stakeholders (professionals involved in the new pathways and patients and carers)

Use of an on-line survey to seek views from a wider group of involved professionals

Review of healthcare performance metrics, as included in the MoU.

A baseline position was ascertained prior to implementation (which begun in October 2016) and comparative analysis was conducted from April 2017 (6 months after implementation began). Qualitative data was collected through in-depth interviews with patients and professionals conducted by the HIN, and quantitative data was collected through the use of stakeholder surveys. As some data is not available at the time of this report it has not been possible to conduct an analysis of related metrics/KPIs. So, rather than a comparative analysis of Quarter Four 2015/2016 with Quarter Four 2016/2017, the CCG will carry out a comparison between Quarter Two 2016/2017 an Quarter Two 2017/2018.



The HIN evaluation project team has been supported in quality assurance for the evaluation by academics from St George’s University Hospitals NHSFT and King’s College Hospital NHSFT. Feedback has been provided to the Evaluation Sub-group throughout the evaluation, and an interim report completed in July 2017. This has ensured that emerging findings have been fed back to Bromley CCG in a timely fashion, to inform the on-going implementation.

Key findings of the evaluation:

1. At the time of writing the report, the ICNs and care pathways are still to be fully implemented and embedded in routine practice. Quantitative data indicates that around half of participants see that delivery of care has already improved in terms of being more integrated or joined up. Additionally, in a small number of cases there is evidence that they are having a really positive impact on patients and carers and the model is giving confidence to professionals. 1.1. The small number of patients and their families / carers who were interviewed reported a

very positive experience, with one carer saying that “my life, and that of my mother, has been transformed”

1.2. Professionals directly involved in the operational delivery also report that the ICNs and new pathways are having a positive impact on patient care, and are improving communication, understanding, and relationships between partner organisations

2. At the time of this report, referrals are below target numbers, and there are some issues with the quality and completeness of referrals, and their appropriateness. Concerns were expressed that workload may be an issue once referrals have increased to expected numbers and MDTs are all full capacity, and that this could be a challenge for both the organisation of the MDTs and also for individual professionals involved. Given that the impact on jobs was reported in the survey results was either “no change” or a “detrimental effect” the issue of workload will need to be carefully monitored.

3. Despite concerns raised pre-implementation over how the MDTs would operate and the time these discussions would take, the experience of those taking part appears to have been largely positive. Going forward it will be important to both resolve any administrative inefficiencies (e.g. with remote access facilities) as well as to communicate the key benefits of the MDT model (e.g. there was most value-added for complex patients) in order to maximise engagement, particularly of GPs. Within the MDTs and pathways, the role of the community matron was recognized as pivotal to success.

4. When it has been possible to obtain input from social care into the MDT process this has been

seen as enormously valuable. The absence of social care from the MoU, and also the very limited ‘on the ground’ engagement with the new pathways has been raised many times by professionals as a key issue throughout the evaluation. Many professionals stated that their consistent presence would add significant value, and that with them involved “the MDT would be a truly one-stop shop for patients”.

5. A significant effort has been made by Bromley CCG to involve patients and citizens in the design

and planning of the ICNs and care pathways, resulting in high level of engagement. This is likely to be a critical factor contributing to their success.



6. The care navigator role has been important in highlighting the value and breadth of third sector

services for patients, with a number of GPs stating that they were previously unaware of the extent of services. However, to maximise the impact and benefits it will be necessary to address perceived problems, such as data-sharing, and co-location of the care navigators with the wider multi-professional team.

7. Although too early to comment on the quantifiable health outcomes for patients, there are

already examples: patient case studies (see appendix E) & patient comments which indicate the potential for the new pathways to make a significant impact. This is supported by a small percentage of professionals who indicate a “radical change” has been made as a result.

Conclusion and recommendations:

Overall, this early evaluation indicates that a positive start has been made with the implementation of the ICNs and care pathways, with some initial signs that there is potential for a significant positive impact on health outcomes for a complex and vulnerable group of patients in Bromley. We recommend that action continues to be taken to tackle the operational issues apparent in the early implementation process, and wider communications and engagement takes place to support a comprehensive, borough-wide implementation of the new delivery models. We also encourage Bromley partners to invest in a more rigorous, summative evaluation in the future, with associated economic analysis. This will demonstrate whether or not the impressive patient stories are associated with measurable reductions in healthcare utilisation and consequent cost reductions, providing payback on the initial investment. Other health economies would be seeking this greater level of evidence if considering investment in a similar model, and the summative evaluation could also serve to tease out the critical success factors of the Bromley experience.



2: Introduction

Integrated Care Networks (ICNs) are a key element of the Bromley Out of Hospital Transformation Strategy (2015), which includes amongst its aims the provision of coordinated care via better integrated services, to reduce avoidable time spent in hospital for a complex and vulnerable set of patients. The Bromley Clinical Commissioning Group (BCCG) commissioned the Health Innovation Network (HIN) in Summer 2016 to complete an independent evaluation of the implementation of the three ICNs, which have been established across the population of the borough of Bromley. The following objectives of the evaluation were agreed:

1. To provide an understanding of how effectively the ICN model is delivering against the stated objectives

2. To demonstrate the impact of the model on key stakeholders 3. To make recommendations for further evaluation as the implementation progresses 4. To note the critical success factors that would support spread and adoption of the model

Representatives of the HIN (both programme managers and academic staff) and a Bromley CCG ICN Evaluation Subgroup worked closely to agree the evaluation approach and methodological framework, and to develop the data collection tools. This Evaluation of Integrated Care Networks in Bromley: Final Report, August 2017 (final report) presents the final findings of the evaluation, and follows the Evaluation of the Integrated Care Network Model in Bromley: Interim Report – Baseline an Emerging Findings, January 2017) or baseline report and Evaluation of the Integrated Care Network Model in Bromley: Interim Report – Stage 2: Emerging Findings and Areas for Consideration and Improvement, July 2017) or emerging findings report.



3: Background and Context

The health and care economy within Bromley borough has a number of significant challenges, including a population that is predicted to continue to grow (by 7.28%) over the next ten years. The 2011 census revealed that when compared against other London boroughs, Bromley had the second highest percentage (16.8%) of residents aged 65 years and over, a percentage that is expected to continue to increase. The London Borough of Bromley (LBB) and Bromley Clinical Commissioning Group (BCCG) recognised that unless significant changes were made to the way in which they delivered health and care services, there would be a substantial gap between the demand for those services and the ability to meet this demand. These challenges are not unique to Bromley, and have been reflected in a number of national policy documents, including the NHS Five Year Forward View (2014), which identified national ‘gaps’ in:

Health and wellbeing

Care and quality

Productivity and efficiency

It states that only transformation in the way health and care operates, rather than incremental change, will make it possible to bridge these gaps. The transformation of out of hospital care, with a focus on a more proactive approach to patient management, is a central theme of the joint BCCG and LBB Out of Hospital (OOH) Strategy, (September 2015). The Out of Hospital Transformation Programme has an overarching aim to provide patients with care that is better co-ordinated, reduces the complexity of their ‘journey’ through services, and most importantly is responsive to individual needs. The ambition is to identify and work directly with the biggest users of NHS services, to deliver better health outcomes and have a measurable impact on reducing avoidable hospital attendances and admissions”.

This programme therefore seeks to tackle the care and quality gap, and by doing so to improve productivity and efficiency, through a reduction in unplanned and avoidable care utilisation. Out of hospital care, or “Community Based Care” is also a central pillar of the South East London Sustainability and Transformation Partnership’s (STP) work programme, to which Bromley contributes. In April 2016, local health and third sector (voluntary and community) organisations in Bromley signed up to a formal Memorandum of Understanding (MoU) setting out their plan to work together to improve the integration of care for patient benefit, through delivery of the Out of Hospital Transformation Programme. Signatories include Bromley CCG, Bromley GP Alliance, Bromley Healthcare, Bromley Third Sector Enterprise, King’s College Hospital NHS Foundation Trust, Oxleas NHS Foundation Trust, and St Christopher’s Hospice (Bromley). Central to the transformation programme are the three Integrated Care Networks (ICNs), which have been established in Bromley, Orpington and Beckenham, and together cover the borough’s whole population. The ICNs are virtual hubs, each bringing together around 15 GP practices and a range of other health and care services, supported by a centralised and dedicated integrated case management team (ICMT). The ICNs support the delivery of the new care pathways for “Proactive Care” and “the community end of the NEW Frailty” (“the pathways”), which were designed in consultation with patient



representatives, and are key elements of the transformation programme. They aim to identify ‘at-risk’ or ‘high-risk’ patients (i.e. at risk of tipping into crisis and requiring urgent intervention) who are significant service users and/or frequent users of a range of services (e.g. A&E and hospital admissions). Diagrams setting out these pathways can be found in Appendix B of this report. In order to ensure uptake and success of these new pathways, GPs have been incentivised to identify and refer eligible patients using a single point of entry form. The patients are then assessed at home by a Community Matron, before being reviewed at a MDT meeting. Following the MDT discussion an integrated care and support plan is agreed. These plans set out the agreed actions, which may be a range of tasks by multiple professionals and organisations. The plan can then be enacted without the need to raise further referrals. It is worth noting that Bromley CCG is continuing to develop and enhance out of hospital services, building on the ICN model. For example, they fund the Connect Well Bromley project, which is provided by Community Links Bromley (CLB) the CVS (Council for Voluntary Service) and Volunteer Centre for the London Borough of Bromley. CLB are developing a database of non-medical services and activities provided by Bromley voluntary and community groups. Once registered referrers scan the services available and then complete a ‘social prescription’ for the patient, which is emailed directly to the selected service provider/s who then contact the patient directly. The pilot phase of the project started April 2017 with a focus on services for older people, the elderly frail and their carers. In recognition of their joint work to provide proactive and joined-up care for the most vulnerable residents, Bromley Health Services were nominated as finalists in the National Healthcare Transformation Awards.



4: Methodology

4.1 Data Collection

This evaluation used a formative evaluation (or “evaluation for improvement”) approach, with a blend of quantitative and qualitative methods. There was a two-phase, comparative approach to data collection:

Phase One: a baseline analysis undertaken in October to November 2016 to understand what joined-up care looked like to stakeholders prior to the implementation of the ICNs, the MDT meetings and the pathways; and

Phase Two: a comparative analysis undertaken in April to June 2017, following the initial implementation of the ICNs, pathways and multidisciplinary team meetings;

The purpose of both phases was to determine whether the ICNs were meeting their primary objectives, and to assess stakeholders’ views on their impact.

Figure 1: Timescales & resource utilisation



The key elements of the formative evaluation approach were as follows in Table 2:

Table 2: Summary of Evaluation Methodology

The overall evaluation approach was co-designed in partnership between the HIN and colleagues from Bromley CCG. The interview guides and self-completion survey were also developed by the HIN in close collaboration with the ICN Evaluation Subgroup, and were designed to explore the elements of the ICNs and the pathways which were contributing to the overarching objectives, and could have the potential to be critical success factors. Full copies of the interview guides and surveys can be found in Appendix C of this report.

Method category Stakeholder Group Methods used Stakeholders involved

Phase One: Baseline or Pre-implementation

Qualitative Professionals In-depth interviews ICN Task and Finish Group GPs Community Matrons

Patients Workshop

Focus groups

Patient Advisory Group (PAG)

Quantitative N/A MoU Metrics Q4 2015-16 n/a

Professionals Stakeholder self-completion survey

Health and social care professionals working in Bromley

Patients Patient Survey Wider patient population

Phase Two: Post Implementation

Qualitative Professionals In-depth interviews ICN Joint Operational

Group Professionals directly

involved in delivery of the proactive care pathway and/or the community aspect of the frailty pathway

Patients In-depth interviews Patients managed through the proactive care pathway and/or the community aspect of the frailty pathway

Quantitative N/A MoU Metrics Q4 2016-17 n/a

Professionals Stakeholder self-completion survey

Health and social care professionals working in Bromley



4.2 Sampling and Response

The ICN Evaluation Sub-group members were instrumental in selection of participants for the in-depth qualitative interviews, and they also led on the distribution of the quantitative survey across the partner organisations involved. During Phase One (baseline) there were 12 in-depth qualitative interviews conducted, and 82 responses were received in the on-line survey. In Phase Two (post-implementation) 23 in-depth interviews were carried out, and 68 people responded to the survey. A detailed breakdown of the participants is included in the table below.

Table 3: Participants Involved in Data Collection

Qualitative In-Depth Interviews with Professionals

Phase One: Pre-Implementation Phase Two: Post-Implementation

The following people were interviewed:

Eight members of the ICN Task and Finish Group, which included at least one representative from each of the seven MOU signee organisations

Two Bromley Healthcare Community matrons, selected on the basis of their availability and willingness to participate

Two Bromley GPs by ‘on the spot’ interviews when approached at the launch of the ICN referral incentive scheme

The following people were interviewed:

Seven members of the ICN Joint Operational Group (which replaced the ICN Task and Finish Group), which equated to one representative from each of the seven MOU signee organisations

Twelve ‘ICN involved professionals’, this included: the GP Chair, MDT Liaison Coordinator, MDT Care Navigator and a Community Matron, of each of the three ICNs

Two GPs who had referred patients to ICNs Two ICN Gerontologists (only two of the

three ICN Gerontology posts are occupied)

Qualitative In-Depth Interviews with Patients


Seven Bromley Patient Advisory Group (BPAG) members with (or caring for someone with) a long-term condition attended a focus group in Jan 2016, which informed the development of care pathways

12 BPAG members attended a workshop (17th May 2016) to consider and provide feedback on the ICN model

The following people were interviewed (one through a home visit and the others by telephone):

Five patients* receiving care through an ICN pathway

Carers (family members) of three patients* receiving care through an ICN pathway

*Patients selected were those who had been reviewed at an MDT within the last six weeks



Quantitative – Self-Completion Survey with Professionals


82 professionals working within health and social care responded to a self-completion survey, distributed electronically by members of the ICN Board using internal email distribution lists (elicited 80 responses) or as a paper copy handed out at professional event (elicited 2 responses)

While the survey was anonymous, participants were asked to provide information on the organisation they worked for and their occupational group – this full profile can be found in Figures 2&3 below

68 professionals working within healthcare (78%), social care (20%) and ‘other’ organisations responded to a self-completion survey, distributed electronically as per phase one

While the survey was anonymous,

participants were asked to provide information on the: organisation they worked for and their occupational group – this full profile can be found in Figures 2&3 below

Quantitative – Self-Completion Survey with Patients Phase One: Pre-Implementation Phase Two: Post-Implementation

129 patients completed a survey launched on the 4th May 2016, to collect views from Bromley residents on their experiences of healthcare

N/A

Quantitative – Metrics from Memorandum of Understanding Phase One: Pre-Implementation Phase Two: Post-Implementation

Quarter 4 2015/2016 (January-March) performance against activity data and metrics agreed by all partners as part of the MoU

Quarter 4 2016/2017 (January-March) performance against activity data and metrics agreed by all partners as part of the MoU *the original methodology design included a

comparative Quarter Four analysis. However, Bromley CCG have decided to compare Quarter Two 2016/2017 (just prior to implementation) with Quarter Two 2017/2018 – therefore the metrics & analysis do not appear in this report

Survey respondents - by organisation and occupational group:

Of note is that in Phase Two more (27) responses were received from those in Bromley GP practices compared to the 11 received in Phase One. Equally, in Phase Two far fewer (1) were received from those working for King’s College NHSFT in comparison with the 13 received in Phase One. While in Phase One there were 11 responses from those in administration roles, none were received in Phase Two. It is unfortunate that the response rate from the voluntary sector was low in both phases, with one response in Phase One and none in Phase Two. Please note that some respondents work for more than one organisation and / or hold more than one role.



Figure 2: Survey respondents by organisation (Phases One and Two)

Figure 3: Survey respondents by occupational group (Phases One and Two)

2

0

1

1

4

11

14

15

27

2

1

7

13

1

10

18

16

11

Other

Voluntary sector organisation

St Christopher's Hospice

King's College Hospital NHS Foundation Trust

Bromley GP Allliance

Oxleas NHS Foundation Trust

Bromley Healthcare

London Borough of Bromley

Bromley GP Practice

Number of survey responses by organisation

Phase 1 Phase 2

2

3

3

7

11

13

29

4

1

11

2

8

6

7

16

10

17

No response

Voluntary

Admin

Commissioning

Nursing or Healthcare Assistants

Operational Management

Allied Health Professionals/ Healthcare Scientists/ Scientificand Technical

Registered Nurses and Midwives

Social Care

Medical and Dental

Number of survey responses by occupational group

Phase 1 Phase 2



4.3 Analysis of data

Qualitative data:

As detailed in table 3, in both phases of the evaluation qualitative data has been collected though in-depth interviews, either face-to-face or by telephone – see appendix C for copies of the interview guides. Participants included:

Professionals: members of the strategic group responsible for the development and monitoring of the ICN model and pathways: Task and Finish Group, which became the Joint Operational Group; those either providing care for patients and their families and/or directly involved in the ICNs; and

Patient representatives and patients & their families In each of the interviews one of the interviewers led the interview and a second took notes. These notes were analysed by thematic analysis, analysing pre-implementation and post-implementation findings by separate groups. Key themes and emerging patterns were identified during the analysis. In addition, focus groups and workshops with patient representatives had been held by Bromley CCG in order to obtain their views and input. The analysis was completed by Bromley CCG and shared with the HIN to inform the baseline assessment.

Quantitative data – surveys:

As set out in table 3, in both phases of the evaluation quantitative data has been collected through self-completion surveys. These included:

A self-completion survey to capture Bromley residents’ experiences of health care

Two self-completion surveys to capture the views of those working in Bromley health and social care and the voluntary sector on joined-up or integrated care both pre ICN implementation and then post ICN implementation – copies of the surveys can be found in the appendix C

In both surveys respondents were asked a range of questions and asked to choose from four or five possible answers the response which best represented their views. For each question, the percentage of participants choosing each of the various response options for each question was calculated. Analysis of all survey respondents by organisation and job type was undertaken for each phase of the evaluation.

Quantitative data – metrics:

Bromley CCG is monitoring a number of metrics, in order to understand whether the ICNs are achieving their objectives. Some of these are routine performance data, e.g. A&E attendances and re-admissions, and some have been developed specifically to monitor the ICNs (additional outcome measures). Furthermore, a number of the agreed KPIs are also linked to a Performance Fund for providers. The full list of all metrics can be found in appendix D.



The baseline report included a table providing the list of metrics and for each metric, their target and actual position at the end of Quarter Four 2015/2016 (pre ICN implementation). This first report stated that this final report, would provide a comparison between the Quarter Four 2015/2016 metrics and the Quarter Four of 2016/2017 (post ICN implementation). However, due to the unavailability of some of the core data at the time of this report, Bromley CCG are now proposing to conduct a comparative analysis once Quarter Two 2017/2018 data is available, and compare that with Quarter Two 2016/2017. It should be noted that the metrics used to support monitoring the effectiveness of the ICN Programme may change over time as new elements of the system come on line.



4.4 Methodology - Strengths and limitations

Strengths of the evaluation methodology

Particular strengths of the methodology used in the evaluation include:

Collaborative approach /co-design: The evaluation methodology and tools were developed through extensive consultation and collaborative work between the Bromley CCG and the external evaluator HIN. Together they identified important elements of the ICNs and care pathways that were contributing to the delivery of the overarching objectives.

Responsiveness to patients and their families: The evaluation allowed an approach which supported and enabled patients and their families to feel comfortable in sharing their experiences by ‘telling their story’.

Representativeness: Whilst it was not possible to be fully representative of the population involved in the proactive care pathway (see limitations below) care was taken to involve a full range of professionals involved in delivering the pathways across all three networks. Whilst there was some selection bias in terms of GP referrers who participated in the qualitative interviews, there was a good response from GPs to the survey, which enabled capture of a wider range of views from this important stakeholder group.

Mixed methods approach: By using a range of quantitative and qualitative methods to evaluate the pathways we ensured that key stakeholders were able to input into the evaluation in the most appropriate and convenient way, using either a survey or depth interview. Analysing the feedback across the full range of methods including the stakeholder survey, progress against MoU metrics, in-depth interviews and patient interviews gives a rich evidence base through both detailed exploration of specific issues in in-depth interviews, and also greater rigour through a larger sample size and the anonymity of a survey approach. This enabled more robust conclusions regarding the effectiveness of the pathways to be drawn.

Limitations of the evaluation

Whilst the evaluation of the new models of care, of which the integrated care networks and proactive care pathway are important elements, has been as thorough and rigorous as was possible, important limitations need to be taken into consideration when deliberating the findings.

Implementation of the ICNs, specifically the proactive care pathway and MDTs, began in October 2016 and this evaluation began soon afterward and completed approximately 9 months later. Such early evaluations have a number of consequences:

Limited recruitment populations: Selection bias is frequently an issue for qualitative evaluations. Ideally, we would have recruited a representative sample of patients and GP referrers from a larger pool of GPs who had made several referrals, and patients that had experience of the ICNs. However, at the time of the evaluation the ICNs and care pathways had not been implemented fully across the whole of Bromley borough, so not all GP practices were as yet referring patients, and the numbers of patients experiencing the new ways of working was still limited. Consequently, the number of people we could approach to participate in the evaluation was limited (given we required the participants to have experience of the new pathways), hence we could only investigate the views and opinions of a relatively small number of professionals and patients.



This increases the chances of recruiting people with biased views and opinions, particularly amongst GP referrers where GPs that had made the most referrals (and therefore were more likely to see the ICNs as being beneficial) were invited to take part in qualitative interviews.

Early adopter bias: People who are the first to implement an innovation, “early adopters”, tend to be enthusiasts, eager for change and have often been involved in initiating and designing new innovations. They often reflect positive opinions about the impact of an innovation. These initial findings may inflate the true benefits, and underestimate the difficulties of the new models of care. “Late adopters” are likely to be less enthusiastic, more critical of an innovation and may require more convincing and incentivising about the need for and benefits of changes. Their opinions may be less positive. It may also take greater effort to convince them to adopt new models of care. However, communicating the enthusiastic, positive experiences and learning from of the early evaluation may encourage them to try something new.

Limited implementation: At the time of the evaluation, the ICNs and new care pathways were not fully embedded as routine practice across the health and social care systems. People were still getting used to new ways of working. As it matures and becomes the norm the new pathways may become more popular, and their efficient application may increase. Alternatively, prolonged use, even by enthusiastic “early adopters”, and enforced implementation by less enthusiastic, critical “late adopters” may expose deficiencies in the ICNs and pathways that are not apparent in the early stages of implementation.

Sustainability: At this stage, it is not possible to determine sustainability of the new model of care

Resource constraints: Implementation of the ICNs and care pathways represents a significant change to the service delivery model for complex services involving professionals and patients/population in Bromley. The financially constrained environment has meant that only a limited budget was available to evaluate the new model of care. This puts limits on the depth and breadth of the evaluation that could be delivered.

Evaluator independence: Although HIN is an independent organisation, and an Academic Health Science Network, it is also a membership organisation, of which Bromley CCG and many of the provider organisations involved are members. Therefore, the HIN could be viewed as not completely independent, having a vested interest in the success of its members. While the close collaboration between the two lead project managers and members of the ICN Evaluation Sub-group on co-design of the evaluation can be seen as a strength, it could also be seen as causing a potential loss of objectivity.

Quantitative analysis: As indicated above, the decision to now use Quarter Two comparative data (ie. 2016/17 vs 2017/18) means that we are now unable to include analysis of MoU performance metrics in this report.

Mindful of these limitations, this evaluation has produced a snapshot of the early impact of the ICNs and pathways. Early findings from the evaluation have already been provided in the emerging findings report (July 2017), and have been used by Bromley CCG to inform the further implementation of the new models of care. However, an adequately funded, robust evaluation when the new models of care have become embedded as routine, (possibly two years after initial implementation in October 2018) would be required to determine more rigorously the full impact of the new models of care.



5. Findings

5.1 Evaluation Objectives

This section of the report presents findings for the first two evaluation objectives:

1. Provide an understanding of how effectively the ICN model is delivering against the objectives (see figure 4 below) – measured by both qualitative and quantitative data; and

2. Demonstrate the impact of the model on the ICNs’ stakeholders – measured through interviews and survey as described in Section 4.

