Implementing Neighbourhoods
Implementing Neighbourhoods
In this final article in our series looking at the 10 Year Plan (“the Plan”) and how it will impact general practice the focus shifts to some practical and legal issues that arise in the development of neighbourhood teams.
Structural and organisational issues are important to get right but the most important phrase to remember is always that ‘form follows function’.
In recent years many areas have been progressing the development of Integrated Neighbourhood Teams (“INTs”) at the scale of approximately 100,000 people. The Plan does adopt the neighbourhood concept but at two different scales being 50,000 or 250,000 which has left many wondering whether the INT development work is fit for purpose.
At the heart of the INT’s is the principle of collaborative working aimed at improving the lives of the local population. This has not changed and it is probably advisable at this time not to worry too much about scale and to focus on service delivery and outcomes.
As these ideas and plans mature and especially when the team start considering how they should be implemented it may be of use to consider the following essential factors.
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Vision and purpose
These terms are frequently used and this is due to their importance in ensuring the success of any project.
Your vision and purpose creates a clear understanding of what it is everyone involved is trying to achieve. The Plan has met some criticism for not necessarily being a ‘plan’ in a delivery sense, but it does have a very strong vision for how the NHS would look if it is successfully implemented. The detail needs to be developed but it gives a target for people to work towards.
Each neighbourhood team should be able to understand what it is they are collectively working towards, and this will make the experience of the change easier for them to deal with.
Once these have been developed it is important to clearly document it. This will highlight different interpretations and variations which will limit the risk of misunderstands arising in the future. It often also provides a core plank of your decision-making and governance systems as the default question should always be does the decision we need to make, the actions we are currently taking, or the changes we are implementing move us closer to achieving our vision and our purpose?
When you transition into the discussion about the form of your neighbourhood this will make it easier to assess what this should look like and to draft the necessary governance documents.
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Workforce
No change programme in health and social care can succeed without the engagement and support of the workforce who will be expected to implement and deliver it.
The delivery of integrated services is complicated by the multitude of employers involved in most pathways. In shaping these the impact on the workforce must be considered.
These are some of the factors to include in this process:
- Will the change result in workers being required to move organisation?
- If so, will this require a transfer with TUPE rights?
- Will their employment terms and conditions change?
- Will any of their non-contractual job requirements change?
- Do any unions need to be engaged?
- If the change does not require workers to move will be it require a new type of contract between the employers to govern the relationship and to define the limits on the services?
- Could redundancies arise and if so, what are the potential liabilities, and who is liable for them?
You may wish to develop a dedicated workforce workstream to help co-ordinate this issue and to identify areas in which further advice is required.
Managing this process will reduce the number of concerns arising and instability within the workforce which often hinders the success of change programmes.
As a word of caution failure to carefully consider these points can result in significant legal liabilities with financial and reputational consequences. It is advisable that before any model is finalised specialist advice on the legal implementation and impact on the workforce be sought.
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Contractual relationships
Whilst this does start to move into the area of ‘form’ over ‘function’ it cannot be overlooked at the initial stage of the planning. Each provider will have its own objectives and requirements which need to be achieved under the terms of their service contracts.
The details of this need to be understood to ensure that expectations are appropriately managed. By way of example if several organisational partners within a neighbourhood are planning a service which runs at the weekends but one of the key partners does not have a contract, funding or workforce to operate at weekends this change will stall.
Other factors related to the contracts could be inclusion and exclusion criteria, activity limits, and additional reporting requirements, all of which may not align with the needs of the neighbourhood team.
There may be ways to overcome these issues by seeking contract variations or seeking commissioner support in commissioning additional services, but this is not a quick process. It is preferrable to identify these issues early in the process so they can be addressed or if not addressed the neighbourhood knows quickly that it needs to consider other options.
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Finances
Another essential consideration which should be at the start of the discussions within any neighbourhood is to understand the budgets available and the resources which can be utilised.
The Plan makes it clear that there will be no new revenue to support neighbourhoods so there is no benefit to making plans which it is known cannot be afforded. Suitable financial modelling should be implemented at the start of any redesign, and this may mean hard decisions are required.
It is preferrable if there can be clear transparency between the different organisations, although this can be difficult. Non-disclosure agreements and initial agreements as to the proportion of money or other resources which will be allocated to specific projects can be agreed to assist with this process.
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Governance
When developing the changes each entity will have its own form of clinical, corporate and financial governance. This can result in frustrations when it is not clear what the decision-making or approval processes are, it can create tensions over risk management, and it can result in perceptions of bureaucratic impediments to improving services.
These issues can be overcome by making it clear what each organisation expects and being realistic about key timeframes. By way of example, traditional GP practice partnerships are renowned for their ability to consider and respond to issues quickly. Councils running social services do not have the same reputation. Whilst it would be great if this discrepancy could be aligned it is not a realistic expectation. It is therefore preferrable to understand the relevant timeframes and ensure that there is clear expectation management to avoid problems arising.
A good way of managing this is to develop project teams and ensuring that the projects have their own governance systems which reflect and adopt those used by the parent organisation of each team member. This ensures that each project is being managed with a clear understanding of the requirements and expectations on them.
This same principle applies to agreeing financial controls which comply with the governance of the different organisations and ensuring that all clinical requirements are met.
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Leadership and Management
This is possibly the most important element. Each neighbourhood needs clear leadership and good management. This may or may not come from the GP team and this will largely depend on the individuals involved and the skill set required.
A good leader is one who helps drive the strategy and motivates the team to achieve the vision. They will be able to bring together the different organisations and will help them to feel integrated before the formal integration has commenced.
However, any good leader must work in tandem with good management. Managers ensure that the objectives are delivered by pulling together the resources, implementing the neighbourhood plans and ultimately ensuring the success of the project.
It is often tempting to make assumptions about who fits these roles and what they are required to achieve. However, this is another essential area which benefits from clear documentation.
Each person in these roles should have a suitable job specification, they should be set targets, and they should be held to account for what they do and do not achieve. This ensures that progress is made, and it helps to identify when a change in individuals is required.
These roles are normally reserved for very senior and experienced individuals, but they are still going to be workers of some variety. Consequently, it is important that their terms of employment or other form of engagement are properly understood. Identifying and clarifying this will make it easier to manage them in the future.
Final thoughts
These are a small sample of key considerations in the development of the neighbourhood teams. There are, however, factors which are immediately relevant and should be implemented by all neighbourhoods regardless of the size they are working at.
The greater the structure and clarity on the above points the more likely that the changes in service delivery to the population being served will be successfully implemented.
This then directly feeds into how your neighbourhood will be treated by the system and it is likely to increase or decrease the amount of scrutiny received once the 10 Year Plan is fully implemented.
For those practices who are concerned about their long-term future this is one area which can be controlled or at the very least influenced by their partners. This will go a long way to evidencing whether the practices have ‘stepped up’ to the challenge they face as identified by several key individuals and addressed in our article asking the question ‘Are traditional GP partnerships at risk?’.
The team at Hempsons is available to discuss any of these issues and to help with advice and guidance regardless of the size and scale of your neighbourhood.