London Health and Social Care Devolution€¦ · London Health and Social Care Devolution...
Transcript of London Health and Social Care Devolution€¦ · London Health and Social Care Devolution...
London Health and Social Care DevolutionMemorandum of Understanding
November 2017
Signed for and on behalf of London, Central Government
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 Stevens
Jim Mackey Dr Yvonne Doyle Director for London, Public Health England
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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).
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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.
Recognisingthatdevolutionisoneofarangeofenablerstosupporthealthandcaretransformation,theLondonHealthandCareDevolutionProgrammehasbeencloselyalignedtootherhealthandcaretransformationactivities.TheseincludetheFiveYearForwardViewNewModelsofCare
4NHSImprovementisnotinitselfastatutoryentity,butcarriesoutthestatutoryfunctionsoftheNHSTrustDevelopmentAuthority(TDA)andMonitor.Referencesto‘NHSImprovement’inthisdocumentshouldbeinterpretedasencompassingNHSImprovement’sroleinrelationtobothTDAandMonitorfunctions.5Sofaras‘Londonpartners’referstoaregionalofficeofanationalorganisation,thesepartnerswillnotsignuptotheagreementseparately,butrelevant‘London’or‘Londonpartner’commitmentswillrefertotheseregionaloffices/departments.6BetterHealthforLondon:thereportoftheLondonHealthCommissionwaspublishedinOctober2014followingaperiodofengagement,whichcapturedtheviewsofover14,000Londoners.Availableat:https://www.london.gov.uk/sites/default/files/better_health_for_london.pdf3NHSFiveYearForwardView,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/BetterHealthforLondonNextSteps_2.pdf9Theterm‘sub-regional’referstoacollectionofLondonboroughsandCCGs.Theterms‘local’referstoanareageographicallydefinedbyoneboroughand/oroneCCGand‘London’referstotheareadefinedbyallboroughs(includingtheCityofLondon)andall32LondonCCGs.10WhileaMoU,bynature,isnotlegallybinding,partnershavecloselyco-developedthisdocumenttoensurethatthestatedcommitmentshavetherequisitesupportanddetailforsuccessfulimplementation.
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programme,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.
3. Londonandnationalpartnerswillworktowardsimprovingoutcomesthroughgreaterintegrationandbyphaseddelegationordevolutionofdecision-makingpowerstothe
11NextstepsontheNHSFiveYearForwardView,March2017.Availableat:https://www.england.nhs.uk/five-year-forward-view/12AsreferencedwithinNextStepsontheNHSFiveYearForwardView(pg.35-37).13Pilotshaveeachutilisedtailoredmechanismsofengagementandco-developmentwithlocalpopulationsandpartners.Thesearefurtherdetailedintherelevantbusinesscases.
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lowest,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.• Strengthenedsystemleadership,supportedbyeffectivegovernance,clear
accountabilityandtransparency.
14NHSEnglandcriteriaavailableat:https://www.england.nhs.uk/commissioning/devolution/
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• 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
a) Capitalandestates
15Businesscaseswouldbeconsideredbythenationalorganisationsstatutorilyaccountablefortherelevantfunctionsorduties.
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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:
16LEBoperatingframeworkNovember2017,availableat:
https://www.london.gov.uk/sites/default/files/london_estates_board_-operating_framework_2017.pdf17Suchdecisionswouldbetakenbywayofrepresentativesfromnationalorganisationsexercisingdelegatedauthorityaspartofamorelocalforum(forexample,asub-regionalestatesboard).
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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),butcruciallywillemphasise
28LondonHealthandCareStrategicPartnershipBoard(SPB)termsofreferenceavailableat:
https://www.london.gov.uk/sites/default/files/london_health_and_care_strategic_partnership_board_-
_terms_of_reference_2017.pdf
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thepartnershipapproachandanagreedstrategyforsustainabilityandtransformationbuiltupfromlocalandsub-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.