5.2 Evaluation Objective One - Are the ICNs Effective in Terms of Delivering Their Objective?

The overarching objective of the ICNs and pathways is to identify and work directly with the biggest users of NHS services, to deliver better health outcomes and have a measurable impact on reducing avoidable hospital attendances and admissions.

Figure 4: Aims of the ICNs and pathways

The follow sections reports how the ICN is meeting each of its aims as listed in the framework (figure 4 above) and the impacts.



Pre-implementation of the ICNs and pathways most (54%) survey respondents found integration of care across Bromley services to be either ‘poor’ or ‘very poor’ and although it was acknowledged that examples of joined-up care existed, the consensus amongst all stakeholders was that more could be done and ICNs were viewed as a positive step in this direction.

Post-implementation of the ICNs and pathways around half (48%) of survey respondents said that the “integration of patient care across services, including: GPs, hospitals, mental health care, community services, social care and the voluntary sector” was either much better (18%) or somewhat better (30%).

Similarly, when asked about “joined-up care provided for the very elderly or frail patient”, 40% of survey respondents said that it was either much better (7%) or somewhat better (33%) with 27% saying it was about the same, see figure 5 below.

Figure 5: Phase Two Survey responses to Question 5

Post-implementation, stakeholders have acknowledged that the ICNs and pathways are relatively new and as would be expected, are continuing to develop and refine. Both those involved in their development and monitoring their progress and those directly involved in their delivery, felt that the framework was in place and were confident that as the learning of those involved continued, so too would their development.

“the ICN approach is great, it could be slicker but we are all learning” and

“on the whole it is working well” Community Matrons

“this is new, we are changing, we are tweaking as we go, if something doesn’t work we change it” and

“left hand is speaking to the right hand, it’s a more joined-up way of working” and

“stopping people who had previously slipped through the net by being holistic – medical and non-medical”

MDT Liaison Coordinators

“ICNs are the most effective vehicle or service available to GPs”

MDT GP Chair

7%

18%

11%

12%

33%

30%

29%

19%

27%

25%

30%

27%

1%

0%

2%

3%

0%

1%

2%

1%

31%

25%

27%

37%

..."joined up" care provided for the very elderly or frailpatient?

...integration of patient care across services - includingGPs, hospitals, mental health care, community…

...systems and processes that allow and support theholistic assessment of patients at the start of and…

...systems and processes that help patients navigate theirway through and find/contact available services?

Thinking about patient care, how would you rate...

Much better Somewhat better About the same Somewhat worse Much worse I don't know



“CNs / pathways are finding the ‘hidden patients’, those with complex co-morbidity who are difficult to treat and the MDT (and care plan) is the only way to manage these patients”

MDT Geriatrician

Each ICN currently includes 15 general practices within its boundaries. As the ICNs are still in their infancy, not all GPs are currently referring into the ICNs. Concerns were raised by stakeholders regarding how the ICNs would manage with workload once they were running at full capacity.

Summary of the right geography:

ICNs are in an early stage of their development, and while there are improvements to be made there is confidence indicated by the stakeholders that the necessary framework is in place and that they will continue to mature. Importantly, the ICNs are already having an impact on the integration of care and support received by patients and their families, who report a very positive experience and in some instances ‘life changing’ improvements.



Pre-implementation stakeholders felt that it was important that all professionals involved in the delivery of the new model, including GPs who would be referring, were ‘on board’ with and understood the benefits and requirements of the new model. The ICN Task and Finish Group acknowledged the importance of the role of GPs in identifying the patients that are most likely to benefit from a multi-disciplinary, proactive approach to managing their care.

Post-implementation the number of referrals received from GPs has been lower than planned but numbers are increasing. In terms of the patient identification aspect of the pathways, almost equal numbers of survey respondents felt that this was working well (12%) or that it required improvement (13%). Concerns were raised about GPs not always referring the ‘right’ patients, those who would be most likely to benefit from review and management by the multidisciplinary team. Contributing factors were thought to include: GPs lacking an understanding of ICNs, the pathways & MDT meetings and an unintended impact of the GP incentive scheme.

“there are some problems with patient identification by GPs, they don’t understand the process” MDT GP Chair

“there is a lack of clarity (for those referring) re: identification of ‘right’ patients” JOG member

“sometimes the community matron goes to assess the patient and finds that they are not appropriate”

Community Matron

“we get some inappropriate referrals, probably coming from pressure from the CCG. If the number (required under the incentive scheme) was cut they would reduce”

MDT GP Chair

To refer a patient the GP is required to complete a designated single point of entry form and stakeholders reported that the form was not always completed and the information that was provided was often brief and not always clear.

“information from GPs does not always provide clear information about why the patient has been referred”

and

“due to the quality of the referral, sometimes I’m not sure what the GP expects me to do” and

“the quality of the information received within the referral is not always high or complete” – Community Matrons

“GPs are supposed to complete a single point of entry form but sometimes they just put “for MDT discussion” MDT GP Chair

GPs responding to the survey spoke of how they struggled to make and find the time to refer patients (and participate in the MDT meetings), although some, but not all acknowledged that there were benefits to being involved.

“Takes up 20 minutes per patient discussed displacing other work until after evening surgery”, “finding time for meetings is a challenge, if you refer four a month that is two hours of precious time I do not have” and “it is extra work to refer in but then most further referrals are done by

other members of the team so it probably balances out in the end”

GP Survey respondents



GPs who have referred patients raised issues with the management of referrals saying that opportunities to ensure the best outcomes for patients may have been lost due to the time between a referral being made and the patient being reviewed.

“there have been instances of a patient being referred and assessed but then admitted to hospital before review”, “there needs to be as shorter possible time between referral and review at MDT”

and “not all GPs understand what the ICNs and MDTs offer and their possible impact” GP Referrers

Pre-implementation, stakeholders identified ‘difficulties with accessing mental health services for patients’ as an issue.

Post-implementation some stakeholders think that GPs might knowingly be referring patients who don’t fit the pathway criteria, particularly those with mental health issues.

It is presumed that this is in the knowledge that in contrast to referrals to other services, a referral via the pathways would result in their patient receiving early assessment and management. Turn-around targets require Community Matrons to assess patients within five working days of the receipt of referral. “we are not in a position to refuse referrals whether we think it’s appropriate or not, which can be

challenging” and

“they know we don’t refuse referrals and that we turn them around quickly (5 days) unlike other services”

Community Matrons

“suspect there is some game-playing going on, patient referred not always appropriate, need robust process around this”

GP Referrer

Summary of the right people:

Bromley GPs are responding to incentives and referring patients via the single point of entry form, although the number of referrals to date has been less than planned. Further work is required to improve the quality of referrals submitted, to reduce the number of inappropriate referrals and improve the management of referrals once submitted. It is recognised that in some instances, GPs may be knowingly submitting inappropriate referrals in response to pressures on other services, particularly mental health.



Pre-implementation stakeholders raised concerns about how MDT meetings would be run. They felt they would need to be tightly managed in order to be effective, that ‘getting the logistics right’ could prove a challenge and they were unsure how decisions would be reached, particularly where there were multiple opinions regarding the best way of managing patient care.

In addition, clinical staff were worried that the meetings would mean an increased amount of time travelling across the borough.

Post-implementation, stakeholders are largely positive about the MDT and MDT meetings, describing the environment as positive and supportive and allowing communication and relationships between members to develop and strengthen.

“they are working well, very good rapport within the MDT, it is a supportive environment” Community Matron

“brings all service providers together on one platform, don’t get opportunity to speak to these colleagues otherwise”

GP Referrer

“I am passionate about this, MDTs are common in secondary care but in primary care it is a different ball game”

MDT GP Chair

They did however, raise issues with the management and administration of the MDT meetings and some felt that more could be done to improve GP understanding of what MDT meetings can offer in terms of managing their workloads and the potential benefits for their patients.

The issues included: problems with the teleconference technology causing frustration and delays; members of the MDT not always having sufficient notice of, which patients were to be reviewed and as a result not having the time they would like to prepare; striking a better balance between the number of new patients and the number of patient reviews and of patients (and their families) not always being aware that they had been referred or why.

“Administration has improved, not good at beginning” GP referrer

“there have been issues with the technology freezing and some practices unable to connect or dial in” JOG member

“Need to improve informing patients /family that they have been referred and feedback after the meeting” and “Patients don’t always understand why they have been referred’

Community Matrons

“sometimes patients are aware of the service, sometimes not and it can be really challenging explaining it to them”

MDT Liaison Coordinators

“Not always sufficient notice given of which patients being reviewed to allow appropriate level of preparation for presentation”

Community Matron

“the real challenge is to help GPs recognise that is a helpful thing, rather than a burden” MDT Geriatrician



A particular issue is scheduling the MDT meetings in a way that meets the competing requirements of all member professions and organisations, along with finding the ‘right’ slot for those who elect to participate for the discussion of a patient/patients only, rather than the whole meeting.

“Set day and time doesn’t always work for GPs – if clinic overruns or an emergency” GP Referrer

“The MDTs are a pain with poor timing, they are not sufficiently flexible for all doctors to access.” GP Survey respondent

Other comments were that MDT meetings were allowing focused, collaborative and coordinated care of patients with multiple problems and complex conditions in a way that cannot be provided by single GPs or GP practices in the time and with the resources they have available.

“having impact on patients “I think implemented a few things that has meant patients didn’t go to hospital”

Community Matron

“ICNs are having a very positive impact on patients” and “used to have to make 23 different contacts to help one patient, just don’t have the time”

GP referrers

“ensures a more direct, person based care based on their home / personal situation” MDT Geriatrician

“MDTs save GPs time in terms of chasing referrals for example” MDT GP Chair

Of the survey respondents, most (35%) found MDT meetings to be working well (see figure 7 below) although some (24%) felt they required further improvement (see figure 8 below).


32%

16%

12%

25%

26%

34%

35%

I don't know

Other

Patient identification

Review of care and support

Follow through on patient action plan

Holistic assessment

Multi-disciplinary team (MDT) meetings

In your view, what aspects of the proactive and/or frailty care pathways are working well?




Pre-implementation stakeholders saw the lack of shared care plans as a barrier to delivering joined-up care and ‘breaking down’ barriers between organisations and everyone working together for the good of the patient, as key elements of integrated care.

Post-implementation when it came to the impact on patients and their care, stakeholders concurred that multiple partners in the same room (either in person or virtually), particularly those that can be hard to access (such as those from mental health) around the same table, at the same time discussing a patient and agreeing a joint care and support plan was extremely beneficial.

Care plans are making a difference and increasing patient-centric care” JOG member

“MDTs are having an impact on patient care because of involvement of all around the table in the discussion and resultant care plan”

Community Matron

Pre-implementation, 27% of stakeholders found the holistic assessment of patients to be ‘good’ or ‘very good’

Post-implementation when asked about systems and processes that allow and support the holistic assessment of patients at the start of and throughout their care journey most (40%) survey respondents found them to be ‘either much better’ (11%) or ‘somewhat better’ (29%), see figure 9.

Figure 9: Phase Two Survey responses to Question 5b

29%

32%

7%

13%

18%

24%

25%

I don't know

Other

Holistic assessment





In your view, what aspects of the proactive and/or frailty care pathways could be improved?

11% 29% 30% 2% 2% 27%

...systems and processes that allow and support theholistic assessment of patients at the start of and

throughout, their care journey?





Fellow MDT members were extremely positive about the contribution of Community Matrons to MDT meetings and of their assessments.

“our Community Matrons are very thorough and good at what they do”

and

“It’s the Community Matron’s assessment that is pivotal, it is so detailed and current” MDT GP Chairs

“the Community Matron is a god-send”

GP Referrer

“It’s the Community Matron’s assessment that is pivotal, it is so detailed and current”

However, it was suggested there would be value in other MDT members assessing patients either in addition to or with the Community Matron.

“really effective when there is a joint assessment by the Community Matron another” GP Chairs

“perhaps other MDT members could also assess (the patient) before the MDT meeting – for example, if there is a known mental health issue, then Oxleas could see them as well”

Community Matron

Pre-implementation stakeholders delivering care identified time lost to ‘chasing up’ health and social care professionals to establish whether actions had been picked up as a significant issue.

Post implementation, stakeholders acknowledged that both the review of care and support and the follow through on patient action plan were aspects of the MDT meetings that needed some improvement.

“We create a care plan but sometimes things go amiss, it’s more difficult with the more complex patients – we review the care plan about 4-6 weeks after they were presented at MDT and

sometimes action points have not been done”

MDT GP Chair

A quarter (25%) of survey respondents identified the review of care and support as an aspect of the proactive pathway that worked well and slightly less (18%) that it needed improvement. Of interest, a quarter (25%) said that follow through on patient action plan was an aspect that needed improvement an almost equal number (26%) felt it was working well, see figures 7 & 8.

Post-implementation, GPs who had referred patients did not always want to present them at the MDT and it was suggested that while steps should be taken to address this, it did not always need to be the referring GP who did this and it could instead be another GP or practice nurse from the same practice or even the Community Matron who had assessed them.

“Maybe it should be the CM that presents the patient rather than the GP”

GP Referrer

“Need to build confidence and understanding of GP”

JOG Member

“GPs not always confident about presenting patients”

MDT GP Chair



Concerns were also raised regarding the capacity of MDT meetings in the future, once the number of referrals received reaches those planned. It was recognised that this outcome will also allow less time than currently available for each patient review.

“Current MDT ‘load’ allows for in-depth discussion, concern this may not be the case once fully booked”

and

“Concerns around workloads / quality of care that will be available once MDTs fully operational and the planned number of referrals are being receive”

JOG members

While there are concerns that the third MDT Geriatrician role remains vacant, the input of the two posts was viewed very positively.

“Geriatricians are great, really helpful and eminently sensible taking a holistic, pragmatic approach”

GP Referrer

“Gerontologist has attended every MDT and her input is excellent” MDT GP Chair

Summary of the right professionals

There are challenges with some aspects of the administration and management of MDT meetings. However, those involved are positive about what they allow not only in terms of patient care but inter-professional & inter-organisation communication, shared learning and relationship building. The follow through on patient action plans developed and agreed at the MDT meetings along with the review of care and support are elements of the pathways identified as needing improvement.



Pre-implementation stakeholders cited social care having not signed up to the MoU as a significant issue. Stakeholders said that they found social care the most difficult sector with which to engage and felt that their absence weakened the potential success of the ICN model.

Post implementation stakeholders reported that individual social workers have attended a small number of MDT meetings for the review of specific patients but have not yet been able to provide a consistent presence at all MDT meetings. Stakeholders felt that not only would the consistent presence and input of social care be extremely beneficial in terms of contributing to patient review and care but they believed that social care professionals would themselves benefit from being involved.

While stakeholders said they understood why social care professionals were not involved, they were extremely keen that efforts continue to secure their commitment and inclusion.

“MDTs would be a ‘one stop shop’ if social care involved”

JOG member

“a real negative that social services are not at MDTs and they would also benefit from being involved”

MDT Geriatrician

“absence of social care is a real issue, we think we know why they are not involved but we shouldn’t just accept it, we need to continue to ask for what is needed”

GP Referrer

“Would really benefit from social services presence “a lot of the patients we see, there’s a social aspect causing their physical health problems because they don’t look after themselves”

Community Matron

Stakeholders stated a preference for attendance by all members of the MDT at the whole of the meeting, rather than for the review of specific patients or patient groups only and that where possible the participants remain the same person to support team building and continuity.

“periodic attendance at MDTs by some members is an issue – need full participation and engagement”

JOG member

Summary of the right level of commitment:

Those involved in MDT meetings are clear that a consistent presence by social care is sorely missed and are keen that all efforts should continue to secure their regular involvement. In the interest of team building and on the basis that everyone has something valuable and unique to contribute to all patient reviews - MDT members support the same representative/s from each member organisation attending the meetings and all members of the team, attending the whole of the meetings rather than just for the review of a particular patient or patients.



Throughout 2016 Bromley CCG carried out a number of patient and public engagement activities to inform the development of the Integrated Care Networks and pathways. The engagement activities carried out include the following:

Members of Bromley CCG’s Patient Advisory Group (PAG) who had a long-term condition or cared for someone who did were invited to participate in a focus group in January 2016 to discuss their experiences of receiving care and what could be improved. The aim of this focus group was to use their experiences to help inform the development of the care pathways (including the proactive pathway). A total of seven PAG members attended to give their views.

A patient survey was launched on the 4th May 2016 to collate views from Bromley residents on their experiences of health care. The survey was open to anyone interested in completing it and was promoted via Bromley CCG website, social media, Bromley communications and engagement network and a number of voluntary sector newsletters. A total of 129 people completed the survey to give their views.

A Patient and Public Workshop on Integrated Care Networks took place on the 17th May 2016. The workshop set out to explore previous patient feedback, including that received as part of the survey and present the new model set out in the ICNs to understand whether the model meets patient needs. It was also an opportunity to explore a series of outcomes to understand which were most important to patients. A total of 12 Patient Advisory Group members attended to give their views. Representatives from Healthwatch Bromley and Community Links Bromley also attended.

Summary – the right level of user involvement:

As planned, patient representative views on the ICN model were captured through a focus group, survey and workshop and used to inform the development of the ICNs and its pathways.



Pre-implementation, stakeholders saw the involvement of the voluntary or third sector as a strength of the ICN model and a key enabler in their success. Expectations included the new role of the Care Navigator bringing an understanding of and access to, a wealth of community services.

Post-implementation the input and impact of this role is viewed extremely positively by fellow members of the central ICMT and MDT and, by patients and their families.

“involvement of the voluntary sector is great, a lot of what they offer is new to GPs” GP Referrer

“Age UK are brilliant, I’ve been a GP for over 20 years and was not aware of the range of services available, it’s amazing”

MDT GP Chair

“GPs didn’t know what is available in the community” MDT Liaison Coordinator

“spoke to Age UK and although they didn’t have any new information for me it was kind of reassuring as I have been doing the right thing maybe”

Patient carer

“Age UK offered financial advice and gave information about taxi services that were available and then came around with the form for the taxi’s and completed it for me”

Patient

Pre-implementation stakeholders felt more could be done to improve how patients were sign-posted to and provided with, information on services.

Post-implementation 31% of survey respondents say that “systems and processes that help patients navigate their way through and find / contact available services” are either ‘much better’ (12%) or somewhat better (19%) with only 3% saying they were ‘somewhat worse’.


Pre-implementation stakeholders saw the lack of shared information systems as a barrier to delivering joined-up care. They were positive therefore about the prospect of joint care records and information sharing across health and the voluntary sector post implementation. Although concerns were raised about how this would work and about how information would be shared safely.

7% 1% 27% 0% 33% 31% ..."joined up" care provided for the very elderly or frail

patient?





Post-implementation despite continuing efforts, the plan to co-locate Care Navigators with the rest of the Integrated Care Management Team (ICMT) is not yet realised and information sharing arrangements are not in place. Both points are seen as challenges to team building and information sharing and as creating duplication of work for the Care Navigators.

“CNs are still separate from the rest of the central ICMT” and “issues remain with sharing information and access to systems”

JOG members

“there is lots of repetition with data entry and documentation –but with two different systems working together takes time to ‘iron out the creases’”

MDT Liaison Coordinator

Pre-implementation stakeholders felt it was extremely important that the ‘right’ people be recruited to the new ICN roles.

Post-implementation, while the roles of the Care Navigator are viewed positively it is felt that a clinical background may better equip the role of the MDT Liaison Coordinator in assessing and managing referrals.

“not clinical so don’t always recognise clues in referral re: actions that should /could be taken”

MDT member

Summary of the right sign-posting:

The new Care Navigator roles are having a positive impact on patients and their families and are bringing a wealth of knowledge about previously unknown community and voluntary sector resources to MDT meetings and patient reviews. Concerns remain that despite on-going efforts, they are not yet co-located with other Integrated Management Care Team colleagues and that data sharing across the health and voluntary sector is not yet achieved.



Post Implementation continued development aside, stakeholders (patients and families) were clear that the ICN pathways and in particular, the MDT meetings are having a positive and tangible impact on the care and support being provided to patients and their families, and reducing the number of GP visits and hospital admissions for some patients.

“I think I implemented a few things that meant patients didn’t go to hospital” Community Matron

“really, really good for patients who are isolated or those who are in ‘crisis’, they are using front-line services less frequently because they feel more supported, they don’t feel like they

have to ring the practice or whatever” MDT GP Chair

While the majority (54%) of survey respondents were also of the view that the pathways had had an impact on patient care, most (26%) said there had been some improvements, 22% said that they had helped a bit and only 6% said that they had radically changed patient treatment and experience – see figure 11.

Figure 11: Phase Two survey responses to Question 2

“Good to have a multidisciplinary discussion about clients’ complex issues and to formulate an action plan with review dates – this has to be beneficial for the clients/patients”

MDT member

“It appears MDT referrals are more efficient” London Borough of Bromley

“the patients that I have referred no longer all for visits and do not bounce in and out of hospital nearly as much”

GP Referrer

32%

16%

12%

25%

26%

34%

35%

I don't know

Other




Holistic assessment


In your view, what aspects of the proactive and/or frailty care pathways are working well?



Over time, analysis of the metrics / KPIs included in the Memorandum of Understanding will determine whether hospital admissions have been reduced and health outcomes improved. For reasons explained previouslu, this analysis is not included within this report.

Summary of the right outcomes:

The ICN pathways and MDT meetings are not only having a positive impact on the care and support

provided to referred patients, but stakeholders indicated that in certain cases they may be leading to

areduction in admissions to hospital and visits to their GP / GP practice.



5.3 Evaluation Objective Two - What is the Impact of the ICNs on their Stakeholders?

ICN stakeholders include:

1. Patients (and their family and/or carers) receiving the care and services provided by the ICN and pathways;

2. Those professionals responsible for the development of the ICNs and pathways: Joint Operational Group, those responsible for delivering the care and services provided by the ICN and pathways: central integrated care management team, the multidisciplinary team and GPs and those working in Bromley health and social care and voluntary sector

Impact on patients and their families or carers

Pre-implementation professional stakeholders (refer to table 3 for details) were positive about the impact that joined-up care can have both on patient experience and on the way that they would deliver care for patients and their families.

At a workshop attended by members of the Bromley Patient Advisory Group along with representatives from Healthwatch Bromley and Community Links Bromley, participants reviewed a list of patient outcomes and chose those they thought the most important.

Table 4 below, details under the three themes of access, communication and self-management, the patient outcomes selected by the majority of workshop participants to be the most important for patients, their families and carers.

Table 4: Summary from patient and public workshop – May 2016

Access

I am confident that the most appropriate services are accessible and available when I need to use them; and I know who I need to speak to when I need information about my care – even if this is delivered from different services

Communication I don’t have to repeat my story to the different people providing my care; I feel involved and informed about the care I receive; and I am listened to and my views are respected in shaping the care that I receive

Self-Management

I feel supported to keep well and take care of my health I feel knowledgeable about the services available to support me If I need to have a care plan, I have influenced what needs to be included

Post implementation, MDT members were clear that the impact of the pathways on patients concurred with some of those identified as ‘most important’ in table 4 above and that they were having a positive impact on patients and their families and the care they received.

“I think we have implemented a few things that has meant patients didn’t go to hospital” and

“patients like having single number (community team contact number) they can ring” Community Matrons

Feedback from patients and where appropriate from their family or carers focused almost exclusively on their recent experience with the MDT Community Matrons and to a lesser degree, that with their GPs / GP practice. While the interview guide was used to prompt as necessary, in most instances those who participated were keen to simply ‘tell their story’ in their own way.

Overwhelmingly, their experience of Community Matrons during their visit/s to the home, and the impact of their interventions during and following the visit, was extremely positive.



Quotes from patients, their family and carers include:

“my life and that of my Mother has been transformed since they have been involved – with everyone now involved we better understand what’s going on with Mum and feel confident that

she is getting what she needs, that we are not missing something”

“you have one person who is dealing with things for you”, I have their phone number and know I can call them if I need to”

“fabulous, cannot praise them enough”, “lovely, lovely person, I can’t speak too highly of them”,

“they were the first person who realised as soon as she met her that my Mum was ‘at risk’, needed help and then acted accordingly”

“it feels like anything that I needed would be available, it’s wonderful”

“I’ve never been taken care of before, it’s very comforting and lovely to know that someone is available if you need them”

“they just worked things out, just managed it all” and “they have been very helpful, they are fantastic”

“they have been able to bring in all sorts of other people in to the care of my Mother, its wonderful” “I haven’t had to do anything, they did it all”

*PLEASE NOTE: A series of case studies giving a full picture of the experience of patients and those caring for them are attached as appendix E.

