Agenda item

The committee gave initial consideration to this item at its special meeting on 30^th July. Members agreed to hold a further meeting, with a particular focus on the ‘place’ aspects. A copy of the previous report is provided as background.

The committee gave initial consideration to this item at its special

meeting on 30 July. It was agreed to hold a further meeting, with

a particular focus on the ‘place’ aspects. A copy of the previous report

had been provided as background.

A two-part presentation was commenced by Anna Hargrave of South Warwickshire CCG. The presentation covered the following areas:

• The role of the clinical commissioner to plan, determine and prioritise, purchase and monitor services.
• How our system fits together, showing the population sizes and purposes of the different levels from the primary care network through to region. The aim was to provide 80% of activity at ‘place level. Some aspects had to be provided over the larger system footprint.
• Why merge? Key aspects were developing place, more efficient decision making, administrative savings, staff recruitment and retention and better access to new opportunities and funding.
• Our current position, showing the engagement undertaken, the application to NHS England in September and the plans for a continued dialogue.
• Importance of place. At the place level, at least 80% of service transformation would happen and decisions be made on how money was spent. This would focus on local populations and support better engagement. 

David Eltringham, Chair of the Warwickshire North Place Executive delivered the next section of the presentation along with Jenni Northcote. Jenni worked jointly for the Warwickshire North CCG and George Eliot Hospital, having a key role in coordinating planning at the place level. Dr Rachel Davies had hoped to co-present but had clinical commitments. She was the GP and primary care representative on the place executive.  This part of the presentation covered:

• Context about the place, showing the profile of the area and the organisations involved in the place executive. This body had no legal standing and each organisation retained their respective accountabilities. Time had been spent in building relationships and understanding the roles of each organisation.
• Plan on a page, showing the vision, aim, the current state and that desired, with detail on a range of topics.
• A graphic showing the model of integrated care, which puts the patient and population at the centre.
• A diagram showing ‘how we work together – connecting from PCN to system through place’. Mr Eltringham explained how the various aspects were connected from PCN’s, which aimed to deliver neighbourhood priorities, through to priority programmes of work to deliver at the place level. A new aspect was delivery assurance, following the requirement by government to establish a reset board. The accountability and oversight aspects were also reported, together with the more strategic role envisioned for the merged CCG.
• Jenni Northcote spoke to the slide ‘How we work together – areas of focus’. This took existing information from a variety of sources to provide six areas of focus. The focuses are urgent and emergency care, long term conditions, mental health, wider determinants of health, community capacity and maternity, children & young people. An emphasis on working collaboratively at the place level and adding value. Examples were given for each area of focus to show how this is working in practice across the local system.
• Benefits at Place. The key benefit of local place working is the collective approach to delivering services within the resources available.
• Examples of what we are doing. A reiteration of the collaborative approach at place level.
• Case Study: hot hubs – implementation at place level. The response to Covid-19 showed how organisations had worked together in providing capacity to safely see patients in primary care settings who were suspected to have Covid-19.
• Key messages – a summary slide on the good progress made to date, the relationships developed, next steps in Covid-19 recovery and development of the Integrated Care System (ICS). 

Questions and comments were submitted, with responses provided as indicated:

• A concern about the slide showing the opportunity to reduce costs of delivery and whether this meant service cuts. In response, it was stated that there was duplication in the system and the potential to be more efficient. An example was reducing reliance on the A&E department by providing alternate services. There was a financial budget but this was an opportunity to move staffing and funding to achieve efficiencies.
• Clarity was sought on how this would work. Using the example of back problems, clinicians could deliver services such as physiotherapy at the local GP surgery or another facility. This would reduce costs. A related concern was the ability of smaller surgeries to accommodate additional services. Adrian Stokes added that the place executive provided a multi-agency forum to agree the best solution for service delivery.
• Members recognised the quality of the presentation and the merits of the place approach. There was good work being undertaken in Warwickshire North Place, which was appreciated.
• Improving health outcomes and reducing health inequalities should be the overall objectives.
• End of life care needed to be referenced in the documents. This would be actioned.
• A question why there needed to be a single CCG overarching the place executives and what the benefits were of joining the CCGs together. The critical issue was funding and further detail was sought on the criteria that would be used in allocating funding to each place to give adequate resources, whilst also addressing health inequalities.
• Anna Hargrave spoke of the challenges of coordinating activity across the three CCGs, an example being capacity to maintain elective activity, whilst also responding to spikes in Covid-19 cases. It was about ensuring connected and coordinated services, also improving health outcomes for key aspects like cancer and stroke services. From the local authority perspective, working with three CCGs was not ideal as each CCG may have slightly different arrangements in place. Another benefit would be joint commissioning arrangements, due to there being less organisations.  It is about making planning more efficient at the system or strategic level, with delivery at the place level. Adrian Stokes added that CCG running costs needed to reduce by 20%. There was a choice on how to achieve this but moving to a single body would reduce the costs and the potential impact on services delivered at place. He reiterated that the funding allocations would remain at the same locations. There were additional benefits of the CCG covering a coterminous area, for example in attracting additional funding.
• Councillor Caborn was the scrutiny chair when the health structure changed from a primary care trust to the three CCGs. The Council was not supportive of that change and he was supportive of the move to a single CCG. He added that the graphic in the presentation needed to make reference to the Health and Wellbeing Board, which would be actioned.
• A point on ensuring that the strategic decisions match what is needed at the place level.
• There was concern that the larger CCG would have less local engagement with reference made to the links between such engagement and recruitment/retention of staff.
• Chris Bain of Healthwatch made a plea for the patient voice to be lodged in the system. The establishment of the ICS by February was effectively a deadline to ensure that it was in place by then. Also, he urged that inequalities were given a higher profile in the ICS.

The Chair thanked the presenters and he considered that they had addressed all the points raised by the committee, when it met previously. He referred members to the report recommendations.

Resolved

That the Committee supports the proposed changes in the structure of the Clinical Commissioning Groups in Coventry and Warwickshire.