Learning from practice

Camden local health community in London is developing a formal governance / decision making mechanism to enable a community to deal with the risks associated with the transfer of clinical services from secondary to primary care. The aim is to incorporate the approach into the community’s ISIP governance arrangements.

The Integrated Service Improvement Programme (ISIP) is the vehicle by which major transformational change will be introduced within the NHS in England. For more on the ISIP methodology see www.isip.nhs.uk

Introduction
In the complex organisational world of the emerging NHS, transformational change is likely to require the shifting of resources between organisations in order to bring about desired outcomes. Moving resources means that money spent one way in today’s world might be directed into entirely different areas tomorrow. These moves will take place over time and be impacted by many uncertainties. Shifting the funding of resources in this way carries an inevitable risk of failure. The risk – sharing approach is a means by which communities identify and deal with such risks.

Payment by Results is another factor that creates risk, by making provider income directly dependent on patient volumes. As services are transferred to the community, traditional income sources of acute providers will need to be replaced by new revenue flows. Risk-sharing aims to provide a structure for sharing financial risk during such periods of change. Clinical and reputation risk are other risk categories. For a PCT, the key risks are associated with the challenge and cost of commissioning new primary care services.

Risk sharing approach
Camden is developing an approach to risk management and risk-sharing that will enable all parties to the transformation to deal effectively with the risks involved in change, and hence will be more likely to navigate change successfully.

The overall aim is to enhance the ISIP approach and in particular ISIP governance arrangements in terms of risk management. By sharing and managing risk more effectively, communities are more likely to engage in transformational rather than incremental change.

There are two major areas of focus:

Smoothing the financial impact of PbR
PbR creates a financial environment where rapid falls in attendances and admissions can impact hospital finances adversely. By understanding and sizing these changes collaboratively, communities can negotiate arrangements that may mitigate their respective financial impacts. Risk sharing should allow communities to explore such options as part of the planning process leading to a decision.

Mitigating implementation risk
A range of other potential risks can impact the actual implementation of change. These risks can militate against the approaches just described to smooth the financial impact of PbR. Risk categories can include clinical risk, operational risk, management risk, reputation risk and external risk.

Testing the methodology
Camden is testing the risk-sharing approach using a current transformational project to implement a Primary Care A&E “front-end” facility at UCLH and Royal Free Hospitals. This project will provide a “see and treat” approach to deal with the significant proportion of A&E attenders with only minor illness or injury.

Further information
See download documents at top of page

• Risk sharing methodology describes the proposed risk-sharing methodology in detail.

• Pilot project Terms of Reference describes how the proposed risk-sharing methodology would be tested using the project to implement a Primary Care A&E “front-end” facility at UCLH and Royal Free Hospitals.