Agenda item

Integrated Care System

A presentation will be provided by Danielle Oum (Chair) and Phil Johns (Chief Executive designate) on the Integrated Care System. This will be followed by questions from members.

Minutes:

A presentation was provided to the Committee by Danielle Oum (Chair) and Phil Johns (Chef Executive Designate) of the Warwickshire Integrated Care System (ICS). Danielle Oum commenced the presentation which covered the following areas:

 

  • The next steps for health and care in Coventry and Warwickshire
    • National move to bring health and care organisations together into an ICS
    • Legislative proposals by the Government for a new Health and Care Bill, building on recommendations in the NHS Long Term Plan
      • This would establish a statutory ICS in each ICS footprint
      • Continuing progress through parliament – currently at committee stage in the House of Lords
    • Already working closely together as a Health and Care Partnership – this was a development of what was believed best for Coventry and Warwickshire
    • The earliest this would become a statutory ICS was July 2022
  • What is different about an Integrated Care System?
    • Break down the barriers between organisations
    • Join up health and care more effectively to make a difference to people’s lives
  • The aims of the ICS
    • Improve outcomes in population health and healthcare
    • Tackle inequalities in outcomes, experience and access
    • Enhance productivity and value for money
    • Help the NHS support broader social and economic development
  • Our Vision – ‘We will enable people across Coventry and Warwickshire to start well, live well and age well, promote independence, and put people at the heart of everything we do’. This was supported by five key strands around enabling everyone to keep well, working together to tackle underlying causes of illness, providing the best possible care, use of technology and valuing staff.
  • Danielle also spoke of empowering citizens to be involved in influencing priorities, a shift of focus from treating ill people to move towards health prevention, in a collaborative way with key partners and communities. An aim to extend both life expectancy and healthy life expectancy, promoting ownership and involvement. Further points about being an ‘anchor institution’, employment links and the opportunity to work together with aligned objectives.

 

Phil Johns spoke to the following slides:

  • System, Place and Neighbourhood – a graphic showing the three layers and areas of responsibility. A number of examples were provided to ‘bring to life’ the work that was taking place and show the vision in practice.
  • For the ‘system’ an example of improving access to services through the elective accelerator programme, an increase in appointments and new ways of delivering care.
  • In the Warwickshire North Place, an example of using technology to improve health and care through remote monitoring. This included care home staff monitoring residents and where changes were identified, reporting this to GPs for intervention. This pilot was being rolled out across Coventry and Warwickshire and for certain conditions in residents’ homes.
  • An example from the Rugby place was enabling everyone to keep well, working with communities to address local needs. Story Circles was an initiative for group discussions, building on communities and shared experiences / support. It built on the compassionate communities’ approach and was targeted to young people with mental health and wellbeing challenges, including hospitalisation through self-harm. It provided a voice and support for young people in accessing services, also with the aim of more tailored support going forwards.
  • In South Warwickshire, an example about development of the primary care networks. This aimed at providing the best possible joined-up care, through developing the role of care co-ordinators. An example of the focus on cancer services providing personalised, expert and ongoing contact and support for cancer patients. It focussed on the experience of the individual and their pathway of care.
  • How the system could fit together. A complex flow chart showing the connectivity between the Integrated Care Partnership (ICP) and Board, the respective HWBBs for Coventry and Warwickshire, care collaboratives, Healthwatch organisations and health scrutiny committees, amongst other bodies.
  • What’s next
    • Ongoing work to establish the strategies and governance, in collaboration with the population and stakeholders
    • The current timeline was that the Integrated Care Board (ICB) and ICP will come into being on 1st July 2022 and the statutory powers would transfer from the CCG to the ICB

 

Questions and comments had been invited from all WCC members in advance of the meeting. The following areas were discussed: 

