Contracting arrangements for integrated care providers – response to consultation

Contracting arrangements for integrated care providers – response to consultation
NHS England March 2019

• NHS England has published its response following a consultation held about a new contract which can help local health and care communities provide better care for patients.
• The ICP Contract will give commissioners the option to commission services through a single contract, to build in integration and remove operational barriers.
• The feedback will be used to further develop the ICP Contract, which will be available in its updated form as an option for use in local health and care systems from spring 2019. Neither use of the ICP Contract nor adoption of lead provider models for integration will be mandatory: they will be options for local commissioners and their providers to consider.

Lessons learned from contract dispute resolution

Lessons learned from contract dispute resolution
NHS England NHS Improvement 2 November 2018

• This document contains ten helpful hints for commissioners and providers to avoid conflict.

The ten hints

Integrated Support and Assurance Process (ISAP) for new care model procurement

Integrated Support and Assurance Process (ISAP)
NHS England and NHS Improvement, 17 August 2017

• It has been recognised that the contractual arrangements through which some new care models will be implemented may mean:
• The contract structure, form, content or the calculation of the financial value of the contract envelope are ‘novel’;
• The bidder’s organisational forms may be complex, as providers form legal entities and arrangements that allow for greater collaboration between partners; and
• A single procurement for a new care model can significantly affect incumbent NHS providers. 
• These documents describe the integrated NHS England and NHS Improvement process for supporting commissioners and providers looking to procure and bid for complex contracts. 
• Part A: Introduction to the ISAP for commissioners and providers looking to procure, or bid for, a complex contract;
• Part B: The questions that will be asked and the submissions from commissioners expected at each stage of the ISAP; and
• Part C: Guidance for NHS trusts and foundation trusts looking to bid for a complex contract. This may also help independent providers bidding for such contracts.

Provision of community care: who, what, how much?

Provision of community care: who, what, how much?
Health Foundation May 2017

• Analysis of information obtained through FOI  requests on the community care contracts held by 78% of CCGs found that NHS providers held more than half of the total annual value of contracts in the sample, while private providers held 5% of the total annual value, but 39% of the total number of contracts issued.
• Private providers tended to hold much smaller contracts, with 6 in 10 holding contracts with a combined value of less than £100,000. Additionally, most held just one contract.

Next steps on the NHS Five Year Forward View: Primary care

Next steps on the NHS Five Year Forward View - Primary Care
NHS England 31 March 2017

• Key improvements for 2017/18 and 2018/19
• Boost GP numbers. 
• By March 2018 at least 40% of the country will benefit from extended access to GP appointments at evenings and weekends. By March 2019 this will extend to 100% of the country. 
• More convenient patient access to GP services. From October 2017 practices who shut for half days each week will not be eligible the extended access scheme.
• Expansion of multidisciplinary primary care through increase the number of clinical pharmacists and mental health therapists in primary care andincentivising physician assistants to work in primary care.
• Modernisation of primary care premises.
• Changes will be implemented through:
• investment in GP services
• Practices will work together in ‘hubs’ or networks.with a combined patient population of at least 30,000-50,000. (The model does not require practice mergers or closures and does not necessarily depend on physical co-location of services.)
• Development of a successor to QOF.

Public Contracts Regulations 2015 for NHS commissioners

Guidance: Public Contracts Regulations 2015 for NHS commissioners
Department of Health 21 October 2016

• This guidance summarises the Public Contract Regulations 2015 (PCR 2015) requirements for NHS commissioners and those supporting them with their procurement of healthcare services.
• Read the Mills & Reeves blog which highlights five areas for commissioners to be alert to.

Integrated Support and Assurance Process (ISAP)

Integrated Support and Assurance Process
NHS Improvement, NHS England 4 November 2016

• A consistent, streamlined process for supporting and assuring the successful delivery of complex contracts.
• This guidance provides an initial introduction to, and overview of the process ISAP and includes:
• lessons learnt from past complex contracts
• key risk management questions for providers, commissioners, NHS Improvement and NHS England
• the stages of the ISAP
• when to apply the ISAP
• how to feedback on the ISAP
• next steps for those working on complex contracts
• NHS Improvement will be publishing the full guidance later this year which will include more information on the submissions and evidence expected from commissioners and providers at each stage of the procurement process.