MDT members were clear that the pathways were having a positive impact on patients and their families and the outcomes matched some of those patient outcomes identified as ‘important’ by patient representatives’ in a pre-implementation workshop – see table 4.

“I think we have implemented a few things that has meant patients didn’t go to hospital” and

“patients like having single number (community team contact number) they can ring” Community Matrons

Summary – the impact of ICNs on patients and their families:

The patient (and their families) experience of ICNs and the pathways is their experience of primarily, the Community Matrons and to a lesser degree their experience of the Care Navigators and their GP/GP practice. Overwhelmingly their experience has been very positive and the outcomes they describe concur with the patient outcomes selected by patient representatives as ‘most important’, including: “I know who I need to speak to when I need information about my care – even if this is delivered from different services” and “I don’t have to repeat my story to the different people providing my care”. Equally, MDT members felt that the ICNs and pathways had had a positive impact on patients and their families.



What is the impact on professionals?

The ICNs and their pathways are a new model of care in Bromley, designed specifically to change the way in which, the care and support required by those who are significant users of health care is provided. Changing ‘the way things are done’ or the way people are required to work cannot be introduced or achieved without having an impact on those involved.

It is not surprising then, that 60% of those responding to the post implementation survey report that the ICNs and pathways have had an impact on their work, with a slightly larger proportion within that group, saying this was a detrimental impact – see figure 12.


Of the 37% of respondents saying introduction of the pathways had had a detrimental effect on their job, most (31%) reported it as a small detrimental effect with only 6% saying it was major detrimental effect. Most of the accompanying free-text comments provided by these respondents spoke of issues with having to commit or find extra time in their work day to attend to the requirements of the ICNs, pathways and MDTs.

“finding time for meetings….if you refer four (patients) a month, that is two hours of precious time I do not have”

and

“it takes up to twenty minutes per patient discussed displacing other work until after evening surgery”

Bromley GPs

In contrast, 23% of respondents said that the effect had been beneficial, with the majority (18%) saying it had a small beneficial effect and 5% saying it had a major beneficial effect. Accompanying comments from this group included the following:

“having less visits” (from particular patients) Bromley GP

“I think the benefit will grow with time, it is a great step forward” Bromley GP Alliance

4

19

25

11

3

They've had a major adverse effect on my job

They've had a small detrimental effect on my job

They've had no impact on my job

They've had a small benefit for my job

They've had a major beneficial impact on my work

0 5 10 15 20 25 30

What impact have the proactive and frailty pathways had on your job?

Total



Of those interviewed most identified the effects or impact of the ICNs and pathways on the role of the MDT: Community Matrons, Liaison Coordinators and Care Navigators and on GPs.

Challenges included their meeting turn-around targets. These include: the requirement for Community Matrons to have assessed a patient no later than five working days following receipt of a referral and the requirement for a patient to be reviewed at an MDT meeting no later than 14 working days following receipt of the referral. Meeting either of these targets can be particularly challenging as rather than a steady stream of referrals received during the week, there can be multiple referrals received in one day, followed by days with none are received.

“the timescales are difficult – the five-day turnaround and 14 days to MDT”


“one day had 18 referrals come in from a GP, it’s hard to turn it around in five days with that many referrals”

and

“we get an influx of referrals in one day and then none for three days but because of the five-day turnaround it can be tricky”

Community Matrons

Concerns were raised about the workload of Community Matrons as only the time required for the initial patient visit and assessment was accounted for and not that required for follow-up and review. In addition, it was felt that both the assessment template and the time allocated for the initial visit and assessment should be reviewed.

“the assessment template (used by community matrons) is long-winded and time consuming” and

“the review of patients is not accounted for in the workload, only the initial assessment” and

“the time allocated for initial assessment needs to be reviewed as the assessment, travel and write-up takes 3 hours not an hour and a half”

Community Matrons

“Community Matrons need additional support as would save time for community matrons to allow them to get on”

and

“Community Matrons do a great job but wonder if they have the capacity to do what they do” GP Referrers

Some interviewees had concerns about some GPs who didn’t appear comfortable presenting their patients at the MDT meeting.

“need to build confidence and understanding of GPs” JOG member

“Initially GPs (referrers) found it difficult to present their patients to the MDT it was /has been a real educational session for GPs”

MDT Geriatrician

MDT meetings are recognised as an opportunity for shared learning. Interviewees felt this was particularly true in terms of gaining a better understanding of what each profession and each organisation ‘brought to the table’ and in gaining knowledge and skills from each other, which would enrich what they could then go on to offer other patients.

“MDT brings together multiple expertise and an increased understanding of what each other do and can provide”

and

“it’s an opportunity to share skills and teach colleagues, to develop and improve relationships” JOG members

“I am always learning something from the others when I attend an MDT” MDT GP Chair



Summary – the impact of ICNs on professionals

Unsurprisingly, the majority of professional stakeholders are reporting that the implementation of the pathways has had an impact or effect on their job.

Within that group, the highest number described it as having a small detrimental effect, followed by those who had experienced a small beneficial impact.

There are concerns around the workloads of some professionals and that turn-around targets for the management of referrals and completion of patient assessments may be causing some stress. Although concerns were voiced around an apparent reluctance by GPs to present their patients at MDT meetings, it is recognised that these meetings allow shared learning and a greater understanding and appreciation between member organisations and professions.



5.4 Discussion of findings – evaluation objectives one & two

Bromley CCG and partners have developed ICNs (and their pathways and MDT meetings) to improve the care and support provided to those Bromley residents:

Who are significant users of health services and/or frequent users of a range of services; and Who are considered by health and care professionals to be ‘at risk’ or ‘high risk’ of tipping into

crisis and needing urgent intervention such as an attendance at accident and emergency and subsequent hospital admission

The first objective for this evaluation was to establish whether the ICNs were effective and whether the intended improvements had been achieved.

Whilst the ICNs are at an early stage of their development, the evaluation provides evidence that they are beginning to show the planned effect, with some very positive stories of impacts on individual patients and professionals.

During the evaluation, stakeholders have raised a number of issues and challenges with respect to the implementation process, as would be expected with any major change to service delivery. Bromley CCG and partners are fully aware of the need to continually review and refine the model, and are committed to acting on feedback. An emerging findings report (July 2017) was produced for this purpose, to which the CCG provided responses summarising their planned and current remedial actions.

Despite the concerns raised, the stakeholders have expressed confidence that a good foundation is in place (with the ICNs and care pathways) and that they will continue to mature. Most importantly, patients (and their families) who are receiving care and support through the ICN pathways are very positive about their experience, and are reporting significant, and in some instances ‘life-changing’ improvements.

Other key findings include:

Bromley GPs are responding to the incentive scheme and referring patients to the ICN. While there are fewer referrals being submitted than first planned, numbers are beginning to increase. Unfortunately, not all referrals are either complete or provide the type or level of information required by those who process or respond to them. Equally, some referrals don’t meet the eligibility criteria for the pathways. It was suggested that in some instances GPs were using a referral to the MDT as a short-cut to a timely assessment and access to other services, particularly for those with mental health needs.

While there are challenges regarding some aspects of the administration and management of MDT meetings, those involved are positive about their ability to facilitate access to appropriate care and support. The view from stakeholders is that MDT meetings allow a significantly better quality of patient care for complex patients than can be provided by a single GP/GP practice. They are also seen to support improved communication, shared learning and relationship building between the member organisations and professions. Review of care and support and follow through on patient action plans are aspects of the pathways identified as needing further improvement.

Those involved in MDT meetings view the lack of a consistent and regular attendance by social care, as a significant and unfortunate gap and are of the view that all efforts should continue to secure their full involvement.

In addition, they feel there is value in having the same representatives from each organisation attend each meeting and all members of the team, attend the whole of the meetings and not just for the review of particular patient/s.



The views of patients and patient representatives captured through a focus group, survey and workshop were used to inform the development of the ICNs and pathways.

The new ICN roles of Care Navigator are having a positive impact on the care and support provided to patients and their families. Employed by the voluntary sector they bring to the MDT meetings a wealth of knowledge about community and voluntary sector resources, much of which is new to the team. Concerns remain that they are not yet co-located with their MDT colleagues and that data sharing between the health and voluntary sector is not yet achieved.

Reducing avoidable hospital attendances and admissions is a key objective of the ICNs and care pathways, however, it is too early to determine whether this quantifiable impact has been achieved, and any impact will be hard to attribute to the new care models, given the complexity of the local health and care system.

The second objective for this evaluation was to understand the impact ICNs have had on stakeholders - both patients and professionals.

As mentioned previously, patients (and their families) who are receiving care and support report a very positive experience. This is based predominantly on their interactions with the community matrons and to a lesser degree, the care navigators and their GP, or GP practice.

Interestingly, patient (and their families) descriptions of their experience concur with the outcomes identified by patient representatives at a pre-implementation workshop, as the ‘most important’. These included: “that I would know who I need to speak to when I need information about my care – even if this is delivered from different services” and “I won’t have to repeat my story to the different people providing my care”. MDT members also felt that the ICNs and pathways had had a positive impact on patients and their families.

“Professionals” refers to all those responsible for the development and delivery of the pathways: Joint Operational Group, those responsible for delivering their care and support: central integrated care management team, the multidisciplinary team and GPs and those working in Bromley health and social care and voluntary sector.

In this group, the majority that responded to the survey reported that the pathways had had an impact or effect on their job, with around a third describing the impact as “detrimental” (37%) and less than a quarter (23%) describing the impact as positive. This is not unexpected in a major service re-design, but will need to be further explored and monitored if professional engagement is to be increased.

There was concern amongst those interviewed that the turn-around targets for the management of referrals and completion of patient assessments can at times be stressful for the Community Matrons and MDT Liaison Coordinators. There were concerns over additional workload as a result of the new pathways, and in particular around the workload of the Community Matrons. Despite there being no time allocated in their work-plan beyond the initial patient visit and assessment, they are responding to patient needs by providing further review and follow-up for a number of patients.

Although concerns were voiced around an apparent reluctance by some GPs to present their patients at MDT meetings, it is recognised that these meetings add value by allowing shared learning and a greater understanding and appreciation between member organisations and professions.



6: Recommendations for Further Evaluation

6.1 Third evaluation objective

Make recommendations for future implementation and for further ongoing evaluation as the implementation progresses.

On-going Evaluation

Bromley CCG have demonstrated their commitment to a continual improvement approach, commissioning a formative evaluation by the HIN which has throughout provided close to real-time feedback to inform the on-going implementation and development of the ICNs and associated pathways.

We recommend that the Bromley partners now build on the approaches used in this formative evaluation to inform their on-going monitoring and development of the work.

This could include:

Use of repeat surveys to obtain wider, anonymised input from professionals re: perceived progress with implementation

Focus groups or interviews with professionals to tease out in more detail the implementation issues (e.g. following up with participants in HIN’s evaluation, where they have given consent to do so). This could explore what is leading professionals to indicate that the implementation is having a “detrimental” impact on their roles, so that any issues can be addressed.

Continually seeking feedback and input from professionals, to inform future implementation and development, giving attention to creating a culture where this is welcomed and actively sought.

Communicating to all stakeholders to explain how their feedback has been used to improve services and care

Proposal for a Summative Evaluation (2018-19)

We recommend that a further formal evaluation is conducted at least two years after the initial implementation which started in October 2016. This should be a summative evaluation, which would more comprehensively answer the questions “have the ICNs and pathways met their objectives”? and “what impact have they had on stakeholders”.

The summative evaluation should also use a mixed methods approach, including qualitative information from in-depth interviews, as well as quantitative data. Where possible, the limitations of the current, formative evaluation should be considered and overcome. For example, a more structured and randomised methodology for selecting patients and professionals for interview would be more appropriate.

After full implementation, when the new delivery models are embedded and have been running as routine practice for some time, it will be more feasible to determine the impact on healthcare utilisation metrics, as included in the MoU. The summative evaluation should also consider appropriate counterfactuals, i.e. can we determine what would have happened to the data had the intervention (i.e. ICN implementation) not taken place? This would require an analysis of trends over time, and ideally also a comparator, such as a borough with similar population where no intervention has taken place.

Given the complexity of health and care systems, and the multiple factors which influence these metrics, it will in any case be extremely difficult to determine causality and attribution with any degree of certainty.



If Bromley partners are to continue to invest in the ICNs and pathways, they will need robust evidence of their value. This will include not only patient stories and benefits to professionals involved, but also evidence of cost savings from the reduction in avoidable hospitalisation. The experiences and data from individual patients will need to be tracked over time to determine their health and care utilisation in the period following their MDT reviewand agreed interventions, and data from a number of sources would be required to do this.

To do this robustly, it will be essential to involve a health economist, statistician and qualitative researcher, working alongside Bromley CCG in the design of the evaluation, and for the summative evaluation to be adequately resourced. This approach will ensure that the important data is identified and captured as close to real-time as possible, and collected prospectively rather than retrospectively.



6.2 Fourth evaluation objective - note the critical success factors that would support spread and adoption of the Bromley ICN model, to other localities.

From this early stage evaluation it is not possible to identify which individual elements of the ICNs and pathways can be clearly attributed to specific outcomes and therefore, proposed as critical success factors for ‘spread and adoption’. What we can say, however, is that the Bromley ICN model as a whole has had a positive impact on patients and their families.

However, the following points are worth noting:

Demonstrable organisational / senior commitment: The Bromley Out of Hospital Strategy, and its operationalization through the implementation of the ICNs and proactive / frailty care pathways, has been an important organisational priority over a considerable period of time. The commitment of senior leaders to this new, integrated approach has been underlined by the signing of the Memorandum of Understaning between all key provider organisations (with the exception of the Local Authority / Social Care, who have been part of the strategic discussions and co-design process, but are not a signatory to the MoU).

Co-ordinated Investment in the integration model: Bromley CCG have backed up the organisational commitment in this priority area of development with significant new investment. This includes funding for a range of new posts, critical to the ICN model, e.g. care navigators, MDT co-ordinators, etc. The funding has been made strategically – available only to providers once they had signed up to a shared vision and an integrated model, with commitment demonstrated via the MoU. Although the new pathways are expected to be cost effective in the long term, through the reduction of unplanned health and care utilisation, it is important that there has been an explicit recognition of the need for up-front investment to establish new ways of working.

Co-design of care pathways: The entire planning process and the implementation delivery has involved all key stakeholders, including the diverse range of providers involved, the commissioners, and also patients and patient representative groups. In addition the ICN Joint Operational Group (and its predecessor the ICN Task and Finish Group) consists of members from all provider organisations who have signed the MOU. This comprehensive approach has helped to ensure that all stakeholders objectives are met and expectations are aligned, as well as securing necessary engagement of all parties.

GP incentive scheme: The evaluation team is aware that an incentive scheme was put in place for GPs to encourage referrals into the MDTs. However, this was not explicitly explored in interviews to determine the extent to which this influenced GPs to actively engage in the new pathways. Transitioning the approach from a new pathway/care model to which referrals are incentivised, to one which is accepted routine practice will require careful planning if it is not to impact on the successful delivery of the new pathways.



7: Considerations for Improvement & Recommendations

It should be noted that Bromley CCG welcomed HIN’s offer of an emerging findings report (July 2017), which followed analysis of Phase Two data and preceded this final report. The purpose of the emerging findings report was to inform the CCG (and partners) of the aspects of the ICNs which may require modification or improvement and consequently allow their address as soon as possible.

The final version of the emerging findings report includes “stakeholder responses and comments”, which demonstrates that the CCG and partners were aware of a number of the issues and challenges raised before receiving the report, and reflects the remedial decisions and actions that were already underway.

7.1 Summary of considerations for improvement:

Administration, management and development of the MDT and MDT meetings:

Strengthen current processes that allow the MDT team to monitor the implementation of all agreed patient care and support plans (i.e. follow up the agreed actions)

Continue efforts to develop an approach to the scheduling of MDT meetings that is not only cost and time effective but able to respond to demand and to the needs of those referring and those participating in the meetings

Address issues with the technology supporting the MDT meetings (e.g. teleconferencing facilities) while ensuring robust ‘back-up’ processes are in place

Continue to monitor referrals to ensure that patients identified by GPs comply with relevant eligibility criteria (appropriateness) and that their referrals are complete and meet the required quality standard

Maintain progress toward co-locating all ICN roles and allowing shared access to care records between professionals and provider organisations

Pursue social care involvement in the ICN model and pathways and whole meeting attendance by all existing MDT members

Continue to support King’s College Hospital NHS Foundation Trust in their efforts to recruit to the third and currently vacant, Gerontologist position

Communication with patients and their families

Identify how communication with patients and their families can be improved to ensure that they are aware that they have been referred by their GP/GP practice for review by the MDT and that they understand what that means and what it will involve

Capacity proofing

Take steps to closely monitor workloads (especially the community matrons) to ensure that the current and future workloads of those delivering the ICN pathways are manageable and support optimal patient care

Test existing ICN turn-around targets to ensure they are not only realistic and add value, but also to ensure they are not having an unintended adverse effect on those responsible for their delivery



Targets and incentives

Review the current GP Incentive Scheme to ensure that it serves to support quality as well as quantity in terms of referrals.

Engagement of GPs and the broader community

Step-up current efforts to increase and improve GP understanding of the ICN model and pathways.

Identify ways to address the view held by some GPs that referring patients to the MDT will only increase their workload rather than potentially reduce it and be of significant benefit to their patients.

Consider how this evaluation report (a summary, or case studies) can be used to share real examples of benefits to patients, which can be used to support further professional engagement.

7.2 Recommendations & next steps

We recommend that the Bromley Partners address the following:

Immediate Recommendations

Sharing the findings of this evaluation as quickly as possible and to the widest possible audience, ensuring this includes those stakeholders who participated in the evaluation.

Addressing as a priority, the points raised in ‘considerations for improvement’ in particular: o Resolving the operational and organisational challenges being faced by professionals who

are currently implementing the new care pathways o Putting in place mechanisms to monitor the workload of professionals involved.

Medium term recommendations

Establish arrangements for informal, on-going evaluation (i.e. regularly collecting and applying the findings of feedback from stakeholders both patients/families and professionals).

Plan investment in a more comprehensive, summative evaluation once the new service models have been fully embedded, to include an economic evaluation.

Thank You

The Health Innovation Network would like to thank Bromley CCG for the opportunity to conduct this evaluation and all those who participated and contributed for their time, energy and commitment.



Glossary Table 1: Terminology and acronyms used in this report

Integrated Care Network (ICN)

An integrated care network (ICN) is a model of care that brings together a range of health and care services to work in a more joined up way, in order to provide better care for patients – reference Bromley Clinical Commissioning Group website

The Pathways The Bromley Proactive Care Pathway and the Frailty Pathway – refer to Appendix B for copies of the two pathways

ICN Evaluation Subgroup

Time limited group, which reported to ICN Steering Group. It consisted of members of the Bromley Clinical Commissioning Group and the Health Innovation Network, and provided oversight and monitoring for the ICN evaluation – refer to Appendix A for full ICN Governance and Reporting Structure

ICN Joint Operational Group (JOG)

Reporting to ICN Steering Group, this group consists of senior representatives of Provider partner organisations signed up to the Memorandum of Understanding. Its purpose was to oversee the implementation of the Proactive (and community end of frailty pathway) ,and has repsosiibility for the operational performance of the pathways – N.B. replaced the original ICN Task and Finish Group

Memorandum of Understanding (MoU)

Formal commitment signed by provider organisations in Bromley setting out their plan to work together to achieve joined-up care. Signatories to the MoU: Bromley CCG, Bromley GP Alliance, Bromley Healthcare, Bromley Third Sector Enterprise, King’s College Hospital NHS Foundation Trust, Oxleas NHS Foundation Trust, and St Christopher’s Hospice (Bromley)

Joined-up care Care from more than one organisation that is delivered to a patient in an integrated manner

Patients Residents of Bromley using health services / receiving care

Professionals

Staff responsible for delivering the ICNs and pathways: Including central integrated care management team, the multidisciplinary team, GPs, consultant gerentologists and those working in Bromley health and social care and voluntary sector

ICN Multidisciplinary (MDT) Team / Meeting

This is a meeting chaired by a GP, which is attended either physically or virtually (teleconference facilities) by MDT members: a Consultant Geriatrician, a Care Navigator from the voluntary sector and representatives from: Oxleas NHSFT, St Christopher’s Hospice and GPs. Other professionals will join the conversation as required e.g. community physiotherapist and social care manager – ref: Bromley Clinical Commissioning Group website


One per ICN, this role, along with the MDT GP Chair is responsible for the administration of the MDT: from receipt of referral to ensuring a completed patient care plan is assigned to the designated lead clinician . Role also requires them to ensure actions are folowd through and completed and communication is provided back to the referring GP on progress with their patient.

MDT Care Navigator

Employed by Age UK, at least one each per ICN, operating as part of the MDT. Key aspects of the role include being a patient advocate and ‘sign-posting’ patients and their families to the most relevant medical and non-medical third sector services



The Health Innovation Network is the Academic Health Science Network for south London and part of the national AHSN Network.

We are a founding partner of DigitalHealth.London building the global digital capital, together.

@HINSouthLondon www.healthinnovationnetwork.com

https://twitter.com/HINSouthLondon/

NHS Standard Contract

Template Alliance Agreement for Virtual MCPs

Version: 1.0 Date: 25/09/2017

NHS Standard Contract Template Alliance Agreement for Virtual MCPs

Version number: 2

First published: December 2016

Updated: NA

Prepared by: NHS Standard Contract Team

[email protected]

Classification: Official

Publications Gateway Reference: 06185

2

mailto:[email protected]

mailto:[email protected]

DATED 30th September 2017

(1) NHS Bromley Clinical Commissioning Group [COMMISSIONER A]

(2) London Borough of Bromley [COMMISSIONER B]

(3) King's College Hospital NHS Foundation Trust [PROVIDER A]

(4) Oxleas NHS Foundation Trust [PROVIDER B]

(5) Bromley Healthcare Community Interest Company [PROVIDER C]

(6) Bromley GP Alliance [PROVIDER D]

(7) St Christopher’s Hospice [PROVIDER E]

(8) Bromley Third Sector Enterprise Community Interest Company

[PROVIDER F]

TEMPLATE ALLIANCE AGREEMENT

FOR

VIRTUAL MCPs

4

CONTENTS

Clause

1. DEFINITIONS AND INTERPRETATION.....................................................................................6

2. STATUS AND PURPOSE OF THIS AGREEMENT ....................................................................6

3. PRE-COMPLETION ....................................................................................................................7

4. COMPLETION .............................................................................................................................7

5. COMMENCEMENT AND TERM .................................................................................................7

6. ALLIANCE OBJECTIVES............................................................................................................8

7. ALLIANCE PRINCIPLES.............................................................................................................8

8. ALLIANCE GOVERNANCE ........................................................................................................9

9. RESERVED MATTERS.............................................................................................................10

10. TRANSPARENCY AND ETHICAL WALLS...............................................................................11

11. SERVICES CONTRACTS .........................................................................................................12

12. KEY PERFORMANCE INDICATORS AND RISK/REWARD MECHANISM.............................13

13. INTELLECTUAL PROPERTY RIGHTS.....................................................................................13

14. CONFIDENTIALITY AND FREEDOM OF INFORMATION ......................................................14

15. PERSONNEL ............................................................................................................................14

16. LIABILITY AND INDEMNITY.....................................................................................................14

17. FORCE MAJEURE ....................................................................................................................15

18. RECTIFICATION, EXCLUSION AND TERMINATION .............................................................16

19. SURVIVORSHIP .......................................................................................................................20

20. VARIATIONS AND CHANGE PROCEDURE............................................................................20

21. TRANSFER TO THIRD PARTIES.............................................................................................20

22. CHANGE OF CONTROL...........................................................................................................20

23. PRECEDENCE..........................................................................................................................20

24. INFORMATION AND FURTHER ASSURANCE .......................................................................21

25. ANNUAL REVIEW .....................................................................................................................21

26. CONTRACT MANAGEMENT RECORDS AND DOCUMENTATION .......................................21

27. WARRANTIES...........................................................................................................................22

28. RELATIONSHIP OF THE PARTICIPANTS...............................................................................22

29. NOTICES...................................................................................................................................22

30. THIRD PARTY RIGHTS ............................................................................................................23

31. SEVERABILITY .........................................................................................................................23

32. ENTIRE AGREEMENT..............................................................................................................23

33. WAIVER ....................................................................................................................................23

34. DISPUTE RESOLUTION PROCEDURE ..................................................................................23

35. COSTS AND EXPENSES .........................................................................................................23

36. LAW AND JURISDICTION ........................................................................................................23

SCHEDULE 1 - PART 1 .........................................................................................................................25

PARTICIPANTS ....................................................................................................................................25

5

SCHEDULE 1 - PART 2 .........................................................................................................................26

ADDRESSES FOR NOTICES................................................................................................................26

SCHEDULE 1 - PART 3 .........................................................................................................................27

SERVICE CONTRACTS ........................................................................................................................27

SCHEDULE 2 .........................................................................................................................................28

DEFINITIONS AND INTERPRETATION................................................................................................28

SCHEDULE 3 - PART 1 .........................................................................................................................34

SHADOW ACCOUNTABLE CARE SYSTEM BOARD – TERMS OF REFERENCE .............................................................34

SCHEDULE 3 – PART 2 ........................................................................................................................38

SHADOW ACCOUNTABLE CARE SYSTEM EXECUTIVE – TERMS OF REFERENCE ..........................................................38

SCHEDULE 4 .........................................................................................................................................42

RISK/REWARD MECHANISM ...............................................................................................................42

SCHEDULE 5 .........................................................................................................................................43

KEY PERFORMANCE INDICATORS ....................................................................................................43

SCHEDULE 6 .........................................................................................................................................44

CONFIDENTIAL INFORMATION OF THE PARTICIPANTS .................................................................44

SCHEDULE 7 .........................................................................................................................................45

FREEDOM OF INFORMATION AND TRANSPARENCY ......................................................................45

SCHEDULE 8 .........................................................................................................................................46

CHANGE PROCEDURE ........................................................................................................................46

SCHEDULE 9 .........................................................................................................................................47

DISPUTE RESOLUTION PROCEDURE ...............................................................................................47

SCHEDULE 10 .......................................................................................................................................49

SCOPE OF SERVICES ..........................................................................................................................49

6

THIS AGREEMENT is made the 30th day of September 2017

BETWEEN the parties listed in Schedule 1.

