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London Health and Social Care DevolutionMemorandum of Understanding

November 2017

Signed for and on behalf of London, Central Government and National Health and Care Partners:

Rt Hon Jeremy Hunt MP Secretary of State for Health Department of Health

Rt Hon Elizabeth Truss MPChief Secretary to the Treasury HM Treasury

Dr Marc RowlandChair, London Clinical Commissioning Council

Cllr Claire KoberChair, London Councils

Sadiq KhanMayor of London

Simon StevensChief Executive, NHS England

Jim MackeyChief Executive, NHS Improvement

Dr Yvonne Doyle Director for London, Public Health England

Health and Care Devolution 5

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LondonHealthandSocialCareDevolutionMemorandumofUnderstanding

1. Introduction

ThisMemorandumofUnderstanding(MoU)aimstoenablethewidestandfastestimprovementinthehealthandwellbeingof8.6millionLondonersbytransformingthewaythathealthandsocialcareservicesaredelivered,howtheyareusedandhowfartheneedforthemcanbeprevented.Londonandnationalpartners1havebeenworkingtogethertoachievethissharedobjective.

InDecember20152,Londonandnationalpartnerscametogethertodescribetheiraimtotestopportunitiestotransformhealthandwellbeingoutcomes,inequalitiesandservicesinLondonthroughnewwaysofworkingtogetherandwiththepublic.Throughaprogrammeofcollaborationandco-developmentwiththefiveLondondevolutionpilots3ithasbecomecleartoLondonpartnersthatdecision-makingandpowersshouldbeadministeredatdifferentspatiallevelswithinLondon.Itisalsoclearthatthepace,degreeandnatureoftransformationislikelytovaryacrossdifferentpartsofthecityandfordifferenthealthandcarefunctions.TheworkcarriedoutthroughtheLondonHealthandCareDevolutionProgrammehasconfirmedthatdevolutionisasmallbutessentialcomponentunlockingfarbroaderchanges,andacceleratingintegrationandmoreeffectivecollaborationinLondon.Tothatend,thisMoUsetsoutaframeworkforachievinggreatercollaborativeworkingbetweenallpartners,andenablingtheLondonsystemtoexercisegreaterinfluenceoverhealthandcareintheCapital.

ThroughthisMoU,LondonpartnersaimtobecomeEngland’slargesturbanareatodelivertransformationatscaleandpace.AllpartnersagreetoactingoodfaithtosupporttheobjectivesandprinciplesofthisMoUforthebenefitofthehealthandwellbeingofallLondoncitizensandpatients,whichincludesacommitmenttodisseminatelearningwithinandbeyondtheLondonsystem.Manyoftheissuesunderconsiderationarecomplexandrequirefurthercollaborationtodesignandunderstandtheimplicationsofnewapproaches.Newapproacheswillalsorequirecontinuingevaluation,toensuremaximumvalueandbestoutcomesarebeingachievedforLondoners.Inadditiontothecommitmentscontainedinthisdocument,nationalpartnersextendanofferofacontinuingdialoguewithLondonpartnersregardingfurtherdelegationordevolutionand,morebroadly,tosupportsharedobjectivesforprevention,healthandsocialcareintegrationandbestvalueforLondon.2. Parties

ThePartiestotheagreementare:

• All32LondonClinicalCommissioningGroups(CCGs),LondonCouncilsrepresentingthe32LondonboroughsandtheCityofLondon,andtheGreaterLondonAuthority(GLA).

• The‘nationalpartners’,comprisingHMTreasury(HMT);theDepartmentofHealth(DH)(includingCommunityHealthPartnerships(CHP)andNHSPropertyServices(NHSPS);the

1Seesection2foradescriptionof‘Londonandnationalpartners’.2LondonHealthDevolutionAgreement,December2015.Availableat:https://www.gov.uk/government/publications/london-health-devolution-agreement/london-health-devolution-agreementLondonHealthandCareCollaborationAgreement,December2015.Availableat:https://www.london.gov.uk/sites/default/files/london_health_and_care_collaboration_agreement_dec_2015_signed.pdf3Therearethreelocalpilots:Lewisham,HackneyandHaringey.Therearealsotwomulti-boroughpilots:NorthCentralLondon(Barnet,Camden,Enfield,HaringeyandIslington)andBHR(Barking&Dagenham,HaveringandRedbridge).

6 Memorandum of Understanding

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DepartmentforCommunitiesandLocalGovernment(DCLG);theDepartmentforWorkandPensions(DWP);theDepartmentforCulture,MediaandSport(DCMS);theDepartmentforEducation(DfE);theNHSCommissioningBoard(referredtointhisdocumentasNHSEngland);HealthEducationEngland(HEE);theNHSTrustDevelopmentAuthorityandMonitor(referredtocollectivelyasNHSImprovement)4;theCabinetOffice;theCareQualityCommission(CQC);theNationalInstituteforHealthandCareExcellence(NICE);andPublicHealthEngland(PHE).

AsNHSEngland,PHEandNHSImprovementallhaveaLondonpresence,theterms‘London’or‘Londonpartners’areusedinthisdocumenttorefercollectivelytoall32CCGs,all33membersofLondonCouncils,theGLA,NHSEnglandLondonRegion,NHSImprovementLondonRegionandPHELondonRegion5.

3. Contextandrelationshiptopreviousagreements

LondonpartnershaveaclearvisionofbetterhealthandcareforthebenefitofLondoners.InOctober2014,theLondonHealthCommissionpublishedavisionforhealthandcare6,buildingontheFiveYearForwardView7andtheviewsofLondonerstodescribeadeliveryplanforLondon.InMarch2015,LondonpartnerscollectivelysigneduptotenjointaspirationsandagreedtocollectiveandindividualactionstohelpLondonbecomethehealthiestmajorglobalcity8.

TheLondonHealthandCareCollaborationAgreement(“the2015CollaborationAgreement”)describedLondon’sthreekeyareasoffocus:prevention,healthandcareintegrationandestates.GiventhecomplexitiesandsizeoftheLondonsystem,Londonpartnersplannedtoworkatthreelevels:local,sub-regional9andLondon-wide.Throughfivelocalandsub-regionaldevolutionpilots,theLondonpartnerspledgedtoexplorehowgreatercollaboration,integrationanddevolutioncouldworkinpractice,includingimpactswithinandbeyondtheLondonsystem.Complementingthe2015CollaborationAgreement,theLondonHealthDevolutionAgreementdescribedcommitmentsbynationalandLondonpartnerstosupportthedeliveryofthisvision.ThisMoUbuildsuponthe2015commitments10.

4NHSImprovementisnotinitselfastatutoryentity,butcarriesoutthestatutoryfunctionsoftheNHSTrustDevelopmentAuthority(TDA)andMonitor.Referencesto‘NHSImprovement’inthisdocumentshouldbeinterpretedasencompassingNHSImprovement’sroleinrelationtobothTDAandMonitorfunctions.5Sofaras‘Londonpartners’referstoaregionalofficeofanationalorganisation,thesepartnerswillnotsignuptotheagreementseparately,butrelevant‘London’or‘Londonpartner’commitmentswillrefertotheseregionaloffices/departments.6BetterHealthforLondon:thereportoftheLondonHealthCommissionwaspublishedinOctober2014followingaperiodofengagement,whichcapturedtheviewsofover14,000Londoners.Availableat:http://www.londonhealthcommission.org.uk/wp-content/uploads/London-Health-Commission_Better-Health-for-London.pdf.3NHSFiveYearForwardView,October2014.Availableat:https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf8BetterHealthforLondon:NextSteps,March2015.Availableat:https://www.london.gov.uk/sites/default/files/gla_migrate_files_destination/Better%20Health%20for%20London%20Next%20Steps_2.pdf9Theterm‘sub-regional’referstoacollectionofLondonboroughsandCCGs.Theterms‘local’referstoanareageographicallydefinedbyoneboroughand/oroneCCGand‘London’referstotheareadefinedbyallboroughs(includingtheCityofLondon)andall32LondonCCGs.10WhileaMoU,bynature,isnotlegallybinding,partnershavecloselyco-developedthisdocumenttoensurethatthestatedcommitmentshavetherequisitesupportanddetailforsuccessfulimplementation.


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Recognisingthatdevolutionisoneofarangeofenablerstosupporthealthandcaretransformation,theLondonHealthandCareDevolutionProgrammehasbeencloselyalignedtootherhealthandcaretransformationactivities.TheseincludetheFiveYearForwardViewNewModelsofCareprogramme,theBetterCareFundandworkstreamsarisingfromNHSEngland’srecentlypublisheddeliveryplan:NextstepsontheNHSFiveYearForwardView11(“theNextStepsdeliveryplan”).London’splansthereforealignwithnationalprioritiesontheintegrationofhealthandsocialcare(includingthecreationofAccountableCareSystems12),oncreatingaseven-dayNHSandontransformingthehealthandcaresystemtosecureitssustainablefinancialfuture.London’stransformationeffortshaveacceleratedoverthelastyearthroughlocalinitiatives,thedevelopmentofthefivesub-regionalsustainabilityandtransformationplansand,atLondonlevel,theestablishmentofHealthyLondonPartnership(HLP)tosupportcollectivetransformation.Bothdevolutionandmulti-boroughplanningencompasstheneedforlong-termsustainabilityandfordecisionstobemadelocallytomeettheneedsoflocalpopulations.ThedevolutionpilotprogrammeshaveinvolvedjointworkingbetweenLondon’slocalauthorities,CCGs,providersofhealthandcareservicesandotherlocalpartnerstoaccelerateprogresswithinexistingpowers,includingdevelopingjointgovernancearrangements.Inmanycases,thesearrangementsbuildonestablishedHealthandWellbeingBoards.

