Archived decisions

12^th April 2006

A Discussion Paper

Introduction

This high level paper has been drafted to stimulate discussion and seek agreement to a strategy and a proposal to bring together planning and delivery arrangements for child health services in Hampshire. It is the intention that this proposal will improve the contribution that health makes to partnership working and implementation of `Every Child Matters' (2004) and the `National Service Framework for Children and Young People and Maternity Services' (2004), underpinned by policy guidance in `Choosing Health' (2005) and `Our health, our care, our say: A new direction for community services.' (2006).

Implementing `Commissioning a Patient Led NHS,' delivering financial balance, and the top national and Strategic Health Authority (SHA) priorities will be the main focus for the PCT/PCT's during 2006/7. None of which will directly contribute to achieving the 5 key outcomes for children. However, it is imperative that the PCT's as they are now, and in the future configuration, are able to support the implementation of the `Change for Children Programme' and deliver the health contribution unimpeded by organisational change in health. This proposal would facilitate and enable this work to progress.

The proposal is part of a stepped approach, the first being the development of a county wide model of child health services which is described in this paper. This would position health services for future work with Hampshire County Council's (HCC) Children's Services to implement a children's trust approach. It also acts as a springboard for testing the `market' and the potential establishment of independent provision. This preparatory work is critical due to the disparate nature and lack of information on cost and quality of current health service provision.

The proposal would offer the following benefits:

i) Strong leadership for children's health and maternity services with direct accountability to PCT Board/ Boards to work alongside the senior management team in HCC's Children's Service.

ii) Bring commissioning (needs assessment, strategic planning, local planning and contracting) together across the HCC area

iii) Development of pathways to deliver consistent models of quality assured health services for maternity, children and young people across Hampshire

iv) Development of common systems and processes for evaluation of services and measurement of health outcomes for children

v) Position health services to work as integrated partners with the Local Authority in implementing the Change for Children Programme led by the Director of Children's Services HCC

vi) Prepare for contestability

The Strategy

A single approach to commissioning of children's health services across Hampshire County Council area which contributes to the delivery of the 5 key outcomes for children through consistent service delivery

Rationale for Change

There are numerous national and local drivers for change to note (Appendix 1) but specifically `Commissioning a Patient led NHS' (2005). Implementation of this key policy will strengthen the commissioning function of PCT's, primary care practitioners and promises to engage patients and the public in both the development and monitoring of services. It requires a separation of the commissioning and providing functions, and in due course, the introduction of contestability into NHS health care. In addition `Our health,our care,our say: A new direction for community services' (2006) provides the framework to facilitate integration of services across health and social care, shifting the balance of care from acute to community and primary care and giving greater control of services provided to young people and their families.

The emerging vision underpinning Hampshire Children & Young Peoples Plan (CYPP) is for an integrated children's service with the local authority and all it's partners. This integration can be achieved through a strong commissioning strategy at a HCC level providing the framework for devolved commissioning to meet local need. In order to achieve integrated delivery, various devices can be employed, these range from: virtual teams ie staff from various organisations working together to agreed priorities; co-location of staff employed by different agencies; to joint management/employment arrangements.

The current position

The various organisational arrangements for needs assessment, strategic planning, service development, contracting and provision of child health services across Hampshire has created a significant challenge for partners and child health leads within the PCT's. Four PCT's have nominated leads for children's services at the executive level and arrangements have been put in place to represent colleagues in the absence of an executive lead. Without dedicated time, children's service planning at an executive level has been limited and fragmented. The child health leads with responsibility for commissioning in each PCT cluster have made considerable progress over the last year. They are beginning to co-ordinate planning activity in order to avoid duplication of effort and provide some coherence and consistency to the planning processes with the Local Authority in particular and other partners.

The PCT's directly provide some child health services and commission from a range of organisations from both within and outside the county. (Appendix 2) Few delivery systems align with Local Authority areas. Recent audits¹²³ have identified inequitable staffing levels, different models of service and access criteria across the county. The investment in children's services is not known, as most service level agreements are part of ill defined block contracts in which activity and cost for services for children are not specified. Inconsistency and paucity of data collection makes it difficult to assess the impact of this fragmented provision on outcomes. The national child health mapping exercise, will provide some comparative data about investment and activity levels for the first time in June 2006. However, experience of the CAMHS mapping would suggest caution in use of the first year of data, due to problems with process, definitions and accuracy.