BACKGROUND

(A) The Participants intend to ensure integrated, high quality, affordable and sustainable health and care services are delivered in the most appropriate way to the GP registered population of the London Borough of Bromley.

(B) This Agreement is an integral part of the vision to promote integrated services that deliver

personalised care, and it is anticipated that this Agreement will facilitate the objectives of Integrated Care Networks as more fully described in this Agreement.

(C) This Agreement is a follow on from the Memorandum of Understanding supporting the

implementation of Integrated Care Networks that expires on 30 September 2017.

(D) Over the period of this Agreement, We will work together positively and in good faith in accordance with the Alliance Principles to achieve the Alliance Objectives.

(E) This Agreement supplements and operates in conjunction with existing Services Contracts

between the one or more of the Commissioner Participants and each of the Provider Participants.

(F) The Commissioner Participants have appointed NHS Bromley Clinical Commissioning Group

as the Representative Commissioner.

IT IS AGREED AS FOLLOWS:

1. DEFINITIONS AND INTERPRETATION

1.1. The provisions of this Agreement are to be interpreted in accordance with Schedule 2 (Definitions and Interpretation).

2. STATUS AND PURPOSE OF THIS AGREEMENT

2.1. We each agree that:

2.1.1. each one of Us is a sovereign persons or organisations;

2.1.2. the Alliance is not a separate legal entity and as such is unable to take

decisions separately from Us or bind Us;

2.1.3. one or more of Us cannot 'overrule' any other of Us on any matter (although all of Us are obliged to comply with the terms of the Agreement); and

2.1.4. each one of Us shall not be required to take any action pursuant to any

provision of this Agreement that causes any one of Us to be in breach of Legislation or any regulatory obligation; and

2.1.5. each one of Us shall not be required to take any action pursuant to any

provision of this Agreement that causes any one of Us to act in a way that is contrary to our interests.

2.2. This Agreement is an NHS Contract pursuant to section 9 of the National Health

Service Act 2006.

2.3. We have agreed to form an Alliance to establish an improved financial, governance and contractual framework for the delivery of the Services; Helping the people of Bromley live longer, healthier, happier lives.

2.4. We recognise that the successful implementation of the Alliance will require strong

relationships and the creation of an environment of trust, collaboration and innovation.

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2.5. This Agreement sets out the key terms We have agreed with each other including the agreed outcomes and indicators for the Services. This Agreement will supplement and operate in conjunction with:

2.5.1. the Services Contracts (see Section C below for more details);

2.5.2. s.75 Agreement between London Borough of Bromley and NHS Bromley

Clinical Commissioning Group;

2.5.3. Our Healthier South East London (OHSEL) Sustainability and Transformation Plan (STP) Memorandum of Understanding (MOU); and

2.5.4. Bromley Data Sharing Agreement (DSA)

2.6. This Agreement supplements and works alongside the Services Contracts. In other

words, this Agreement is the overarching agreement that sets out how We will work together in a collaborative and integrated way and the Service Contracts set out how We will provide the Services.

2.7. Each of Us will perform Our respective obligations under Our respective Services

Contract. We acknowledge that the overall quality of the Services will be determined by Our collective performance and We agree to work together as described more fully in Section B below. Our plans for delivering the Services and improving care are set out in Section C and Our agreed sharing of risks and rewards is described in Section D.

2.8. The terms of this Agreement are set out in the following sections:

2.8.1. SECTION A: sets out the objectives and principles of the Alliance.

2.8.2. SECTION B: sets out each of Our roles in the Alliance, and the governance of

the Alliance.

2.8.3. SECTION C: sets out Our agreed arrangements relating to the Services Contracts for the delivery of the Services, ensuring improved coordination of care and greater collaboration between primary, community, acute and social care.

2.8.4. SECTION D: sets out how We manage Our performance, financial risk and

benefit sharing mechanisms.

2.8.5. SECTION E: sets out the remaining contractual terms.

3. PRE-COMPLETION

Each of Us acknowledges and confirms that as at the date of this Agreement we have obtained all necessary authorisations to enter into this Agreement.

4. COMPLETION

4.1. Completion is conditional upon the execution of a Service Contract between the

relevant Commissioner Participant and the relevant Provider Participant. [Each Service Contract shall include a specification incorporating the Alliance Objectives.]

5. COMMENCEMENT AND TERM

5.1. Clauses 1 (Definitions and Interpretation), 2 (Status and Purpose of this Agreement),

3 (Pre-completion), 4 (Completion) and 5 (Commencement and Term) will be effective from the Commencement Date.

5.2. The remainder of this Agreement will be effective from a date specified in a notice

from the Commissioner Participants to the Provider Participants confirming that

8

Service Contracts between each relevant Commissioner Participant and each relevant Provider Participant has been executed (the "Completion Date").

5.3. This Agreement shall, subject to Clauses 5.4 and 5.5 remain in force until the Initial Expiry Date unless terminated in accordance with this Agreement (the "Initial Period").

5.4. The Commissioner Participants may with the consent of the Provider Participants not

less than six (6) months prior to the expiry of the Initial Period serve notice to extend this Agreement for period of o n e ( 1) year from the expiry of the Initial Period.

5.5. Any extensions beyond the Initial Period will be on the same terms and conditions as

this Agreement.

SECTION A: ALLIANCE PRINCIPLES, OBJECTIVES AND COMMITMENTS

6. ALLIANCE OBJECTIVES

6.1. The Alliance Objectives agreed by Us are to deliver sustainable, effective and efficient Services with significant improvements over the Term. In particular We have agreed the following: 6.1.1. Continue to work together towards an Accountable Care System for Bromley 6.1.2. Strengthen approach to integrated working developed in the Memorandum of

Understanding 6.1.3. Reduce the number of emergency admissions to secondary care (acute and

mental health) 6.1.4. Reduce the number of delayed discharges from secondary care 6.1.5. Reduce the number of Accident and Emergency attendances 6.1.6. Reduce the number of patients readmitted to hospital within 30 days of

discharge 6.1.7. System wide approach to managing financial allocations, including delivery of

commissioner Quality Innovation Prevention and Performance (QIPP) initiatives 6.1.8. Improve the health and wellbeing of the Bromley population.

6.2. We acknowledge and accept that the Shadow Accountable Care System Board is

unable in law to bind any Participant so it will function as a forum for discussion of issues, including but not limited to discussing appropriate allocation of activity and service specifications under the respective Services Contracts in order to achieve the Alliance Objectives. We will utilise the provisions, mechanisms and flexibilities in the Services Contracts to effect the necessary changes in service specifications, activity plans, etc.

6.3. We acknowledge that We will have to make decisions together in order for Our

Alliance to work effectively and, except for the Reserved Matters listed at Clause 9.1 below, We will work together on a Best for Service basis in order to achieve the Alliance Objectives.

7. ALLIANCE PRINCIPLES

7.1. In consideration of the mutual benefits and obligations under this Agreement, We will

work together to perform the obligations set out in this Agreement and, in particular, achieve the Alliance Objectives and, subject to and in accordance with the provisions of this Agreement, We will:

7.1.1. work towards a shared vision of integrated service provision;

7.1.2. commit to delivery of system outcomes in terms of clinical matters,

Service User experience and financial matters;

7.1.3. commit to common processes, protocols and other system inputs;

7.1.4. commit to work together and to make system decisions on a Best for Service basis;

9

7.1.5. accommodate risk reward scheme where We all share in savings

generated by reduction in acute activity.

7.1.6. take responsibility to make unanimous decisions on a Best for Service basis;

7.1.7. always demonstrate the Service Users’ best interests are at the heart of Our activities;

7.1.8. adopt an uncompromising commitment to trust, honesty, collaboration,

innovation and mutual support; 7.1.9. establish an integrated collaborative team environment to encourage open,

honest and efficient sharing of information, subject to competition law compliance;

7.1.10. adopt collective ownership of risk and reward, including identifying,

managing and mitigating all risks in performing our respective obligations in this Agreement; and

7.1.11. co-produce with others, especially service users, families and carers, in

designing and delivering the Service,

(together the “Alliance Principles”).

7.2. Over the life of the Alliance, the actual provision of Services will alter on the basis of the most effective utilisation of staff, premises and other resources (in terms of cost and quality) and whilst there will be co-operation as to the service design this will not:

7.2.1. preclude competition between Us in respect of service provision as is needed

to achieve the Alliance Objectives and which will be reflected in the Services Contracts and changes to those Services Contracts; or

7.2.2. restrict the Commissioner Participant's statutory obligations including

obligations under procurement law to contract with provider(s) most capable of meeting the Commissioner Participants requirements, and obligations under Legislation (for example, the Public Contract Regulations 2015 and the National Health Service (Procurement, Patient Choice and Competition) (No 2) Regulations 2013).

10

SECTION B: ALLIANCE GOVERNANCE

8. ALLIANCE GOVERNANCE

Shadow Accountable Care System Board

8.1. We all agree to establish the Shadow Accountable Care System Board. For the avoidance of doubt the Shadow Accountable Care System Board shall not be a committee of any Participant or any combination of Participants.

8.2. The Shadow Accountable Care System Board is the group responsible for leading the

Alliance. The Shadow Accountable Care System Board will hold to account the Shadow Accountable Care System Executive. It will have other duties and the authority and accountability defined in its Terms of Reference.

8.3. The terms of reference for the Shadow Accountable Care System Board shall be as

set out in Part 1 of Schedule 3 (Shadow Accountable Care System Board – Terms of Reference).

Shadow Accountable Care System Executive

8.4. We agree to establish the Shadow Accountable Care System Executive which will be

responsible for managing the Alliance and the delivery of the Services. For the avoidance of doubt the Shadow Accountable Care System Executive shall not be a committee of any Participant or any combination of Participants.

8.5. The terms of reference for the Shadow Accountable Care System Executive shall be

as set out in Part 2 of Schedule 3 (Shadow Accountable Care System Executive – Terms of Reference).

8.6. We will be bound by the actions and decisions of the Shadow Accountable Care

System Board and the Alliance Management carried out in accordance with this Agreement.

Joint Operating Group

8.7. We agree to establish the Joint Operating Group which will be responsible for

managing the Alliance and the delivery of the Services.

8.8. The terms of reference for the Joint Operating Group shall be as set out in Part 3 of

11

Schedule 3 (Joint Operating Group – Terms of Reference).

8.9. We will be bound by the actions and decisions of the Shadow Accountable Care System Executive and the Alliance Management carried out in accordance with this Agreement.

Admitting new Participants

8.10. Where a Participant or Participants wish to admit a new person or organisation

to be a Participant under this Agreement, such a proposal shall be considered at the next Shadow Accountable Care System Board meeting.

8.11. The relevant Participant or Participants that wish to admit a new

person or organisation shall serve a written notice on the Shadow Accountable Care System Board setting out the details of:

8.11.1. the proposed new person or organisation (where known);

8.11.2. reasons and rationale for the proposed admission of a new person or

organisation;

8.11.3. the likely impact on the Services; and

8.11.4. the likely impact on the payments to be made under Schedule 4 (Risk/Reward Mechanism).

8.12. Following receipt of the notice referred to in Clause 8.11, the Shadow

Accountable Care System Board shall then consider the proposal and decide what actions (if any) need to be taken, in terms of varying this Agreement, for example.

9. RESERVED MATTERS

9.1. We acknowledge that each of the Commissioner Participants is required to comply

with various statutory duties as commissioners. Therefore, notwithstanding any other provision of this Agreement or any Services Contract, each of the Commissioner Participants must be free to determine the following matters as they see fit. Each of the Commissioner Participants will strive to achieve a consensus and an alignment amongst Us, but We recognise that, ultimately, each of the Commissioner Participants must be free to determine the following "Reserved Matters":

9.1.1. any Mandatory Variation required to be implemented by the Commissioner

Participants;

9.1.2. any matter upon which the Commissioner Participants may be required to submit to public consultation or in relation to which the Commissioner Participants may be required to respond to or liaise with a Local Healthwatch organisation;

9.1.3. any decision of the Commissioner Participants to exercise its rights in relation

to Clause 17 (Force Majeure);

9.1.4. any steps taken by the Commissioner Participants pursuant to Clause 18 (Rectification, Exclusion and Termination);

9.1.5. any steps taken by the Commissioner Participants in relation to Clause 21

(Transfer to Third Parties); and

9.1.6. any matter which requires the Commissioner Participants to invest further monies in respect of the Services, or under the Services Contracts or under this Agreement.

9.2. We agree that:

9.2.1. the Reserved Matters are limited to the express terms of Clause 9.1;

12

9.2.2. the Reserved Matters shall not be exercised so as to require a Provider Participant to breach any regulatory obligations (including for any Provider Participant that is an NHS Foundation Trust the terms of its NHS Provider Licence or for any Provider Participant any directions issued pursuant to direction 6(c) of the National Health Service Trust Development Authority Directions and Revocations and the Revocation of the Imperial College Healthcare National Health Service Trust Directions 2016) or to breach any legislative requirements including the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010;

9.2.3. the Shadow Accountable Care System Board may not make a final decision

on any of the matters set out in Clause 9.1(a) and 9.1(b), which are reserved for determination by the Commissioner Participants only;

9.2.4. where exercising a Reserved Matter under Clause 9.1(c) to 9.1(f), and subject

to any need for urgency because to act otherwise would result in the Commissioner Participants breaching their statutory obligations, the Commissioner Participants will first consult with the Shadow Accountable Care System Board in respect of its proposed exercise of a Reserved Matter;

9.2.5. should the need arise, a Commissioner Participant will give a written notice to

the Shadow Accountable Care System Board that it is exercising a Reserved Matter; and

9.2.6. if a decision in respect of any Reserved Matter is notified to the Shadow

Accountable Care System Board, We will implement that decision as if it were a decision of the Shadow Accountable Care System Board.

10. TRANSPARENCY

10.1. We will provide to each other all information that is reasonably required in order to achieve the Alliance Objectives and to design and implement changes to the ways in which Services are delivered (and where the Services are delivered from).

10.2. We will have responsibilities to comply with competition laws and We

acknowledge that We will all comply with those obligations. We will therefore make sure that We share information, and in particular Competition Sensitive Information, in such a way that is compliant with competition law and, accordingly, the Shadow Accountable Care System Executive will ensure that the exchange of Competition Sensitive Information will be restricted to circumstances where:

10.2.1. It is essential; 10.2.2. it is not exchanged more widely than necessary; 10.2.3. it is subject to suitable non-disclosure or confidentiality agreements which

include a requirement for the recipient to destroy or return it on request or on termination of this Agreement; and

10.2.4. it may not be used other than to achieve the Alliance Objectives.

and We acknowledge that Competition Sensitive Information is defined in Schedule 2. To assist in applying the definition to information to categorise it as Competition Sensitive Information, We acknowledge that it is for each Provider Participant to decide whether information is Competition Sensitive Information but We recognise that it is normally considered to include any internal commercial information which, if it is shared between Provider Participants, would allow Provider Participants to forecast or coordinate commercial strategy or behaviour in any market.

10.3. No matter what else is written in this Agreementthe Provider Participants will

ensure that they provide the Commissioner Participants with all financial cost resourcing, activity or other information as the Commissioner Participants may require so that the Commissioner Participants can be satisfied that the Alliance Objectives, in particular those of a financial nature, are being satisfied.

10.4. We will make sure the Shadow Accountable Care System Board establishes

appropriate non-disclosure or confidentiality agreements between and within the

13

Provider Participants so as to ensure that Competition Sensitive Information and Confidential Information are only available to those members of the Provider Participants who need to see it for the purposes of the Alliance and for no other purpose whatsoever so We do not breach competition law.

10.5. It is accepted by the Alliance that the involvement of the Provider Participants

in the Alliance is likely to give rise to situations where information will be generated and made available to the Provider Participants, which could give the Provider Participants an unfair advantage in competitions which may be capable of distorting such competitions (for example, disclosure of pricing information or approach to risk may provide one Provider Participant with a commercial advantage over a separate Provider Participant).

14

10.6. The Provider Participants therefore recognise the need to manage the information referred to in Clause 10.5 above in a way which maximises their opportunity to take part in competitions by putting in place appropriate procedures, such as appropriate non-disclosure or confidentiality agreements.

10.7. A Provider Participant will have the opportunity to demonstrate to the

reasonable satisfaction of the Commissioner Participants in relation to any competitive procurements that the information it has acquired as a result of its participation in the Alliance, other than as a result of a breach of this Agreement, does not preclude the Commissioner Participants from running a fair competitive procurement in accordance with the Commissioner Participants’ legal obligations.

10.8. Notwithstanding Clause 10.7 above, the Commissioner Participants reserve

their rights to take such measures as they consider necessary in relation to such competitive procurements in order to comply with their obligations under Legislation (for example, the Public Contract Regulations 2015 and the National Health Service (Procurement, Patient Choice and Competition) (No 2) Regulations 2013) including, but not limited to, excluding any potential bidder from the competitive procurement in accordance with the laws governing that competitive procurement.

10.9. Nothing in this Agreement shall absolve any of the Provider Participants

from their obligations under each Service Contract, particularly in relation to ensuring that the Services are provided in accordance with the requirements of the relevant Service Contract.

10.10. Where there are any Patient Safety Incidents or Information Governance

Breaches relating to the Services, for example, the Provider Participants shall ensure that they each comply with their individual Service Contract and, where required by the Commissioner Participants, work collectively and share all relevant information to that Patient Safety Incident or Information Governance Breach (or other similar issue) for the purposes of any investigations and/or remedial plans to be put in place, as well as for the purposes of learning lessons in order to avoid such Patient Safety Incident or Information Governance Breach in the future.

10.11. Without prejudice to any obligations in the Service Contracts, the Provider

Participants shall each notify the Shadow Accountable Care System Board of any Serious Incident that has arisen in connection with the relevant Provider Participant's involvement in providing the Services set out in the Service Contract, without delay and no longer than two (2) Business Days of that Serious Incident taking place.

SECTION C: SERVICES CONTRACTS AND COORDINATION OF THE SERVICES

11. SERVICES CONTRACTS

11.1. Each of Us must perform Our respective obligations under, and

observe the provisions of, any Services Contract to which We are a party.

11.2. Nothing in this Agreement relaxes or waives any of Our obligations pursuant to any Services Contract. As stated in Clause 6.2, We acknowledge and accept that the Shadow Accountable Care System Board may decide that activity is shifted and that service specifications under the respective Services Contracts are varied in order to achieve the Alliance Objectives. Where proposed changes are approved by the Shadow Accountable Care System Board, We must not refuse to record and implement the agreed change under the relevant Services Contract.

11.3. Save as set out in Clause 16 (Liability and Indemnity) each Provider Participant

will be responsible for the acts, omissions, defaults or negligence of its directors, officers, employees and agents in respect of its obligations under the Services Contracts as fully as if they were acts, omissions, defaults or negligence of itself.

11.4. Where any Provider Participant has any other contract for services with any

of the Commissioning Participants, the Provider Participant concerned will ensure that there is no duplicated recovery of charges for the same service or resource, nor is

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any activity moved between contracts to provide a financial advantage to that Provider Participant.

SECTION D: PERFORMANCE MANAGEMENT, FINANCIAL RISK AND BENEFIT SHARING OF THE ALLIANCE

12. KEY PERFORMANCE INDICATORS AND RISK/REWARD MECHANISM

12.1. We agree that the provisions of Schedule 5 (Key Performance Indicators) will

apply to the performance and monitoring of the Services.

12.2. We agree that the provisions of Schedule 4 (Risk/Reward Mechanism) will apply.

SECTION E: REMAINING CLAUSES

13. INTELLECTUAL PROPERTY RIGHTS

Our existing Intellectual Property

13.1. Each of Us has Our own existing Intellectual Property and We have agreed that We will be able to protect Our respective existing Intellectual Property as set out in this Agreement.

13.2. We also agree that, in the interests of achieving the Alliance Objectives, We

should share Our own existing Intellectual Property but, and except as set out in this Clause 13, none of Us will acquire the Intellectual Property of any other Participant to this Agreement.

13.3. Each Provider Participant grants each Commissioner Participant and each

of the other Provider Participants a fully paid up non-exclusive licence to use its existing Intellectual Property for the purposes of the exercise of the Commissioner Participants’ functions and obtaining the full benefit and utilisation of the Services under this Agreement and/or the fulfilment of the Provider Participants' obligations under this Agreement.

13.4. The Commissioner Participants grant the Provider Participants a fully paid

up non- exclusive licence to use the Commissioner Participants’ Intellectual Property under this Agreement for the sole purpose of providing the Services pursuant to this Agreement.

13.5. In the event that any Provider Participant at any time devises, discovers or

acquires rights in any Improvement it must:

13.5.1. promptly notify the owner of the Intellectual Property to which that Improvement relates, giving full details of the Improvement and whatever information or explanations as the rest of Us may reasonably require to be able to use the Improvement effectively; and

13.5.2. assign to the Representative Commissioner all rights and title in

any such Improvement without charge.

13.6. We agree that any Improvement as described in Clause 13.5 will be treated as Alliance Intellectual Property and therefore be dealt with in accordance with Clauses 13.7. and 13.8 below.

Alliance Intellectual Property

13.7 If any of Us create any Alliance Intellectual Property, the Participant which creates the

Alliance Intellectual Property will assign to the Representative Commissioner, with full title guarantee, title to and all rights and interest in the Alliance Intellectual Property so created.

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13.8 In turn, the Representative Commissioner will grant to the rest of Us a fully paid up non-exclusive licence to use the Alliance Intellectual Property for the purposes of the achievement of the Alliance Objectives under this Agreement.

14. CONFIDENTIALITY AND FREEDOM OF INFORMATION

14.1. We agree that We shall comply with Schedule 6 (Confidential Information of

the Parties) and Schedule 7 (Freedom of Information and Transparency).