  • Councillor John Holland welcomed the arrangement of this additional meeting and the plans for integration. He had submitted questions in advance which he presented with additional context regarding the Joint Strategic Needs Assessment (JSNA), challenges for ambulance services, which needed more integration with A&E departments and hospital discharge delays associated with the need for care packages to be arranged. The first question concerned the criteria for success or failure of the ICS and how it would be assessed. One measure was an increase in life expectancy, but recently data showed this was reducing.
  • Phil Johns acknowledged the current ambulance handover delays. Monitoring could take place to see if such delays reduced under the revised arrangements. Of more significance was avoiding the need for hospital admission. There were a number of clear metrics which could be monitored. The discharge process would be reviewed, whilst monitoring the process could show levels of success. Mr Johns spoke about the patient experience and gathering feedback to inform the design of services. There were some areas outside the remit of the NHS such as carers pay levels. People were being encouraged to take up roles in the NHS and care as the workforce aspects were key. Danielle Oum added about the need to work together at all levels to agree shared priorities and success criteria. This would need to include the public priorities too. In the first year of the ICS, agreement of the priorities and how they would be achieved could be a success indicator.

·       Councillor Holland referred to the structure chart in the presentation, speaking about the role of the HWBB. Phil Johns confirmed there would be a two-way relationship between the HWBB and ICP.

·       Councillor Holland was aware of concerns raised by a campaign group that the ICS may be linked to privatisation of NHS services. He asked for clarification of the relationship of the ICS and the private and voluntary sectors. Mr Johns confirmed that the relationship remained unchanged where some services were bought from the private and independent sector to add capacity. Danielle Oum added that the voluntary sector an important role to play. This included providing the voice and needs of the community whilst some organisations also delivered services.

