Integrated cancer systems – governance workshop

Integrated cancer systems – governance workshop 19th May 2011

Agenda

Progress to date • Model of care published in August, subject to engagement, and now agreed by the NHS in London • Integrated cancer system specification developed with providers and issued on 3rd May • Emerging picture of two systems, one in NE and NCL, the other encompassing NWL, SWL and SEL • Governance has emerged as the biggest challenge – getting this right will be key

Objectives of the session • To expand upon the integrated cancer system governance requirements set out in the specification. • To discuss the governance needs of tumour boards. • To outline the possible governance models and their respective advantages. • To share thoughts on emerging governance models across London. • To identify any areas where further support in submission development may be necessary.

Workshop session – The governance needs of tumour groups Rachel Tyndall

Governance of tumour groups • The final integrated cancer system specification states that MDTs and tumour groups should be the organising principles of systems. • Identifying the governance needs of tumour groups will inform the eventual choice of system governance model.

Group session On your tables consider: • What are the governance arrangements that need to be in place for tumour groups to: • Handle incidents? • Maintain consistent standards? • Consolidate specialist services? • What are the clinical leadership arrangements that should be in place? Should the clinical lead be: • Appointed and freestanding? • Appointed and hosted by one of the members? • First amongst equals within the system?

Lessons from elsewhere Rachel Tyndall

Specification • There should be an overarching governance board (as part of a lead organisation, or a holding company or joint venture) to lead and manage the integrated system as a single entity. • Commissioners will need to contract with a legal entity that can enter into an NHS contract. • A lead contracting body should be identified to hold this NHS contract (this does not have to be the lead organisation itself). It is for each ICS and its constituent members to agree the governance arrangements that suit them best

Lessons from the US • Successful approaches are always built upon strong clinical leadership and robust management processes • Different approaches work • Culture and leadership that promotes integrated working • Clarity about who is accountable for delivery and performance • Have to be able to meet internal (integrated) and external (not integrated) requirements • Developed sophisticated approaches to risk management and the use of incentives • These are between commissioner or payer and provider • Little evidence that core payment systems impact behaviour and quality • Experimentation with different payment mechanisms to remunerate high quality integrated care • Internal systems to minimise provider risk based on service line reporting • Developed integrated health information technology • There are alternatives to large comprehensive IT systems • Focus must be on systems that improve the co-ordination of care • All systems and networks have invested in consumer information Across the Pond – Lessons from the US on integrated healthcare. Richard Gleave. Nuffield Trust 2008.

Levels of joint working • Strategic/direction setting • Setting vision or direction • Discussing concerns • Agreeing common goals and priorities • Monitoring progress • Executive/resource sharing • Using vision to allocate resources • Set targets • Oversee performance • Operational/service delivery • Managing performance • Delivering services to meet the agreed goals Audit commission

Lessons on partnership working: governance • Agreement on a limited number of shared objectives • Clarity about roles and responsibilities • Robust monitoring arrangements on achievement of objectives • Shaping policy and practice • Leverage to hold individual organisations to account A review of health partnerships suggested that there had been too much emphasis on process and structure and not enough on outcomes. Governance and leadership needed to be less rigid and fixated on process, more open ended and inclusive, and more focused on achieving ends that are emergent rather than pre-determined.

Lessons on partnership working: practical issues The governance and leadership needs to attend to these issues to support integrated working • Information sharing and information sharing protocols • Common processes and procedures • Mapping of cost information and identification of efficiencies

Lessons on partnership working: cultural factors • Understanding the world from each other’s perspective • Alignment of priorities between the individual and collective concerns • Getting the balance right between local and collective priorities • Developing zipped up approaches so there are consistent expectations at all levels across the organisation • Allow innovation

Skills required • Switching from macro to micro, seeing how pieces fit together, applying a whole systems approach • Flexibility, transfer of knowledge to new settings, ability to use skills across boundaries • Self motivation, self reliance, innovation, tolerance of ambiguity • Political skills and awareness • Realistic and pragmatic art of the possible • Value systems and an ethos of working for the public good

Factors that influence the governance model • Trust – levels of trust between the participants. Trust is based on reputation and past interaction experience • Size – number of participants and their diversity • Goal consensus – general consensus on collective goals, both content and process, and a lack of conflict. Trust not necessarily related to consensus • Nature of the task – when additional skills are required to deliver the agreed goals, usually when there is lots of interdependency between members to achieve the goals