15. PERSONNEL

15.1. We all understand that We have certain responsibilities to each other in the way We deal with staff and employment law issues. For example, We need to manage the risk that some staff could transfer from one Participant to another under the Transfer Regulations.

15.2. We agree that We will each have responsibility for Our own staff and that,

where internal reorganisation or redeployment of staff is needed, [We shall be individually responsible for any costs of that reorganisation or redeployment.] We do not expect staff to transfer from one Participant to another as a result of the Transfer Regulations but where that does happen then:

15.2.1. in respect of staff that deliver the Services, the provisions that deal with a

transfer of staff as a result of the Transfer Regulations contained in the relevant Service Contract shall apply; and

15.2.2. in respect of staff that manage and run Our Alliance pursuant to this

Agreement, each of Us commits to each of the others that We shall, in order to fulfil the Alliance Objectives and in accordance with the Alliance Principles, co-operate and negotiate, acting reasonably and in good faith, to determine and agree how all financial, operational, legal and other consequences of such staff transfers are shared between Us.

16. LIABILITY AND INDEMNITY

16.1. In the majority of cases, Our respective responsibilities and liabilities in the

event that things go wrong with the Services will be allocated under Our respective Services Contracts.

16.2. Where responsibilities and liabilities arise that are not covered by a Services

Contract, We agree that, in relation to the matters set out in this Agreement, We shall have no liability to each other in respect of any losses, liabilities, damages, costs, fees and expenses (howsoever caused or arising) except as set out in this Clause 16 and Clause 18 (Rectification, Exclusion and Termination).

16.3. The Commissioner Participants may bring a claim against the Provider

Participants (or such Provider Participant as it reasonably considers relevant) in respect of or arising from:

16.3.1 any overpayment;

16.3.2 any Misappropriation; or

16.3.3 any loss or damage suffered by the Commissioner Participants from

breach of the provisions of Clauses 13 (Intellectual Property Rights), 14 (Confidentiality and Freedom of Information) and 16.7.

16.4 The Fund Holder may bring a claim against the Commissioner Participants in respect

of or arising from any breach of the provisions of Schedule 4.

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16.5 Any Provider Participant may bring a claim against the Commissioner Participants in respect of or arising from any loss or damage suffered by the Provider from breach of the provisions of Clause 13 (Intellectual Property Rights) or Clause 14 (Confidentiality and Freedom of Information).

16.6 Any Provider Participant may bring a claim against the Fund Holder in respect of or arising from any breach of the provisions of Schedule 4.

16.7 Each Provider Participant agrees to ensure that it shall, at all times, have in place adequate Indemnity Arrangements for the purposes of the Services that it is providing at any relevant time, and shall provide details of the same to the Commissioner Participants in accordance with the terms of the relevant Service Contract.

16.8 Each Provider Participant is responsible for ensuring their regulatory compliance of the Services that they provide. Each Provider Participant will deal directly with the relevant regulatory body in relation to the Services performed by that Provider Participant organisation and it is not intended that there will be any collective responsibility or liability for any regulatory breaches or enforcement actions.

17. FORCE MAJEURE 17.1 Sometimes certain events outside of Our reasonable control (an "Event of Force

Majeure") might prevent one or more of Us (each being an "Affected Participant") from complying with Our respective obligations under this Agreement.

17.2 Many of Our Services Contracts will include provisions that dictate what happens if there is an Event of Force Majeure. If an applicable Services Contract dictates what happens if there is an Event of Force Majeure then We will comply with Our obligations under the Services Contract and will do everything We reasonably can to make sure that the Event of Force Majeure does not have a material adverse effect on the overall Services and Our Alliance. If the applicable Services Contract does not dictate what happens if there is an Event of Force Majeure then those of Us affected must comply with Clauses 17.3 to 17.9 (inclusive) below.

17.3 If an Event of Force Majeure occurs, the Affected Participant must: (a) take all reasonable steps to mitigate the consequences of that event; (b) resume performance of its obligations as soon as practicable; and (c) use all reasonable efforts to remedy its failure to perform its obligations under

this Agreement. 17.4 The Affected Participant must send an initial written notice to each of Us immediately

when it becomes aware of the Event of Force Majeure. This initial notice must give sufficient detail to identify the Event of Force Majeure and its likely impact. The Affected Participant must then serve a more detailed written notice within a further 5 Business Days. This more detailed notice must contain all relevant information as is available, including the effect of the Event of Force Majeure, the mitigating action being taken and an estimate of the period of time required to overcome the event and resume full delivery of its obligations under this Agreement.

17.5 If it has complied with its obligations under Clauses 17.1 and 17.4 (Force Majeure), the Affected Participant will be relieved from liability under this Agreement if and to the extent that it is not able to perform its obligations under this Agreement due to the Event of Force Majeure.

Effect of an Event of Force Majeure

17.6 We must at all times following the occurrence of an Event of Force Majeure use all reasonable endeavours to prevent and mitigate the effects of an Event of Force Majeure. We must at all times whilst an Event of Force Majeure is subsisting take

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steps to overcome or minimise the consequences of the Event of Force Majeure and facilitate the continued performance of this Agreement.

17.7 None of Us will be entitled to bring a claim for breach of obligations under this

Agreement by another of Us or incur any liability to another of Us for any losses or damages incurred by that other Alliance Participant to the extent that an Event of Force Majeure occurs and the Affected Participant is prevented from carrying out obligations by that Event of Force Majeure.

17.8 In the event that a Participant reasonably believes that the effects of the Event of

Force Majeure will make it impossible for this Agreement to continue, that Participant may serve notice of this on the Shadow Accountable Care System Board in order that the Shadow Accountable Care System Board can consider whether this Agreement should terminate in accordance with Clause 18.18.

Cessation of Event of Force Majeure

17.9 The Affected Participant must notify each of Us as soon as practicable after the Event

of Force Majeure ceases or no longer causes the Affected Participant to be unable to comply with its obligations under this Agreement. Following such notification, this Agreement will continue to be performed on the terms existing immediately prior to the occurrence of the Event of Force Majeure.

18. RECTIFICATION, EXCLUSION AND TERMINATION

18.1 This Clause 18 sets out the circumstances in which one of Us may be excluded from

the Alliance. These circumstances include:

(a) Wilful Default as more fully described in Clause 18.3 below;

(b) the termination of a Services Contract; or

(c) an event of Insolvency affecting one of Us.

18.2 In cases where the default can be remedied then the Defaulting Participant will be given the opportunity to rectify the problem as set out in Clauses 18.4 to 18.6 below.

Wilful Default

18.3 In this Agreement the phrase "Wilful Default" means that a Participant has committed

one of the following acts or omissions. The Participant committing the act is called the "Defaulting Participant". The acts or omissions are:

(a) an intentional or reckless act or omission by the Defaulting Participant or any

of its officers or representatives appointed to the Shadow Accountable Care System Board or Shadow Accountable Care System Executive which that Defaulting Participant or any of its officers or representatives appointed to the Shadow Accountable Care System Board or Shadow Accountable Care System Executive knew or ought reasonably to have known:

(i) was likely to have harmful consequences for the Alliance, one or more

other Participants, or the Service Users; or

(ii) was a breach of an Alliance Principle;

(b) an intentional or reckless act or omission by the Defaulting Participant or any of its officers or representatives appointed to the Shadow Accountable Care System Board or Shadow Accountable Care System Executive without regard to the possible harmful consequences arising out of the act or omission;

(c) an intentional failure by the Defaulting Participant or any of its officers or

representatives appointed to the Shadow Accountable Care System Board or Shadow Accountable Care System Executive to act in good faith as required under this Agreement;

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(d) a repudiation of this Agreement by the Defaulting Participant;

(e) a failure by the Defaulting Participant to honour an indemnity provided under this Agreement;

(f) a failure by the Defaulting Participant to pay moneys due under this

Agreement within 14 Business Days of being directed to do so in writing by the Shadow Accountable Care System Board;

(g) a fraudulent act or omission by the Defaulting Participant or any of its officers

or representatives appointed to the Shadow Accountable Care System Board or Shadow Accountable Care System Executive;

(h) an intentional failure of, or refusal by, the Defaulting Participant, to effect and

maintain appropriate insurance policy or Indemnity Arrangement which it is obliged to effect and maintain under a Services Contract, this Agreement or at law; or

(i) an intentional or reckless breach of a confidentiality obligation, or other

obligation, in Clauses relating to confidentiality in this Agreement or in a Services Contract although this does not mean any innocent or negligent act, omission or mistake the Defaulting Participant or any of its officers, employees or agents acting in good faith.

Opportunity to Rectify Default

18.4 If at any time a Participant considers that one of Us is in Wilful Default, then that

Participant may call a meeting of the Shadow Accountable Care System Board to decide what action it may take for the good of Our Alliance (a “Rectification Meeting”). Any meeting called under this Clause will be conducted in accordance with Part 1 of Schedule 3 (Shadow Accountable Care System Board – Terms of Reference). We all agree that We will attend all Rectification Meetings.

18.5 At a Rectification Meeting, We will all discuss the reasons why the Defaulting

Participant is failing to comply with its obligations under this Agreement. The Participant calling the Rectification Meeting will have an opportunity to explain why it has called the Rectification Meeting and the Defaulting Participant will have an opportunity to explain why it is so failing. The other Participants to this Agreement will also have an opportunity to give their views.

18.6 If by the end of the Rectification Meeting all Participants other than the Defaulting

Participant consider that an action needs to be taken in order to ensure that the best possible services are being provided to Service Users, then all Participants other than the Defaulting Participant may together issue a Rectification Notice setting out the actions or directions that the Defaulting Participant will take. All Participants other than the Defaulting Participant will always make sure that any actions or directions given under a Rectification Notice are given for Best for Service reasons. We all agree that, if any one of Us is the Defaulting Participant, We will carry out the actions or directions given under the Rectification Notice.

Further Rectification or Exclusion

18.7 If the Defaulting Participant fails to properly carry out the actions or directions set out

under a Rectification Notice then a Participant may call a further meeting in the same way as set out in Clause 18.4. Any meeting called under this Clause 18.7 will be conducted in accordance with Part 1 of Schedule 3 (Shadow Accountable Care System Board – Terms of Reference). If by the end of that further Rectification Meeting all Participants other than the Defaulting Participant are still concerned that the Defaulting Participant is preventing the Service Users from receiving the best service reasonably possible in accordance with the Key Performance Indicators then all Participants other than the Defaulting Participant may together issue a further Rectification Notice or an

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Exclusion Notice to the Defaulting Participant. We all agree that, if any one of Us is the Defaulting Participant, We will abide by the provisions of an Exclusion Notice.

Additional Grounds for Exclusion

18.8 The Commissioner Participants may serve an Exclusion Notice on a Provider

Participant at any time:

(a) if that Provider Participant’s Services Contract is terminated for any reason; or

(b) if that Provider Participant is subject to an act of Insolvency.

Consequences of Exclusion or Termination

18.9 Where a Provider Participant is excluded from the Alliance:

(a) because a Provider Participant's Services Contract is terminated by the Representative Commissioner without cause; or

(b) because a Provider Participant's Services Contract is terminated by the

Provider Participant following a breach or default of the Services Contract on the part of the Representative Commissioner,

and, as a consequence of such termination, that Provider Participant suffers loss, expense or damage then subject to that Provider Participant making reasonable efforts to mitigate its losses:

(c) where Clause 18.9(a) applies, the Representative Commissioner shall

indemnify the Provider Participant in respect of such loss, expense or damage; or

(d) where Clause 18.9(b) applies, the Representative Commissioner shall

indemnify the Provider Participant in respect of such loss, expense or damage.

18.10 Any amounts due in respect of such costs shall be due and payable when actually

incurred by the respective Provider Participant.

18.11 Where a Provider Participant is excluded from the Alliance:

(a) as a result of Insolvency (pursuant to Clause 18.8); or

(b) as a result of Wilful Default (pursuant to Clause 18.7); or

(c) as a result of the Provider Participant's Services Contract has been terminated by the Representative Commissioner following a breach or default on the part of the relevant Provider Participant; or

(d) as a result of the Provider Participant's Services Contract has been terminated

by the relevant Provider Participant without cause;

and where, as a consequence of such exclusion or termination, this causes the Commissioner Participants or any other Provider Participant financial loss, expense or damage then, subject to Clause 16 (Liability and Indemnity) and the Commissioner Participants and any remaining Provider Participants making reasonable efforts to mitigate their losses, the excluded Provider Participant shall indemnify the Commissioner Participants and any other Provider Participant as the case may be, in respect of such loss, expense or damage.

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18.12 Any amounts due in respect of such costs shall be due and payable when actually incurred by the respective Commissioner Participant or Provider Participant (as the case may be).

No double recovery

18.13 We agree that where loss, expense or damage is suffered by one of Us and may be

recovered from one or more of Us pursuant to this Agreement but also pursuant to a Service Contract (for example by way of an indemnity of a claim for breach of contract) then We shall be entitled to recover the loss, expense or damage but shall not seek to recover any such loss, expense or damage more than once. Any sums recovered under one claim shall be accounted for and credited under any separate claim for the same loss, expense or damage.

18.14 Where a Provider Participant is excluded under this Clause 18 or its relevant Service

Contract is terminated in circumstances envisaged under Clause 18.9, that excluded Provider Participant:

(a) shall not be entitled to any payment in respect of overheads, margin or any

reward payment whether or not such payments relate to a period before or after the date of the relevant Exclusion Notice;

(b) shall provide a statement of accounts to the Shadow Accountable Care

System Board setting out the payments it has received under this Agreement and what it has spent in relation to this Agreement up to the date of exclusion and shall return any overpayment where directed to do so by the Shadow Accountable Care System Board within 30 days of such a direction; and

(c) shall be paid any Direct Costs which relate to services provided by it up to the

time of exclusion/termination.

18.15 A Provider Participant which has been excluded or whose Services Contract has been terminated shall have no further interest in Our Alliance nor shall it be represented on the Shadow Accountable Care System Board or Shadow Accountable Care System Executive.

18.16 Nothing shall prevent any of Us entering into separate contractual arrangements with

any excluded Provider Participant (in accordance with Clause 18.17) for the purposes of providing the Services, notwithstanding that it is no longer a member of Our Alliance.

Impact of Exclusion on Services Contracts

18.17 Where a Provider Participant is excluded from the Alliance, We recognise that the

associated Services Contract is likely to be terminated and/or amended at the same time as the exclusion to reflect how the impacted services are to be delivered (by way of example only, the Provider Participant may be requested by the Representative Commissioner to provide the impacted services under a services contract outside the scope of Our Alliance or the Representative Commissioner may look to Our Alliance to deliver the impacted services). In addition to any specific obligations under the relevant Services Contract to ensure a smooth transfer of Services, We agree to work together in good faith to agree the necessary changes so that services continue to be provided for the benefit of the Service Users.

Termination of this Agreement

18.18 The Shadow Accountable Care System Board may resolve to terminate this Agreement

if an Event of Force Majeure renders the continuation of the Agreement impossible pursuant to Clause 17.8.

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18.19 The Shadow Accountable Care System Board may resolve to terminate this Agreement if a Dispute cannot be resolved pursuant to paragraph 1.6(c)( i ) of Schedule 8 of this Agreement.

19. SURVIVORSHIP

19.1 If:

(a) any of Us are excluded from the Alliance; or

(b) this Agreement is terminated or expires for any reason then such termination

or expiry will be without prejudice to rights or obligations accrued as at the date of such termination or expiry and,

those provisions of this Agreement which are expressly or by implication intended to come into or remain in force and effect following such exclusion from the Alliance or termination or expiry of this Agreement, will so continue and continue to apply to a Participant that has been excluded from the Alliance, subject to any limitation of time expressed in this Agreement.

20. VARIATIONS PROCEDURE

20.1. The provisions of this Agreement may be varied at any time by a Notice of Variation signed by the Participants in accordance with this Clause 20. This does not apply where a Variation is a Mandatory Variation.

20.2. If a Participant wishes to propose a Variation, that Participant must submit a draft Notice of Variation to the Chair of the Shadow Accountable Care Board to be considered at the next meeting of the Shadow Accountable Care Board.

20.3. A draft Notice of Variation must set out: 20.3.1. the Variation proposed and details of the consequential amendments to be made to

the provisions of this Agreement; 20.3.2. the date on which the Variation is proposed to take affect; 20.3.3. the impact of the Variation on the achievement of the Alliance Objectives and the Key

Performance Indicators; and 20.3.4. any impact of the Variation on any Service Contracts.

20.4. The Shadow Accountable Care System Board will consider the draft Notice of Variation and either:

20.4.1. Accept the draft Notice of Variation, in which case all Participants will sign the Notice of Variation;

20.4.2. Amend the draft Notice of Variation, such that it is agreeable to all Participants, in which case all Participants will sign the Notice of Variation;

20.4.3. Not accept the draft Notice of Variation, in which case the minutes of the relevant Shadow Accountable Care System Board shall set out grounds for non-acceptance.

21. TRANSFER TO THIRD PARTIES

21.1 Nothing in this Clause 21 (Transfer to third parties) affects any relevant Provider

Participant's rights to assign, delegate, sub-contract, transfer, charge or otherwise dispose of all or any of its rights or obligations under a Services Contract.

21.2 The Provider Participants may not sub-contract any or all of their obligations under

this Agreement.

21.3 The Provider Participant may not assign, delegate, transfer, charge or otherwise dispose of all or any of its rights or obligations under this Agreement without the prior written consent of the Commissioner Participants.

21.4 Each Provider Participant will be responsible for the performance of and will be liable

to each of Us for the acts and omissions of any third party to which it may assign, transfer or otherwise dispose of any obligation under this Agreement as if they were the acts or omissions of that Provider Participant unless:

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(a) the Provider Participant in question has obtained the prior consent of the Commissioner Participants in accordance with Clause 21.3; and

(b) the terms of that assignment, transfer or disposal have been approved and

accepted by that third party so that that third party is liable to each of Us for its acts and omissions.

21.5 This Agreement will be binding on and will be to the benefit of each of Us and Our

respective successors and permitted transferees and assigns.

21.6 Each of the Commissioner Participants may only novate the whole (not part) of this Agreement to any central government department, NHS body or a Minister of the Crown provided it also novates any Services Contract.

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22. PRECEDENCE

22.1 Unless otherwise specifically provided to the contrary in this Agreement, in the event of a conflict or inconsistency between any provision of any of the Services Contracts or any resolution of the Shadow Accountable Care System Board or of the Shadow Accountable Care System Executive with any provisions of this Agreement, the order of precedence below will apply:

(a) the clauses then schedules then appendices and then annexures of any

Services Contract; then

(b) all other documents, if any, which are stated in a Services Contract to be incorporated in that agreement; then

(c) the Clauses then the Schedules of this Agreement; then

(d) any resolution of the Shadow Accountable Care System Board; then

(e) any resolution of the Shadow Accountable Care System Executive.

23. INFORMATION AND FURTHER ASSURANCE

23.1 Each of the Provider Participants will during the Term:

(a) promptly provide to the Commissioner Participants, and to any other person

involved in the performance and achievement of the Alliance Objectives, such information about the Services and such co-operation and access as the Commissioner Participants will reasonably require from time to time in connection with the Alliance Objectives, provided that if the provision of such information, co-operation or access amounts to a Variation, then the Variation Procedure will apply;

(b) identify and obtain all consents necessary for the fulfilment of its obligations

under the Services Contracts; and

(c) comply with any reasonable instructions and guidelines issued by the Commissioner Participants from time to time provided that such compliance does not amount to a Variation in which case the Variation Procedure will apply,

in each case to the extent that such action does not cause a Provider Participant to be in breach of the Exclusion Notice or any Legislation.

23.2 During the Term We will, and will use Our respective reasonable endeavours to

procure that any necessary third parties will, each execute and deliver to the each of Us such other instruments and documents and take such other action as is reasonably necessary to fulfil the provisions of this Agreement in accordance with its terms.

23.3 Subject to Clauses 13 (Intellectual Property Rights), 14 (Confidentiality and Freedom

of Information) and 20 (Variation Procedure) and any associated Schedules, We must during the Term promptly notify each other of any modification, upgrade, improvement, enhancement or development to the Services, or which could be applied to the Services, in each case on a Best for Service basis.

24. ANNUAL REVIEW

24.1 We must ensure that the Shadow Accountable Care System Board carries out an

annual review, on a Best for Service basis unless the Commissioner Participants decide otherwise, to enable the Commissioner Participants to ascertain the extent to which the Key Performance Indicators and the Alliance Objectives will be achieved. The annual review shall address the governance arrangements for the alliance, including the Terms of Reference for the Shadow Accountable Care System Board

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and the Shadow Accountable Care System Executive.

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25. CONTRACT MANAGEMENT RECORDS AND DOCUMENTATION

25.1 Each Provider Participant must at all times during the Term keep, or cause or procure to be kept, and retain, and thereafter for a period not less than six (6) years following expiry or termination of this Agreement, accurate accounts and full supporting documentation containing all data reasonably required for the computation and verification of the provision of the Services and all monies payable or paid under any Services Contract to which that Provider Participant is a party by the Commissioner Participants and give the Commissioner Participants or its agents every reasonable facility from time to time having given reasonable notice in writing during normal business hours to inspect the said accounts records and supporting documentation and to make copies of or to take extracts from them. To the extent that Legislation or the terms of the applicable Services Contract impose more onerous obligations that this Clause 25.1 then We shall comply with the more onerous obligations. We agree that We shall collect and make available all necessary data to ensure that the Commissioner Participants can meet their statutory responsibilities.

25.2 Before We exchange or share any Confidential Information or personal data among

Us, We shall enter into appropriate data sharing agreements.

26. WARRANTIES

26.1 Each of Us warrants to the others that:

(a) it has full power and authority to enter into this Agreement and all governmental or official approvals and consents and all necessary consents have been obtained and are in full force and effect;

(b) its execution of this Agreement does not and will not contravene or conflict

with its constitution, any Legislation, or any agreement to which it is a party or which is binding on it or any of its assets; and

(c) to the best of its knowledge, nothing will have, or is likely to have, a material

adverse effect on its ability to perform its obligations under this Agreement.

26.2 The warranties set out in this Clause 26 (Warranties) are given on the date of this Agreement and repeated on every day during the term of this Agreement.

27. RELATIONSHIP OF THE PARTICIPANTS

27.1 Each of Us will not pledge the credit of one or more other Participants or represent

Ourselves as being one or more other Participants, or an agent, partner, employee or representative of one or more other Participants and none of Us will hold Ourselves out as such or as having any power or authority to incur any obligation of any nature, express or implied, on behalf of one or more other Participants.

27.2 Nothing in this Agreement will be construed as creating a legal partnership or a

contract of employment between any of Us.

27.3 Save as expressly provided otherwise in this Agreement, none of the Provider Participants will be, or be deemed to be, an agent of the Commissioner Participants and none of the Provider Participants will hold itself out as having the authority or power to bind the Commissioner Participants in any way.

27.4 None of Us will place or cause to be placed any order with the Provider Participants or

otherwise incur liabilities in the name of any of the other Participants or their representatives.

28. NOTICES

28.1 Any notices given under this Agreement must be in writing and must be served in the

ways set out below in this Clause 28.1 at the addresses set out at in Part 2 of Schedule 1. The following table sets out the respective deemed time and proof of

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services:

Manner of Delivery

Deemed time of delivery

Proof of Service

Personal delivery

On delivery

Properly addressed and delivered

Prepaid first class recorded delivery domestic postal service

9.00am on the second Business Day after posting

Properly addressed prepaid and posted

29. THIRD PARTY RIGHTS

29.1 A person who is not a Participant has no right under the Contracts (Rights of Third Parties) Act 1999 to enforce or enjoy the benefit of this Agreement.

29.2 Our rights to terminate, rescind or agree any variation, waiver or settlement under this

Agreement are not subject to the consent of any person that is not a Participant.

30. SEVERABILITY

30.1 If any part of this Agreement is declared invalid or otherwise unenforceable, it will be severed from this Agreement and this will not affect the validity and/or enforceability of the remaining provisions.

31. ENTIRE AGREEMENT

31.1 This Agreement and the Services Contracts constitute Our entire agreement and

understanding and, subject to the terms of each Services Contract, supersedes any previous agreement between Us relating to the subject matter of this Agreement.