A number of PCT's are reconfiguring child health services in order to achieve congruence with organisational boundaries and partners, however, this change is placing services at risk. For example: the Surrey PCT's are withdrawing from services provided by Blackwater Valley and Hart PCT, the remaining service will not have the critical mass to be viable without merging with other services in Hampshire. Similarly in SW Hants PCTs an exercise to reconfigure some of the children's services provided by Southampton City PCT was undertaken which illustrated similar difficulties regarding the critical mass and thus the viability of specialist services.

A SWOT analysis of the current position can be found in Appendix 3

The Proposal

A single service model for commissioning and delivery of child health and maternity services

1) To separate the resources, commissioning budgets and staff providing services, for children from those for adults and older people.

2) Establish a single directorate for children's health services, with distinct commissioning and provider functions, serving the population in HCC area. Depending on the outcome of consultation on PCT configuration this will be in a single PCT or hosted by one PCT on behalf of the others. The accountability arrangements within health and with HCC Children's Service will need to be determined. Evidence from early pathfinder trusts would suggest joint accountability to PCT and Directors of Children's Services. This arrangement should be considered between the PCT/PCTs and HCC.

3) To develop a county wide model of provision working to agreed pathways, delivered through multi disciplinary teams serving communities aligning to the emerging school clusters, children centre developments and, if possible, practice based commissioning localities. This may be through directly provided services or through services commissioned to a common specification. The synergy that this will generate with partners including primary care will facilitate more integrated service provision for children and young people, mirroring the care pathways illustrated by the `Windscreen of Needs' developed by HCC Children's Service Appendix 4. The implementation of the model at a local level to meet local needs will necessitate the development of strong professional networks and agreed clinical governance arrangements to monitor and address problems across organisational boundaries. (A description of the proposed service components can be found in Appendix 5)

4) To mandate the PCT Child Health leads to develop a commissioning plan and options for organisational arrangements which will support implementation of the strategy within the new PCT/PCTs arrangements. (A SWOT analysis of the proposed model is at Appendix 6).

Questions for consideration

1. Do you support the strategy for a single approach to commissioning of children's health services across the Hampshire County Council area?

2. Do you support the proposal to separate resources for children from those for adults and older people to mirror the emerging arrangements in Hampshire County Council?

3. What structure and reporting arrangements would best support commissioning and delivery of health services for children in the new PCT arrangements?

4. Do you support the proposed model of provision with service components aligning to emerging structures for delivery in Hampshire County Council?

5. Are there additional strengths/ weaknesses/ opportunities or threats that have not been identified?

6. It is proposed that commissioning and provision are led from a single Directorate, although the two functions will need to be separately structured and resourced. Would this structure be supported in light of the national directive to separate commissioning and providing functions within `Commissioning a Patient Led NHS'?

Appendix 1

Drivers for change

Children Act (2004) - Places a legal `duty' for health services to co-operate with Local Authority Children's Services and strategically facilitates an integrated model of working together with all partner agencies, statutory and voluntary Choosing Health (2004) - Encourages front-line practitioners to focus on prevention and early intervention and addresses health inequality

Youth Matters (2005) - Provides direction for `health' particularly school nurses in terms of enabling young people to make healthy choices and avoid risk taking behaviours

Children & Young People and Maternity Services NSF (2004) - Provides quality standards from universal prevention and early intervention to specialist services for ill children, children with learning disabilities, mental health, maternity and medicines management

Commissioning a Patient Led NHS (2005) - drives a fundamental change in focus through strengthening commissioning and promoting choice, diversity and contestability in service provision and places the patient at the centre

Practice Based Commissioning (2005)- furthers the opportunities for service development in primary and community care developing appropriate alternatives to secondary care providing quality care closer to local communities. Draft Strategic Framework for the Development and Implementation of Practice Based Commissioning in H & IoW SHA suggests in point 7.45 that Children and Maternity Services will not normally be considered within the local scope of PBC during 2005/6 & 2006/7

Our health,our care,our say: A new direction for community services (2006) provides the framework to facilitate integration of services across health and social care, shifting the balance of care from acute to community and primary care and giving greater control to young people and their families.

