Agenda item

Engagement with the Committee on the ICP Strategy and associated plan.

The Committee received an update and presentation from Liz Gaulton and Rose Uwins of the Coventry and Warwickshire Integrated Care Board (C&WICB). Initially, background was provided on the Integrated Care System (ICS), a partnership of organisations that came together to plan and deliver joined up health and care services. It explained the role of the C&WICB and the IC Partnership, those which rested with local authorities, care collaboratives and provider collaboratives.

The report set out the requirements to develop an Integrated Care Strategy, to meet the assessed needs, from the previously developed Joint Strategic Needs Assessments (JSNAs). In Coventry and Warwickshire considerable work on integration had already taken place. The Integrated Care Strategy would build on this to further the required transformative change to tackle the significant challenges facing health and care. The strategy presented an opportunity to do things differently.

The ICP had agreed a work programme to develop the strategy, led by a working group and with input from key stakeholders. The draft strategy needed to be submitted to NHS England for review on 14^th December. The report outlined the planned approach and format for developing the strategy, signposting to existing strategies, the mapping which had taken place and identification of proposed priority or ‘strategic focus’ areas. The draft priorities had been discussed at the Integrated Health and Wellbeing Forum, resulting in a series of commitments that would run through the strategy.

Details were provided on engagement activity, to ensure that development of the strategy and the Integrated Care 5-year Plan were done in an aligned and connected way. A separate engagement task and finish group had been established for this purpose which included broad representation from stakeholders. Wide public engagement was also planned with over 30 scheduled events, planning for more events and an online survey. Stakeholder engagement would continue with regular updates, including with this committee.

The requirements to produce a five-year Integrated Health and Care Delivery Plan were reported. The delivery plan would be refreshed before the start of each financial year and meet the reported statutory requirements from the Health and Care Act 2022. Further guidance was expected shortly from NHS England, which would be provided to members via a stakeholder briefing.

The report concluded by referring to the strategy content and next steps, as well as providing the national timeline for producing the strategy and the five year delivery plan.

The presentation included slides on:

• Integrated Care - a huge opportunity.
• ICS aims – improve outcomes, tackle inequalities, enhance productivity and value for money and support broader social and economic development.
• The ICS vision.
• Planning for the future – development of the Integrated Care Strategy and 5-year Joint Forward Plan.
• The vision for integration and collaboration across the system to achieve the four key aims.
• Grounded in the reality of now. The strategy would be built from local assessments, include consultation with Healthwatch and statutory components of national guidance. It would set out how assessed needs would be met, show regard to the Secretary of State’s mandate and any guidance and set out views on how health and care services could be more closely integrated.
• Engagement and involvement through a phased approach. Additional information was provided on the processes, the engagement undertaken or planned, and the feedback received to date, which showed a number of consistent key themes. These included access to GP services, trust in services and digital services. Some patients could not access digital services and others did not want to use them, preferring face-to-face appointments. This was an area for further consideration on how to approach digital services and working with patients.
• Through engagement and involvement the ICS had iteratively developed the priorities for the strategy.
• The priorities:
  • Improving access to health and care services and increasing trust and confidence
  • Prioritising prevention and improving future health outcomes 
  • Tackling immediate system pressures and improving resilience.
• The commitments:
  • Improve outcomes
  • Tackle inequalities
  • Enhance productivity and value for money
  • Support social and economic development.

Questions and comments were invited with responses provided as indicated:

• Several members thanked the ICB representatives for the presentation.
• A question on the response from rural parts of north Warwickshire and whether feedback had been sought from organisations like the Citizens Advice Bureau (CAB) in Atherstone. There had been a dialogue with the CAB, and it would be checked if this included the Atherstone branch specifically. Rurality was a recognised theme within the feedback on access to services. It was questioned whether a mobile GP service could be provided to rural areas similar to the mobile libraries. This suggestion would be researched.
• A comment that some people did not like to use digital services. Problems could be experienced using online services if the options available didn’t meet the customer’s needs. An example was given using a financial institution to demonstrate this. There was a need to consider service delivery options for those who could not access services digitally. Liz Gaulton replied that the aim was to make best use of digital services. This was the same for health and the County Council’s services and there may be merit in working collaboratively to give confidence to communities to access services digitally. The councillor said that nationally the digital service provision was the default and there should be more consideration for those who could not access services in this way.
• On face-to-face appointments and trust, patients also valued a relationship with their GP. It was known that GP practices were, in the main, private businesses and was questioned how the ICB was able to influence practices to undertake more face-to-face appointments.
• Liz Gaulton explained the ICB’s role to give assurance on the quality of GP services, working in a collaborative way. Generally, this worked well but this may be an area for more detailed focus with the appropriate senior ICB officer at a subsequent meeting. Overall, patient satisfaction was good.
• Rose Uwins added that the feedback regarding GP access was much wider than just face-to-face appointments. It included access to appointments and seeing the right person first time, rather than having a GP appointment before accessing the specific service needed. The member pursued this change from the traditional route of a GP referral and it was questioned how this would work.  Rose replied that this was a work in progress and options were being considered. There were known workforce challenges. An example being piloted in Coventry was the use of first contact practitioners, linked to GP practices who would make the referral instead of the patient seeing a GP. As pathways changed, these would be communicated.
• Dr Shade Agboola spoke of the duty for GPs to engage with the system and its quality assurance processes. She gave an outline of the better reporting arrangements under the ICB structures, including regular performance management reports. She attended the ICB committee and the recent report showed an increase in the number of face-to-face GP appointments, compared to the same period last year. These processes enabled challenge and constructive feedback to be provided. For the first time, it gave a clear line of sight for primary care services.
• Councillor Holland commented that many people saw the move to the ICB as positive. Previously he had asked how this change would be measured, or whether it might be seen as another layer of bureaucracy, but he had not received a clear response. He referred to the public question earlier in the meeting and access issues for people in new housing developments. The key issue was the shortage of GPs and he asked how the ICB would address this. Liz Gaulton responded on the wider strategy and the feedback received from stakeholders that improving access to primary care services and building trust/confidence were key. It had been suggested to have a dedicated session on primary care at a future committee meeting.
• Reference was made by Councillor Holland to the JSNAs. It was suggested that the boundaries selected for these areas could have been more customer focused. He then spoke about the ‘place-based’ approach. The primary care networks (PCNs, groups of GP practices) had been based on the JSNA areas and he asked if these could be changed to be more cohesive. Liz Gaulton confirmed that the work on JSNAs had been undertaken by the County Council. It was understood the methodology used for grouping PCNs was more complex than just basing them on JSNA areas. This could be covered in the subsequent session, or a written briefing be provided on the methodology used.
• A point that having a consistent GP meant they knew the patient’s medical history.
• A question about the progress made in achieving needs identified through the JSNAs for each of the places. Shade Agboola responded that the findings from the JSNAs were used in formulating the Health and Wellbeing Strategy (HWBS), for both Coventry and Warwickshire. In Warwickshire the place-based programme had been completed for 22 areas. She explained that this had been replaced with a thematic approach, giving examples of some focus areas. The JSNA had influenced both the HWBS and the ICS Strategy for the local system. She then advised how the JSNA priorities were translated into actions through the three place partnerships, drawn from the HWBS and with a series of local priorities and strategies. This work was supported by the Council’s Public Health and Strategic Commissioning teams. Examples could be provided to the committee to show how identified priorities had been implemented.
• Councillor Holland referred to the background information circulated to the Committee, from a Health and Wellbeing Board (HWBB) development session. Reference was made to the linkages between this committee and the local system. This document included a statement on shared accountability between the local organisations. The councillor viewed that accountability could not be shared, suggesting that the HWBB should revisit this aspect.
