GREATER MANCHESTER JOINT COMMISSIONING BOARD

Date: 17 September 2019

Subject: GM Delegated Specialised Commissioning 2018/19 Annual Report

Report of: Sarah Price, Executive Lead for Population Health and Commissioning, Greater

Manchester Health and Social Care Partnership (GMHSCP)

PURPOSE OF REPORT:

This document provides an Annual Report of the GM Specialised Commissioning Oversight Group in 2018/19. It includes the financial performance of the Specialised Commissioning portfolio that has been delegated to the Greater Manchester Chief Officer. It also outlines some key achievements of integrating specialised commissioning arrangements in GM and the collaborative progress made by the GM Specialised Commissioning Oversight Group (SCOG) throughout the year.

KEY ISSUES TO BE DISCUSSED:

The GM Joint Commissioning Board (GM JCB) is asked to:

• Support plans to use improved specialised commissioning data as the basis to provide intelligence to draw attention to areas of GM variation and opportunity to support Quality Innovation Productivity and Prevention (QIPP) improvements and future specialised service reviews.

• Support the planned work to review and further strengthen GM specialised commissioning arrangements beyond 2019/20.

RECOMMENDATIONS:

The Greater Manchester Joint Commissioning Board is asked to:

• Note the benefits of place-based approach to specialised commissioning arrangements demonstrated in 2018/19 successes.

• Note the balanced financial plan agreed in 2018/19 contracts with GM providers and delivered in Month 12 2018/19.

• Note the improved data compliance that will allow improved scrutiny and oversight of the specialised delegated portfolio.

CONTACT OFFICERS: Rebecca Tunstall, Head of Finance (Specialised)

North West Specialised Commissioning, NHS England and NHS Improvement rebecca.tunstall@nhs.net Louise Sinnott, Head of Place Based Commissioning – GM North West Specialised Commissioning, NHS England and NHS Improvement GM Joint Commissioning Team louisesinnott@nhs.net

SYSTEM ENGAGEMENT

Please complete the information below to outline the discussion with sectoral governance groups prior to submitting to the GM Joint Commissioning Board. If it is not appropriate / deemed necessary for a discussion with a particular group please state why.

GM SPECIALISED COMMISSIONING FINANCE AND CONTRACTS SUB GROUP

Has the paper been discussed by GMSCOG Finance Sub Group? Yes.

GM SPECIALISED COMMISSIONING OVERSIGHT GROUP

Has the paper been discussed by GMSCOG? Yes

GM HEALTH AND SOCIAL CARE PARTNERSHIP SENIOR MANAGEMENT TEAM

Has the paper been discussed by GM SMT? Yes

PRIMARY CARE ADVISORY GROUP (PCAG) Has the paper been discussed by PCAG? No If no please outline the reason: N/A PROVIDER FEDERATION BOARD (PFB) Has the paper been discussed by PFB? No If no please outline the reason: N/A WIDER LEADERSHIP TEAM (WLT) Has the paper been discussed by WLT? No If no please outline the reason: N/A STRATEGIC PARTNERSHIP EXECUTIVE BOARD (PEB) Has the paper been discussed by PEB? No If no please outline the reason: N/A GM CCG DIRECTORS OF COMMISSIONING (DOCS) Has the paper been discussed by DoCs? No If no please outline the reason: N/A GM CCG CHIEF FINANCE OFFERS (CFOS) Has the paper been discussed by CFOs? No If no please outline the reason:

GM Specialised Commissioning Oversight Group Finance and Contracts sub group supported ongoing work throughout 2018/19 in relation to delegated financial and activity reporting.

GM LA HEADS OF COMMISSIONING (HOCS)

Has the paper been discussed by HoCs? No If no please outline the reason: N/A

1.0 INTRODUCTION

1.1. When the Greater Manchester Health and Social Care Partnership (GMHSCP)

formally took charge of the £6bn health and social care budget on 1 April 2016, it

also assumed delegated responsibility for a wide range of specialised services.

1.2. The total specialised commissioning budget in GM is c.£1bn. In 2018/19 for devolved

acute Tier 1 services (excluding drugs and devices expenditure of £105m) was

£330.2m, representing 32% of the total budget for GM acute providers. A further

£44.4m was the total budget for devolved mental health Tier 1 services.

1.3. While NHS England remains legally responsible for the delivery of its statutory

functions, a Memorandum of Understanding (MOU) has delegated responsibility for

the operational management of these services to the GM Chief Officer (GMCO). In

practice, the commissioning arrangements for existing delegated specialised services

to GM means that:

the GM Chief Officer is the budget holder for those services that have been

delegated;

financial and activity reporting remains the responsibility of NHS England’s

North West Specialised Commissioning Team and as such, part of the financial

control total for the North West and follow the North West regional

governance framework;

the services are commissioned in line with the principles agreed in the MOU,

which gives a commitment to continue to adhere to national services

standards, commissioning policies and specifications.

