A Practical Guide for the NHS

1
A Practical Guide for the NHS
Governance for Service TransformationThis guide
explains the value of governance in managing
complex change across an LHC and illustrates this
with case studies from the LHC Demonstrators
2
The Benefits of LHC Wide Governance in Managing
Complex Change

• What do we mean by LHC wide programme governance?
• Getting the basics right in terms of managing
  complex change starts with having an overarching
  LHC governance framework that supports PCTs,
  Practice Based Commissioners, local hospital
  trusts, primary care, third sector providers and
  social care partners, as well as other
  stakeholder groups to achieve successful service
  transformation.
• An LHC wide Programme Governance framework
  defines how such complex cross organisational
  change programmes are set up, managed and
  controlled.

• Why LHC wide governance for managing complex
  change matters?
• An LHC wide governance structure will help to
• clarify leadership roles and responsibilities
• support the decision-making process, including
  sign-off from all appropriate bodies
• ensure local co-ordination and cohesion
• enable monitoring of progress towards goals
• make best use of scarce resources
• align organisational agendas and priorities
• identify and manage risk
• create a culture of mutual respect and trust.

3
Governance The Process
Shared Vision
Change Programmes
Mandated Projects
Workstreams of Service Change

• Action The areas of required change are divided
  into defined Change Programmes, which could be
  the main care group strategies of older people,
  children, adult services, mental health and
  learning disabilities, combined and integrated
  with preventative care, urgent care, scheduled
  care, and long term care
• Main Documents Care Group and Service Strategies
  with a confirmed programme mandate and when
  appropriate developed into a service
  specification
• Governance Body Programme Board with confirmed
  Terms of Reference, Senior Responsible Officer
  and Programme Manager

Action A Shared Vision translated into an LHC
Strategy for service change Main Documents to be
formally agreed Commissioning Strategy / Health
Needs Assessment Strategy, taking account of LDP
and LAA performance measures Governance Body
LHC Partnership Board with senior representatives
of all local organisations attending
Action Workstreams of Service Change Main
Documents Departmental / Care Team Redesign
through revised, operational policies, care
protocols and policies Governance Body Monitor
via Contacting arrangements and project
management arrangements

• Action Programmes then need to be broken down
  into Mandated Projects, which will start the
  progress towards the change programmes
  implementation and the realisation of the LHC
  strategy and performance targets. This process
  needs to confirm the responsibility of both
  commissioning organisations and providers of
  service and be reflected in the contracting of
  services
• Main Documents Project Mandate or revised
  Contract and Service Level Agreements both having
  outcome and benefits defined and measured
• Governance Body Project Board with confirmed
  Terms of Reference, Senior Responsible Officer
  and Project Manager

4
Demonstrator Experience - Walsall

• Our situation
• Walsall LHC has a strategic vision to
• Transform the delivery of Urgent Care by
  redesigning services to ensure that all patients
  receive timely treatment, by the appropriate
  professional, in the right place. This will
  include streaming, referring or signposting
  patients to the best possible care to improve
  clinical outcomes and patient experience
• Transform the delivery of care to people with a
  LTC and improve patient experience by shifting
  care closer to home. This shift of care away
  from acute services will help to reduce bed
  numbers to enable the development of a PFI on the
  Manor Hospital site
• Meet the 18 week referral to treatment target as
  an early achiever and ensure that improvements
  are sustainable by commissioning value for money
  care pathways.

• What we did
• We understood there were a number of
  inter-dependencies between these programmes and
  an acknowledgement that the benefits will only be
  fully realised as part of an integrated process
• We agreed strategic objectives across the three
  leading organisations
• Developed working groups to involve stakeholders
  at the level of each project a total of 15
  projects across the three programmes all working
  groups have a lead clinician
• Undertook workshops involving wider stakeholder
  groups, including service users and the public,
  for all three programmes and also at individual
  project level
• Used other techniques including surveys and
  discovery interviews
• Developed communications plans in urgent care and
  palliative care
• Formal consultation process completed for
  Palliative Care and planned for Urgent Care.