LondonpartnershavebuiltontheunderpinningprinciplesofengagementmodelledthroughtheLondonHealthCommission.Fromtheoutset,devolutionproposalshavebeenco-developedlocallybypilotsandtheirpopulations13,andshapedthroughcollaborationwithnationalandLondonpartners.Frontlinehealthandcarestaffhavebeenengagedin–andhaveoftenled–thedevelopmentoftheworkstreamswithineachpilot.Thepilotshavewidepartnershipsincludinglocalproviders,clinicalleaders,thevoluntarysectorandwiderpublicsectorpartners.Theycontinuetocollaborateandengagewiththeirlocalstakeholdersandcommunities,andsuchactivitiesareconsideredtobeanintegralcomponentofthedevolutionoffer.EngagementontheimplicationsofhealthandcaredevolutionhasalsotakenplaceonabroaderscalewithintheLondonsystem.Goingforward,programmesofengagementwillcontinueatlocal,multi-boroughandLondonlevel,asappropriate.

TheLondonHealthandCareDevolutionProgrammeBoardhasprovidedaforumtodevelopandtestemergingproposals.ThisBoardhasbroughttogetherrepresentativesofLondonandnationalpartnersandreportstotheLondonHealthBoard(LHB).Theseeffortshaveculminatedinthisformalagreementtocollaborateonstepstowardsdevolution,delegationorsharingoffunctions,powersandresourcescurrentlyexercisedorheldbynationalpartners,wherethereisaclearcasethatthiswillassist,enableoraccelerateimprovementsinhealthandcare.

4. Overarchingprinciples

Allpartnersarecommittedtoupholdingtheprinciplessetoutinthe2015Agreement(describedinAnnex1).Inparticular:

1. Subsidiarity–decisionsshouldbetakenorinfluencedlocallywhereverpossible.

2. LondonshouldbeinvolvedinalldecisionsthatmateriallyimpactonLondon’shealthandcare.

11NextstepsontheNHSFiveYearForwardView,March2017.Availableat:https://www.england.nhs.uk/five-year-forward-view/12AsreferencedwithinNextStepsontheNHSFiveYearForwardView(pg.35-37).13Pilotshaveeachutilisedtailoredmechanismsofengagementandco-developmentwithlocalpopulationsandpartners.Thesearefurtherdetailedintherelevantbusinesscases.


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3. Londonandnationalpartnerswillworktowardsimprovingoutcomesthroughgreaterintegrationandbyphaseddelegationordevolutionofdecision-makingpowerstothelowest,mostappropriatelevel.Anysuchchangeswillbesubjecttothe‘receiver’demonstratingrobustgovernanceandaccountabilitymechanismsandwillreflectthestatutoryaccountabilitiesofindividualorganisations,nationallyagreedprinciplesandcriteriaforassessmentofdevolutionproposals14.

4. HealthcareservicesinLondonwillremainpartoftheNHS.ThecommitmentsdescribedinthisMoUaimtostrengthenhealthandcareintheLondonareaandcontinuetoupholdtheNHSvaluesandstandards,includingtheNHSConstitutionandothernationalcommitments,ongoinginvolvementofthepublicandco-developmentofplanswithlocalpopulations.

5. Nationalpartnersarecommittedtocontinueaco-productionapproachwithLondonpartnerstofacilitateultimatedecisionsondevolution–bothbynationalpartnerstodevolveandbyLondontoexerciseand‘receive’devolvedfunctions.Partnersshareanexpectationthattheseco-producedsolutionswill,intime,transformtheentireLondonhealthandcareeconomy.

6. Furtherdevolutionordelegationdecisionswillcontinuetobesubjecttocarefulconsiderationbynationalpartners,takingintoaccounttheneedsofpeopleinLondonandelsewhereandreflectingtheprinciplesandcriteriaagreedbyNHSEngland.

LondonpartnerscommittoworkingwithnationalpartnerstoensurealignmentbetweennationalpolicyobjectivesandthestrategicdirectiontakenbyLondon.Londonpartnerswillworktogethertosupportnationallyagreedpriorities,includingthosesetoutintheFiveYearForwardViewandtheNextStepsdeliveryplan.Allorganisationsretaintheircurrentstatutoryaccountabilitiesforhealthandsocialcare,andanycommitmentsmadearesubjecttoorganisations’continuingabilitytomeettheseaccountabilities.

5. ScopeThisMoUconstitutesaroadmap,withinitialcommitmentsthatcanbeagreedbyeachconstituentpartynow,andfurtheranticipatedstepsthatwillrequireconsiderationinthelightofexperienceanddevelopmentsinthefuture.ThescopeofLondon’stransformationalplanscoversallaspectsofhealthandcare,specifically:

• Primarycare• Acutecare(includingspecialisedservices)• Communityservices• Mentalhealthservices• Socialcare(adultandchild)• Publichealth,includingmaximisingopportunitiestoinfluencewiderdeterminantsof

health

Keyenablerswillinclude:• Delegationordevolutionoffundingandcommissioningfunctionsasagreedwiththe

relevantnationalpartners.• Financialandregulatoryleverstopromotehealth.

14NHSEnglandcriteriaavailableat:https://www.england.nhs.uk/commissioning/devolution/


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• Strengthenedsystemleadership,supportedbyeffectivegovernance,clearaccountabilityandtransparency.

• Asharedstrategicapproachtoestatesplanning,includingNHScapitalinvestmentdecision-making.

• Jointworkforcestrategicplanning.• Fullinvolvementindevelopmentofnewpaymentmechanismstosupportnewmodels

ofcare.

6. Futureroadmap

ThisMoUdescribestheaspirationforLondon(includingthewiderLondonsystemandlocalandsub-regionalareas)toachievetransformationofhealthandsocialcareatpaceandscale.Londonandnationalpartnerswillcontinuetoworktogetherduring2017/18andbeyondtoagreethepreferredmechanismsandtimescalesforanydevolutionordelegationofpowersandresourcestoachievetheaimsandobjectivesdescribedinthisMoU.

ThroughthisMoU,devolutionmayultimatelybesecuredbytheLondonsystem,withlocalandsub-regionalareashavingtheabilitytodrawdowndelegatedordevolvedfunctionssubjecttodevelopingsuitableplans,deliveryandgovernancearrangements.ProgressiontowardsdelegationanddevolutionofresponsibilitiesandresourcesfromnationalpartnerstotheLondonsystemwilltakeplaceinagreedphasesofchange,withprogressionsubjecttoachievementofnationallyapplicabledevolutioncriteria,demonstratedcapability,robustgovernancearrangements,acleardeliveryplanandgatewaymilestones.NewapproachesundertakenwithinLondonwillbetestedandevaluated,toassessimpactsandensuremaximumvalueforLondoners.

ThisMoUsetsouthownationalpartnerswillsupportimplementationofthepilotsaswellasnewwaysofworkingatpan-Londonlevel,subjecttolocalreadinessandinaccordancewithnationalstatutoryresponsibilitiesandtheprinciplessetoutinSection4.Eachpilothasdevelopedabusinesscasesettingoutmoredetailedarrangementsforimplementation,tobesupportedbyrobust,transparentgovernance.ThesebusinesscasesarepublishedalongsidethisMoU.TheyarelocallyowneddocumentsandthereforedonotrepresentNationalGovernmentpolicyintheirownright.Pilotswillcommenceimplementationinaccordancewiththetimelinesdescribedinthesedocuments,recognisingtheneedforaphasedapproach.

Withinnon-pilotareas,anydevolutionofhealthfunctionswillbesubjecttotheappetiteofthoseareas,carefulconsiderationofbusinesscases15andappropriategovernanceandaccountabilityarrangements.ItisrecognisedthatLondonprovidesexpertiseandservicesforpeoplewholiveoutsidethecapitalandthatbenefitthecountrymorewidely.LondonwillworkcollaborativelywithotherregionsandnationalbodiestoconsiderandmitigatetheimpactofLondondecisionsonsurroundingpopulationsreliantonLondon-basedservices.

Byworkingtogether,Londonandnationalpartnerswillbeabletofullyunderstandandmanageriskcollectively.TheLondonsystemwilltakemorecontrolofitsownfutureandresponsibilities,inaphasedwaythatissafeandbeneficialforpatientsandcommunitiesandensuresthatthedutiesandaccountabilitiesintheNHSConstitutionandlegislativeframeworkcontinuetobeupheld.

7. Sharedcommitmentsbetweengovernment,nationalpartnersandtheLondonpartners

15Businesscaseswouldbeconsideredbythenationalorganisationsstatutorilyaccountablefortherelevantfunctionsorduties.


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a) Capitalandestates

TheNHSestateinLondonisconsiderable,butsignificantcapitalinvestmentisrequiredtoensurehighqualityhealthandcareinfrastructureandgreaterinvestmentinprimaryandcommunitycarefacilities.Partnersrecognisetheopportunitytoimprovesystem-wideplanning,reduceunder-utilisation,releasesurpluslandandcapitalandrealisewideronepublicsectorestateopportunities.