Governance models • Participant governed – where everyone interacts with every one else. JCPCTs are an example of this way of working. Not a legal entity although has powers to act delegated from boards. Relatively cheap and easy to establish, flexible. • Brokered – one organisation relates to the others in the membership • Lead organisation. The role of the lead organisation may be more or less dominant. Examples include Local Strategic Partnership (LSP). These were voluntary partnerships (in legal terms as ‘unincorporated associations’) where the Local Authority had a clear leadership role which they exercised differently (and the regeneration grants flowed through them). • Organisation established for the task. If it is also to hold the contract, needs to be established by an AHSC to have FT and non-FT members.

Participant governed • Depends exclusively on the involvement and commitment of all • Good when the commitment to collective goals is high • All participants are responsible for internal and external issues • All members participate on an equal basis • Collectively partners make all the decisions and manage all the business • Power held symmetrically • Works best when • Trust is high and widely shared (high density, decentralised) • There are few participants (6-8) • Collective goal consensus high • Need for additional competencies (interdependencies) low

Brokered – lead organisation • Occurs in vertical buyer-supplier relationships and horizontal multilateral networks when one organisation has sufficient resources and legitimacy to play a lead role • All major system level activities and key decisions are co-ordinated through and by a single participant member acting as the lead organisation • Governance highly centralised and brokered and asymmetrical • Leadership role may emerge or may be mandated • Works best when • Trust is narrowly shared (low density, highly centralised), • Moderate number of system members, • Goal consensus is moderately low, • Need for additional competencies moderate

Brokered – system organisation • Separate entity set up specifically • Separate and external to all organisations • All major system level activities and key decisions are co-ordinated through and by the organisation • Governance highly centralised and brokered and asymmetrical • Can be as small as a single person or carry out more functions Works best when • Trust moderately to widely shared (moderate density) • Moderate number of participants • Goals consensus is moderately high • Need for additional competencies (interdependencies) high.

Board structure • Three options for board structure and therefore decision-making process: • One member, one vote • A mix of voting and non-voting members • Proportional representation based on population, activity, income or a hybrid model

Tensions Efficiency vs inclusiveness • Participant models tend to be very inclusive but inefficient, brokered models more efficient but participants can feel left out. Lots of inclusion is not efficient and can lead to disenchantment and tends to result in move to a more centralised model. The system organisation model is the best compromise. Internal vs external legitimacy • Reflects the tension between individual and collective concerns and which is the greater priority. Participant governance best suited to internal legitimacy and lead organisation model is best suited to external legitimacy and the lead is usually motivated to do this. The system organisation model is the compromise but may fail on both counts Flexibility vs sustainability • Flexibility important for rapid network responses to changing needs and demands, sustainability important for consistent responses to stakeholders and efficiency. Participant governance is highly flexible. Brokered organisation models tends towards sustainability, especially if the lead is dominant.

Commissioning model • A number of options available and commissioners will be clear on the extent to which each option will be used: • Money works as now through clusters • Money works as now but through systems • Bundle contracting with systems to drive required behaviours – systems’ internal funding flows • Incentive payments to drive required behaviours

Cancer income

Summary

Regulation • It will be helpful if Monitor, CQC, SHA, NHSLA etc recognise the existence of the ICSs and reflect their ways of working in their regulatory and performance management functions • The programme team has already met with Monitor and will work with the emergent ICSs on this • Collaboration needs to be an integral part of performance management of the ICS, and of the ICS’ management of its members

Workshop session Rachel Tyndall

Workshop session • On your tables consider the advantages and disadvantages of the possible models: • Participative or brokered governance board • Structure of governance board • Concentrated or dispersed leadership • Money controlled or hosted

Next steps • Final integrated system submissions due by 30th June • Further support available during submission development: • Workshops for all providers in each system w/c 23rd May • Workshops for leads of each system w/c 6th June • Workshop for leads of all systems 9th June • Assurance of submissions begins 1st July • Ongoing work on commissioning an integrated system • For further information visit www.londonhp.nhs.uk/publications

Integrated cancer systems – governance workshop