  • Nigel Minns provided context on the proportion of patients in hospital who were receiving support associated with discharge arrangements. The 103 people included some who lived out of county, people who had Covid, or could not leave hospital for safeguarding reasons. Around two thirds of this number were awaiting a care package. This was estimated at three percent of those in hospital. There were other reasons why people who were medically fit to be discharged remained in hospital but they did not require WCC assistance with a care package. However, discharge arrangements remained a problem. He also reminded that the vast majority of care provision was delivered by the private, voluntary and community sectors. These relationships were important as was their involvement on the ICP.
  • Becky Hale spoke about providers, inflation and costs of care. The inflationary awards would be notified to care providers in the next week. A fair cost of care exercise would be undertaken collaboratively across Coventry and Warwickshire, as part of the delivery of social care reforms. This was a positive move over the next year to ensure a sustainable care market and was critical for the NHS too. She mentioned the report to the January HWBB on the commissioned workforce strategy and the measures which were being progressed to support the social care workforce. 
  • Councillor Rolfe sought more information about the remote monitoring initiative, its success, how this was measured and plans for rollout across Warwickshire. Becky Hale confirmed this was a successful pilot which was implemented in the Warwickshire North area. It involved care homes for older people and those for people with learning disabilities. The pilot was now being expanded to Kenilworth and Warwick with Rugby to follow in the coming months. Data showed the positive impact in terms of reduced hospital admissions from care homes.  People in their own homes could access the service and there were plans to expand to other cohorts who would benefit from remote monitoring. The service was undertaken through a clinical hub as part of the out of hospital arrangements. A presentation was planned for a future meeting of the HWBB.
  • In response to a follow up question from Councillor Rolfe, Phil Johns explained how the remote monitoring worked, through scripted questions and looking at vital signs, with the person in the home submitting data into a system.
  • Councillor Bell added that a comprehensive presentation had been requested to the HWBB on all the technology solutions being used both in care homes and in the community.
  • Chris Bain welcomed open dialogue established with Danielle Oum and Phil Johns. He spoke about the elective accelerator programme and asked how this could be achieved given the workforce challenges.
  • Chris Bain raised issues referred to Healthwatch as key priorities. The first was mental health services in the community, difficulty of access and the impact this had on patient outcomes. Next, access to NHS dentistry had been a longstanding issue. In some areas, there were no NHS dentists and from survey feedback, the position was worsening. Healthwatch would like to know how the population and especially younger people could access NHS dentists. General practice was a further area where complaints were received. The issues were getting access, the technology challenges and the absence of face-to-face appointments. Finally, discharge from acute settings and the experience of carers was raised. There were some challenges from ‘seldom heard’ groups. Chris Bain closed by focussing on the complexity of the system and how to ensure the patient voice was heard at all levels of the system.
  • Danielle Oum said it was important to develop a strategic approach, referring to the people and community engagement strategy. This would set out the principles for all bodies to build in patient voice to key decision making. She outlined how HWW would be involved actively or as an observer at all key levels, whilst ensuring their independence was not compromised. There were plans for a voluntary and community alliance to enable sharing of intelligence, supporting engagement, influencing direction of travel and providing feedback. As the various layers were established, the principles around engagement would be embedded.
  • Phil Johns responded to the points raised by HWW. The elective accelerator work would be dependent on existing people being willing to provide additional clinical sessions and revised ways of working through GPs to reduce demand on outpatient appointments and consultants. Use of artificial intelligence and maximising throughput in theatre were further points. Without growth in the workforce, it would be difficult to maintain the expected level of service. This may require greater use of the independent sector for elective surgery for the next two to three years. There would also be requirements to support neighbouring NHS systems which had larger waiting lists. The discharge of medically fit patients from hospital was a key aspect.
  • Phil Johns spoke of the need to ensure GP access, the additional constraints about unmet need where patients were not presenting. It was a difficult task to address the waiting lists for elective procedures. Whilst funding was available, the need for additional staffing was the challenge.
  • Mr Johns then acknowledged the impact of the pandemic on community mental health service demands. This had forced a focus on crisis cases, directing resources away from earlier interventions. There were no easy solutions, but a need to refocus on providing interventions at an earlier stage, possibly through accessing services from other organisations in the short term.
  • Danielle Oum provided a comparison to the relative position elsewhere, where community services had been reduced to focus on inpatient care. There was an opportunity to get ‘upstream’ and provide care earlier. However, the next two to three years would be a challenge.
  • On dentistry, an update had been provided to the January HWBB. Phil Johns confirmed that dentistry would transfer to the ICB in 2023. There would be a dialogue with NHS England as this approached, but he was not sufficiently informed at this stage to be able to respond to the points made. There may be opportunities for dentistry to link in with other services. It was expected that the local system would inherit a challenging position on dentistry.
  • On GP access the CCG had invested to extend access to services.  Phil Johns gave comparative data on the position in November 2019 to that in November 2021 on the number of GP appointments and of those, the number that were face-to-face. This showed that more appointments were held in November 2021. The number of face-to- face appointments was increasing and nearly at the level of 2019. The demand for GP appointments was increasing. A further point that some people preferred remote appointments at different times to fit around other commitments, whilst many still preferred a face-to face appointment. Mr Johns praised GP doctors for the services provided during the pandemic, including the vaccination programme. Many went above and beyond, but there was high demand for services and expectations of the population. Endeavours were made with specific practices, where issues were identified, within the scope of the GP contract.
  • Chris Bain confirmed that HWW was not seeking a return to the service provision prior to the pandemic, which had contributed to the problems identified. A survey by the Patients’ Association indicated that delayed assessments and treatments were leading to a loss in patient confidence in the NHS. Such confidence was needed to have an impactful and effective preventative programme. There was a significant communication challenge to be addressed, as a matter of urgency.
