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Network, Learn & Share
Evening Seminar
Successful commissioning to
improve public health services
Cliff Hoyle - [email protected] for Health and Justice, NHS England, South (for South West)and
Richard Lyle - [email protected] Director, Community & Partnerships/Deputy Operations Director, NHS Bristol Clinical Commissioning Group
9 June, 2016@academyjustice
Academy for Justice Commissioning
mailto:[email protected]?subject=Academy Bristol seminar querymailto:[email protected]?subject=Academy Bristol seminar query
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Learn, Network & Share
Background to the Academy
• The Academy’s mission is to bring people together to share knowledge and best practice and to promote excellence in social justice commissioning
• The Academy was created in 2007 and now has over 3000 cross sector members
• Services are designed to support the development of social justice commissioning and include nationwide events, elearning, commissioning themed learning groups and a website offering commissioning information
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Commissioning StructureIn Justice
• CCG’s- Local
• Local Authorities
– Including Public Health Functions
• Police and Crime Commissioners
– Non-operational (e.g. police custody drug services)
• National Offender Management Service
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Commissioning StructureNHS England
• Directly commissioned activity for services with a wider footprint:
– Health and Justice (includes)
• Prisons
• Liaison and Diversion
• Sexual Assault and Referral Centres (SARCs)
• Secure Children Homes
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Commissioning StructureNHS England
• Directly commissioned activity for services with a wider footprint:
– Specialised Commissioning• Mental Health
– Eating Disorders– Secure Hospitals– Secure CAMHS (tier 4)
– Highly Specialised
– Medical and Pharmacy etc
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My Portfolio
• Mental Health Lead
• Liaison and Diversion- SW
• Secure Children Homes
• INNF and IFR requests
• Medication to manage Sexual Arousal (Leyhill)
• Death in Custody Reviewer
• Projects– CAMHS Transition– ACCT review (prison suicide and self harm policy)
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Joining it Up
• Various Commissioning Structures and Key Stakeholders- (even within the NHS).
• Different geographical boundaries:
– Commissioning
• e.g. SW prison management covers Dorset
– Providers
• e.g. Health borders by city or county with Police Force areas covering two counties
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Successes
Liaison and Diversion
1. All services in the South West configured to police force footprints:
– Police are the main stakeholder
– Requires partnership working by dual providers to present a single outward facing operational model
– Economies of scale achieved in non-clinical functions (management, admin etc)
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SuccessesLiaison and Diversion
2. Sub-Contracting of local support– Achieved from previous savings
– Focus on the development of peer mentoring
– Local voluntary sector recruitment and support of volunteers
– Time limited (don’t create professional service users or rely on unpaid workforce)
– Therapeutic benefits- Confidence and CV Building; Reciprocation in terms of engagement.
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SuccessesLiaison and Diversion
3. Ready Made infrastructure– Established structures, SLA’s and IT framework for
large areas.
– Ability to host or embed other activity
– Cornwall example:• 2 staff hosted from CCG to expand the capacity of the team
to have additional forensic functions
– Somerset Example• Additional CCG allocation to fund staff working into the
team with other specialist skills (AMHP, Psychology)
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Frustrations
• Police Custody Healthcare
• Applicable legislation– e.g. s75 NHS Act 2006 only mandates arrangements between NHS and
Local Authorities for co-commissioning. This works well for substance misuse services overseen by public health embedded in local authorities.
• Long term forward planning to synchronise commissioning time-lines. Therefore work is based on long term collaborative working that may be ‘person’ reliant.
• Government changes mind. Re Police Custody Healthcare
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Futures
• Street Triage– Choices from CCGs and PCCs
• Host conurbations in Crisis Teams (as Bristol)• Host more discrete functions (e.g. control room) in L&D as per
Devon Trial- Avon and Somerset is considering this
• Substance Misuse in Police Custody– PCC directly commissioned for A&S.– Embed whole function in L&D
• DEVOLUTION
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Does ‘Good’ look good to all?
That is a really good bit of
commissioning
I don’t like the look of
this!