31.2 Each of Us acknowledges and agrees that in entering into this Agreement We do not

rely on and have no remedy in respect of any statement, representation, warranty or understanding (whether negligently or innocently made) of any person (whether a Participant or not) other than as expressly set out in this Agreement.

31.3 Nothing in this Clause 31 (Entire Agreement) will exclude any liability for fraud or any

fraudulent misrepresentation.

32. WAIVER

32.1 Any relaxation or delay of any of Us in exercising any right under this Agreement must not be taken as a waiver of that right and must not affect Our ability subsequently to exercise that right.

33. DISPUTE RESOLUTION PROCEDURE

33.1 Subject as otherwise specifically provided for in this Agreement, We agree that any

Dispute arising out of or in connection with this Agreement or any of the other Services Contracts will be resolved in accordance with Schedule 8 (Dispute Resolution Procedure) in preference to any right We have to refer the matter to the NHS dispute resolution procedure.

34. COSTS AND EXPENSES

34.1 Each of Us will be responsible for paying Our own costs and expenses incurred in

connection with the negotiation, preparation and execution of this Agreement.

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35. LAW AND JURISDICTION

35.1 This Agreement and any Dispute arising out of or in connection with it, whether such Dispute is contractual or non-contractual in nature, such as claims in tort, for breach of statute or regulation, or otherwise, will be governed by, and construed in accordance with, the laws of England.

35.2 Subject to:

36.2.1 the Participants first complying with Clause 33 (Dispute Resolution

Procedure) and Schedule 9 (Dispute Resolution Procedure); and

36.2.2 any requirement under a Services Contract to refer the matter to the NHS dispute resolution procedure,

the Participants hereby submit to the exclusive jurisdiction of the English courts.

36. COUNTERPARTS

This Agreement may be executed in any number of counterparts, each of which will be regarded as an original, but all of which together will constitute one agreement binding on all of Us, notwithstanding that all of Us are not signatories to the same counterpart.

IN WITNESS OF WHICH We have signed this Agreement as set out in Schedule 1.

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SCHEDULE 1 - PART 1

PARTICIPANTS

No. Participant Address of Principal Office of Participant

Signed for and on behalf of the Participant

1 NHS Bromley Clinical Commissioning Group ("Bromley CCG")

Beckenham Beacon 379 Croydon Road Beckenham BR3 3QL 01689 866544

Print Name:

Signature:

Date:

2 London Borough of Bromley ("Bromley Council")

Civic Centre Stockwell Close Bromley BR1 3UH 020 8464 3333

Print Name:

Signature:

Date:

3 King's College Hospital NHS Foundation Trust ("King's")

Denmark Hill London SE5 9RS 020 3299 9000

Print Name:

Signature:

Date:

4 Oxleas NHS Foundation Trust ("Oxleas")

Pinewood House Pinewood Place Dartford DA2 7WG 01322 625700

Print Name:

Signature:

Date:

5 Bromley Healthcare Community Interest Company ("Bromley Healthcare")

Global House 10 Station Approach Hayes BR2 7EH 020 8315 8880

Print Name:

Signature:

Date:

6 Bromley GP Alliance ("Bromley GP Alliance")

Numeric House 98 Station Road Sidcup DA15 7BY 01689 871933

Print Name:

Signature:

Date:

7 St Christopher's Hospice ("St Christopher's")

51-59 Lawrie Park Road London SE26 6DZ 020 8768 4501

Print Name:

Signature:

Date:

8 Bromley Third Sector Enterprise Community Interest Company ("BTSE")

Community House South St Bromley BR1 1RH 0208 315 1903

Print Name:

Signature:

Date:

Participant [1] and [2] are together referred to in this Agreement as the "Commissioner Participants".

Participants [3] to [8] are together referred to in this Agreement as the "Provider Participants". The Commissioner Participants and the Provider Participants are together referred to as "We", "Us" or "Our" as the context requires.

"Participant" means any of Us.

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SCHEDULE 1 - PART 2

ADDRESSES FOR NOTICES

Participant Address for Notices NHS Bromley Clinical Commissioning Group

Angela Bhan Chief Officer NHS Bromley CCG Beckenham Beacon 379 Croydon Road Beckenham BR3 3QL

London Borough of Bromley

Ade Adetosoye OBE Deputy Chief Executive & Executive Director Education, Care and Health Services London Borough of Bromley Civic Centre Stockwell Close Bromley BR1 3UH


Nick Moberly Chief Executive King's College Hospital NHS Foundation Trust Denmark Hill London SE5 9RS

Oxleas NHS Foundation Trust

Ben Travis Chief Executive Oxleas NHS Foundation Trust Pinewood House Pinewood Place Dartford DA2 7WG

Bromley Healthcare Community Interest Company

Jacqueline Scott Chief Executive Officer Global House 10 Station Approach Hayes BR2 7EH 020 8315 8880

Bromley GP Alliance Clare Ross Interim Chief Operating Officer Bromley GP Alliance 42 High Street Chislehurst BR7 5AQ

St Christopher's Hospice Heather Richardson Joint Chief Executive St Christopher's Hospice 51-59 Lawrie Park Road London SE26 6DZ

Bromley Third Sector Enterprise Community Interest Company

Colin Maclean Chair Bromley Third Sector Enterprise Community House South St Bromley BR1 1RH

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SCHEDULE 1 - PART 3

SERVICE CONTRACTS

Provider Participant

Organisation contract with

Date contract entered into

[insert Provider Participant]

[insert other party(ies) to the Service Contract]

[insert date Service Contract entered into]


NHS Bromley CCG 01/04/2017

Oxleas NHS Foundation Trust NHS Bromley CCG 01/04/2017

Bromley Healthcare Community Interest Company


Bromley GP Alliance NHS Bromley CCG 01/04/2017

St Christopher's Hospice NHS Bromley CCG 01/04/2017

Bromley Third Sector Enterprise Community Interest Company


32

SCHEDULE 2

DEFINITIONS AND INTERPRETATION

1 Interpretation

1.1 The headings in this Agreement will not affect its interpretation.

1.2 Reference to any statute or statutory provision or to Legislation includes a reference to that statute or statutory provision or Legislation as from time to time updated, amended, extended, supplemented, re-enacted or replaced.

1.3 Reference to a statutory provision includes any subordinate legislation made from time

to time under that provision.

1.4 References to Clauses and Schedules are to the Clauses and Schedules of this Agreement, unless expressly stated otherwise.

1.5 References to any body, organisation or office include reference to its applicable

successor from time to time.

1.6 Any references to this Agreement or any other documents or resources includes reference to this Agreement or those other documents or resources as varied, amended, supplemented, extended, restated and/or replaced from time to time and any reference to a website address for a resource includes reference to any replacement website address for that resource.

1.7 Use of the singular includes the plural and vice versa.

1.8 Use of the masculine includes the feminine and vice versa.

1.9 Use of the term “including” or “includes” will be interpreted as being without limitation.

1.10 The following words and phrases have the following meanings:

“Affected Participant” has the meaning set out in Clause 17;

“Agreement” means this Agreement;

“Alliance” means the Participants working together as an alliance to achieve the Alliance Objectives;

"Alliance Intellectual Property"

means any new Intellectual Property developed by Us under this Agreement and in connection with the Alliance;

“Alliance Objective(s)” means the objective set out in Clause 6.1;

"Shadow Accountable Care System Board"

means the board of the Alliance established pursuant to Clause 8;

"Shadow Accountable Care System Executive"

means the team established pursuant to Clause 8;

“Alliance Principles” has the meaning set out in Clause 7.1 (Alliance Principles);

“Best for Service” means best for the achievement of the Alliance Objectives on the

basis of ensuring coherence with the Alliance Principles;

33

“Business Day” means any day which is not a Saturday, Sunday or a bank or public holiday in the United Kingdom;

"Chair" has the meaning set out in paragraph 5.5 of Part 1 of Schedule 3;

“Commencement Date” means 1st October 2017;

“Commissioner Participants”

has the meaning set out in Schedule 1;

“Competition Sensitive

Information”

means Confidential Information which is owned, produced and marked as Competition Sensitive Information including information on costs by one of the Provider Participants and which that Provider Participant properly considers is of such a nature that it cannot be exchanged with the other Provider Participant(s) without a breach or potential breach of competition law;

“Confidential Information”

means the existence of this Agreement, the provisions of this Agreement and all information which is secret or otherwise not publicly available (in both cases in its entirety or in part) including commercial, financial, marketing or technical information, know- how, trade secrets or business methods, in all cases whether disclosed orally or in writing before or after the date of this Agreement;

"Defaulting Participant" has the meaning set out in Clause 18.3;

"Direct Costs" means those costs identified as direct in Schedule 4;

“Dispute” has the meaning set out in Paragraph 1 of Schedule 9 (Dispute

Resolution Procedure);

"EIR" means the Environmental Information Regulations 2004

“Exclusion Notice” means a notice issued pursuant to Clause 18 (Rectification, Exclusion and Termination) which must specify the grounds on which the Exclusion Notice has been issued and which will have the effects specified in Clause 18;

“Event of Force Majeure”

means an event or circumstance which is beyond the reasonable control of any Affected Participants claiming relief under Clause 17 (Force Majeure), including war, civil war, armed conflict or terrorism, strikes or lock outs, riot, epidemic, fire, flood or earthquake, and which directly causes the Affected Participant to be unable to comply with all or a material part of its obligations under this Agreement;

"FOIA" means the Freedom of Information Act 2000

34

"Fund Holder" means Bromley Healthcare Community Interest Company unless otherwise agreed by the Provider;

"IG Guidance for Serious Incidents"

means the Health and Social Care Information Centre’s Checklist Guidance for Information Governance Serious Incidents Requiring Investigation dated June 2013:

“Improvement” means any improvement, enhancement or modification to the

Intellectual Property of a Provider Participant which cannot be used independently of the Intellectual Property of a Provider Participant;

"Indemnity Arrangement"

means either:

(i) a policy of insurance;

(ii) an arrangement made for the purposes of indemnifying a person or organisation; or

(iii) a combination of (i) and (ii);

"Information Governance Breach"

means an information governance serious incident requiring investigation, as defined in IG Guidance for Serious Incidents

"Initial Expiry Date" means 31st March 2019;

“Initial Period” means the period set out in Clause 5.3;

"Insolvency" means any of the following events or circumstances:

(a) where the Provider Participant is or is deemed for the

purposes of any Legislation to be, unable to pay its debts or insolvent;

(b) where a Provider Participant admits its inability to pay its

debts as they fall due;

(c) the value of a Provider Participant’s assets being less than its liabilities taking into account contingent and prospective liabilities);

(d) where, by reason of actual or anticipated financial

difficulties, a Provider Participant commences negotiations with creditors generally with a view to rescheduling any of its indebtedness;

(e) where a Provider Participant suspends, or threatens to

suspend, payment of its debts (whether principal or interest) or is deemed to be unable to pay its debts within the meaning of Section 123(1) of the Insolvency Act 1986;

(f) a moratorium is declared in respect of any of a Provider’s

Participant's indebtedness;

(g) where a Provider Participant calls a meeting, gives a notice, passes a resolution or files a petition, or an order is made, in connection with the winding up of that Participant (save for the sole purpose of a solvent voluntary reconstruction or amalgamation);

(h) where a Provider Participant has an application to appoint

31

an administrator made or a notice of intention to appoint an administrator filed or an administrator is appointed in respect of it or all or any part of its assets;

(i) where a Provider Participant has a liquidator, trustee in

bankruptcy, judicial custodian, compulsory manager, receiver, administrative receiver or similar officer (in each case, whether out of court or otherwise) appointed over all or any part of its assets or a person becomes entitled to appoint the above over such assets;

(j) where a Provider Participant takes any steps in

connection with proposing a company voluntary arrangement or a company voluntary arrangement is passed in relation to it, or it commences negotiations with all or any of its creditors with a view to rescheduling any of its debts; or

(k) where a Provider Participant has any steps taken by a

secured lender to obtain possession of the property on which it has security or otherwise to enforce its security; or

(l) where a Provider Participant has any distress, execution

or sequestration or other such process levied or enforced on any of its assets which is not discharged within 14 Business Days of it being levied;

(m) where a Provider Participant has any proceeding taken,

with respect to it in any jurisdiction to which it is subject, or any event happens in such jurisdiction that has an effect equivalent or similar to any of the events listed above; and/or

(n) where a Commissioner Participant substantially or

materially ceases to operate, is dissolved, or is de- authorised by NHS England, the Department for Health or the Secretary of State.

(o) Where the Commissioner is clinically and/or financially

unsustainable as a result of any clinical or financial intervention or sanction by the regulator responsible for the independent regulation of NHS Foundation Trusts or the Secretary of State and which has a material adverse effect on the delivery of the Services; and

(p) a trust special administrator is appointed under the

National Health Service Act 2006 or a future analogous event occurs;

“Intellectual Property” means rights in and to inventions, patents, design rights

(registered or unregistered), copyrights (including rights in software), rights in confidential information, database rights and any similar or analogous rights that exist anywhere in the world and including any application for any registration of the foregoing;

“Key Performance Indicators”

means the key performance indicators set out in Schedule 5 (Key Performance Indicators);

“Legislation” means any applicable statute, statutory rule, order, directive,

32

regulation or other instrument having force of law (including any directive or order promulgated by any competent national or supra national body) and all other legislation as may be in force from time to time;

"Local Healthwatch" means an organisation established under section 222 of the Local

Government and Public Involvement in Health Act 2007;

“Mandatory Change” means any Change in the scope of the Services which the Commissioner Participants are required to implement by reason of a change in Legislation or applicable health or social care guidance, direction, standard or requirement to which the Commissioner Participants have a duty to have regard;

"Monitor" means the corporate body known as Monitor provided by section

61 of the Health and Social Care Act 2012;

"Misappropriation" means any use of the payments made under this Agreement for matters unrelated to the provision of the Services;

"NHS England" the National Health Service Commissioning Board established by

section 1H of the NHS Act 2006 Act, also known as NHS England;

"NHS Serious Incident Framework"

NHS England’s serious incident framework;

”Participants” has the meaning set out in Schedule 1;

"Patient Safety Incident"

means any unintended or unexpected incident that occurs in respect of a Service User, during and as a result of the provision of the Services, that could have led, or did lead to, harm to that Service User;

"Primary Care Provider Participant"

has the meaning set out in Schedule 1;

“Provider Participants” has the meaning set out in Schedule 1;

"Rectification Meeting" has the meaning set out in Clause 18.4;

"Rectification Notice" means a notice issued by the Representative Commissioner

pursuant to Clause 18.6 which sets out the actions or directions that the Defaulting Participant needs to take to address any failure to meet its obligations under this Agreement;

“Representative Commissioner”

means NHS Bromley Clinical Commissioning Group for the purposes of this Agreement in accordance with Schedule 3;

"Regulatory or Supervisory Body"

any statutory or other body having authority to issue guidance, standards or recommendations with which the relevant Participant and/or staff must comply or to which it or they must have regard;

“Reserved Matters” means each of the matters listed in Clause 9;

33

"Serious Incident" has the meaning given to it in the NHS Serious Incident Framework;

"Service Users” means the people that live in Bromley and are in receipt of the

Services;

“Services” means the Integrated Care Networks pathways as described in Schedule 10 (Scope of the Services) and provided by a Provider Participant pursuant to its Services Contract or by any of the Provider Participants pursuant to the Services Contracts, as the case may be, and as amended from time to time through Schedule 8 (Change Procedure);

“Services Contracts” means the services contracts listed in Part 3 of Schedule 1;

“Term” means the Initial Period and any period of extension made under

Clause 5.4;

"Transfer Regulations" means the Transfer of Undertakings (Protection of Employment) Regulations 2006 and EC Council Directive 77/187; and

"Wilful Default" has the meaning set out in Clause 18.3.

34

SCHEDULE 3 - PART 1

SHADOW ACCOUNTABLE CARE SYSTEM BOARD – TERMS OF REFERENCE

1 Purpose

1.1 The Alliance Leadership has been established to provide strategic direction to the

alliance, to manage risk and to hold to account the Shadow Accountable Care System Executive for the performance of the alliance such that it achieves the objectives set for it.

2 Status and authority

2.1 The Alliance is established by the Participants, who remain sovereign organisations,

to provide a financial and governance framework for the delivery of the Services. The Alliance is not a separate legal entity, and as such is unable to take decisions separately from the Participants or bind its Participants; nor can one or more Participants 'overrule' any other Participant on any matter (although all Participants will be obliged to comply with the terms of the Agreement).

2.2 The Agreement establishes the Shadow Accountable Care System Board to lead the

Alliance on behalf of the Participants. As a result of the status of the Alliance the Shadow Accountable Care System Board is unable in law to bind any Participant so it will function as a forum for discussion of issues with the aim of reaching consensus among the Participants.

2.3 The Shadow Accountable Care System Board will function through engagement

between its members so that each Participant makes a decision in respect of, and expresses its views about, each matter considered by the Shadow Accountable Care System Board. The decisions of the Shadow Accountable Care System Board will, therefore, be the decisions of the Participants, the mechanism for which shall be authority delegated by the Participants to their representatives on the Shadow Accountable Care System Board.

2.4 Each Participant shall delegate to its representative on the Shadow Accountable Care

System Board such authority as is agreed to be necessary in order for the Shadow Accountable Care System Board to function effectively in discharging the duties within these Terms of Reference. The Participants shall ensure that each of their representatives has equivalent delegated authority. Authority delegated by the Participants shall be defined in writing and agreed by the Participants, and shall be recognised to the extent necessary in the Participants' own schemes of delegation (or similar).

2.5 The Participants shall ensure that the Shadow Accountable Care System Board

members understand the status of the Shadow Accountable Care System Board and the limits of the authority delegated to them.

3 Responsibilities

3.1 The Shadow Accountable Care System Board will:

(a) ensure alignment of all organisations to the Integrated Care Networks

vision and objectives;

(b) promote and encourage commitment to the Alliance Principles and Alliance Objectives amongst all Participants;

(c) formulate, agree and ensure that implementation of strategies for

achieving the Alliance Objectives and the management of the Alliance;

(d) discuss strategic issues and resolve challenges such that the Alliance Objectives can be achieved;

35

(e) respond to changes in the operating environment, including in respect of

national policy or regulatory requirements, which impact upon the Alliance or any Participants to the extent that they affect the Participants' involvement in the Alliance;

(f) agree policy as required;

(g) agree performance outcomes/targets for the Alliance such that it achieves the

Alliance Objectives;

(h) review the performance of the Alliance, holding the Shadow Accountable Care System Executive to account, and determine strategies to improve performance or rectify poor performance;

(i) ensure that the Shadow Accountable Care System Executive identifies and

manages the risks associated with the Alliance, integrating where necessary with the Participants' own risk management arrangements;

(j) generally ensure the continued effectiveness of the Alliance, including by

managing relationships between the Participants and between the Alliance and its stakeholders;

(k) ensure that the Alliance accounts to relevant regulators and other stakeholders

through whatever means are required by such regulators or are determined by the Shadow Accountable Care System Board, including, to the extent relevant, integration with communications and accountability arrangements in place within the Participants;

(l) address any actual or potential conflicts of interests which arise for members

of the Shadow Accountable Care System Board or within the Alliance generally, in accordance with a protocol to be agreed between the Participants (such protocol to be consistent with the Participants' own arrangements in respect of declaration and conflicts of interests, and compliant with relevant statutory duties);

(m) oversee the implementation of, and ensure the Participants' compliance with,

this Agreement and all other Services Contracts;

(n) review the governance arrangements for the Alliance at least annually.

4 Accountability

4.1 The Shadow Accountable Care System Board is accountable to the Participants.

4.2 The minutes of the Shadow Accountable Care System Board will be sent to the Participants within ten working days.

4.3 The minutes shall be accompanied by a report on any matters which the Chair

considers to be material. It shall also address any minimum content for such reports agreed by the Participants.

5 Membership and Quorum

5.1 The Shadow Accountable Care System Board will comprise:

(a) Chief Officer, Chief Financial Officer and Director of Transformation from NHS Bromley Clinical Commissioning Group

(b) Deputy Chief Executive & Executive Director – Education, Care and Health Services from London Borough of Bromley

(c) Chief Operating Officer for King’s College Hospital NHS Foundation Trust (d) Chief Executive for Oxleas NHS Foundation Trust (e) Chief Executive for Bromley Healthcare Community Interest Company (f) Chair for Bromley GP Alliance Limited (g) Director of Nursing and Medical Director for St Christopher’s Hospice

36

(h) Chair for Bromley Third Sector Enterprise 5.2 The following persons may attend meetings of the Shadow Accountable Care System

Board as observers but will not participate in decisions:

(a) Representative of the Local Medical Committee

5.3 Other members/attendees may be co-opted as necessary.

5.4 The Shadow Accountable Care System Board will be quorate if two thirds of its members are present, subject to the members present being able to represent the views and decisions of the Participants who are not present at any meeting. Where a member cannot attend a meeting, the member can nominate a named deputy to attend. Deputies must be able to contribute and make decisions on behalf of the Participant that they are representing. Deputising arrangements must be agreed with the Chair prior to the relevant meeting.

5.5 The Shadow Accountable Care System Board will initially be chaired by Angela Bhan,

Chief Officer, NHS Bromley Clinical Commissioning Group (the "Chair"). Mark Cheung, Chief Financial Officer, NHS Bromley Clinical Commissioning Group will be the Deputy Chair.

5.6 A work plan will be created during the life of this Alliance Agreement to define the

structure of the Accountable Care Organisation and the recruitment of (a shadow) ACS Chief Executive Officer and Non-Executive roles.

5.7 Where the Chair is absent, the Deputy Chair shall take on the role of the Chair.

6 Conduct of Business

6.1 Meetings will be held monthly.

6.2 The agenda will be developed in discussion with the Chair. Circulation of the meeting

agenda and papers via email will take place one week before the meeting is scheduled to take place. In the event members wish to add an item to the agenda they need to notify TBC who will confirm this will the Chair accordingly.

6.3 At the discretion of the Chair business may be transacted through a teleconference or

videoconference provided that all members present are able to hear all other parties and where an agenda has been issued in advance.

6.4 At the discretion of the Chair a decision may be made on any matter within these

Terms of Reference through the written approval of every member, following circulation to every member of appropriate papers and a written resolution. Such a decision shall be as valid as any taken at a quorate meeting but shall be reported for information to, and shall be recorded in the minutes of, the next meeting.

7 Decision Making and Voting

7.1 The Shadow Accountable Care System Board will aim to achieve consensus for all

decisions of the Participants.

7.2 To promote efficient decision making at meetings of the Shadow Accountable Care System Board it shall develop and approve detailed arrangements through which proposals on any matter will be developed and considered by the Participants with the aim of reaching a consensus. These arrangements shall address circumstances in which one or more Participants decide not to adopt a decision reached by the other Participants.

8 Conflicts Of Interests

8.1 The members of the Shadow Accountable Care System Board must refrain from

actions that are likely to create any actual or perceived conflicts of interests.

37

8.2 The Shadow Accountable Care System Board shall develop and approve a protocol for addressing actual or potential conflicts of interests among its members (and those of the Shadow Accountable Care System Executive). The protocol shall at least include arrangements in respect of declaration of interests and the means by which they will be addressed. It shall be consistent with the Participants' own arrangements in respect of conflicts of interests, and any relevant statutory duties.

9 Confidentiality

9.1 Information obtained during the business of the Shadow Accountable Care System Board must only be used for the purpose it is intended. Particular sensitivity should be applied when considering financial, activity and performance data associated with individual services and institutions. The main purpose of sharing such information will be to inform new service models and such information should not be used for other purposes (e.g. performance management, securing competitive advantage in procurement).

9.2 Members of the Shadow Accountable Care System Board are expected to protect

and maintain as confidential any privileged or sensitive information divulged during the work of the Alliance. Where items are deemed to be privileged or particularly sensitive in nature, these should be identified and agreed by the Chair. Such items should not be disclosed until such time as it has been agreed that this information can be released.

10 Support

10.1 Support to the Shadow Accountable Care System Board will be provided as part of

a programme management approach.

10.2 The programme structure and supporting work groups will be developed and agreed as part of the Shadow Accountable Care System Board work plan.

11 Review

11.1 These Shadow Accountable Care System Board terms of reference will be formally

reviewed annually.