LondonandnationalpartnerscommittoestablishingaLondonEstatesBoard(LEB)todirectlysolvesomeofthechallengesinvolvedinsecuringNHSestatesapprovalsanddisposals,workinginmoretransparentandcollaborativewaysforthebenefitofLondon’shealthandcaresystem.TheLEBwillprovideasingleforumforestatediscussionsinLondonandensureearlyinvolvementofLondongovernmentpartners.Asitmatures,subjecttoagreedhurdlecriteria,theLEBwouldalsoprovideaforumwithinwhichNHScapitalinvestmentdecision-making,includingdelegatedbusinesscaseapprovalsandcapitalallocationconsiderations,couldbeexercised,sofarasstatutorypowerspermitthisandwithinnationalapprovalthresholds.Thesearrangementswillfacilitateawhole-system,collaborativeapproach.AnyLEBdecisionsmustbeconsistentwith,andalignedto,estatestrategiessetoutatlocalandsub-regionallevel.TheworkoftheLEBmustalsobeconsistentwithjointlyownedpolicyobjectivesandthelegislativeframework.TheLEBaimstofacilitatemorejoined-upstrategicdecision-makingforLondonandtoenhancetheeffectiveness,efficiency,qualityandtransparencyofprocessesanddecisions.ThenatureoftheLEB’sfunctionsanditsdecision-makingabilityisexpectedtobephasedovertime.TheLEBwillcommenceinastrategicandadvisoryformand,subjecttotheachievementofcleargatewaycriteria,progresstotakeonalevelofdelegateddecision-makingfunctions,wherethatispossibleinaccordancewiththelegislativeandpolicyframeworkandstatutoryaccountabilitiesofLEBmemberorganisations.ThisisdescribedinfullintheLEBOperatingFramework16.TheLEBwillworkwiththeGLAtoensureoptimumlandassemblythroughlinkswiththeHomesforLondonersBoardandLondonLandCommission.Thiswillincludeenablingwiderpublicsectorutilisation(e.g.forhousing)wherelandissurplustohealthandcarerequirements.TheLEBwillworkwiththefivesub-regionalestatesboardstosupportthedevelopmentofaclear,affordablecapitalandestatesplanforeachsub-regionthatisalignedtoclearcommissioningstrategies.TheseplanswillbuildupfromthelocalestatesstrategiesdevelopedbyCCGsandlocalauthoritiestosetouttheplannedsourcesandintendedapplicationsofcapitalfunding,runningupto2021.Sub-regionalandlocalboardswillbesupportedtodevelopaccountabilityandgovernancearrangementstoasufficientstandardtoenabledelegateddecisionstobetakenatmorelocallevels17.TheLEB,sub-regionalandlocalestatesboardswillbesupportedbyaLondonEstatesDeliveryUnit(LEDU),avirtualteambringingtogetherregionalandregionally-basednationalexpertisetosupportthecollaborativedevelopmentofrobustestatesstrategiesandcapitalbusinesscases.ItisintendedthattheLEBwillbetheLondonregionalexpressionofestatesgovernanceandthatrelevantstrategicdeliveryexpertisewillbeaccessedthroughtheLEDU.Toachievethis:

16LEBoperatingframework,XX2017,availableat:[DN:tobepublishedonsameday–linktodocumentandinsertdate]17Suchdecisionswouldbetakenbywayofrepresentativesfromnationalorganisationsexercisingdelegatedauthorityaspartofamorelocalforum(forexample,asub-regionalestatesboard).

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November 2017, available at: https://www.london.gov.uk/sites/default/files/london_estates_board_-operating_framework_2017.pdf


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• NHSEngland,NHSImprovement,DH,OnePublicEstate(OPE)andHMTagreeinprinciple,andsubjecttoagreedphasingandtheachievementofagreedgatewaycriteria,tosupport,sofarasconsistentwiththestatutoryframework,theinternaldelegationsofalevelofbusinesscaseapprovalauthoritytonamedindividuals,operatingasmembersoftheLEB.ThiscommitmentexcludesdecisionsrequiringministerialapprovalwheretheLEBwouldmakeanon-bindingrecommendation.

• DecisionsoncapitalexpenditurewithinLondon'sallocatedfunds,includingNHSEnglandCDEL18budgets(particularlyETTF19),andothernationalcapitalallocationdecisionswillbedelegatedinternallytoanLEBrepresentative,onaphasedbasisandsubjecttothegatewaycriteriaintheLEBOperatingFramework.

• AllhealthandcarecapitalcaseswhicharebestconsideredjointlywithintheLondonsystem,coveringbothNHSEnglandandlocalgovernmentinvestments,willultimatelybeconsideredbytheLEBor(forlowerlimits)localorsub-regionalestatesboards.

• Allpartnerscommittosupportingsub-regionalestatesboardstodevelopgovernanceandaccountabilitymechanisms,toenablesuchboardstohavethecapabilitytoadministerdelegatedordevolvedfunctions.

• NHSImprovement,NHSEngland,DH,CHP,NHSPS,OPEandLondonpartnerscommittheirexistingLondonestatesresourcestoworkcollaborativelyaspartofavirtualteamintheLEDUtodevelopclearpriorities,measurableobjectives,rolesandresponsibilitiesandappropriatewaysofworkingtogether.Thiswillincludeconsiderationofjointappointmentsasappropriate.

• TheCHPandNHSPSestateplanningteamshavingalreadybeenbroughttogethertofunctiontogetherasoneteam,workingwithexistingpartnershipssuchasLIFTCompanies(LIFTCo)20.ThisteamwillformpartoftheLEDU.

• Londonpartnerswilloperateinlinewiththecommissionercapitalcontroltotalframeworksetbynationalpartnersand,subjecttorobustgovernancestructures,sub-regionalestateboardscouldtakeonamanagementroleofcapitalcontroltotals,withinaLondonenvelope.

• NationalandLondonpartnerswillagreesetcapitalbudgets,whichLondonwilloperatewithineachyear.Thesebudgetswillincludetheagreedspendingprofileforretainedcapitalreceipts.TheLEBandsub-regionalestatesboardswillmakerecommendationsontheapplicationofcapitalreceiptstoinformdiscussionwithnationalLEBrepresentativesoncapitalallocations.

Londonandnationalpartnersarecontinuingtoexploresystemicissuesthatmaybeabarriertobestuseofestatesorassets;ormaybehinderingthedisposalofsurplusland.Partnersalsorecognise

boththesignificantcapitalinvestmentrequirementswithinhealthandcareinLondonandthesignificantopportunitiesforgeneratingreceiptsandadditionalhousingfromthedisposalofsurplusland.Toaddressthis:

• NationalpartnersagreeinprincipletoNHSTrustsandFoundationtrustsinLondonretainingcapitalreceipts,onthebasisthattheLEBwillidentifyhowtoreinvestthesereceiptstosupportagreedsystem-widehealthpriorities.ToinformthisprioritisationtheLEBwilldevelopanagreedannualpan-Londoncapitalplanbasedonrobustlocalandsub-regional

18NHSCapitalDepartmentalExpenditureLimitfund19EstatesandTechnologyTransformationFund20LocalImprovementFinanceTrust(LIFT)companiesarelocally-basedjointventuresbetweenthepublicandprivatesectors.


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estatescapitalstrategiesandwiththefullinvolvementofLondonpartners,includingNHSTrustsandFoundationTrusts.

• WhileindividualNHSTrustsandNHSFoundationTrustsownmostofthehealthestate,theDH-ownedpropertycompanies(NHSPSandCHP)holdsomelandutilisedbythehealthand

caresysteminLondon.Thisincludesestateusedforprimaryandcommunityservices.ItisthereforeimportantthatdecisionsaroundthisestateareinformedbydiscussionswiththeLEB,toensurethatallopportunities(includingformarriagevalue)areconsidered.Thisis

consistentwiththe‘onepublicestate’approach.Tothisend,DH,NHSPSandCHPcommittoworkinginpartnershipwiththeLEBtodevelopanapproachforNHSPSandCHPinvestmentsandsales,whichbalancesnationalandLondonneedsandpriorities.

• WhilethedeploymentofcapitalintheNHSfromallsourcescombinedmustbeequitableinrelationtoneedacrossdifferentpartsofthecountry,itisrecognisedthatinLondonthereis

significantlygreateropportunitytoraisecapitalthroughdisposalofsurplusassets,butalsothatthecostsofcapitalinvestmentarealsosignificantlyhigherthanelsewhereinthe

country.TheprincipleofequitymustthereforerecognisethehighercostofdevelopingbuildingsandservicesinLondon.Itisalsorecognisedthatincentivesareneededforthehealthandcaresystemstoreleasesurplusland.Nationalpartnerscommittoworkingwith

theLondonsystemthroughtheLEBtoexplorehowthehealthandcaresystemincentivescanbeoptimised.TheLEBprovidesanopportunitytoexplorethesethroughexamplecasesinthefirstyearofoperation.

• Recognisingthedifferenceinstatutoryobligationsofthebodiesconcerned,oversightandfreedomsofdifferentestateholders,theLEBwillworkwithDHandsub-regionalareasto

ensurethatwhensurplusNHSsitesarereleased,thisisdonewithdueconsiderationofwiderlocalhealtheconomyandpublicsectoropportunities.

Londonandnationalpartnersagreethatbothsub-regionalandLondon-wideplanswouldneedtoalignwithanddeliveragainstanynationalhealthestateorpublicsectortargetsandestates/assetsaleplans.NationalpartnerscommittoclarifyingandseekingtoagreetheserequirementsinpartnershipwiththeLondonsystemintheearlyphasesoftheLEB’soperation.