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Richard Lyle, Programme Director,
Community & Partnerships
Modernising mental health services in
Bristol a commissioning case history
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My personal thoughts on a super sized, high profile, high stakes, multi-year, high expectation, high stress commissioning
process, its eventual outcome and ongoing legacy
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Mental health challenges in Bristol
• Unmet need - access for a diverse population
• Historic legacy of poor services
• Poor patient experience
• Disillusioned staff – poor staff satisfaction scores
• Long waiting times
• High access criteria
• Overstretched crisis services
• High caseloads
• Over utilisation of inpatient bed capacity
• Inpatient rehabilitation model
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We decided to do something about it
• We agreed we would consult with users, carers and professionals to establish what they thought about the current services, how they could be improved and what services should look like in the future
• They told us an awful lot about what they didn’t like and what they felt had to happen to improve things
• The feeling that something had to significantly change was very clear and consistently expressed
• Eventually the PCT/CCG decided that it felt a formal procurement was the best way to effect significant change
• A lot of people tried to dissuade us from going through a procurement as it was seen as high risk and destabilising
• CCG stuck to its guns and gave notice to the existing services and initiated a procurement process
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Values and Principles
• Transformational approach/blank sheet of paper
• Work with patients to promote resilience and wellbeing and service
design and delivery
• Be inclusive
• Be locally accountable and Bristol focussed
• Meet the diverse needs of Bristol’s population
• Deliver high quality services regardless of age
• Consider the wider context of the patient
• Recognise and deal with safeguarding issues
• Focus on patient outcomes rather than activity (i.e. results rather than numbers)
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BRISTOL COMMUNITY MENTAL
HEALTH SERVICES
PRIMARY CARE
PRACTICES (GPs)
Bristol Wellbeing
Therapy
Services
(aviliable now)
Community Access
Support
Employment
Service Assertive Engagement
Service
INPATIENT SERVICES
Assessment and Recovery Service
Crisis Service
Community Rehabilitation
Service
Complex
Psychological
Interventions
Service
Social Prescribing
Bristol Sanctuary
Early Intervention in Psychosis
Service
Dementia Wellbeing Service
Mens Crisis House
Womens Crisis House
(available now)
System
Leadership
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Modernising Mental Health Services in Bristol
Engagement
Co-design
Procurement
Transition
Implementation
tim
elin
e
2010
May 2013
May –Oct 2014
Autumn 2014
2011 - 2013
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Key Process Factors
• Very high stakes/high profile for all partners
• Consultation and co-production with service users carers and stakeholders across Bristol
• High quality, robust service specifications, tested and validated by professionals
• Well resourced programme team, flexible resourcing– Programme Director, Project Manager, Project Support– Finance Lead, IMT Lead, HR Lead– Procurement Lead– Commissioning lead
• Senior level ownership– Chief officer was SRO – Programme Board included Chair, GP leads, Directors from the local
council
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• Biggest NHS Mental Health procurement ever -£200m over 5 years• Thorough planning/high level of scrutiny including media• Publicity to develop market & attract bidders• Provided comprehensive information to bidders through multiple
means• Support involvement of third sector in bids
– Facilitated workshops – Small grants for bid writing services administered by Voscur and the Care
Forum
• Constructive dialogue sessions for complex lots• Service users, carers, stakeholders and out-of-area experts as well as
CCG team evaluated bids• Recruitment and payment of service users and carers
Key Factors - Procurement
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Key Factors - communications
• Engaged communications team at the outset
• Stakeholder engagement plan implemented
• Engaged with the media and pro-actively managed stories whenever possible
• Made sure the service user voice was part of our story
• Engaged with service user and carer groups and other lobby groups and took the time to meet them
• Used a dedicated web site with social media
• Collaborated with bidders to streamline communications post tender
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What was the eventual outcome?
• High level of interest from a broad range or organisations
• However a lot of bidders dropped out after the first stage
• Biggest lot became a two horse race between two large NHS Trusts including incumbent provider
• Really innovative ideas, models and partnerships
• Bids focussed on transformational rather than transactional changes
• Process run broadly to time schedule and was run to the letter of the law
• A range of new (or new to us) providers (6)
• But main service block remained with existing provider AWP, albeit within a broader consortia
• Outcome not popular with everyone and created a lot of challenge in regard to whether effort expended in the process had been worth it
• Most people agreed focus on making the services work but some people no longer wanted to be involved in the project
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What’s happened since implementation?
• Overall good but could be much better
• Not all models have worked as expected
• Perhaps surprisingly those services that were new have embedded most quickly and services that were already in Bristol have found the change harder
• Culture and ownership (or lack of) can eat strategy for breakfast
• Some real successes, dementia pathway, mainstreaming access for PWLD
• However, real challenges within community services, high turnover of staff, resilience of model
• There have been delays and cost over runs
• Some elements of model notably the System Lead function have found it difficult to assert themselves within existing services and find the right way to support the more challenged services
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Assertive
Contact &
Engagement
Bristol
Sanctuary
Employment
Service
Inpatient
Services
Women's
Crisis House
Community
Rehabilitation
Service
Bristol
Wellbeing
Therapies
Service
(IAPT)
Dementia
Wellbeing
Service
Community
Access
Support
Service
Assessment &
Recovery
Service
Crisis Service
Early
Intervention in
PsychosisComplex
Psychological
Interventions
Service
Men's Crisis
House
System
Leadership
Services are at different stages of evolution
Most stable
Still developing
Most challenged
Least changed
Street Triage
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What did we learn?
• People don’t like change therefore as many people wanted it to fail as succeed?
• It took longer than expected
• You won’t end up with lots of credible bids, however they were of good quality
• High level of expressed emotion throughout the whole process
• Perhaps too much change in one go, despite phasing e.g. a lot of ‘moving parts’
• Expectations will be raised which may not coincide with the likely delivery
• Need to keep a strong link between the project team and the long term commissioners
• Operational staff may be demotivated and disempowered during the process and this has an impact and a legacy of its own
www.mentalhealth.bristolccg.nhs.uk
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What would we do differently?
• Assured more and assumed less
• Made more direct attempts to work with existing staff teams
• Focussed more on cultural change
• Supported some of the operational services more directly
• However balance between micro management and ‘pure’ commissioning?
• Where possible test assumptions around capacity and capability of organisations to effect significant change
• Systems management is a relatively underdeveloped concept in most settings
www.mentalhealth.bristolccg.nhs.uk
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Was it worth it?
• A qualified yes… is it better? Best ask users and carers?
• Service users broadly positive …but GP’s less so
• Brought innovation and change to services, however not all services have yet met their full potential
• Demonstrated CCG would act on feedback
• Disruptive and traumatic for many provider staff
• Costly in time and effort
• Control group of other CCG’s with services running the ‘old’ model have faced similar challenges so doing ‘nothing’ unlikely to have worked either?
• Significant level of cost volatility
www.mentalhealth.bristolccg.nhs.uk
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Any questions?