38

SCHEDULE 3 – PART 2

SHADOW ACCOUNTABLE CARE SYSTEM EXECUTIVE – TERMS OF REFERENCE

12 Purpose

12.1 The Shadow Accountable Care System Executive has been established to manage the alliance, particularly in respect of the delivery of plans to achieve the Alliance Objectives and strategies agreed by the Shadow Accountable Care System Board, and to manage performance and risk.




13.2 The Agreement establishes the Shadow Accountable Care System Executive to

manage the Alliance on behalf of the Participants. As a result of the status of the Alliance the Shadow Accountable Care System Executive is unable in law to bind any Participant so it will function as a forum for discussion of issues with the aim of reaching consensus among the Participants.

13.3 The Shadow Accountable Care System Executive will function through engagement

between its members so that each Participant makes a decision in respect of, and expresses its views about, each matter considered by the Shadow Accountable Care System Executive. The decisions of the Shadow Accountable Care System Executive will, therefore, be the decisions of the Participants, the mechanism for which shall be authority delegated by the Participants to their representatives on the Shadow Accountable Care System Board.

13.4 Each Participant shall delegate to its representative on the Shadow Accountable

Care System Executive such authority as is agreed to be necessary in order for the Shadow Accountable Care System Executive to function effectively in discharging the duties within these Terms of Reference. The Participants shall ensure that each of their representatives has equivalent delegated authority. Authority delegated by the Participants shall be defined in writing and agreed by the Participants, and shall be recognised to the extent necessary in the Participants' own schemes of delegation (or similar).

13.5 The Participants shall ensure that the Shadow Accountable Care System Executive

members understand the status of the Shadow Accountable Care System Executive and the limits of the authority delegated to them.

14 Responsibilities

14.1 The Shadow Accountable Care System Executive will:

(b) promote and encourage commitment to the Alliance Principles and Alliance

Objectives amongst all Participants;

(c) implement strategies agreed by the Shadow Accountable Care System Board to achieve the Alliance Objectives;

(d) identify and escalate to the Shadow Accountable Care System Board

strategic issues and resolve challenges such that the Alliance Objectives can be achieved;

39

(e) implement decisions on the Shadow Accountable Care System Board in response to changes in the operating environment, including in respect of national policy or regulatory requirements, which impact upon the Alliance or any Participants to the extent that they affect the Participants' involvement in the Alliance;

(f) manage the performance of the Alliance, accounting to the Shadow

Accountable Care System Board in this respect;

(g) identify and manage the risks associated with the Alliance, integrating where necessary with the Participants' own risk management arrangements;

(h) implement arrangements through which the Alliance accounts to relevant

regulators and other stakeholders through whatever means are required by such regulators or are determined by the Shadow Accountable Care System Board, including, to the extent relevant, integration with communications and accountability arrangements in place within the Participants;

(i) address any actual or potential conflicts of interests which arise for members

of the Shadow Accountable Care System Executive or within the Alliance generally, in accordance with a protocol to be agreed between the Participants (such protocol to be consistent with the Participants' own arrangements in respect of declaration and conflicts of interests, and compliant with relevant statutory duties);

15 Accountability

15.1 The Shadow Accountable Care System Executive is accountable to the Shadow

Accountable Care System Board.

15.2 The minutes of the Shadow Accountable Care System Executive will be sent to the Shadow Accountable Care System Board within five working days.


considers to be material. It shall also address any minimum content for such reports agreed by the Shadow Accountable Care System Board.


16.1 The Shadow Accountable Care System Executive will comprise:

(a) Chief Officer, Chief Financial Officer and Director of Transformation from NHS

Bromley Clinical Commissioning Group (b) Head of Programme Design (Commissioning) from London Borough of Bromley (c) Managing Director for South Sites from King’s College Hospital NHS

Foundation Trust (d) Deputy Chief Executive and Director of Service Delivery from Oxleas NHS

Foundation Trust (e) Operations Director from Bromley Healthcare Community Interest Company (f) Director of Nursing for St Christopher’s Hospice (g) Chief Operating Officer from Bromley GP Alliance Ltd (h) Chair from Bromley Third Sector Alliance Community Interest Company

16.2 The following persons may attend meetings of the Shadow Accountable Care

System Executive as observers but will not participate in decisions:

(a) X


16.4 The Shadow Accountable Care System Executive will be quorate if two thirds of its members are present, subject to the members present being able to represent the views and decisions of the Participants who are not present at any meeting.

40

16.5 Where a member cannot attend a meeting, the member can nominate a named

deputy to attend. Deputies must be able to contribute and make decisions on behalf of the Participant that they are representing. Deputising arrangements must be agreed with the Chair prior to the relevant meeting.

16.6 The Shadow Accountable Care System Executive will be chaired by [Insert name job

title and organisation] (the "Chair"). [Insert name job title and organisation] will be the Deputy Chair.





agenda and papers via email will take place one week before the meeting is scheduled to take place. In the event members wish to add an item to the agenda they need to notify TBC who will confirm this will the Chair accordingly.






18.1 The Shadow Accountable Care System Executive will aim to achieve consensus for all

decisions of the Participants.

18.2 To promote efficient decision making at meetings of the Shadow Accountable Care System Executive it shall develop and approve detailed arrangements through which proposals on any matter will be developed and considered by the Participants with the aim of reaching a consensus. These arrangements shall address circumstances in which one or more Participants decides not to adopt a decision reached by the other Participants.


19.1 The members of the Shadow Accountable Care System Executive must refrain from

actions that are likely to create any actual or perceived conflicts of interests.

19.2 The Shadow Accountable Care System Executive shall adopt and comply with the protocol for addressing conflicts of interests as approved by the Shadow Accountable Care System Board.

20 Confidentiality

20.1 Information obtained during the business of the Shadow Accountable Care System

Executive must only be used for the purpose it is intended. Particular sensitivity should be applied when considering financial, activity and performance data associated with individual services and institutions. The main purpose of sharing such information will be to inform new service models and such information should not be used for other purposes (e.g. performance management, securing competitive advantage in procurement).

20.2 Members of the Shadow Accountable Care System Executive are expected to protect

and maintain as confidential any privileged or sensitive information divulged during the

41

work of the Alliance. Where items are deemed to be privileged or particularly sensitive in nature, these should be identified and agreed by the Chair. Such items should not be disclosed until such time as it has been agreed that this information can be released.

21 Support

21.1 Support to the Shadow Accountable Care System Executive will be provided as part of a programme management approach.

21.2 The programme structure and supporting work groups will be developed and agreed

as part of the Shadow Accountable Care System Executive work plan.

22 Review

22.1 These Shadow Accountable Care System Executive terms of reference will be formally reviewed annually.

42

SCHEDULE 3 – PART 3

JOINT OPERATING GROUP – TERMS OF REFERENCE

23 Purpose

23.1 The Joint Operating Group has been established to manage the specific alliance delivered services, as directed by the Shadow Accountable Care System Executive, and to manage operational performance and risk.




24.2 The Agreement establishes the Joint Operating Group to manage the de legated

Alliance services and pathways on behalf of the Participants. As a result of the status of the Alliance the Joint Operating Group is unable in law to bind any Participant so it will function as a forum for discussion of issues with the aim of reaching consensus among the Participants.

24.3 The Joint Operating Group will function through engagement between its members so

that each Participant makes a decision in respect of, and expresses its views about, each matter considered by the Joint Operating Group. The decisions of the Joint Operating Group will, therefore, be the decisions of the Participants, the mechanism for which shall be authority delegated by the Participants to their representatives on the Shadow Accountable Care System Executive.

24.4 Each Participant shall delegate to its representative on the Joint Operating Group

such authority as is agreed to be necessary in order for the Joint Operating Group to function effectively in discharging the duties within these Terms of Reference. The Participants shall ensure that each of their representatives has equivalent delegated authority. Authority delegated by the Participants shall be defined in writing and agreed by the Participants, and shall be recognised to the extent necessary in the Participants' own schemes of delegation (or similar).

24.5 The Participants shall ensure that the Joint Operating Group members understand the

status of the Joint Operating Group and the limits of the authority delegated to them.

25 Responsibilities

25.1 The Joint Operating Group will:

(j) promote and encourage commitment to the Alliance Principles and Alliance Objectives amongst all Participants;

(k) implement strategies agreed by the Shadow Accountable Care System

Executive to achieve the Alliance Objectives;

(l) identify and escalate to the Shadow Accountable Care System Executive strategic issues and resolve challenges such that the Alliance Objectives can be achieved;

43

(m) implement decisions on the Shadow Accountable Care System Executive in response to changes in the operating environment, including in respect of national policy or regulatory requirements, which impact upon the Alliance or any Participants to the extent that they affect the Participants' involvement in the Alliance;

(n) manage the performance of the Alliance, accounting to the Shadow

Accountable Care System Executive in this respect;

(o) identify and manage the risks associated with the Alliance, integrating where necessary with the Participants' own risk management arrangements;

(p) implement arrangements through which the Alliance accounts to relevant

regulators and other stakeholders through whatever means are required by such regulators or are determined by the Shadow Accountable Care System Executive, including, to the extent relevant, integration with communications and accountability arrangements in place within the Participants;

(q) address any actual or potential conflicts of interests which arise for members

of the Joint Operating Group or within the Alliance generally, in accordance with a protocol to be agreed between the Participants (such protocol to be consistent with the Participants' own arrangements in respect of declaration and conflicts of interests, and compliant with relevant statutory duties);

26 Accountability

26.1 The Joint Operating Group is accountable to the Shadow Accountable Care System

Executive.

26.2 The minutes of the Joint Operating Group will be sent to the Shadow Accountable Care System Executive within five working days.


considers to be material. It shall also address any minimum content for such reports agreed by the Shadow Accountable Care System Executive.


27.1 The Joint Operating Group will comprise:

(a) Head of Programme Design (Commissioning) from London Borough of Bromley (b) Head of Health Systems Partnerships from King’s College Hospital NHS

Foundation Trust (c) Clinical Director for Older People’s Mental Health Services from Oxleas NHS

Foundation Trust (d) Business Development Director from Bromley Healthcare Community Interest

Company (e) Head of Operations from Bromley GP Alliance Ltd (f) Director of Nursing from St Christopher’s (g) Chair from Bromley Third Sector Alliance Community Interest Company (h) Chief Executive from Age UK Bromley and Greenwich

27.2 The following persons may attend meetings of the Joint Operating Group as

observers but will not participate in decisions:

(b) X


27.4 The Joint Operating Group will be quorate if two thirds of its members are present, subject to the members present being able to represent the views and decisions of the Participants who are not present at any meeting.

44

27.5 Where a member cannot attend a meeting, the member can nominate a named deputy to attend. Deputies must be able to contribute and make decisions on behalf of the Participant that they are representing. Deputising arrangements must be agreed with the Chair prior to the relevant meeting.

27.6 The Joint Operating Group will be chaired by [Insert name job title and

organisation] (the "Chair"). [Insert name job title and organisation] will be the Deputy Chair.





agenda and papers via email will take place one week before the meeting is scheduled to take place. In the event members wish to add an item to the agenda they need to notify [TBC] who will confirm this will the Chair accordingly.






29.1 The Joint Operating Group will aim to achieve consensus for all decisions of the

Participants.

29.2 To promote efficient decision making at meetings of the Joint Operating Group it shall develop and approve detailed arrangements through which proposals on any matter will be developed and considered by the Participants with the aim of reaching a consensus. These arrangements shall address circumstances in which one or more Participants decides not to adopt a decision reached by the other Participants.


30.1 The members of the Joint Operating Group must refrain from actions that are likely to

create any actual or perceived conflicts of interests.

30.2 The Joint Operating Group shall adopt and comply with the protocol for addressing conflicts of interests as approved by the Shadow Accountable Care System Executive.

31 Confidentiality

31.1 Information obtained during the business of the Joint Operating Group must only be

used for the purpose it is intended. Particular sensitivity should be applied when considering financial, activity and performance data associated with individual services and institutions. The main purpose of sharing such information will be to inform new service models and such information should not be used for other purposes (e.g. performance management, securing competitive advantage in procurement).

31.2 Members of the Joint Operating Group are expected to protect and maintain as

confidential any privileged or sensitive information divulged during the work of the Alliance. Where items are deemed to be privileged or particularly sensitive in nature, these should be identified and agreed by the Chair. Such items should not be disclosed until such time as it has been agreed that this information can be released.

45

32 Support 32.1 Support to the Joint Operating Group will be provided as part of a programme

management approach.

32.2 The programme structure and supporting work groups will be developed and agreed as part of the Joint Operating Group work plan.

33 Review

33.1 These Joint Operating Group terms of reference will be formally reviewed annually.

46

SCHEDULE 4

RISK/REWARD MECHANISM 1. The funding initially allocated to this Alliance Agreement will comprise the recurrent budget

for the named ICN roles related to the Proactive Care and Frailty pathways, £606k Full Year Effect.

2. In addition to this, any under performance against the Performance Fund made available

through the Memorandum of Understanding will be carried forward as an investment fund in to the Alliance Agreement (range £0 to £500k). The Performance Fund will be reviewed (2016/17 Q2 v 2017/18 Q2) in December 2017.

3. Further, subject to London Borough of Bromley Executive approval, allocations in the Better

Care Fund and Integrated Better Care Fund related to Care Homes and Therapy Services (ICN Next Steps projects) can be bid against by the Shadow Accountable Care System Board (range TBC).

4. In the first instance (while in Shadow form), Commissioner Participants will the risk on

delivery. There is an expectation that this risk will become collective, proportionally, as governance structures are developed towards a full Accountable Care System.

47

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48

SCHEDULE 5

KEY PERFORMANCE INDICATORS

[For local determination]

Modelling

170831 ICN ROI v2.xlsx

No.

KPI description and

threshold to be achieved

Method of

measurement

Evidence to be provided

Frequency

of application

of KPI

Consequence of

not achieving threshold

1 Reduction in 2017/18 emergency admissions by 1,595 Spells.

Spells SUS Quarter on Quarter

TBC

2 Reduction in Delayed Transfers of Care 2017/18 – as per NHS England trajectory TBC

Days england.nhs.uk Quarter on Quarter

TBC

3 Reduction in 2017/18 A&E visits by 1,876 attendances.

Attendances SUS Quarter on Quarter

TBC

4 Reduction in 2017/18 emergency readmissions within 30 days by x Spells.


TBC

5 Reduction in 2018/19 emergency admissions by 2,197 Spells.


TBC

6 Reduction in Delayed Transfers of Care 2018/19 – as per NHS England trajectory TBC

Days england.nhs.uk Quarter on Quarter

TBC

7 Reduction in 2018/19 A&E visits by 3,168 attendances.

Attendances SUS Quarter on Quarter

TBC

8 Reduction in 2018/19 emergency readmissions within 30 days by x Spells.


TBC

49

SCHEDULE 6

CONFIDENTIAL INFORMATION OF THE PARTICIPANTS

1. CONFIDENTIAL INFORMATION OF THE PARTICIPANTS

1.1 We will, except as permitted by this Schedule 6, keep confidential all information disclosed to any one of Us by any Participant in connection with this Agreement, and We will use all reasonable endeavours to prevent staff in Our organisations from making any disclosure to any person of that information.

1.2 Paragraph 1.1 above will not apply to disclosure of information that:

(a) is in or comes into the public domain other than by breach of this Agreement;

(b) the receiving Participant can show by its records was in its possession before it

received it from the disclosing Participant; or

(c) the receiving Participant can prove it obtained or was able to obtain from a source other than the disclosing Participant without breaching any obligation of confidence.

1.3 A Participant may disclose the other Participant’s Confidential Information:

(a) to comply with applicable Legislation;

(b) to any appropriate Regulatory or Supervisory Body;

(c) in connection with any dispute resolution or litigation between the Participants;

(d) as permitted under any other express arrangement or other provision of this

Agreement; and

(e) where the disclosing Participant is a Commissioner Participant, to NHS bodies for the purposes of carrying out their duties.

50

SCHEDULE 7

FREEDOM OF INFORMATION AND TRANSPARENCY

1 Freedom of Information and Transparency

1.1 We acknowledge that certain Participants are subject to the requirements of FOIA and

EIR. We will assist and co-operate with each Participant to enable it to comply with its disclosure obligations under FOIA and EIR. We agree:

(a) that this Agreement and any other recorded information held by any of Us for

the purposes of this Agreement are subject to the obligations and commitments of the Participants that are subject to the FOIA and EIR;

(b) that the decision on whether any exemption under FOIA or exception under

EIR applies to any information is a decision solely for the Participant to whom a request for information is addressed;

(c) that where a Participant receives a request for information relating to this

Agreement, it will liaise with the Shadow Accountable Care System Board as to the contents of any response before a response to a request is issued and will promptly (and in any event within 2 Business Days) provide a copy of the request and any response to the Shadow Accountable Care System Board;

(d) that where a Participant receives a request for information and the Participant

is not itself subject to FOIA or as applicable EIR, it will not respond to that request (unless directed to do so by the Participant to whom the request relates) and will promptly (and in any event within 2 Business Days) transfer the request to the Shadow Accountable Care System Board;

(e) that any Participant, acting in accordance with the codes of practice issued

and revised from time to time under both section 45 of FOIA and regulation 16 of EIR, may disclose information concerning another Participant and this Agreement either without consulting with the relevant Participant, or following consultation with the Participant and having taken its views into account; and

(f) to assist each Participant in responding to a request for information, by

processing information or environmental information (as the same are defined in FOIA or EIR) in accordance with a records management system that complies with all applicable records management recommendations and codes of conduct issued under section 46 of FOIA, and providing copies of all information requested by that Participant within 5 Business Days of that request and without charge.

1.2 We acknowledge that, except for any information which is exempt from disclosure in

accordance with the provisions of FOIA, or for which an exception applies under EIR, the content of this Agreement is not Confidential Information.

1.3 Notwithstanding any other term of this Agreement, We consent to the publication of

this Agreement in its entirety (including variations), subject only to the redaction of information that is exempt from disclosure in accordance with the provisions of FOIA or for which an exception applies under EIR.

1.4 In preparing a copy of this Agreement for publication the Shadow Accountable Care

System Board may consult with the Participants to inform decision-making regarding any redactions but the final decision in relation to the redaction of information will be at the Shadow Accountable Care System Board's absolute discretion.

1.5 We will assist and cooperate with each other to enable this Agreement to be

published.

52

SCHEDULE 8

DISPUTE RESOLUTION PROCEDURE

1 Avoiding and Solving Disputes

1.1 We commit to working cooperatively to identify and resolve issues to Our mutual satisfaction so as to avoid all forms of dispute or conflict in performing our obligations under this Agreement.

1.2 We believe that:

(a) by focusing on our agreed Alliance Objectives and Alliance Principles;

(b) being collectively responsible for all risks; and

(c) fairly sharing risk and rewards as part of the Risk/Reward Mechanism

reinforce our commitment to avoiding disputes and conflicts arising out of or in connection with Our Alliance.

1.3 We shall promptly notify each other of any dispute or claim or any potential dispute or

claim in relation to this Agreement or the operation of Our Alliance (each a 'Dispute') when it arises.

1.4 In the first instance the Shadow Accountable Care System Executive shall seek to

resolve any Dispute to the mutual satisfaction of each of Us. If the Dispute cannot be resolved by the Shadow Accountable Care System Executive within 10 Business Days of the Dispute being referred to it, the Dispute shall be referred to the Shadow Accountable Care System Board for resolution.

1.5 The Shadow Accountable Care System Board shall deal proactively with any Dispute

on a Best for Service basis in accordance with this Agreement so as to seek to reach a unanimous decision. If the Shadow Accountable Care System Board reaches a decision that resolves, or otherwise concludes a Dispute, it will advise Us of its decision by written notice. Any decision of the Shadow Accountable Care System Board will be final and binding on Us.

1.6 We agree that the Shadow Accountable Care System Board, on a Best for Services

basis, may determine whatever action it believes is necessary including the following:

(a) If the Shadow Accountable Care System Board cannot resolve a Dispute, it may select an independent facilitator to assist with resolving the Dispute; and

(b) The independent facilitator shall:

(i) be provided with any information he or she requests about the

Dispute;

(ii) assist the Shadow Accountable Care System Board to work towards a consensus decision in respect of the Dispute;

(iii) regulate his or her own procedure and, subject to the terms of this

Agreement, the procedure of the Shadow Accountable Care System Board at such discussions;

(iv) determine the number of facilitated discussions, provided that there

will be not less than three and not more than six facilitated

53

discussions, which must take place within 20 Business Days of the independent facilitator being appointed; and

(v) have its costs and disbursements met by the Commissioner

Participants.

(c) If the independent facilitator cannot facilitate the resolution of the Dispute, the Dispute must be considered afresh in accordance with this Schedule 9 and only after such further consideration again fails to resolve the Dispute, the Shadow Accountable Care System Board may decide to:

(i) terminate the Alliance; or

(ii) agree that the Dispute need not be resolved.

54

SCHEDULE 10

SCOPE OF SERVICES THE INTEGRATED CARE NETWORK MODEL • The NHS Five Year Forward view sets out a clear direction for the NHS to

develop new models of care to provide more integrated services; To make this happen, barriers between hospital, community and primary care will need to be removed so the focus is on patients and systems of care rather than individual organisations.

• An ICN model for providing more integrated care services for patients in Bromley has been co-developed with key stakeholders (including representatives from Healthwatch and patient representatives), where services will be brought together and care will be more co-ordinated.

• These have been put in place in Bromley from October 2016, across three geographical areas each covering around a third of the registered Bromley population.

• The ICN model of care brings together a range of health and care services to work in a more joined up way to provide care for patients, and enables services to be more responsive to the needs of patients by focussing on preventing ill health and proactively managing patients with complex or long term health conditions.

• The ICN model has been developed in partnership with local health and social care providers, GPs and other clinical leaders; The plans have also been tested with patients and further refined following their feedback.

• To make the ICN model of care work, there will be extra resources and staff and new ways of working that will bring services together in a more seamless way, and improve the care of our most vulnerable patients.

• From October 2016 the Proactive Care Pathway has been introduced, identifying those patients with complex or long term conditions that need extra support to keep well and avoid having a crisis and ending up in hospital.

PROACTIVE CARE: PATIENT IDENTIFICATION

55

PROACTIVE CARE: ELIGIBILITY CRITERIA

• A set of eligibility criteria will be applied to patients identified through the case finding and risk stratification tool.

• As part of the eligibility criteria, patients with a certain ‘Rockwood Frailty Index’ score will be picked up through the risk stratification as requiring integrated case management.

• In addition, an appropriate form of consent will need to be in place for all patients referred to this service. Appropriate consent may include written confirmation from any referring professional (e.g. via a referral/clinic letter or completed referral form) evidencing that verbal consent was given by the patient. The Community Matron will discuss the role of the MDT and the support that will be available with the patient. This will be supported by provision of an information leaflet to allow the patient and their families, if appropriate)to make an informed choice.

INCLUSION CRITERIA EXCLUSION CRITERIA

• Adults over 18 years of age identified as high risk and high system users

• Patients with a Bromley GP, who can be safely managed at home or in a community setting with support from appropriate agencies

• Patients must not require emergency medical treatment or extensive medical investigations to be undertaken in an acute setting

• People entering into the proactive care pathway should be ‘complex patients’ with two plus co-morbidities.

• Based on clinical opinion, the patient is likely to benefit from symptom and disease management including support to meet their continuing and changing needs. Patient presentations may include e.g.:

High risk of hospital admission and / or a history of hospital discharge/admission/A&E visit

Acute change in condition from baseline/considered to be at risk of acute changes

Change in functional status/decline in condition over 14 days

Deterioration in cognitive impairment and / or in condition (as per Rockwood Frailty Score) where it is deemed they would benefit from MDT case management to proactively prevent a likely crisis situation

• Individuals under 18 years of age • Patients who do not have a Bromley

GP, but who definitely require emergency or continued medical treatment in an acute setting.

• Patients with challenging behaviour or who require specialist psychiatry or psychology interventions. (patients may be deemed suitable for management in the Proactive Care Pathway , following specialist interventions and advice to the team that they can be safely managed)

• Patients on an end of life pathway: Patients are ‘approaching the end of life’ when they are likely to die within the next 12 months. This includes patients whose death is imminent (expected within a few hours or days) and those with:

Advanced, progressive, incurable conditions

General frailty and co-existing conditions that mean they are expected to die within 12 months

Existing conditions if they are at risk of dying from a sudden acute crisis in their condition

Life-threatening acute conditions caused by sudden catastrophic events.