1.4. The MOU sets out internal arrangements between the GMCO (acting on behalf of

NHS England) and NHS England’s North West Specialised Commissioning Team and

lists the range of services included in the internal scheme of delegation (Appendix

A). The MOU which has been approved by the GM Health and Social Care Partnership

through the GM Strategic Partnership Board and NHS England runs in its current form

until 2019/20.

1.5. The recent 100 Day Commissioning Review and Review of GM Commissioning Final

Report approved by the GM Joint Commissioning Board (GMJCB) in April 2019

identified that ‘The GMJCB needs to assure itself of the progress on the breadth of

commissioning of acute services outside of the relatively narrow definition of

‘improving specialist care services’ including the portfolio of specialised

commissioning’. To date, financial balance, system sustainability and continuous

quality improvement has been overseen by the GM Specialised Commissioning

Oversight Group (GM SCOG). Through GM SCOG, proposals have been developed to

establish assurance mechanisms in relation to the delegated GM Specialised

Commissioning portfolio within established and emerging GM structures.

2.0 GREATER MANCHESTER SCOG KEY ACHIEVEMENTS AND FLAGSHIP SPECIALISED

SERVICES IMPROVEMENT INITIATIVES 2018/19

2.1. Our ambition is to fully join commissioning pathways – so that coordinated decisions

are made in GM and funding is used in the more effective way possible to improve

outcomes for the population.

2.2. Key achievements

2.3. The integration of specialised commissioning responsibilities within GM has enabled

the delivery of a wide range of key achievements throughout 2018/19:

The Improving Specialist Care Programme Investments into Specialised

Commissioned level 1 Neurorehabilitation to deliver the new standards within

the Model of Care.

GM Population Health Priorities supporting plans to roll out Lung Health

checks in localities and joint planning for increased tertiary lung resections,

following an increase in CCG screening initiatives. Specialised commissioning

recommendations have also informed the case for reshaping services for

people living with HIV in GM within the GM Sexual and Reproductive Health

Strategy.

GM Mental Health Transformation Programmes supporting the development

of new delivery models for Tier 4 Child and Adolescent Mental Health Service

and Adult Secure service provision.

Regional and national specialised service developments (non-delegated

services) within Greater Manchester including the establishment of of the GM

level 2 adult Congenital Heart Disease service as an integral part of a North-

West Congenital Heart Disease Network at Manchester Foundation Trust (FT)

and establishing new CAR-T treatments therapies for children and young

people with B cell acute lymphoblastic leukaemia.

NHS England national policy service developments including implementation

of 5-year delivery plans for Intra Arterial Thrombectomy (IAT) across GM to

achieve a 24/7 service by 2021/22.

New Innovations with GMs identified with ‘Early Adopter’ status for Primary

Care-led Transgender Health Service development.

2.4. Flagship specialised service improvement initiatives

2.5. In addition to the achievements outlined above in 2018/19, via GM SCOG, there was

a specific focus on four flagship areas of work to bring about quality improvements

in:

Neurosciences

Specialised HIV services

Specialised mental health services

Gender identity services

2.6. Neurosciences – Right Care approach

2.7. A Right Care approach ‘deep dive’ was undertaken to understand any unwarranted

variation in GM’s neurosciences services (costs, volume of activity and length of stay)

when compared to other neurosciences centres nationally. This compared a range

of indicators within individual GM CCGs with their demographic peers i.e. similar

footprint CCGs. When this data was collated and assessed it highlighted limited

opportunity for improvement and the variation in GM was justified.

2.8. Specialised HIV Services

2.9. A specialised service review of current HIV provision has played key role in informing

future GM service reconfiguration. Right Care work undertaken in 2018/19 (again,

through a ‘like CCG’ comparator method) identified that expenditure within GM is

higher than comparators. While some of this is explained by significant disease

prevalence, a significant variance remains. In 2019/20, work will address

inconsistencies in current contractual arrangement (currencies, tariffs and drugs)

and existing pathways.

2.10. Specialised Mental Health Services

2.11. In April 2018, the addition of new specialised Mental Health services to the delegated

GM specialised commissioning portfolio was agreed by NHS England’s National

Commissioning Committee. This agreement was made to supporting the ambitions

set out within a Greater Manchester ‘Value Proposition’ to implement the GM

Mental Health Strategy.

2.12. Work has been prioritised to develop CAMHS and Adult Secure Mental Health

provision to develop more coherent population and pathway approaches. Within

these programmes, GM providers and commissioners have agreed a set of design

principles to deliver the Value Proposition through pre-commissioning

transformation design work. As a system, GM stakeholders have agreed that new

pathway and service models will be developed under the leadership of Provider

Transformation Leads, working collaboratively to involve other providers, services

users and their friends and families in the development of proposals that will be

subject to decisions by Commissioners.