• What we achieved
• We put the following arrangements in place
• The Programme Boards Report to the ISIP Steering
  Group is a cross organisational executive group
  to oversee development and delivery of the three
  programmes. The Directors in this group have
  given consistent support to delivery of change
  using the ISIP approach. The members of the group
  actively work to resolve serious programme risks
  / issues
• The Service Improvement Board, which consists of
  the Chief Executives of the three lead
  organisations, the Director of Commissioning and
  Performance and the Head of Change Programmes,
  functions to ensure that programme direction is
  aligned with wider strategic objectives
  nationally and regionally. It also provides
  positive encouragement and feedback
• Each project has a small board or delivery team,
  usually including a commissioner, lead provider
  manager, clinicians and service users where
  appropriate. The projects report to the relevant
  Programme Board.

5
Demonstrator Experience WalsallIllustration Of
Governance Structure
Walsall LHC have used the following structure to
implement their key change programmes. In this
slide the detail of the project level for 18weeks
is illustrated, within the context of overall
change portfolio governance.
6
Demonstrator Experience Wolverhampton

• Our situation
• Wolverhampton Health system has enjoyed a
  comparatively stable environment in regard to
  organisational changes
• Has the benefit of the PCT being co-terminus with
  the Local Authority, and its population being
  served mainly by one Acute Hospital. This has
  aided the setting up and maintenance of our LHC
  governance process.

• What we did
• As an LHC we have taken the ISIP approach to
  governance and refined it to suit our local needs
• Established a named director, responsible for the
  effective functioning of the ISIP Board and
  developing the technical change process
• Developed a Project Initiation process as
  follows
• Project brief to ISIP Change Programme Board
  agreed and tested against LHC strategy and
  priorities
• Detailed submission using standard template
  agreed at ISIP change programme board
• Final project mandate worked up with
  commissioning / contracting team, including when
  required joint LA / PCT commissioning /
  contracting team to enable contracted service
  change
• Permission for implementation by ISIP change
  programme board
• Project management agreed, usually shared
  reasonability between PCT / LA and Acute Trust
• The delegation of defined responsibly to project
  managers to undertake their role and access
  senior mangers is in place to resolve issues
  rapidly.

• What we achieved
• An ISIP Change Programme Board that has a shared
  function of overall vision and strategy
  development based on three main documents, the
  PCT Commissioning Strategy, SSDP, and Acute Trust
  Clinical Services Strategy. The board ran two
  major change programmes, Transfer of Care and
  Access and Responsiveness
• Established a Practice Based Commissioning
  planning process
• The PCT has three practice based commissioning
  groups covering the same areas as the former
  primary care groups, which aided consistency and
  working relationships in the new PBC arrangements
• These PBC areas are supported by managers from
  the PCT commissioning directorate, who assist in
  ensuring that the local focus links to the wider
  PCT / LA strategies and change governance.
• The PBC areas agree for one area to develop and
  test out a service change, which is then adopted
  by the other two
• This summer we reviewed our governance
  arrangements using the LHC Change Capability
  Appraisal Model. We were pleased that we appeared
  to be scoring well in most areas, but identified
  some areas for addition work. We then feed the
  results back to the ISIP LHC Board to action.

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Demonstrator Experience Warwickshire

• Our situation
• Warwickshire PCT is the local NHS organisation
  responsible for commissioning health services for
  the residents of Warwickshire. It was set up in
  October 2006, incorporating South Warwickshire,
  North Warwickshire and Rugby Primary Care Trusts
  (PCT). This required the development of new LHC
  governance structure following the merger
• We needed to take account of
• The previous PCT arrangements
• The County Council and Borough Councils
• The need for a co-ordinated commissioning
  approach to be developed with Coventry PCT due to
  the two organisations commissioning from the same
  providers.
• The newly established Practice Based
  Commissioning Consortiums
• New arrangements were quickly put in place, but
  it was felt these needed to be reviewed as we
  developed our Commissioning Strategy.

• What we did
• As a PCT we are in the process of writing our
  Health and Wellbeing Commissioning Strategy for
  presentation to the PCT Board at the end of
  September. This has been informed by the outcomes
  of care group strategy workshops and public
  meetings
• The care group strategy workshops were undertaken
  for Scheduled Care, Older People, LTC, Children
  and Maternity Services, Mental Health, and
  Learning Disability, in August
• The principles of Integrated Service Improvement
  supported the workshops with the Roadmap for
  Transformational Change as a key focus. This lead
  to a discussion on present and proposed LHC
  governance, and at the end of the workshops the
  discussion outcomes were fed back for
  consideration
• This feedback will inform Warwickshire Health and
  Wellbeing Commissioning Strategy and a governance
  structure will be presented to support the
  strategy and commissioning / planning process
  within the document.