New models of care - services and contract mechanisms

New Models of Care – Services and contract mechanisms: A rapid review of existing evidence
Healthy London November 2016

• A rapid review of current literature and some key examples of initiatives by the Vanguards and other sites across the country. 

Multi-Speciality Community Provider framework

Multi-Speciality Community Provider (MCP) framework
NHS England 28 July 2016

• Close work with 6 local systems has supported the development of a Multi-Speciality Community Provider (MCP) framework which provides a way forward on commissioning, contracting, financial flows and organisational form. 
• The fully integrated MCP is a place-based model of care. with a single whole population budget across the range of services it provides. It creates a new care model, backed by a new business model, based on the GP registered list and is a critical enabler of the GP Forward View.
• The building blocks of an MCP are the ‘care hubs’ of integrated teams. Each typically serves a community of around 30-50,000 people. 
• The MCP care model operates at four different levels:
• at the whole population level, the MCP aims to bend the curve of future healthcare demand. It aims to address the wider determinants of health and tackle inequalities. It builds social capital by mobilising citizens, local employers and the voluntary sector; 
• for people with self-limiting conditions, the MCP helps build and forms part of a more coherent and effective local network of urgent care; 
• for people with ongoing care needs, it provides a broader range of services in the community that are more joined-up between primary, community, social and acute care services, and between physical and mental health; and 
• for small groups of patients with very high needs and costs, it delivers an ‘extensive care’ service.
• Three contacting models are emerging:
• the ‘virtual’ MCP, brought about through an alliance contract. 
• the ‘partially integrated’ MCP contract, which means that whilst general medical services are an integral part of the MCP model of care, the GPs retain their GMS contract, which ‘sits alongside’ the MCP contract.
• the ‘fully integrated’ model with a single whole population budget across all primary and community based services.
• A MCP contract development team is working on development of new commissioning, contracting, organisational forms and funding methodologies.
• A draft MCP contract will be published at the end of September.
• For a list of MCP Vanguards see here.
• See NHS England Board paper 

How to secure good outcomes for patients when awarding contracts

Briefing for clinical commissioning groups: options for selecting providers and awarding contracts
NHS Improvement, 26 May 2016

• This note supports CCGs to make good decisions by clarifying what they need to do when selecting providers and awarding contracts. It points to the guidance which should be taken into consideration when procuring services. While there are requirements for commissioners to be fair and transparent about what they are doing, it is not true that all contracts must be awarded using a competitive tender process.
• The Department of Health will shortly issue guidance detailing the specific requirements from recent changes to general procurement law.

Salford Together - the business case

Full Business Case: Integrated Care Organisation
Salford CCG 12 April 2016

• This summary brings together the key elements of the Full Business Case (FBC) to develop an Integrated Care Organisation (ICO). 
• It sets the strategic context for the creation of an ICO and then summarises the main chapters in the FBC, together with the recommendations. 
• It also describes the approach to risk management, key decisions at FBC stage, and the key areas of work that will need to take place following an FBC approval.

Review of models of integrated care contracts

Contracting for integrated health and social care: a critical review of four models by Jenny Billings  and Esther de Weger

Journal of Integrated Care, Vol. 23(3) pp.153 – 175

• A description and critical account of four models of contracting, namely Accountable Care Organisations, the Alliance Model, the Lead Provider/Prime Contractor Model, and Outcomes-based Commissioning and Contracting.
• The review conlcudes that:  “further research is required to determine the most effective approach for integrated care contracting.”
• Abstract (Contact your local NHS Library for a full copy of this article)

Use of contractual mechanism in commissioning

Study of the use of contractual mechanisms in commissioning
PRU Comm, May 2015

• This three year project investigated how commissioners negotiated, specified, monitored and managed contractual mechanisms to improve services and allocate financial risk in their local health economies, looking at both acute services and community health care. 
• A series of three in depth case studies of three local health economies and telephone surveys (2012/ 2014) found that most of the contractual relationships between NHS owned acute providers and commissioners were characterised by the use of general annual financial settlements outside the terms of the National Tariff rules and the contract. 
• Financial incentives (CQUINs) to improve quality contained in contracts were in widespread use. However, CQUINs were seen as time consuming to negotiate and monitor. There was concern that there were too many different CQUINs each year, and some areas had started to reduce the numbers used.