LondonandnationalpartnersalsocommittoworkingtowardstheaimofoptimisingtheuseofexistingNHSestate,by:

• London,indiscussionwithnationalpartners,developingaLondonreportonNHSestate

utilisationin2017andconsideringtherecommendationsthroughtheLEBthereafter.

• DHandNHSEnglandintroducingavacantspacepolicyin2017.

Londonpartnersagreetoshareanddeploytheirknowledge,expertise,resourceandcontactnetworksinsupportofthisagendaincluding,whereappropriate,fromboroughs,CCGs,andtheGLA.

b) Commissioningmodelsandpaymentmechanisms

Londonpartnersrecogniseopportunitiestocommissionserviceswithawhole-systemoutlook,withtheoverallaimofimprovingoutcomesforserviceusersbyenablingmoreintegrated,joined-uppathwaysandservicesthatfocusontheindividualratherthantheserviceprovider.

Londonpartners,GovernmentandNHSEnglandcommittosupportingplace-basedcommissioningofhealthandcareservicesatthemostappropriateleveltobestmeettheneedsofpatientsandcommunitiesacrossLondon.Partnersrecognisethatpaymentmechanisms,financialallocationsand


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budgetpoolingarekeyenablerstogreaterintegrationandsupportfurtherdevelopmentwithinstatutorypermissions.

CentraltotheGovernment’sobjectivesoverthisParliamentistherestorationoffinancialbalanceinthehealthsystem,bothintermsofproviders’andcommissioners’finances,aswellasadeterminedfocusonoperationalperformanceandqualityofcare.LondonpartnerscommittobuildonSustainabilityandTransformationPlandevelopmentbycontinuingtodevelopdetailedandcredibleplace-basedplans,andstrengthenedlocalandmulti-boroughpartnerships,toenableLondon’shealtheconomytoachievesustainabilitywhilstmaintainingandimprovingqualityandoutcomes.ALondon-levelstrategicplan,drawnfromsub-regionalhealtheconomyplans,willenableoversightoftheimpactonhealthoutcomesandfinancialsustainabilityacrossthecapital.

NHSEnglandandNHSImprovementcommittosupportinglocalandsub-regionalareasinLondontoco-developandadoptinnovativemodelsofpayment,buildingontheworkoftheNewCareModelsandAccountableCareSystemprogrammes.Inreturn,Londoncommitsto:

• Rapidpilotingofnewpaymentmodelsatdifferentspatiallevelsandacrossawiderangeofsectorsandorganisations.

• Co-developmentofscalablesolutionsthatcanbeimplementedmorewidelywithinLondonandbeyond.

• Robustassessmentofefficacyanddisseminatinglearningatpace.

Transformationwillrequirecommissionersandproviderstoworkinpartnershipincludingensuring,wherepossible,greateralignmentofdecisionmakingtoinformjointcommissionerandproviderplansandgreaterinvolvementofcommissionerstosupportprovidersindelivery.

NHSEnglandcommitstoenabledelegationordevolutionofitsfunctionsandbudgetstowithintheLondonsystem,subjecttoitsestablishedprocessforreadinessassessmentsandtakingaccountoftheobjectivessetintheMandate,andtoenabletargetedallocationsandmoreintegratedapproachestocommissioningacrosshealthandcare.Specifically,NHSEnglandcommitsto:

• Delegateprimarymedicalservicescommissioningtothelocallevel,subjecttoCCGagreement,andtoconsiderinthisfinancialyearhowstepstowardsfurtherdevolutioncouldbetaken,subjecttotherelevantdecision-makingcriteriabeingmet.

• DelegateLondon’sfairshareoftransformationfundingtoLondonfromApril201821.• Exploreinternaldelegationofsomespecialisedcommissioningfunctions,excludinghighly

specialisedcommissioning,tothesub-regionallevelfromApril2018.Thiswouldbecontingentonthedevelopmentofrobustplansandgovernancearrangements,andsubjecttoNHSEngland’sstandardreadinessassessment.

PHE,NHSEnglandandDHcommittocollaboratingwithLondonpartnerstoexplorehowimmunisationandscreeningcommissioningarrangementsandserviceprovisionrelatetolocalplansandhowpartnerscouldorganisefromApril2018sothatthisresourceandexpertisecanbesharedtodelivermutualobjectivesandenablemoreeffectivelocaldelivery.DHandNHSEnglandwillworkwithLondonpartnerstoconsiderwhatfurtherstepscouldbetakentosupportmorepersonalised,joinedupcareatallspatiallevels.Thisincludesdevelopingasharedunderstandingofanycurrentbarrierstojointorleadcommissioningarrangementsandwhetherthereisacaseforchangefor

21ThisfunctionwillbeexercisedthroughtheLondonHealthandCareStrategicPartnershipBoardbywayofinternaldelegationswithinNHSEnglandtorepresentativeswhowillmakedecisionswithintheforumofthatBoard.Thisdoesnotincludesustainabilityfundingtowhichseparatearrangementsapply.


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addressingsuchissues,takingintoaccountwiderpolicyconsiderations,viewsfromotherlocalareasandlegislativeimplications.

NationalandLondonpartnerswillagreeannualcommissionerandproviderrevenuetotalsduringthespendingreviewperiodandtheLondonsystemwillactwithinthesetotals.Londonwillbeabletoaccessanyrelevantneworadditionalhealthand/orsocialcarefundingstreamsthatbecomeavailableduringthespendingreviewperiod.

Londonpartnerscommitto:

• Utilisingthesearrangementstoenablefinancialincentivisationandprioritisationthatmoreaccuratelyrespondstolocalneeds.

• Movingtomoreformalintegratedjointworking,buildingonaproventrackrecordinLondon.

• Developingdetailedandcrediblelocalandsub-regionalhealthandcareplanstoenableLondon’shealtheconomytoachievesustainabilitywhilemaintainingandimprovingqualityandoutcomes.

• Usingopportunitieswithinlegislativeandpolicyframeworkstopoolbudgetsinordertomoreappropriatelyallocatefundingtoprimaryandcommunitycareandincentiviseearlyinterventionandrapiddischarge.Londonpartnerswouldutilisefundingandconductfunctionswithintheseframeworks.

• PuttingtherequiredcapabilitiesandstandarddelegationagreementsinplacetooperatedelegatedprimarymedicalcarecommissioningbyCCGsinlocalareas22.

• Sharingandspreadinglearningfrompilotprogrammes-bothwithinLondonandnationally.

NICEcommitstoprovidingguidance,standardsandadvicetolocalandsub-regionalareasashealthandcaretransformationplansaredevelopedandimplemented.

c) Regulationandoversight

Londonpartnersarecommittedtotransformingthehealthandcarelandscapeincludingsupportingcommissionersandproviderstomoveatpacetodesignandimplementnewmodelsofcare.Toenablethis,nationalpartnerssupportgivinggreateraccountabilitytolocalhealthandcaresystems.BycloseralignmentwithLondon’sambitionsfortransformation,regulationcansupportandreinforcelocalhealthandcarecollaborationandintegration.

Althoughlegislationdoesnotpermitdevolutionofnationalregulatoryfunctionsforhealthservices,regulatorscommittotakingamorealignedapproachinLondon.NHSEnglandandNHSImprovementcommittostreamliningregulationandoversightwithjoinedupprocessesatregionallevel,includingjointappointmentsforsomekeyroles.CQC,NHSImprovementandNHSEnglandcommittocloserworkingatLondonlevel,includingalignmentofregulatoryactionsandtimelinesforreportingwhereverpossible.Londoncommitstoworkingwithnationalpartnerstoensurethatanyjointarrangementsdevelopedminimisetheadministrativeburdenandensurerobustgovernanceandconflictofinterestmanagement.

Londonwillworkwithnationalpartnersandpilotstoexplorethepotentialfornewmodelsofoversighttoenableandpromotetheimplementationofambitiousnewwaysofintegratedworking.Insupportoflocalintegrateddeliverymodels,Londonwillpilotaplace-basedframeworkforsystemregulation,ensuringclearcommitmenttocomplyingwithagreedcorestandardsandexistinglegal

22ThemajorityofLondonCCGs(30)willoperatewithfullydelegatedpowers(level3delegationstatus);howevertwowillcontinuetooperateaco-commissioningarrangement(level2delegationstatus)duringFY2017/18.


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responsibilities.Nationalregulatorypartners(NHSEngland,NHSImprovementandCQC)willworkwithLondontodevelop,supportandresource23aregulationandoversightmodelthatmeetstheneedsoftheLondonsystem.ConsistentwithwidernationalpolicyincludingtheNextStepsdeliveryplan,andworkingwithinthelegislativeframework,thiswillinclude:

• Theabilityforanintegrated/singledeliverysystemtoberegulatedasawhole,alongsidetheunderlyingdistinctorganisationaloperatingunits24.

• Supportingthedevelopmentofleadaccountableproviders,whotakeresponsibilityforprovidingintegratedhealthandcareservicesacrossalocalityandcanthereforebeaccountableforqualityandproductivityacrossindividualunits,withclearprotocolstoprotectpatientchoiceandensuretransparentreferralpatterns.

• BringingtogetherasfaraspossibletheoversightofCCGsandtheoversightofprovidersintoasinglesharedframeworkwithinLondon.