• What we achieved
• The development of the Health and Well Being
  Commissioning Strategy has given an opportunity
  for a wide group of stakeholders to comment on
  the present governance arrangements and suggest
  further refinement of the process for LHC signoff
• A clinical network governance structure will
  oversee the implementation of the major care
  group strategies
• Pulled together all current local policy,
  strategies, operational policies and guidelines.
  This will ensure that future provision will be
  able to take this previous knowledge into account
  and build on identified local good practice.

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Demonstrator Experience Nottinghamshire

• Our situation
• In 2006, the PCTs and Local Authorities in
  Nottinghamshire resolved to work with the ISIP
  team to align planning and delivery of integrated
  service transformation, to support both the Local
  Area Agreements (LAAs) and health Local Delivery
  Plans (LDPs)
• The main objectives were
• develop integrated governance arrangements to
  drive integrated planning and delivery of service
  transformation
• establish firm plans to align the LAA (healthier
  communities and older people block) with the NHS
  ISIP plans for transformation of care for Long
  Term Conditions
• agree integrated financial and non-financial
  performance measures by which the delivery of
  benefits would be assessed
• establish management responsibilities for
  delivery
• transfer skills from the ISIP team to the health
  and social care teams
• The initial focus for the work was on older
  people and long term conditions, which arose
  from some initial mapping of LAA.

• What we did
• As a result of work on these issues, the
  Nottinghamshire communities resolved that
• Projects within the ISIP plans where delivery is
  dependant on partnership working with Local
  Authority services should be included within the
  LAA
• Such projects should be jointly governed through
  LAA governance mechanisms. This includes
  mandating of projects, securing authority to act,
  financial decisions and performance management
• To ensure that achievement of benefits within
  that project are synchronised with benefits from
  the other ISI projects within the programme, the
  project should report achievement of milestones
  to both the LAA governance structure and the ISIP
  programme structures
• Membership of all groups within the LAA
  governance structure and ISIP programme
  governance structures should comprise people who
  have the authority to make decisions on behalf of
  their organisation.

• What we achieved
• A formally initiated Nottinghamshire Falls
  Prevention and Treatment Programme, which seeks
  to align working across health and social care
  using the LAA as a mechanism to integrate
  planning, commissioning and delivery.

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Key Messages
Clear and robust change templates are welcomed by
clinical staff as a means of placing their
aspirations for service change on the agenda and
to track progress.
Effective governance helps to create a culture of
mutual respect and trust, and an underlying can
do approach. Manage conflict by working with
individuals both in a formal and informal setting.
Robust Knowledge Management builds on previous
experience and helps to avoid repetition of work
and past failures.
Ensure you have the necessary resources to
support change, so that you can cope with
competing demands of undertaking strategic work,
while ensuring day to day problems are resolved.
Ensuring that there are competent project and
programme managers who understand the technical
process of change management and can engage
effectively with key stakeholders.
Consider using the LHC Change Capability
Appraisal Model as a way of assessing the fitness
of an organisation to deliver a programme of
change.
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Where to go for more information

• External references
• Office of Government and Commerce
  www.ogc.gov.uk/delivery_lifecycle_governance.asp
• LHC Change Capability Appraisal
  http//www.isip.nhs.uk
• The NHS Integrated Service Improvement Programme
  www.isip.nhs.uk

Named contacts Justine Richards, Associate
Director of Strategy Development, Warwickshire
PCT, justine.richards_at_swarkpct.nhs.uk Harry Ward,
Director of Commissioning, Wolverhampton PCT,
harry.ward_at_wolvespct.nhs.uk Andrea Bigmore,
Head of Change Programmes, Walsall PCT,
andrea.bigmore_at_walsall.nhs.uk Dr Barbra Brady,
Public Health Consultant, Nottinghamshire County
Teaching PCT, barbara.brady_at_nottinghamshirecounty
-tpct.nhs.uk Cathy Harvey, Nottinghamshire County
Council, Adult Social Care and Health Dept,
cathy.harvey_at_nottscc.gov.uk Joe Pidgeon,
Nottinghamshire County Council, Adult Social Care
and Health Dept, joe.pidgeon_at_nottscc.gov.uk