• Councillor Bell, as Chair of the HWBB advised that an update from each of the place partnerships would be provided to the January board meeting. Having met with them recently, she gave a brief outline and example of how JSNA priorities were being implemented. She confirmed that the HWBB was accountable to this scrutiny committee.
• Further reference to digital services with an example of the challenges faced by some elderly people. A resident was moving to another GP as they were unable to gain access to the surgery car park which required use of a mobile telephone application.
• There would need to be follow up reports to the committee with data on what had been achieved. It was questioned how the ICB would collect data to show the direction of travel and achievements. Liz Gaulton gave an outline of the performance reporting arrangements. A meeting of the ICB would be held in public later in the day and its agenda included a performance update. She gave examples of the service performance monitored, including that set by NHS England and which had continued from the earlier clinical commissioning group arrangements. There would also be locally set measures, to monitor areas within the strategy, to assess what success looked like. Examples were given around reducing waiting times, better outcomes, service access and reducing inequalities. A report back could be provided to the committee.
• On digital services, further discussion about supporting communities on how to access services in this way. This would include identifying barriers, seeing if they could be addressed, but also recognising that some people may not be able to use them and ensuring services were inclusive. It was viewed that the emphasis was on people needing to learn and change, rather than designing a service to meet their needs. It was more about assessing the challenges, to see if these could be overcome, but not relying solely on digital services. There were many benefits from digital services, especially with the workforce challenges and service delivery in rural areas. It was made clear that no-one would be left without access to services.
• Chris Bain of HWW commented that the greatest challenges for the ICS were workforce, culture and unnecessary complexity. An example was the care collaboratives. He referred to the key aims and would have added putting patients at heart of everything you do. He drew comparison to the supermarket Tesco which considered itself to be customer ‘obsessed’, with the customer benefit being the core focus for every action.
• Chris Bain of HWW confirmed the need for trust in services, but also in decision makers and the system. There was a need for continual dialogue to build trust, to ‘sense check’ and to get early warning messages. The voluntary sector was well placed to do this but needed support and resources to do it effectively. On digital services, the aim should be for a digital service which is part of the NHS, which works for people who access it.
• On digital services, a further aspect was the messaging. On most occasions, people were encouraged to use an application or website. This shouldn’t be the first option or indeed the only option. Also, the length of pre-recorded telephone message options was frustrating.
• Examples of good practice were provided by a member for their local practice which had effective triage and offered rural home visits. Some people would never access digital services and should not feel excluded.
• An important aspect was face-to-face access for patients with dementia and their carers. Dementia cafes were providing great community support and were often run by volunteers. An example was provided in one member’s division. However, when people were in crisis they were being signposted to these voluntary services. This was a significant gap in the system which needed resourcing and replicating in other parts of the county. Dementia cases were not going to decrease. There was a need to ensure this cohort had speedy face-to-face access to GPs and specialist support. The member sought reassurance that this would be taken on board. Councillor Bell asked if GPs received extra funding to monitor dementia patients and undertake periodic reviews. This would be researched but could also be raised at the HWBB.
• Liz Gaulton thanked members for the examples provided which demonstrated some issues in the local system.
• The Chair reminded of previous comments she had made about GPs and the critical responses she’d received from GPs. She was glad that the issue had been recognised and stood by her earlier statements, expecting further feedback. She was also pleased that GPs should not be seen as the gatekeepers for accessing healthcare and this had led to backlogs. The self-referral piece was a good start. She then stated the immeasurable improvements at her local GP practice over the last year, referring to the effective triage. This meant her health needs had been resolved by seeing a nurse without needing a GP appointment. Triage at the point of contact was a good idea but was not necessarily provided by all surgeries. She was heartened by the update. The lack of GP access was a significant issue for residents, and she was supportive of a further specialist conversation on this area.
• Rose Uwins confirmed that the engagement work had highlighted the importance of access to GPs, and it needed to be reflected in the strategy. It was about how to support GPs to deliver what they could, given the workforce challenges, to build trust and ensure that people could access the healthcare system. Liz Gaulton added that this had been a useful and honest discussion.

The Chair thanked the speakers for their attendance.

Resolved

That the Committee notes the presentation and adds to the forward plan for a specialised session on GP services and access to primary healthcare.