NHSEngland,NHSImprovementandCQCcommittoco-developingarobustassuranceapproachwhichrecognisesthechallengesfacedbylocalareasinmovingtoanintegratedcommissioningand,potentially,deliverysystem.Theframeworkwillenableappropriatefreedomsandflexibilitiesduringthedevelopmentofsuchmodelsandwhileintheearlystagesofimplementation.Thiswillensuredeliveryofagreedcoreresponsibilities(includingtheNHSConstitutionandMandate)andthatriskiskeptwithinacceptabletolerance.

d) Workforceandskills

ThepeoplewhoworkinhealthandcarearecriticaltoachievingLondon’stransformationgoals.Londonwillbuildonitspositionasthehomeofpopularandworld-classhealtheducationtodevelopnewroles,securetheworkforceitneedsandsupportcurrentandfuturestafftoforgesuccessfulandsatisfyingcareersinhealthandcare.Londonpartnershaverecognisedtheneedforjointhealthandcaretrainingandworkforcedevelopment,tosupportintegratedworkingasakeyenablertonewmodelsofcare.Toachievethis,HEE,SkillsforHealth,SkillsforCare,theDfE,DHandLondonpartnerscommittothefollowing,sofarasispossibleinaccordancewiththelegislativeframeworkandstatutoryaccountabilities:

• EstablishingaLondonWorkforceBoardthroughexpandedmembershipoftheLondonandtheSouthEastLocalEducationandTrainingBoard(LETB)forissuesrelatedtoLondon,toensureacollaborativestrategicandimplementationapproach25.Recognisingthecriticalimportanceofclinicalrepresentation,theLondonWorkforceBoardwillincludeappropriateclinicalmembership.

• EmpoweringtheLondonWorkforceBoardtoseekagreementamongstmemberorganisationstopoolresourceswhereappropriateandachievablewithinthelegislativeframework,forspendingonjointprojects.ThiswillincludeconsiderationofHEE’sdelegatedtransformationanddevelopmentfunding.Anypoolingandsubsequentspendingwillrespectthegovernance,statutoryaccountabilitiesandprioritiesofmemberorganisations.

23Itisintendedthatthisworkwillbefundedfromwithinexistingresources.24Itisrecognisedthat,underthecurrentstatutoryandpolicyframework,regulatorsmustcontinuetobeabletoconductanassessmentofeachorganisationalunit.25ALondonWorkforceBoardhasbeenestablishedinshadowformeffectiveMarch2017.


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• WorkingwithnationalpartnersandthroughtheLondonWorkforceBoardtoensurethatemployerswithinanintegratedhealthandcareworkforcecantakeadvantageoftheopportunitiesofferedbytheapprenticeshiplevy.Consistentwiththenationalpolicytoenabletransfersbetweenemployersby2018,thiswillincludetheabilitytotransferfundsbetweenindividualemployerswithinanintegratedhealthandcaresystem.TogetherwiththedelegatedHEEtransformationanddevelopmentfunding,thiscouldenableintegratedtrainingandworkforcedevelopment.

• Workingwithintheexistingstatutoryframework,establishingacollaborative,London-wideworkforcedeliverysystemwithHEE,SkillsforHealthandSkillsforCareworkingtogetheronkeytraininganddevelopmentpriorities.

Londonpartners,withtherelevantcentralGovernmentdepartments,willworktoharmonisethisactivitywitheffortschampionedbytheGLAandLondonCouncilstomaximiseopportunitiesforlinkswithfurthereducationcollegesandlocaltrainingeffortstosupportunemployedLondoners.Tosupportintegratedworking,LondonandnationalpartnerscommittoworkinpartnershipwithtradeunionsandemployerstoexplorerisksandissuesofpayarrangementsthatcoverallstaffinlinewithGovernmentpaypolicy.Thiscouldinclude:

• Exploringopportunitiesformoreunifiedperformancemanagementarrangementswhererolescrosshealthandcare.

• Exploringopportunitiestoovercomechallengesinpayarrangementsforjointrolesacrosshealthandcare.

• Exploringhowco-locationofhealthandsocialcarestaffcanbesupportedwherethishasbeenidentifiedbyemployersandstaffasabarriertocollaborativeworking.

Londontrainsasignificantproportionofthenationalhealthandcareworkforcebutcontinuestoexperiencechallengesinstaffretentionandturnover.LondonpartnerswillworkwithDHtoexploreLondonweightinginthiscontext.

e) Prevention

ImprovementsinthehealthandwellbeingofLondonershavetobeledwithincommunities.Throughaplace-basedapproachthatputshealthandwellbeingattheheartofdevolutionplans,Londonpartnershaverealopportunitiestotacklethewiderdeterminantsofhealth-includingemployment,planningandhousing-andaddresshealthinequalities.Devolutioncouldprovidefurtheropportunitiestocreatebetterenvironmentsinwhichpeoplecanflourish,complementingtheeffortsofindividualLondonerstostayhealthy.Overthecomingmonths,theexistingLondonPreventionBoardwillbestrengthenedtoenableeffectiveoperationasaforumforhealthandcarepartnersacrosstheCapitaltoundertakecollaborativeinitiativesasappropriate.

Londonandnationalpartnerscommittocollaboratingonandcontributingexpertisetoestablishtheopportunitiesandexploretheevidencebaseforvariouspublichealthinitiatives.Thesewouldincludeestablishingaborough-ledLondon-wideillegaltobaccoandcounterfeitalcoholenforcementteam.Thisteamwouldworktoreducetheavailabilityofcheapillicittobaccoandalcoholandminimisehealthharms,especiallytochildrenandyoungpeople,strengthencitywideactiononillegaltobaccoandalcoholandgeneratemoredutiespaidtotheexchequer.

Thesoftdrinkslevyprovidesopportunitiestoinvestinmeasurestocombatchildhoodobesity,whichisaparticularchallengeinLondon.TheGovernmenthassetoutthatthemoneyraisedfromthelevyduringthisParliamentwillbeinvestedingivingschool-agedchildrenabetterandhealthier


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future,supportingactionstoaddresschildhoodobesity.Londonisalreadyundertakingsignificanteffortstosupportphysicalactivityinschoolsandtoensurehealthierschoolenvironments.DfEwillengageLondonpartnerstodevelopguidanceasrevenuefromthesoftdrinksindustrylevyisallocatedtoschools,withtheaimthatbysynergywithwiderlocalpublichealthstrategies,goodvaluecanbeachievedforyoungLondoners.Goingforward,DHandDfEcommittoworkingwithLondonpartnerstoensuretheeffectivecoordinationofnationalandregionalprogrammeswhichaimtocombatchildhoodobesity.Throughoutthedevelopmentofthis,Londonpartnerswillcontinuetoengagewithprimaryschoolsacrossthecity.

Locallydeterminedreliefsanddiscountsalreadyenabletheopportunityforstrategicplanningaroundhighstreets,tomeetwiderpublichealthobjectives,forexamplebyrebalancingthefoodofferonthehighstreetawayfromtheproliferationofunhealthytakeaways.LondongovernmenthasputforwardanambitioussetofproposalsinresponsetotheGovernment’sagendaforreformstobusinessrateandthelocalgovernmentfinanceregime.Londonwillsupportcity-levelactiontoaddressthewiderdeterminantsofhealthwherethisisthemosteffectivescale.TheMayorofLondon’sactionsonairqualityillustrateLondongovernment’scommitmenttoissuesofhealthharm.

Londonpartnersremaincommittedtoactiononchildhoodobesity,consistentwithrecentnationalplans.Insupportofthisapproach,LondonpartnerswillexploretheinteractionbetweenplanningpolicyandLondon’shealthandwellbeingobjectives.DCLGcommittoanongoingdialoguewithLondonpartners,inordertoexploreopportunitiestoprogresspreventionaims.

Londonpartnerswillexploreoptionstofurtherrestricttheadvertisingandmarketingofunhealthyfoodanddrinkinspecificlocationsbasedonhealthharm.LondonpartnerscommittotestandevaluatetheimpactofsuchpoliciesandtofurtherexploretheevidencebaseforaLondon-specificapproachinordertotacklethecity’sobesityepidemic.LondonpartnerswillworkcloselywiththeCommitteeofAdvertisingPracticeastheybringintoeffecton1July2017newrulesbanningtheadvertisingofhighfat,saltorsugar(HFSS)foodordrinkproductsinchildren’smedia.

Togofurtherintacklingharmscausedbygamblingandsmoking,nationalpartnersmakethefollowingcommitments:

• LondonpartnerstoworkcloselywithDCMSastheyundertaketheirreviewofgamingmachinesandsocialresponsibilitymeasures26.DCMSaimstopublishitsfindingsandanyresultingproposalsin2017andcommitstoliaisingcloselywithallstakeholders,includingLondon’sdevolutionpilots,asthereviewprogresses.

• InvolvingLondonpartnersinHMRevenueandCustom’s(HMRC)reviewofsanctionstotackleillicittobacco.Thisincludesexploringhowtomakethebestuseofexistingsanctionsandconsiderationofproposalsfornewsanctions,onwhichHMRCwillbeconsultinglaterthisyear.

• DrawingonevidencefromHaringeyandotherLondonboroughsinDH’scomplementaryreviewofthesanctionsforbusinessesthatbreaktobaccolaws,includinglookingatfurtheruseofcivilpenaltieswhereappropriate.

26ThereviewwillconsiderrobustevidenceontheappropriatemaximumstakesandprizesforgamingmachinesacrossallpremiseslicensedundertheGamblingAct2005;thenumberandlocationofgamingmachinesacrossalllicensedpremises;andsocialresponsibilitymeasurestoprotectplayersfromgambling-relatedharm.ItwillalsocloselookattheissueofB2gamingmachines(morecommonlyknownasFixedOddsBettingTerminalsorFOBTs)andspecificconcernsabouttheharmtheycause,bethattotheplayerorthecommunitiesinwhichtheyarelocated.Thereviewaimstoensurethatlegislationstrikestherightbalancebetweenallowingtheindustrytogrowandcontributetotheeconomywhilstensuringconsumersandcommunitiesareprotected.