2.13. Significant work has been undertaken to develop care models for future Specialised

Mental Health Services via a Mental Health SCOG Sub Group chaired by the GMHSCP

Executive Lead for Population Health and Commissioning and attended by GM

Commissioners and NHS Providers. It is NHS England’s intention to mainstream New

Care Models by giving responsibility for specialised mental health services at a

population level to Provider Collaboratives. GM is already developing a model that

is consistent with the NHS Long Term Plan’s vision for greater local system

integration and autonomy. Whilst GM is not required to participate in the national

selection process for Provider Collaboratives for delegated specialised mental health

services, work will continue in 2019/20 to ensure there is comparable rigour and

transparency in the considerations GM makes in confirming its own provider

collaboratives across entire pathways.

2.14. GM Gender Identity Services

2.15. NHS England is establishing an early adopter pilot in Greater Manchester that will

evaluate, over two years, whether the role of a Gender Dysphoria Clinic could be

safely and effectively delivered in a local setting by an appropriately trained primary

care team. A working group has been established, chaired by NHS Wigan CCG

Accountable Officer. The group comprises local stakeholders and one independent

member from NHS England’s National Gender Identity Programme Board. The group

delivered an outline delivery model and an outline service specification for the pilot

service. GM market engagement ensued and an outline business case has now been

agreed. An approach to provider selection is in development with mobilisation and

delivery planned for 2019/20.

2.16. Establishing new cross commissioner systems and processes

2.17. Through greater integration, work has been undertaken to address ‘cross-

commissioner issues’ via the GM SCOG Finance and Contracts Sub-Group chaired by

the Chief Finance Officer and Deputy Chief Accountable Officer of NHS Salford CCG.

This has seen close working between CCG and Specialised commissioners to address

in-year service pressures and resolve commissioning issues to improve patient

experience and outcomes.

2.18. The quality of GM’s tertiary services is routinely reported to the GM Quality Board

and issues are reported by exception to the GM senior management team monthly

via GM SCOG. Specialised commissioning is also included within GM’s quality

surveillance groups.

3.0 FINANCIAL PERFORMANCE 2018/19 – GM DEVOLVED SPECIALISED SERVICES

3.1. This section of the report highlights:

An overview of budgets for 2018/19

Improvements to data quality

Tier 1 Expenditure in 2018/19

3.2. Overview of budgets for 2018/19

3.3. Expenditure on specialised services within GM falls within the following categories:

3.4. Tier 3 Services: These are highly specialised services which are commissioned

nationally typically for populations of over 10m from only a very small number of

providers across the country. Within GM this includes services such as the Chronic

Pulmonary Aspergillosis service provided by Manchester FT, Proton Beam Therapy

at The Christie FT and the Autologous Intestinal Reconstruction service at Salford

Royal FT.

3.5. Tier 2 Services: These services are commissioned on a sub-regional basis for

population sizes of between 2.5m and 10m from providers who provide the service

on behalf of the region or across a Sustainability and Transformation Partnership

(STP). Within GM this includes services such as the Cystic Fibrosis service at

Manchester FT, Stereotactic Radiosurgery and Stereotactic Radiotherapy

(Intracranial) at Salford Royal FT and Radiotherapy at The Christie FT.

3.6. Tier 1 Services: These services are commissioned at a local health system level within

an STP or Integrated Care System (ICS) for populations of typically 1m to 2.5m. This

includes services such as adult specialist cardiac services and chemotherapy which

are commissioned from several providers within GM. Devolved responsibility for the

operational and strategic commissioning of Tier 1 specialised services within GM has

been given to the GM Chief Officer.

3.7. The current budgets for Tier 1 services within GM are based on the following:

Acute services - Historical expenditure with GM providers by GM CCGs adjusted

for agreed growth/service developments each year. This currently excludes drugs

and devices as the national datasets do not include service code or CCG.

Expenditure on drugs and devices is £105 m.

Mental Health services historical expenditure with all providers for GM CCGs

adjusted for agreed growth/service development. This includes services

commissioned from providers outside of GM.

3.8. Overall the notional budgets in 2018/19 for devolved Tier 1 services within GM were:

£330.2 m for acute services (excluding drugs and devices), which represents 32%

of the total specialised budget for GM acute providers.

£44.4m for devolved mental health services.

3.9. Over time, the national direction of travel is to set specialized commissioning

budgets at STP-level on a fair share population basis. Early work by the GM SCOG

has started to identify areas of variation in spend when compared to demographic

peers i.e. similar footprint CCGs.