  • The Chair would be suggesting an item on dentistry for the committee’s future work programme. This would provide a useful benchmark before the transfer of dentistry to the ICB.
  • In response to a question from Councillor Matecki, Danielle Oum confirmed the national core responsibilities to be adopted by the 42 ICS’s. Councillor Matecki commented that these measures should be happening anyway and not need stating. He welcomed a lot of the points made including ‘places’ taking ownership of their priorities. However, there was a need for staff and finance to deliver those priorities. He agreed with the aims for prevention both for residents and for organisations in finance terms. However, additional resources both staff and finance were required to achieve this transition. He asked if the additional money was available, as without it, progress could not be made. The identification of priorities at place level was welcomed and he advocated that once they had been achieved for that place, they be implemented across the whole area.
  • Phil Johns agreed on the points about resourcing for the place priorities. There would be additional monies for the local system, with examples given of the types of targeted funding. However, clarity was awaited on the financial settlement. This funding was needed to enable investment in mental health services and GP services for example. At the same time, the system may need to achieve some savings. It would be useful to map the resource for health and care for this committee. He reiterated there was a clear commitment to devolve resource down to the place level.
  • Councillor Golby spoke of a meeting recently about the use of digital services and preventative work in the North East and Cumbria.  Reinstating preventative work post-Covid was a national issue.
  • Councillor Roodhouse spoke of the benefits provided through the compassionate communities and story circles initiatives. He then referred to the complex local system shown in the presentation. Priorities agreed at the ‘place’ level would feed into the system but also have to align with many organisational, health and wellbeing and other strategies, all agreed in collaboration, with stakeholders and the public. He asked how a balance would be arrived at for funding decisions, especially if the top-down funding was not sufficient. He referred to the new white paper on integration and the key was pooling budgets. He referred to the current arrangements for the Better Care Fund, which comparatively was a much smaller element. Councillor Roodhouse spoke about the amalgamation of funds targeted to agreed priorities like prevention. This would take time, which wasn’t available, and he sought views from both health and social care leads on this. 
  • Danielle Oum agreed that this was about a willingness to work differently. The final bill was awaited. There was acceptance that current arrangements did not meet what was required. Working together to achieve a balance was referenced. This was needed at the same time as achieving transformation, firefighting, efficiency and productivity. Achieving that balance would need a compromise.
  • Phil Johns added that there should be a clear link through the various priorities and strategies. It was complex and system leaders would need to challenge themselves to work in a different way and collaboratively. He was an advocate for pooled resources and there was a need to understand the total resource available. Some funding had to be targeted, an example being the prevention agenda.
  • Councillor Roodhouse explored how the pooled budgets could operate in practice to agree the allocation of funding across streams and respective contributions from partners. He also referred to the additional challenges posed by the ‘fair cost of care’.  Phil Johns responded that there was a lot of discussion needed before achieving the concept that Councillor Roodhouse had outlined.  Other aspects, agencies and services needed to be included too.
  • Councillor Humphries spoke of her experience from work in dementia services, about the need for coordination of different health disciplines and social care, sharing information to avoid duplication.  Phil Johns confirmed that the work on integrated health and care records was a key strand of the new white paper. Work in the local system was ongoing but was by no means complete.
  • The Chair agreed that a ‘single view of the customer’ shared by the NHS and social care would be a significant step forward. She also considered that people delivering services could be a key contributor to systemic changes. Danielle Oum confirmed that the engagement strategy would include those delivering services.
  • Councillor Kettle asked how the new ICS arrangements would assist GPs in improving the health care offering, including for onward reference to other services. Phil Johns referred to ‘shared care’ of patients with multiple conditions. The ICS may be able to assist in a number of ways. The examples given were coordination of secondary care appointments with GPs, keeping patients informed of where they were on waiting lists, co-location of other services like physiotherapy at GP practices and making patient records available to the patient.
  • Councillor Kettle asked how the ICS could assist with the effective allocation of developer contributions. He quoted an example where such funds had been lost due to a failure to reach agreement between the GP practice and CCG. Phil Johns agreed that on estates development and facilities, there was a great opportunity for partnership working. An offer to talk outside the meeting on the specific matter raised to ensure learning for the future. It was understood that there was a process in place for the allocation of funds from development for additional health facilities and a need to be aware of such developments in the near future. The Chair used an example of the expected population growth and need for additional GP services through developments in the Nuneaton and Bedworth area.
  • Councillor Humphreys referred to the process and time taken to apply for care. This was not a role for the GPs to undertake and it was about allocation of appropriate staffing to undertake the role.
  • A suggestion that this useful session could be extended to the wider Council membership. The meeting had been publicised to all members of Council and written questions invited from any member.
  • Councillor Drew sought an assurance about how people could access care and other services.
  • Councillor Seccombe felt there was value in an ongoing dialogue about the ICS between now and its commencement in July. She referred to spending on social care and there was a need for an equal partnership. She referred to the integration white paper and the good working relationships between health and care in Coventry and Warwickshire. Development of the white paper could be monitored alongside the ongoing discussions about the ICS. Danielle Oum agreed this white paper provided a great opportunity, also the importance of health and care working together and building on the work that was already happening.

 

The Chair thanked Danielle Oum and Phil Johns for their time, the presentation and responses to members’ questions. It was perceived that everyone wanted the same outcomes for the best services for the area. Time would be needed to achieve the desired changes, and this would be assisted by an ongoing dialogue. The Committee would welcome a commitment to hold further meetings which Danielle Oum gave an assurance to do.

 

Resolved

 

That the Committee receives the presentation on the Warwickshire Integrated Care System.