Can the NHS handle the outsourcing of clinical services?

The contracting NHS – can the NHS handle the outsourcing of clinical services?
Centre for Health and the Public Interest (May 2015)

• Little is known about how CCGs inspect and enforce contracts with the private sector. 
• Using available official data, and data from 181 CCGs which responded to a survey, this report concludes "that the NHS is poorly equipped to ensure that healthcare services outsourced to for-profit providers will provide safe, high-quality care and good value for money. "
• The report makes a number of recommendations relevant to commissioners in CCGs relating to how contracting records are managed; processes for monitoring contracts; mechanisms to define and identify poor performance; processes and governance arrangements for managing poor performance; the support (e.g. commercial, legal) available for managing contracts with large commercial organisations; the resources and specialist skills required and available to manage contracts going forward.

Mills & Reeves Short legal guides for CCGs

Short guides from Mills & Reeves
Mills & Reeves Health Commissioning portal

• Short guides to some of the key legal issues relevant to clinical commissioning groups including: 
• Contracting skills for CCGs 
• Governance issues 
• Information governance 
• Introduction to contracts 
• Introduction to procurement and competition 
• Introduction to the standard NHS contract (2013/14) 
• NHS Continuing Healthcare 
• Introduction to prioritisation

NHS outsourcing - effective monitoring is key

The contracting NHS –can the NHS handle the outsourcing of clinical services?
Centre for Health and the Public Interest, March 2015

• Over the last four years there has been a 50% increase in the amount spent in the private sector on community health services and secondary care services by local commissioning bodies and NHS trusts, and this trend looks set to continue with the requirement on CCGs to put services out to competitive tender. 
• The safety and quality of healthcare in England now depends increasingly on how effectively the NHS monitors and enforces this myriad of contracts with the private sector. But contracting for healthcare is highly problematic and little is known about how CCGs inspect and enforce contracts with the private sector. 
• The report makes a number of recommendations if the outsourcing of NHS clinical services to the private sector is to continue including:
• an independent audit of CCGs’ capacity to monitor and manage contracts with non-NHS providers
• a reconsideration of plans to privatise the contract monitoring of NHS contracts.
• CCGs should be required to publish regular performance data on the number and value of contracts they hold, how they know whether contracts are performing well, the number and type of staff they employ to monitor and enforce contracts, and the amount of any over-payments they may have made to providers due to error or fraud.

Public Contracts Regulations 2015

User Guide to the Public Contracts Regulations 2015
Mills & Reeve, February 2015

• This note provides a (non-exhaustive) overview of some of the key new provisions in the PCR 2015. The main focus is on the implications for contracting authorities and the public sector.

Community services after TCS

Improving community services
Monitor 22 January 2015

• This report looks at what CCGs are doing about community services as the contracts entered into after the Transforming Community Services (TCS) programme expire.
• Many of the community services contracts put in place 3 to 5 years ago are expiring, giving commissioners an opportunity to move to new ways of working or new models of care or test which providers are most likely to achieve the changes that commissioners want for patients.
• The report summarises how the ‘Procurement, Patient Choice and Competition Regulations’ apply to some of commissioners’ decisions about commissioning community services.
• Includes  case studies to show how some commissioners have commissioned community services or models of care.

NHS Provider Licence - being prepared for April 2014

Briefing for commissioners on the NHS provider licence
Monitor, 28 November 2013

• This document outlines the action commissioners now need to take to be ready for 1 April 2014

Oxford CCG COBIC contract issues

Oxford CCG COBIC contract problems
HSJ 13 November 2013 (subscription required)

• Oxfordshire Clinical Commissioning Group is working on capitated outcomes based contracts for adult mental health, older people’s services and maternity services. If implemented as currently set out, the contracts would account for 30-40 per cent of Oxfordshire CCG’s £612m commissioning budget.
• This HSJ article reports concerns expressed by the chief executive of Oxford University Hospitals Trust and the chief executive of Oxford Health Foundation Trust. 
• Read the Oxford CCG business case