3.10. Improvements in Data Quality

3.11. A key priority during 2018/19 has been to work closely with GM’s providers of acute

specialised services to improve data quality resulting in completeness of 90+% and

thus improve the accuracy of the reporting of expenditure on Tier 1 services.

Significant improvements have been made in the data being reported, which means

that we have a better understanding of variation in access to specialised services in

Greater Manchester. Access to better quality data has also supported GM SCOG to

understand in-year fluctuations within the delegated portfolio for example, as

Commissioners we able to understand a significant underperformance in

Chemotherapy activity within the Christie contract as a result of the introduction of

alternative immunosuppressant prescribing.

3.12. The value of coded activity at the end of each financial year is illustrated in the table

below:

Critical Field

% Value of Activity Coded (excluding drugs &

devices)

16/17 17/18 18/19

Specialised Service Code 60% 94% 100%

CCG 66% 85% 90%

3.13. The current reporting of devolved specialised services encompasses activity relating

to GM CCGs at GM providers. This currently excludes high cost drugs and devices due

to the structure of national reporting datasets for these areas which means plans

cannot be broken down to CCG level.

3.14. Financial position for devolved Tier 1 specialised services 2018/19

3.15. Overall, the expenditure on tier 1 services in 2018/19 was £3.4m underperformance

against the 2018/19 budgets, comprising a favourable variance on acute services of

£4.7m and an adverse variance on mental health services of £1.3m. This is

summarised in the table below.

Table 1: GM Tier 1 Services Financial Position as at Month 12

Annual Budget

£m Expenditure

£m Variance

£m

Acute services 330.2 325.5 (4,7)

Mental Health services 44.4 45.7 1.3

TOTAL 374.7 371.3 (3.4)

3.16. Overall, whilst there was an underperformance on the Tier 1 2018/19 budget, this is

against a notional budget based on historic expenditure and not the “fair share”

allocation for GM. This under performance is not available to spend within GM and

is considered within the overall NW specialised commissioning financial

performance.

4.0 PLANS FOR 2019/20

4.1. In the last year, significant progress in our understanding of service use at locality

level and GM as a whole has been made. Moving forward, this allows us to assess

opportunities to target specific parts of the patient pathway to support a more

preventable approach.

4.2. Work is underway to further build on 2018/19 progress and provide the GM JCB with

assurance on the breadth of specialised acute and mental health commissioning

arrangements by strengthening reporting within existing and emerging GM

structures. With improved data that allows GM SCOG to oversee the delegated

specialised commissioning budget at both CCG and tertiary service-line level, work is

planned to agree further place-based specialised commissioning priorities. Early

proposals for these improved arrangements would see the GM SCOG more closely

linked with existing GM Quality, Performance and Finance Boards the emerging sub-

structures of the GM JCB to address variation in specialised service provision with a

view to informing future recommendations to the JCB joint commissioning board.

4.3. GM Specialised Commissioning financial strategy is in development for 2019/20. This

strategy will confirm GM’s arrangements to support the national direction of travel

to set specialised commissioning budgets at STP-level on a fair share population

basis. It will also set out the guiding principles for stewardship of the GM delegated

specialised commissioning budget and options to develop a place-based approach to

risk/gainshare arrangements associated with investment decisions.

Appendix 1: Services within GM’s delegated Specialised Commissioning portfolio

Internal Medicine

Programme of Care

Cancer Programme

of Care

Blood & Infection

Programme of Care

Trauma Programme

of Care

Women’s & Children’s

Programme of Care

Mental Health

Programme of Care

(from April 2018)

Cardiac Surgery

Cardiac ICD/CRT

Cardiac MRI

Cardiac EP and

Ablation

Cardiac PPCI

Vascular Surgery

Complex IBD

Faecal Incontinence

TEMS Surgery

Acute Kidney Injury

Renal Dialysis

OG Cancer

Kidney Bladder

Prostate Cancer

Chemotherapy

(Adult)

PET-CT

Head & Neck Cancer

Thoracic Surgery

HIV (Adult)

Specialised

Immunology

Specialised Allergy

Specialised Rehab

Neurosurgery (Adult)

Specialised

Neurosciences

Specialised

Orthopaedics

Specialised

Ophthalmology

Complex Spinal

Surgery

Major Trauma

Implantable Hearing

Aids (BAHA)

Paed Rheumatology

Paed Endocrinology &

Diabetes

Paed Respiratory

Paed Allergy

Neonatal Critical Care

Gynae: Endometriosis

Gynae:

Urogenital/Anorectal

Gynae:

Incontinence/Prolapse

Gynae: Cancer

CAMHS Tier 4 General

Adolescent

CAMHS Tier 4 Eating

Disorders

Adult Inpatient Eating

Disorders

Specialised Perinatal

Mental Health –

Mother and Baby Unit

Low Secure Mental

Health

Low Secure and

Forensic Support

Team Services -

Learning Disabilities