Whole Systems Integrated Care in North West London
Over 30 organisations, community groups and lay partners worked together to develop a vision for Whole Systems Integrated Care (WSIC) across North West London (NWL).
We were asked to design a contractual structure for the Whole Systems Integrated Care Programme. The structure needed to:
- Foster collective accountability of providers for outcomes;
- Support integrated working;
- Facilitate joint decision making; and
- Enable capitated funding.
Crucially, at the same time as innovating in this way, the design needed to keep within the mandatory framework for NHS contracts.
Through co-design with commissioners and providers of health and social care services, we developed a contractual structure for an integrated system as follows:
- Whole Systems Commissioning Agreement – a tri-partite agreement between health and local authority commissioners setting out a framework (in accordance with section 75 of the NHS Act 2006) under which they may seek to pool budgets, delegate functions to each other and decide who will enter into service contracts with various providers;
- Integration Agreement – a contract that set out the "rules of the game" between commissioners and the accountable care partnership;
- Accountable Care Partnership ("ACP") Agreement – a contract that set out the "rules of the game" between the providers who form the ACP;
- Service Contracts – individual NHS Standard Contracts, primary care contracts or social care contracts where applicable, between commissioners and each provider. Each Service Contract will include the full specification of services and outcomes to be collectively achieved by the ACP;
- Integrated Services Schedule – details of how each provider will contribute to the ACP’s outcomes – this will be a living document and allows the ACP flexibility in how they deliver the services.
Overcoming the challenges
The Whole Systems Commissioning Agreement includes the regulatory requirements of a section 75 agreement and therefore gives NHS commissioners and local authorities the opportunity to pool budgets and delegate the exercise of certain functions to one another.
At the time of drafting the Whole Systems Commissioning Agreement, primary care commissioning could not fall within section 75 agreement arrangements. The section 75 agreement regulatory framework has now been amended to allow commissioning of certain primary medical services to fall within the auspices of section 75 agreements.
Currently, the NHS Standard Contract must be used by CCGs and NHS England when commissioning certain health services. The NHS Standard Contract only allows for one provider to hold the contract, and is not drafted (and cannot be amended) to allow for multiple providers under the same contract. It is for this reason that a separate Integration Agreement is necessary (as it is not possible to have one NHS Standard Contract for commissioning services with a number of providers as parties to the same contract with commissioners).
There are also a range of procurement and competition law issues that must be considered by commissioners and providers when implementing the Whole Systems model.
NWL have considered information sharing issues in detail as part of the Integrated Care Pilot. Further detail in relation to the information sharing issues can be found here.
We have recently completed a report on issues affecting Accountable Care Partnerships in NWL, in collaboration with FTI Consulting. The report can be found by clicking here.