Hampshire Children and Young Peoples' Plan ((2006) - the opportunity to make a real difference by working differently maximizing efficiency and effectiveness across agencies to agreed priorities

Local Area Agreement (2006) will mirror plans within the CYPP

Overview & Scrutiny Committee Review of Therapy Services (2004) - identified inequitable provision and inconsistent service models across the county

Office of Public Management Acute Paediatric Review (2005) - highlighted variation in models of service delivery, difference in reference costs and vertical integration of acute and community services

Appendix 2

Current commissioning and provision arrangements

The PCT's are responsible for commissioning services from Health providers through Service Level Agreements (SLA's).

Acute Services

Services provided within the SLA for acute services include

· General Paediatrics

· In patient, Outpatient

· Maternity

· NICU

· Specialist services such as Ophthalmology, ENT

Community Services

Services provided within the SLA for community services include

· Health Visiting

· School Nursing

· Child Protection

· Children Looked After

· Community Paediatrics

· Learning Disability

· Physiotherapy

· Occupational Therapy

· Speech and Language Therapy

· Children Community Nursing

· Child and Adolescent Mental Health Services

Tertiary / Specialist Services are commissioned by a Specialist team which commissions on behalf of all PCTs in HIOW and along the central south coast

Tertiary Providers

Specialist services provided within the SLAs include

· Tier 4 CAMHS

· Burns

· Cleft Palate

· Genetic screening

Complexities of commissioning

· PCTs commission services from a number of different providers following historic patterns of referral. Services have evolved differently in each area resulting in a variation of models of service, capacity, access criteria, quality and measurement of input or outcomes. This variation occurs not only between PCT's but also within the PCT's presenting a challenge to commissioning and the redesign of provision.

· A number of the SLAs are with providers from outside the Local Authority boundary.

· Some areas have community and acute services provided by the same organisation, whilst others have different providers for community and acute services covering the same geographical area - both create different challenges.

· There are a number of intra provider SLAs between some PCT and acute providers for support services which add to the complexity of the SLAs and which impact on the services children receive.

* Key to provider codes

FPH Frimley Park Hospital NHS Trust

NHHT North Hampshire Hospital Trust, Basingstoke

PHT Portsmouth Hospital Trust

RSCH Royal Surrey County Hospital, Guildford

SUHT Southampton University Hospital Trust

WEHT Winchester and Eastleigh Healthcare Trust

SHCT Salisbury Health Care Trust

RBT Royal Berkshire NHS Trust , Reading

RBCH Royal Bournemouth and Christchurch NHS Trust

PGH Poole General Hospital NHS Trust

St RH St Richards NHS Trust, Chichester

PCPCT Portsmouth City PCT

SCPCT Southampton City PCT

** Acute Hospitals providing some community services

Appendix 3

A SWOT analysis of current arrangements for commissioning and service delivery

Appendix 4

Windscreen of Needs

Appendix 5

Service Components from universal to specialist and acute provision to meet `Windscreen of Needs'

Services contribute at different stages of the pathway building services around the needs of the child and family

Primary Care

· General medical services

· General dental services

· Opticians

· Pharmacies

Prevention and Early Intervention services aligned to communities served by the developing Children's Centres and Extended schools clusters, composing of.

· Health Visiting

· School Nursing

· Primary Mental Health Workers

· SALT

· Midwifery

· Public Health/ Dental Health Promotion

Specialist Multi disciplinary services for children with developmental problems and supporting prevention and early Intervention services comprising of:

· Community paediatrics

· Occupational Therapy

· Physiotherapy

· SALT

· Special Needs Co-ordination

Specialist Learning Disability services for children with severe learning disabilities and supporting prevention and early Intervention services comprising of:

· LD Nursing

· Psychology

· Psychiatry

Specialist CAMHS services for children with complex mental health problems and supporting Prevention and Early Intervention Teams comprising of:

· Psychiatry

· Psychology

· Nursing

· Social Workers

· Therapists

Community and Specialist Nursing supporting care of the child at home and in school

Acute Ambulatory care, Inpatient and highly specialist tertiary services

Special needs dentistry

Screening and diagnostic services eg. Audiology, Orthoptics

Appendix 6

SWOT

Proposal for a single service model for commissioning and delivery of child health and maternity services