PROACTIVE CARE: DEMAND ON THE SYSTEM

• 2% of the adult population requires risk stratification and care planning per annum (as per the NHS England requirement for GPs)

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• In Bromley this equates to circa 6,500 people per annum. • 0.5% of the adult population are classed as ‘very high risk’ and require

integrated case management (per the Kaiser Permeante risk stratification pyramid)1.

• In Bromley this equates to circa 1,600 people per annum. • This equates to eight people per GP per annum (based on there being circa 200

GPs in Bromley). • The average additional time input needed for each person referred into the

proactive care pathway is 20 hours per annum, broken down as follows: • Initial holistic assessment, including write up: 3 hours • Development and update of an integrated care plan: 6.5 hours • Arranging regular MDTs based on 0.25 hours per week for 10 weeks: 2.5 hours • Point of contact for person based on 0.5 hours per week for 10 weeks: 5 hours • Step down holistic assessment, including write up: 3 hours

PROACTIVE CARE: THE PATHWAY

PROACTIVE CARE: HOLISTIC ASSESSMENT

• Once an individual has been selected as being eligible for the proactive care pathway and they have confirmed they are happy for this then they will have a holistic needs assessment carried out by a Community Matron.

• The Holistic Assessment adds structure and rigour in to the ICM process to ensure all aspects, namely physical, social, psychological and spiritual aspects, of a person are considered.

• There are a variety of non-medical needs which can contribute to poor health outcomes, for example social isolation, insufficient physical activity, poor diet or inadequate housing conditions.

• The Holistic Assessment acts as an overview of all health and social care needs, and provides up to date patient information, as well as helping the MDT

1 The Kaiser Permeante risk stratification pyramid illustrates how the biggest users of the health and social care system account for 0.5% of the population. These are the cohort of people that the ICNs are aiming to target and provide more coordinated case management for in order to proactively manage their comorbidities and LTCs and prevent them entering into crisis and requiring an acute intervention.

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members identify any wider patient needs that may not have been considered by health and care professionals reviewing the patient from a single service perspective.

• Individual services will continue to complete their individual assessments and bring these along to the MDT meetings, but where possible information will be collated from these pre-existing assessments prior to the wider holistic assessment being carried out with the patient. This will help to reduce duplication as well as highlighting any potential gaps in the existing care provision.

• Patient’s needs are categorised through an initial holistic assessment in the form of a guided discussion with the patient, which will identify the individual needs of the person (clinical, psychological, social, economic, practical, physical, spiritual). including the patient’s abilities, strengths and preferences.

• The Community Matron will focus on the needs identified and prioritise them (with input from the individual).

• The assessment acts as part of the care planning process in the context of a collaborative working relationship between the patient and the health and care professionals supporting them.

• Patients will be signposted to other services that might help support them and more effectively self-manage their conditions.

• Patients appointments will be coordinated through the MDT Liaison Coordinators and the Care Navigators to ensure there is no duplication of appointments / diagnostics / tests.

PROACTIVE CARE: INTEGRATED CARE PLANNING

• Personalised care planning is a way of ensuring that individuals living with one or more LTCs and their health and care professionals have more productive and equal conversations, focused on what matters most to that individual. It is a collaborative process between equals to discuss: What is important to them, setting goals they want to work towards. Things they can do to live well and stay well (and for some people, dying

well). What support they need for self-management. Agreeing actions they can take for themselves. What care and support they might need from other and how this can best

fit in with the rest of their lives. What good support looks like to them as an individual. Preparing for the future, including making choices and stating in advance

preferences for care at the end of their life (where relevant and appropriate).

• The aim should be for a single plan to be developed that includes all aspects of an individual’s health, wellbeing and life.

• Care plans should be developed collaboratively with the patient and in conjunction with other health and social care plans. The care plan should help the patient to feel in control of their care and should draw on the expertise from a number of health and social care providers.

• All plans should include the patient’s goals and what both the services and the patient needs to do to enable the patient to reach those goals and manage their health and wellbeing effectively. Care plans should enable appropriate interventions, including support and information, and signposting or referral to other services if required.

• Using the outputs of the Holistic Needs Assessment, the Community Matron (supported by the MDT Liaison Coordinator) will develop an Integrated Care and Support Plan for the individual.

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• This plan will be discussed and updated at the MDT meetings, with input from all relevant health and care professionals.

• The person will receive a copy of their Integrated Care and Support Plan. PROACTIVE CARE: MDT MEETINGS

• The purpose of the MDT meetings are to bring the right professionals together in order to support more joined-up patient care, and to review the care of each individual, and to update the integrated care and support plan.

• The MDT team composition is vital as the relevant key professionals and partners involved in the patient’s care need to form part of an effective MDT. Each MDT member has clearly defined roles and responsibilities within the team which they have signed up to and which are included in their job plans and each play a role in sharing learning and best practice with peers. The ICN MDTs will be attended by representatives from each relevant health and care group, but as a minimum will include a MDT GP Chair, Interface Geriatrician, Community Matron, MDT Liaison Coordinator, Social Worker, Mental Health professional, and a Care Navigator.

• Effective clinical governance is essential to the success of MDTs. The purpose of the MDT and its expected outputs should be clearly defined, with agreed policies, guidelines or protocols

• At the MDT meeting where a patient is initially presented, the MDT members will jointly identify any gaps in the patient’s care and develop an integrated care and support plan to close those gaps, and also to provide more joined up care for the patient. In the meeting there will be a requirement to capture information discussed and each member, as a representative of their organisation, should ensure the appropriate referrals and actions are made.

• When the MDT first assesses an individual they will collectively agree the primary care need of the individual, and assigns a named clinical lead to manage that primary need.

• Once a care plan has been agreed, it is necessary for representatives from different services to continue to meet on a regular basis to discuss any progress made on the individual cases, to identify and flag any deterioration or increase of needs, to agree next / follow up actions, and to update the care plan to reflect these conversations. The MDT will meet at regular intervals (either physically or virtually) to assess the care needs of the individual and amend their care plan as necessary.

• The MDT team will collectively agree when an individual’s health and care needs have improved to a point where their needs can be reviewed on a less regular basis.

• In addition to the roles of members of the MDT, it is vital that there is organisational support for MDTs underpinning the system.

PROACTIVE CARE: SOCIAL PRESCRIBING PORTAL

• There is a new online Bromley social prescribing directory called ‘Bromley Connect for Wellbeing’, that will be delivered by Community Links Bromley, and is based on Essex and East Kent models.

• The portal will hold up to date information on local and national information and services.

• The portal will be supported by a new role – the Social Prescribing Administrator – who is responsible for the operational delivery of the social prescribing portal.

• Healthcare professionals, MDT Liaison Coordinators and Care Navigators within the ICNs will be able to refer patients into the Social Prescribing Portal.

• Referrals will be matched with community based providers of activities and

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services that improve health and well being. • Patients will be supported on an individual basis to identify activities which

improve their health and well being. • Community based providers will support needs such as social isolation, long

term health conditions, wellbeing, housing, unemployment, welfare benefits. • Patients will be also supported to access volunteering opportunities through the

portal. • There is a facility to track and analyse referrals so outcomes from social

prescribing activities can be monitored. • Outcomes will be monitored by the provider Joint Operational Group and the

CCG. PROACTIVE CARE: SOCIAL PRESCRIBING ADMINISTRATOR

• The Social Prescribing Administrator will be responsible for the operational delivery of the web-based online Bromley Social Prescribing Directory - Bromley Connect for Wellbeing - as a quality assured and up-to-date source of information providing a referral system for the Bromley ICNs.

• The role will require proactive engagement with the MDT Liaison Coordinators, Care Navigators and other professionals within the ICN MDTs to raise awareness of and stimulate interests in – and usage of – the Bromley Social Prescribing Directory.

• The main tasks of the Social Prescribing Administrator are: To develop a comprehensive, wide knowledge of support services in the

community to meet different needs including: social isolation, long term health conditions, wellbeing, housing, unemployment, welfare benefits.

To keep the web-based Social Prescribing Directory up-to-date with links to other related national and local websites for quality assured and up-to-date sources of information.

To act as the central point of contact for enquiries about referrals to the Bromley Social Prescribing Directory.

To provide information on local community services and activities to the MDT Liaison Coordinators, Care Navigators and people referred on the Proactive Care and Frailty pathways, including signposting and brokering where appropriate.

To support the continuous improvement of the Social Prescribing Directory by liaising within CLB and other key Third Sector partners.

To support people on the Proactive Care and Frailty pathways to access volunteer opportunities through the CLB Volunteer Centre either via the face-to-face service or by web site / email / phone.

To match health champion volunteers with people who have been identified on their ICN support and care plan as requiring motivation and encouragement with self-care and self-management.

To set up and coordinate special events and outreach events in the community locations in order to promote the benefits of the Directory.

PROACTIVE CARE: CARE NAVIGATOR

• Each Care Navigator is aligned to one of the ICNs in Bromley, and a key element of this role will be in developing good working relationships with Community teams including Primary Care and other key stakeholders within each ICN.

• This role includes supporting people identified through both the Proactive Care and Frailty pathways by helping to signpost them to the most relevant services (medical and non-medical third sector services) to enable those individuals to

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achieve improved health and care outcomes. • The Care Navigators are part of the MDT meetings with a focus on encouraging

self-care and self-management, including signposting to voluntary and community organisations and local relevant education programmes.

• They have responsibility for non-medical assessment; development and co-ordination of plans for individual in association with the professionals in the ICN, monitoring those services and their impact on client care, giving feedback on outcomes and client satisfaction to the organisation.

• They work with colleagues from across a number of services in developing a multi-disciplinary approach to patient care, ensuring a holistic approach is taken.

• They will ensure that services work together to provide a seamless service which adds both financial and patient value, reduces unnecessary duplication, builds relationships between services and manage perceived gaps in care.

• The Care Navigator is an advocate for clients, and works with both clients and providers, to achieve the best outcomes.

• They provide both emotional support for vulnerable clients, and motivational skills to support change management and create a supportive working environment for both the organisation and service users.

• They also liaise with the Social Prescribing Administrator in using and updating the Social Prescribing Portal, which is an (online) directory of all health and care services in Bromley (including voluntary services).

• The Care Navigator will work with the MDT Liaison Coordinator to book appointments for patients (either directly or following a referral from a health and care professional).

PROACTIVE CARE: CARE NAVIGATOR MANAGER

• The Care Navigator Manager will primarily be based at the Integrated Unit at Orpington Hospital.

• They will line manage the team of Care Navigators based within the ICNs, providing support and resilience to the Care Navigators, including a strong sense of community focused care planning.

• They will also lead on providing a hospital interface for the Care Navigation team.

• The Care Navigation Manager will be involved with supporting patients to avoid hospitalisation where possible, as well as ensuring the Care Navigator team is effectively managing and responding to the non-medical referrals from GPs and other health and care professionals to support patients in self-management.

• They will also lead on linking with key hospital based staff involved in the medical care of people on the Proactive Care and Frailty pathways if they are admitted for acute care, and in consultation with them, identify the non-medical support or changing needs of people on the pathways whilst they are inpatients.

• Prior to discharge from hospital they will provide people with information / advice, proactively signposting and supporting them to access a range of non-medical services to promote their health and wellbeing, maintain their independence within the community and help to prevent unnecessary readmission to hospital.

• This role is will operate as the non-medical interface between the hospital and the community and will support the Proactive Care and Frailty pathways, ensuring patients being discharged have access to the right third sector services to help avoid future admissions, as well as supporting them to self-manage going forward where possible.

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PROACTIVE CARE: MDT LIAISON COORDINATOR

• Each of the MDT Liaison Coordinators is aligned to one of the new emerging ICNs in Bromley, and a key element of this role will be in developing good working relationships with Primary Care (GPs and practice staff) and other key stakeholders within each ICN, and the main tasks of the MDT Liaison Coordinator are to: Proactively develop strong working relationships including with Primary

Care, specifically with GPs, Practice Nurses and Practice Managers. This will include travelling between the various locations within the relevant ICN, as well as across the borough-wide area.

Process the initial referral via Bromley Healthcare’s Single Point of Entry. This will include taking messages from GPs, processing referral information and internal enquiries received from Bromley Healthcare.

Communicate with the patient’s GP if any additional information is required for the referral, being able to give consistent, up to date and accurate information.

Act as the point of contact for the MDT GP Chair once referrals onto the Proactive and Frailty Pathways start to be accepted from other health professionals.

Arrange for the initial holistic assessment by the Community Matron (or other Trusted Assessor as appropriate), within agreed timescales.

Coordinate the resulting integrated care plan and all relevant patient information and include the patient in the most appropriate MDT within the ICN.

Arrange the MDT sessions, including ensuring the attendance of all relevant personnel and coordinating a dial in facility for each patient’s GP.

Schedule all MDT meetings including managing the meeting agenda items, ensuring all new referrals are identified, and circulating the relevant papers / information to MDT members in advance of the meeting.

Ensure the MDT meetings run effectively and are well structured and all decisions are recorded.

Ensure an updated integrated care plan is completed post the MDT session and assigned to the relevant lead clinician.

Hand over the appropriate elements of the patients’ details to the assigned Clinical Lead and Care Navigator, ensuring initial contact is made with the patient within the agreed time period.

Act as a point of escalation for the Care Navigator should they encounter any blockages in the system.

PROACTIVE CARE: MDT GP CHAIR

• Patients will be proactively identified and referred to the ICN, and discussed at regular MDT meetings, of which the MDT GP chair will be the lead.

• Each of the MDT GP Chair roles will be aligned to one of the new emerging ICNs in Bromley, and a key element of this role will be in providing clinical leadership to the MDT meetings and providing clinical judgement and oversight to the case finding by other health and care professionals to ensure the right patients are identified for the integrated case management.

• The key responsibilities of the MDT GP Chair are to: Provide clinical leadership within the MDT by overseeing the primary

focus of the MDT and the management of the patient journey. Lead monthly MDT meetings with all healthcare professionals.

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Apply clinical judgement to ensure consistency of referrals from local Practices and non GP identified cases (year 2).

Ensure the efficient running of the MDT by identifying the appropriate clinical lead assigned to the patient and that continued coordinated care is provided appropriately by the MDT Liaison Coordinator and Care Navigator.

Clarify expectations and goals to Provider members of the MDT, provide feedback and effective evaluation and hold individual Provider members of the MDT to account.

Act as a support liaison to GP’s and primary care, and encourage them to refer to the Proactive Care and Frailty Pathways.

Oversee clinical governance and quality assurance and identify opportunities for improvement for the frailty and proactive pathways.

Act as a senior point of escalation for the members of the MDT should they encounter any problems and provide support and motivation for all members of the MDT; Make professional, autonomous decisions in relation to presenting problems.

Record clear and contemporaneous consultation notes to agreed standards.

Triage of referrals in year 2. PROACTIVE CARE: INTERFACE GERIATRICIAN

• The interface geriatrician is a newly defined role in Bromley and will operate as an integral part of the ICNs.

• The overall remit for the interface geriatrician is to work cooperatively with a wide range of partners and pathways to provide holistic, evidence-based out of hospital medical assessment and treatment of older patients, where possible avoiding inappropriate admission to hospital and ensuring safe timely discharge.

• Playing a key role within the ICN, the Interface Geriatrician works to improve access to local health and social care services for people in Bromley.

• The Interface Geriatrician takes primary responsibility for comprehensive geriatric assessments where required; the development and co-ordination of plans for the service users on the Proactive Care and Frailty Pathways; monitoring those services and their impact on client care, collating feedback on outcomes and client satisfaction to the ICN Board.

• They will work with colleagues from across a number of services in developing a multi-disciplinary approach to patient care, ensuring an holistic approach is taken.

• Fundamental to this approach will be ensuring that services work together to provide a seamless service which adds both financial and patient value, reduces unnecessary duplication and builds relationships between services.

• The Interface Geriatrician is confident in the use of patient identification and case finding approaches to assist in identifying at risk client groups

• They will provide input to community based clinics in order to provide rapid, high quality one stop face to face assessment/treatment, plus telephone advice to GPs

• They will act as an Interface with secondary care team / integrated discharge team (including Post Acute Care Enablement team) to promote high quality care transitions.

PROACTIVE CARE: MENTAL HEALTH PROFESSIONAL

• This is a new post which has been developed to enhance the Out of Hospital Transformation in Bromley. The key roles of the post are:

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To develop, and in collaboration with professional colleagues, to deliver effective and efficient mental health services for people with dementia and other mental health problems, and to provide clinical leadership for excellent care.

To support the Proactive Care and Frailty pathways that form part of the ICN model of care in Bromley.

• The main roles and responsibilities of the post are: Management of patients in the community mainly resident in Bromley. Joint working and support and advice about the management of Old Age

Psychiatric patients to members of the Community Mental Health Teams as well as to colleagues in Social Service departments.

To participate in the ICN MDT meetings and provide advice / support and contribute to integrated care plans.

To work with the local ICN MDT providing advice and support. To provide medical leadership and senior clinical support to the ICN

MDT, and ensure all mental health needs are adequately addressed in the resulting integrated care plans.

In Year 2 of the delivery of the ICN model of care to assist in identifying patients and case finding those who will benefit from being put onto the Proactive Care Pathway.

Where identified by the ICN MDT as being the appropriate clinical lead assigned to the patient to work with the MDT Liaison Coordinator and Care Navigator, to oversee the care for the patient.

To ensure that appropriate Mental Health professionals are involved in the care for patients on the Proactive Care Pathway depending on patient need, and coordinate the identified required mental health care required with their colleagues.

To promote the ICNs and the proactive approach, and act as a support liaison to other colleagues, and encourage them to refer to the Proactive Care and Frailty Pathways.

To participate in care planning meetings. FRAILTY: SUMMARY

• Over the past eight months the CCG has been working closely with Bromley Providers and clinical leaders to co-develop a new pathway that is linked to the ICN model of care and helps to support the frail elderly population of Bromley in a more integrated and coordinated way, both in and out of hospital.

• This has involved weekly Frailty Clinical Interface Group meetings which include representatives from King’s / PRUH (“KCH”), the CCG, Oxleas, the BTSE, the GP Alliance, St Christopher’s and Bromley Healthcare.

• Key components of the Frailty Pathway are: Component Summary The Orpington Unit Two sub-acute, short stay wards on the Orpington Hospital site run

by KCH. Patients can step down from the acute trust and step up from the community .

Geriatrician gateway and consultant geriatric hotline

All decisions to admit or attend the Orpington Unit are made by a Geriatrician. If a GP would like to send a patient to Orpington they can phone the hotline and speak to a geriatrician. GPs can also contact the hotline for urgent acute queries.

Hot clinics Patients can be sent to a hot clinic either a multidisciplinary chair clinic at the Orpington Unit or a hot clinic at the PRUH.

Comprehensive Geriatric Assessment

A multidisciplinary assessment of a patients needs. Aligned to the proactive care pathway community matron assessment. Linked to the electronic patient record.

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Component Summary Discharge to the community

Patients will arrive at the Orpington Unit with a clear discharge plan to ensure patient flow. The discharge process will involve a Care Navigator Manager from Age UK who will ensure patients have access to the right third sector services to help avoid future admissions.

Older Persons Assessment and Liaison (“OPAL”) Team

Development will resume in January 2017. Likely to involve the development of a team who carry out an early comprehensive geriatric assessment in the acute hospital to prevent avoidable admissions to inpatient wards.

Rockwood Frailty Score The score is being rolled out in primary care and in future through the electronic patient record other healthcare professionals including geriatricians will be able to access this to help with their treatment.

FRAILTY: BGS RECOMMENDATIONS

• Older people should be assessed for the presence of frailty during all encounters with health and social care professionals.

• Provide training in frailty recognition to all health and social care staff • Do not offer routine population screening for frailty. • Carry out a comprehensive review of medical, functional, psychological and

social needs based on the principles of comprehensive geriatric assessment. • Consider referral to geriatric medicine where frailty is associated with significant

complexity, diagnostic uncertainty or challenging symptom control. • Consider referral to old age psychiatry for those people with frailty and complex

co-existing psychiatric problems, including challenging behaviour in dementia. • Conduct evidence-based medication reviews for older people with frailty. • Generate a personalised shared care and support plan (CSP) outlining

treatment goals, management plans and plans for urgent care. In some cases it may be appropriate to include an end of life care plan.

• Where an older person has been identified as having frailty, establish systems to share health record information (including the CSP) between primary care, emergency, secondary care and social services.

• Develop local protocols and pathways of care for older people with frailty. • Ensure that the pathways build in a timely response to urgent need. • Recognise that many older people with frailty in crisis will manage better in the

home environment but only with appropriate support systems. FRAILTY: ASSESSING FRAILTY

• Frailty exists on a spectrum, reinforcing the importance of person-centred care. Physical exercise and maintaining a healthy diet can help to prevent and minimise the impact of frailty.

• The Rockwood Clinical Frailty Scale (“the Rockwood scale”) assumes an accumulation of deficits (ranging from symptoms e.g. loss of hearing or low mood, through signs such as tremor, through to various diseases such as dementia) which can occur with ageing and which combine to increase the ‘frailty index’ which in turn will increase the risk of an adverse outcome.

• The Rockwood scale was designed for use after a comprehensive assessment of an older person; this implies an increasing level of frailty which is more in keeping with experience of clinical practice.

• In Bromley the Rockwood scale is being incorporated into: • The Community Nurse assessment template being used when assessing

patients being referred onto the Proactive Care Pathway, and if those same patients are referred to the Gerontologists for specialist geriatric input (via the

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Geriatric Gateway to the Frailty Pathway); and, • The Comprehensive Geriatric Assessment template being used when patients

are discharged from the Orpington Integrated Frailty Unit. • The use of the Rockwood scale in these assessments will enable the

gerontologists in Bromley to quickly assess the level of frailty of the patients they are seeing, and to plan the care they need accordingly. It will also help to standardise the assessment of the frail elderly population across Bromley.

FRAILTY: THE ROCKWOOD SCALE Not all frail people are the same; we need to understand the stages of frailty in order to identify where to focus our time and resources.

FRAILTY: THE PATHWAY

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FRAILTY: ELIGIBILITY CRITERIA [Version 1.1 – GO LIVE, 19/12/16]

KEY REQUIREMENTS STEP UP STEP DOWN • Non-acute elderly care • Patients whose

condition is likely to require some medical input

• Level of Frailty: scoring at least 6-7 on the Rockwood Frailty Scale (age not deciding factor)

• Hours of decision making for referrals: proposed 8am-5pm based on availability of Geriatrician • Patients with a

Bromley GP (test impact after 2-3 months)

• Access – via step up or step down through Geriatrician gateway

• Unit is consultant led with a MDT approach - TBC

• 7 day access

• Referral through one of the following Gerontology gateways: Geriatrician hot clinic MDT referral from

Proactive Pathway GP referral via

geriatric hotline where patient has been suitability assessed as not requiring admission to acute site

• Patients with known diagnosis or ongoing needs but cannot be treated at home, requiring a stay of less than in the region of 7 days

• Patients with delirium or dementia who require non-acute support can be discussed and considered for this support

• Step up via Rehab Home Pathway or MRT for patients who are not safe to be supported at home and require inpatient rehabilitation

• Management of venous ulcers and patients with long term conditions that have been gradually failing with an identified cause e.g. increased leg oedema

• People discharged, where the package of care is inadequate or there was a non-acute reason for the package of care not being supportive (recurrent admissions)

• All step down patients will have had a Comprehensive Geriatric Assessment started before transfer

• Recuperation/rehabilitation for patients whose condition is not currently reaching Lauriston criteria (slow stream)

• People who are medically stable but require support because their carer has been admitted

• Minor illness and falls not covered by the current fracture pathway

• Resolving Delirium / Dementia (slow stream requiring longer length of stay) - TBC

FRAILTY: ACUTE GERONTOLOGY HOTLINE

• This is a direct line for GPs to one of the Consultant Gerontologists at the Princess Royal University Hospital

• The line is available from 09:00 to 17:00, Monday to Friday • For urgent queries and referrals to hot clinics and the Orpington beds at the

discretion of the Gerontologist.

a meeting of the governing body of nhs bromley clinical ... - integrated care... · communication,...

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