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f) Employmentandhealth

Londonandnationalpartnershaveasharedaimtoimproveboththeemploymentoutcomesforpeoplewithhealthconditionsanddisabilitiesandthehealthoutcomesofworkingagepeoplethroughactivelabourmarketparticipation.GiventhestrengthofLondon’sjobsmarket,therearesignificantopportunitiesforimprovingoutcomesforpeoplewithhealthconditionsanddisabilitiesinLondonandLondonpartnersareambitiousabouttheCapital’sabilitytodeliverthebestserviceforitsresidents.

The2015SpendingReviewconfirmedthattheLondonboroughsandMayorofLondonwilljointlycommissionemploymentsupport(outsidetheJobcentrePlusregime)toassisttheverylong-termunemployedandthosewithhealthconditionsanddisabilitiesto(re-)enterwork.Londonpartners,DHandDWPcommittoensuringthatlocalareasinLondonareabletojointlyshapeeveryelementofthecommissioningprocess:fromstrategytoservicedesign,managingproviderrelationshipsandreviewingserviceprovision.DWPcommitstothetransferoftheWork&HealthProgrammefundingtoLondontoenableLondontoprocureanddeliveranequivalentprogrammetailoredtotheneedsofLondoners.

Londonpartnersarekeentopilotfurtherjoiningupoflocalpublicservicesinordertoimproveoutcomesforthisgroup,exploringnewmodelsforintegratinghealthandemploymentsupportandtherolepreventionandearlyinterventioncanplay.ThroughthejointWorkandHealthUnit,DHandDWPcommittoworkingwithHaringeyandLondonpartnerstotestimprovementstosupportpeopleatriskofbecominglongtermunemployed;tounderstandwhatvolumesofadditionalreferralstoFitforWorktheenhancedservicewillachieve;andtoexploresignpostingfromFitforWorktolocalservicesthroughtheReturntoWorkplan.

ThroughtheHaringeypilot,Londonandnationalpartners(NHSandDWP27)committoexploringoptionsrelatedtodatasharingbetweenrelevantpartnerstofacilitatearobustevaluationoftheimpactofenhancedlocalsupportforpeopleexperiencingmentalhealthproblemsandwhoareatriskoffallingoutofwork.

g) Governancearrangementsandaccountability

Governancearrangementswillreflecttheimportanceandcomplementarityoflocal,sub-regional,andLondon-levelworking,withdecisionstakenatthemostlocallevelsofarasispossiblewithinthelegislativeframework,consistentwiththeprinciplesunderpinningdevolution.LondonpartnershaveagreedthefollowingarrangementsasthebestmeansofleadingandassuringthenecessaryimprovementsinhealthandwellbeingforthepopulationofLondon.

Localandsub-regionalarrangements

Governancearrangementsforlocalandsub-regionalworkingaimto:

• Beco-developed,ownedandagreedbylocalpartners.Theywillbedevelopedbylocalandsub-regionalareasandmaytakedifferentformsindifferentareas.ThedifferentgovernanceandaccountabilitymodelsdevelopedbyLondon’sfivedevolutionpilotsareillustrativeofthisapproach.

• Enableorganisationstoidentifyareasofcomplementaritybetweenpartsofthehealthandcaresystem,toworktogethertoavoidduplicationandensurethatsolutionsareworkable

27DWPwillfacilitatediscussionswiththeFitforWorkproviderwhenappropriate.


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andbeneficialforthelocalpopulation.Thisbuildsonworkunderwaythroughlocalandsub-regionalplanningprocesses,includingcompositionandutilisationofJointStrategicNeedsAssessments.

• Enablepartnershipworkingandsharedownershipbylocalhealthandgovernmentpartnersinordertoachieveplansandstrategiesthatreflecttheneedsofthelocalhealtheconomy,withtheabilityforbothhealthandcaretoinfluencedecisionsregardingtheadministrationofdelegatedordevolvedpowers.

• Ensurethatmechanismsareinplaceforappropriatelyengagingthepublicandstakeholders,inordertoensurethatplansreflectpopulationwantsandneeds.Thoseproposingtransformationwillaimtogetthewidestpossiblelocalsupportandwilltakefullaccountoftheconsultationandengagementresponsibilitiesofconstituentorganisations.

• Ensurethatpartnerscollectivelyenableimprovementinhealthandcarewhichaddressesthehealthandwellbeingneedsoflocalpopulations.Differentplacesandtypesofinstitutionwillbeonanequalfooting.Allorganisations,includingproviders,willbekeypartnersinplans,engagementandimplementationandwillworktocollectivelyshapethefutureofhealthandcareinthelocalarea.

• Ensurethatresponsibilitiesandaccountabilitiesremainclearlywithinthestatutoryframework,withrobustmonitoringofthepotentialforconflictsofinterest.

Todeliverthis:• Arrangementswillbelocallydetermined,whilstensuringthattheysatisfyaccountabilityand

statutoryrequirements,andarecomplementarywiththewiderLondonsystem.• Localandsub-regionalareaswillneedtoestablishtheextenttowhichorganisationswantto

workcollectivelyandthelevelsatwhichjointorpartnershipworkingshouldtakeplace.Themajorityoffunctionsthatcurrentlysitlocallyarelikelytocontinuetobeexercisedatthislevel,buttheSustainabilityandTransformationPartnershipsanddevolutionpilotshaveidentifiedthatsomefunctionsmaybemoreappropriatelyexercisedcollectivelyatamulti-boroughlevel.

• Arrangementswillprovidehealthandcarecommissionerswiththeopportunitytojointlydevelop,engageonanddeliverstrategicplans,allowingjointdecision-makingandpooledresourceswherepossible.Providerswillbekeypartnersinplans,engagementandimplementation,whilerespectingtheneedforclearseparationofproviderandcommissionerfunctions.

• Partnershiparrangementsmustenableprovidersandhealthandcarecommissionerstobeabletomakestrategicandadvisoryrecommendationswithintheboundsofarobustconflictsofinterestframeworkand–ifdelegatedordevolvedpowersaresought–totakedecisionsinpartnership,inaccordancewithlocalstrategies.Ifformaljointgovernanceistobecommencedwithamorelimitedpartnership,itwillbenecessarytomakeanassessmentofhowwiderinvolvementandengagementwillbesought.

• Localandsub-regionalgovernanceislikelytoevolve,anditisappropriatethatthiswouldhappenatdifferentpacedependingonlocalappetiteorrequirements.Thesearrangementscouldbephased,commencingwithastrategicandadvisoryfunctionandevolvingtotakeonmoreformaldecision-makingfunctions,commencingwithsomejointfunctionsorbudgetsandevolvingtotakeonformalstrategicandcommissioningfunctionsifdesiredbythelocalpartnership.Devolvedordelegateddecision-makingfromrelevantbodieswouldbeagreed–andrelatedresourcesreleased–basedonthedecision-makingcriteriapublishedbythosebodies,workinginpartnershiptomeetthesecriteria.

• Governancearrangementsatlocalandsub-regionalarrangementswilldescribetheintendedpoliticaloversightarrangements.


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• Robustmechanismswillpreservefinancialandclinicalaccountabilityofrelevantbodies,withstrongclinicalinputateveryspatiallevel.Governancearrangementsthatinvolvepooledbudgetswillneedtobesupportedbyajointlydevelopedfinancialstrategyandagreedfinancialmanagementprocesses.

Londonarrangements

Londonhasastrongfoundationofjointworking.ImprovedcollaborationandlocalaccountabilitywillenablemoreambitiouspartnershipworkingandhelpachievetheaspirationsandobjectivesagreedforLondon.London-levelgovernanceaimstoprovidecomplementaryfunctionstoaddvaluetolocalandsub-regionalarrangements.GovernancemechanismsinLondonwillbephasedtoevolvefromexistingarrangements.

Underlyingdesignprinciples:

• Subsidiaritytothelowestappropriatespatiallevelisthekeystonetoaframeworkofprinciples.Thedefaultpositionshouldbetotheboroughlevel.

• Multi-boroughgovernancemusthavetheagreementofallrelevantpartiesandmayvaryaccordingtolocallydeterminedneed.

• FunctionswillonlybeaggregatedtotheLondonlevelwherethereisaclearcaseanditispreferabletoallpartnerstodo“onceforall”toavoidduplication,enablescaleoracceleration.

• Anynewregionalandmulti-boroughgovernancewillbeimplementedwithaviewtorationalisingthewidergovernanceinfrastructuretoensureduplicationisavoided.

• Anyarrangementsmustconsidertheimplicationsforbothdevolutionandwidertransformationandoperationalgovernance.Approacheswillbe‘future-proofed’toallowevolutiontoaccommodatefurtherdevolution,delegationandjointdecision-making,withfunctionsphasedovertime.

• TheNHSinLondonwillremainwithinthewiderNHSandsubjecttotheNHSConstitutionandMandate.

ThesegovernancearrangementsaredescribedinFigure1.

LondonHealthBoard

Politicalleadershipisvitalatallspatiallevelsandare-castLondonHealthBoardwillenablepoliticalaccountabilityofhealthandcareinLondon,andprovidepoliticaloversightofwiderLondontransformationefforts.TheLondonHealthBoardwillcontinuetobechairedbytheMayorofLondon.Membershipwillbestrengthenedasrequiredtoreflectpoliticalleadershipfromsub-regionalgroups.TheLondonHealthBoardwillhavestrategicpoliticaloversightforhealthandcareinLondon.

LondonHealthandCareStrategicPartnershipBoard

TheLondonHealthandCareStrategicPartnershipBoard(SPB)metforthefirsttimeinshadowforminMay2017and,goingforward,thisboardwillprovidestrategicandoperationalleadershipandoversightforLondon-levelactivities28.TheSPBwillbuildonnationaldirection(suchastheFiveYearForwardView)andLondonplans(includingBetterHealthforLondon),butcruciallywillemphasisethepartnershipapproachandanagreedstrategyforsustainabilityandtransformationbuiltupfrom

28LondonHealthandCareStrategicPartnershipBoard(SPB)termsofreferenceavailableat:[DN:tobepublishedonsameday–linktodocument]

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• Robustmechanismswillpreservefinancialandclinicalaccountabilityofrelevantbodies,withstrongclinicalinputateveryspatiallevel.Governancearrangementsthatinvolvepooledbudgetswillneedtobesupportedbyajointlydevelopedfinancialstrategyandagreedfinancialmanagementprocesses.

Londonarrangements

Londonhasastrongfoundationofjointworking.ImprovedcollaborationandlocalaccountabilitywillenablemoreambitiouspartnershipworkingandhelpachievetheaspirationsandobjectivesagreedforLondon.London-levelgovernanceaimstoprovidecomplementaryfunctionstoaddvaluetolocalandsub-regionalarrangements.GovernancemechanismsinLondonwillbephasedtoevolvefromexistingarrangements.

Underlyingdesignprinciples:

• Subsidiaritytothelowestappropriatespatiallevelisthekeystonetoaframeworkofprinciples.Thedefaultpositionshouldbetotheboroughlevel.

• Multi-boroughgovernancemusthavetheagreementofallrelevantpartiesandmayvaryaccordingtolocallydeterminedneed.

• FunctionswillonlybeaggregatedtotheLondonlevelwherethereisaclearcaseanditispreferabletoallpartnerstodo“onceforall”toavoidduplication,enablescaleoracceleration.

• Anynewregionalandmulti-boroughgovernancewillbeimplementedwithaviewtorationalisingthewidergovernanceinfrastructuretoensureduplicationisavoided.

• Anyarrangementsmustconsidertheimplicationsforbothdevolutionandwidertransformationandoperationalgovernance.Approacheswillbe‘future-proofed’toallowevolutiontoaccommodatefurtherdevolution,delegationandjointdecision-making,withfunctionsphasedovertime.

• TheNHSinLondonwillremainwithinthewiderNHSandsubjecttotheNHSConstitutionandMandate.

ThesegovernancearrangementsaredescribedinFigure1.

LondonHealthBoard

Politicalleadershipisvitalatallspatiallevelsandare-castLondonHealthBoardwillenablepoliticalaccountabilityofhealthandcareinLondon,andprovidepoliticaloversightofwiderLondontransformationefforts.TheLondonHealthBoardwillcontinuetobechairedbytheMayorofLondon.Membershipwillbestrengthenedasrequiredtoreflectpoliticalleadershipfromsub-regionalgroups.TheLondonHealthBoardwillhavestrategicpoliticaloversightforhealthandcareinLondon.

LondonHealthandCareStrategicPartnershipBoard

TheLondonHealthandCareStrategicPartnershipBoard(SPB)metforthefirsttimeinshadowforminMay2017and,goingforward,thisboardwillprovidestrategicandoperationalleadershipandoversightforLondon-levelactivities28.TheSPBwillbuildonnationaldirection(suchastheFiveYearForwardView)andLondonplans(includingBetterHealthforLondon),butcruciallywillemphasisethepartnershipapproachandanagreedstrategyforsustainabilityandtransformationbuiltupfrom

28LondonHealthandCareStrategicPartnershipBoard(SPB)termsofreferenceavailableat:[DN:tobepublishedonsameday–linktodocument] https://www.london.gov.uk/sites/default/files/london_health_and_care_strategic_partnership_board_-_terms_of_reference_2017.pdf


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localandsub-regionalplans.TheSPBwillreplaceexistingcollaborativeLondon-widefora.TheDevolutionProgrammeBoardwillcontinueoperationbutmeetquarterlyduring2017toenablenationalandLondonpartnerstokeepabreastofthedevolutionprogrammeanddevelopmentswithintheLondonsystem,andallowexplorationofanyfurtherdevolutionopportunities.

Underthecurrentframework,theSPBwillnothavestatutoryorlegalresponsibilitiesandwillnotaffectorreplacethestatutoryresponsibilitiesandaccountabilitiesofeachpartner,orchangetheoperationalarrangementsforapplicationofbudgets.TheSPBwillalsobeaccountabletotheindividualpartnersthroughtheirrespectivemembership.

MembershipoftheSPBwillmatureasLondoncontinuesonitsjourneytogreaterautonomy,andwillbereviewedformallyfollowingthesigningoftheMoU.Itwillbeimportanttoensurethatlocalandsub-regionalpartnerscontinuetobeabletoshapethemodelofLondongovernancegoingforward.Membershipwillincluderepresentativesfromthefollowingorganisationsorgroups:

• Threesub-regionalleadsnominatedbyeachLondonSustainabilityandTransformationPartnership(comprisingofaCCG,localauthorityandproviderrepresentativeforeachofthefiveLondonPartnerships).

• LondonCouncils:Tworepresentatives.OneoftherepresentativeswillbetheLeadChiefExecutivenominatedtosupportLondonCouncils’workonHealth.

• LondonCCGs:Onerepresentative• GLA:Tworepresentatives• PHE:RegionalDirector• NHSEngland:TworepresentativesincludingtheLondonRegionalDirector• NHSImprovement:ExecutiveRegionalManagingDirector• CareQualityCommission,HealthEducationEngland,thirdsectorandpatientgroups.

Inadditiontotheaboveinvitedmembers,representativesfromotherLondonandnationalpartnerswillattendasappropriate.TheSPBwillbeco-chairedbytheLondonRegionalDirectorofNHSEnglandandtheLeadChiefExecutivenominatedtosupportLondonCouncils’workonHealth.Governancearrangementswillensureclearlinesofaccountabilityforanyrelevantfundingasagreedandoutcomesasappropriate.Membershipandgovernancearrangementswillbereviewedandfurtherdefinedasandwhendelegatedordevolvedresponsibilitiesaretakenontoensureprobityandaddressanyarisingconflictsofinterest.

Detailedgovernancearrangementsareunderdevelopment,andwillincludeclearprotocolsfordecision-makingandensuringrobustclinicalinput.ItisanticipatedthatarrangementswillberefinedastheSPBmatures,andgovernancedocumentswillbeupdatedaccordingly.PartnershipCommissioningBoard

London-widehealthandcareoperationalfunctionswillultimatelybeadministeredthroughaLondonlevelPartnershipCommissioningBoard.ThesefunctionsarelikelytoincludeassuranceandtheadministrationofanyLondon-leveldelegatedordevolvedcommissioningfunctionsandbudgets,andwouldinitiallybeexercisedthroughaperiodofshadowrunning.

TheLondon-levelcommissioningboardwillnotaffectstatutorylocalcommissioningordecision-makingfunctions,butlookathowsomenationalcommissioningfunctionscouldbeexercisedattheregionallevelorhowexistingregionalfunctionscanbeadministeredthroughgreaterengagementwithlocalgovernmentandotherpartners.


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DuringtheinitialphasesofLondongovernance,partnerswillfinalisedetailedstrategiesforadministrationoffunctionsdelegatedtoLondon.DecisionswillbetakenatLondonlevelbywayofinternaldelegationswithinconstituentorganisations,andtherearecurrentlynoproposalsthatchangelegalresponsibilitiesorfinancialaccountabilities.

WherepossibletherewillbecomplementaritybetweenrepresentativesonthePartnershipCommissioningBoard,theSPB,localandsub-regionalgovernancemechanisms.

Partnershipdeliverygroup

ALondonpartnershipdeliverygroupwillsupportdelivery,systemtransformation,andcollaborativeworkingatallspatiallevels,andwillbuildonthetransformationcurrentlyundertakenbyLondonstructuressuchastheHealthyLondonPartnership.Londonpartnersagreetoshareanddeploytheirknowledge,expertise,resourceandcontactnetworksinsupportofthecommitmentsmadeinthisMoU.AfullfinancialplantosupportthedeliveryofthesecommitmentswillbedevelopedduringtheadvisoryphaseoftheSPB,withresourcingarrangementsinplacebytheendof2017.

Phasing

AphasedapproachtoLondongovernanceforhealthandcaretransformationwilldescribecleargatewaysforprogressionagreedbetweentheLondonsystemandnationalpartners.ProgressionthroughthesephaseswillbeagreedbetweenLondonandnationalpartners.

1. Advisory:RepresentativesfromexistinggovernancestructureswillinitiallymeetastheSPBtoco-developtheframeworkunderwhichLondongovernancewilloperate.TheSPBwillprovideapan-Londonforumfordiscussion,andsitinanadvisorycapacitytosupportpartnerstocommenceimplementationofagreeddevolution.Duringthisphase,theSPBwillsupportpartnerstoestablishnewoperatingmodels,includingjointapproachestoregulation.ThisphasebeganinMay2017,anditisenvisagedthattheSPBwillbereviewedagainstagreedgatewaycriteriaforthestrategicphaseaftersixmonthsofoperationtodeterminewhethertheSPBcanmoveintothenextphase.

2. Strategicleadership:TheSPBwillprovideacentralpointforco-locationofcurrentstrategicoversightmechanisms.Duringthisphase,theSPBwillbegintheprocessofbuildingtheLondonlevelstrategicplanrequiredforeffectiveoversight,supportsub-regionalareastodevelopandimplementrobuststrategiesandactasbrokerforproposalsbetweennationalpartnersandlocalareas.Itisenvisagedthatthisphasewillbereviewedagainstagreedgatewaycriteriaforshadowdecision-makinginearly2018todeterminewhethertheSPBcanmoveintothenextphase.

3. Shadowdecision-makingatLondonlevel:TheSPBwillcontinuetooperateasapan-Londonstrategicforum,andLondonwillalsobegintheprocessofshadowrunningbywayofrecommendationsmadetonationalorganisations.Decision-makingaroundaLondonshareofcertainbudgetswouldbegin,inshadowform,withintheforumoftheSPBasagreedwithrelevantnationalorganisations,althoughtherewouldbenochangetostatutoryaccountabilities.Itisenvisagedthatthisphasewouldbereviewedagainstagreedgatewaycriteriaforthedecision-makingphaseinApril2018todeterminewhethertheSPBcanmoveintothenextphase.

4. Decision-makingatLondonlevel:TheSPBwillcontinuetooperateasapan-Londonstrategicforum.Followingagreementbynationalpartners,certainbudgetsandcommissioningfunctionsmaybeappropriateforformaldelegationstoaLondonlevel.Partnerscouldbegintheprocessofformaldecision-makinginphase4,bywayofinternaldelegationstoorganisationalrepresentativesonLondongovernancestructures.


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TheLondonsystemaspirestoprogressintoamorefullydevolvedmodelviaaphase5,anditisrecognisedthatthiswouldrequireastrongevidencebaseofefficient,effectiveandrobustoperation,aswellasfurtherconsiderationoftheavailablelegislativeoptionstosupportsuchanapproach.AnyfuturedecisionswouldbesubjecttoafullreadinessassessmentandtorelevantnationalorganisationsbeingabletomeettheirongoingstatutoryaccountabilitieswithregardstobothLondonandtherestofthecountry.


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Figure1.GovernancearrangementsforhealthandcaretransformationinLondon

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Annex1:Aspirations,objectivesandprinciples

AspirationsandobjectivesThepartieshaveasharedcommitmenttodeliveronthe10aspirationstopromotehealthandwellbeingsetoutinBetterHealthforLondon:NextStepsand,indoingso,deliverontheNHSFiveYearForwardViewandsecurethesustainabilityofhealthservicesandsocialcare.Tomeettheseaspirations,thepartiessharethefollowingobjectives:

• ToachieveimprovementinthehealthandwellbeingofallLondonersthroughastronger,collaborativefocusonhealthpromotion,thepreventionofillhealthandsupportingself-care.

• TomakerapidprogressonclosingthehealthinequalitiesgapsinLondon.• ToengageandinvolveLondonersintheirhealthandcareandinthehealthoftheirborough,

sub-regionandcityincludingprovidinginformationsothatpeoplecanunderstandhowtohelpthemselvesandtakeresponsibilityfortheirownhealth.

• Toimprovecollaborationbetweenhealthandotherservicestopromoteeconomicgrowthinthecapitalbyaddressingfactorsthataffectbothpeople’swellbeingandtheirwidereconomicandlifeopportunities,throughstrongerpartnershipsaroundhousing,earlyyears,employmentandeducation.

• Todeliverintegratedhealthandcarethatfocusesonmaximisingpeople’shealth,wellbeingandindependenceandwhentheycometotheendoftheirlivessupportsthemwithdignityandrespect.

• Todeliverhighquality,accessible,efficientandsustainablehealthandcareservicestomeetcurrentandfuturepopulationneeds,throughoutLondonandoneveryday.Toreducehospitalisationthroughproactive,coordinatedandpersonalisedcarethatiseffectivelylinkedupwithwiderservicestohelppeoplemaintaintheirindependence,dignityandwellbeing.

• Toinvestinfitforpurposefacilitiesfortheprovisionofhealthandcareservicesandtounlockthepotentialinthehealthandcareestatetosupporttheoverallsustainabilityandtransformationofhealthandcareinthecapital.

• Tosecureandsupportaworld-classworkforceacrosshealthandcare.• ToensurethatLondon’sworld-leadinghealthcaredelivery,academicandentrepreneurialassets

providemaximumbenefitforLondonandthewidercountry;andthathealthandcareinnovationisfacilitatedandadoptedinLondon.

Principles

Allpartieshaveagreedkeyprinciplesforreformanddevolution:

• ImprovingthehealthandwellbeingofLondonerswillbetheoverridingdriverforreformanddevolution.

• Wewillworktosecureasignificantshiftfromreactivecaretoprevention,earlyintervention,self-careandcareclosetohomethatsupportsandenablespeopletomaximisetheirindependenceandwellbeing.

• LondonwillremainpartoftheNHS,publichealthandsocialcaresystem,upholdingnationalstandardsandcontinuingtomeetandbeaccountableforstatutoryrequirementsandduties,includingtheNHSConstitution.

• Jointworkingwillimprovelocalaccountabilityforservicesandpublicexpenditure.Wherethereislocalagreementtochangeaccountabilityarrangements,accountabilitytoNHSEnglandwillbemaintained–inrelationtoissuesincludingdeliveryoffinancialrequirements,nationalstandards


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andtheNHSConstitution.Anychangestocurrentaccountabilitiesandresponsibilitieswillbeagreedwithnationalpartnersasnecessaryandmaybephasedtobalancethepaceofprogresswithensuringasafetransitionandstronggovernance.Wecommittofulfilthelegalrequirementsformakingsignificantchangestocommissioningarrangements,includingstatutorydutiestoinvolvethelocalpopulationandsubmitproposalsforlocalauthorityscrutiny.

• Decision-makingwillbeunderpinnedbytransparencyandtheopensharingofinformationbetweenpartnersandwiththepublic.

• Transformationwillbelocallyownedandledandwillaimtogetthewidestpossiblelocalsupport.Wewillensurethatcommissioners,providers,AcademicHealthScienceNetworks(AHSNs),patients,carers,thehealthandcareworkforce,thevoluntarysectorandwiderpartnersareabletoworktogetherfromdevelopmenttoimplementationtoshapethefutureofLondon’shealthandcare.

• AlldecisionsaboutLondonwillbetakeninoratleastwithLondon.OurgoalistoworktowardsresourcesandcontrolbeingdevolvedtoandwithinLondonasfaraspossible,certainlyinrelationtooutcomesandservicesforLondoners.

• Collaborationandnewwaysofworkingwillbeneededbetweencommissioners,providers,patients,carers,staffandwiderpartnersatmultiplelevels.RecognisingthattheLondonsystemislargeandcomplex,commissioninganddeliverywilltakeplaceatthreelevels:local,sub-regionalorpan-London.Aprincipleofsubsidiaritywillunderpinourapproach,withdecisionsbeingmadeatthelowestappropriatelevel.

• GivenLondon’scomplexitywerecognisethatprogresswillhappenatdifferentpacesandindifferentordersacrossthedifferentspatiallevels.Wewillensurethatlearning,bestpracticeandnewmodelsfordeliveryandgovernancearesharedtosupportandaccelerateprogressinallareas.Subsidiarityasaprinciplewillextendtotheadoptionofideaspilotedinotherareastoallowflexibilityandadaptationtolocalconditions.

• Thepeoplethatworkinhealth,healthcareandsocialcarearecriticaltoachievingLondon’stransformationgoals.WewillbuildonLondon’spositionasthehomeofpopularandworld-classhealtheducation,todevelopnewroles,securetheworkforceweneedandsupportcurrentandfuturestafftoforgesuccessfulandsatisfyingcareersinaworld-classLondonhealthandcaresystem.

• Werecognisethatconsiderableprogresscanbemade,buildingonexistingfoundations,withexistingpowersandfunding–andwearecommittedtodoingso.Butdevolutionwillbesoughttosupportandaccelerateimprovementswheretheappropriatenationalcriteriaaremet.

• Whileembeddingsubsidiarity,wewillensurethestrategiccoherenceandmaximisethefinancialsustainabilityofthefuturehealthandcaresystemacrossLondon.Politicalsupportforjointlyagreedchangewillbeanimportantfeatureofthearrangements.NewLondon-levelarrangements,includinggovernanceandpoliticaloversight,willbeestablishedtosecurethis.Wecommittominimisingbureaucracyasmuchaspossibletoenabledeliveryoflocalinnovation.

• In2016/17sustainabilityandtransformationplanshavebeendevelopedforhealthandcareaspartofNHSandlocalauthorities’planningarrangements.ALondon-levelstrategicplan,drawnfromsub-regionalsustainabilityandtransformationplans,willenableoversightoftheimpactonhealthoutcomesandfinancialsustainabilityofthesystemacrossthecapital.

• WerecognisethatLondonprovidesexpertiseandservicesforpeoplewholiveoutsidethecapitalandthatbenefitthecountrymorewidely.LondonwillworkcollaborativelywithotherregionsandnationalpartnerstoconsidertheimpactofLondondecisionsonsurroundingpopulationsreliantonLondon-basedservices,andmitigateanyadverseeffects.

london health and social care devolution - nhs england · dr marc rowland chair, london ... mayor...

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