The West Yorkshire and Harrogate Joint Health Overview and Scrutiny Committee meeting on 30 July seemed deeply unimpressed with the Integrated Care System update.
So are we. The report is long – around 2.3K words. But we feel this sorry info needs to be out there, along with Councillors’ attempts to wrestle with the steam from the bean counters’ spin machine.
Demand for hard facts by October 8th
The Committee demanded that the West Yorkshire and Harrogate Integrated Care System (aka Health and Care Partnership) provide hard facts before the next meeting on October 8th, about the many questions they were unable to answer – particularly regarding:
- The proposed Partnership Board and whether it’s democratically accountable
- Care Closer to Home/out of hospital services
- Clinical Commissioning Groups’ lack of money (referred to as “financial challenges”)
- Where the £1.2bn cuts by 2020/21 would fall
- Where local authority social care and public health services fit in
- Specialisation of hospitals
We think Christine‘s ck999 deputation statement at the start of the meeting about the West Yorkshire and Harrogate Integrated Care System (downloadable here -.doc file) helped focus Councillors’ minds, particularly on the projected £1.2bn cuts by 2020/21, and the need to finally start scrutinising the whole shebang.
The £1.2bn cuts
Strangely enough, these weren’t mentioned in his update by Ian Holmes, Director of the Integrated Care System.
But Cllr Rhodes went through the list of £1.2bn cuts by 2020/21, asking for information on all of them:
- £0.5bn efficiency cuts through delivering services in different ways
- £0.4m [presumably this is a typo for £0.4bn?] “right care”
- £0.1bn projects delivering savings across region
- £0.2bn sustainability and transformation funding
She questioned how these “propositions for the future” translate into the effect on public services, and pointed out:
“That is most important and that information should be delivered as fast as possible, before the next meeting.”
In the meantime, she added,
“All these planning process are moving on now. We need a further breakdown of those £1.2bn by the next meeting so we can see the consequences of what it will mean.”
She also referred to paragraph 19 in the Integrated Care System update paper, which said that partners are to specialise, to free up specialist hospital care to do what only they can do. The Committee wants further information on that too. What partners and what specialist care?
Ian Holmes replied that the £1.2bn “financial challenge” is the difference between demand and funding available. He asserted that the new NHS settlement will change that.
Dr Andy Withens, the Clinical Chair of Bradford District Clinical Commissioning Group and West Yorkshire & Harrogate Stroke Programme Chair, explained the “Right Care” methodology that looks at variations between spend and outcomes, compared to peers. He explained it was a value for money comparison. The variations may be justified but it’s a way to have a conversation about what could be improved.
He did not mention that recent research published in the Journal of Public Health concluded:
“RightCare promises illusory savings based on an inappropriate fixed comparator group and faulty statistics…If RightCare is used to justify savings in NHS budgets, it is acting as a cover for cuts.”)
Or that the West Yorkshire and Harrogate STP Right Care Value Pack shows Musculo Skeletal services as a “headline opportunity” – the service with highest “opportunity” for cutting spending.
Clinical Commissioning Groups’ lack of money and what the Integrated Care System Partnership Board is going to do about it
The North Yorkshire Councillor said certain Clinical Commissioning Groups in North Yorkshire are the worst funded bit of the NHS, with a £46m cumulative deficit at the end of the last financial year. He added,
“All North Yorkshire Clinical Commissioning Groups are therefore acting unlawfully, apart from Airedale, Wharfedale and Craven. How will that affect working with the Partnership Board?
North Yorkshire Clinical Commissioning Groups have been ignoring letters about spending money they don’t have – what do other Clinical Commissioning Groups do about such letters?
How will the Integrated Care System tackle this?”
The North Yorkshire Councillor hoped the Integrated Care System partnership could get control of Clinical Commissioning Groups that are not acting within the law or taking auditors’ advice to set up proper financial controls.
He was worried about extra money being put into the NHS that isn’t properly accounted for. Clinical Commissioning Groups are spending money on primary care, but have the dual role of commissioners and providers. He added,
“Rules for balancing budgets don’t seem to apply to the NHS as it does to Local Authorities.”
In contrast, Cllr Rhodes (Wakefield) asked if there was any monitoring of the effects of the Clinical Commissioning Groups’ financial challenges on them.
And whether the Transformation funding for cancer, mental health, diabetes etc is new money – eg was the mental health transformation money part of the new mental health money that’s already been announced?
Ian Holmes said that new money for mental health is coming into West Yorkshire over and above what’s coming to Clinical Commissioning Groups.
But he said he didn’t want to get into specific issues with this forum, and also Harrogate Clinical Commissioning Group is not the only NHS organisation that is facing significant financial cahllenge. That won’t impact on their ability to be full partners.
He asked rhetorically,
“Does the Partnership let us tackle these issues better? There’s not enough money coming into healthcare, but transformation funding will help.
Sharing info about successful turnaround is more likely to be successful than waiting for the regulator to wait for a red light to flash and then come in with focussed performance management.”
Begging the question of where successful turnaround in West Yorkshire and Harrogate had taken place.
Jo Webster added that no partnership arrangements will take away Clinical Commissioning Groups’ statutory responsibilities to stay within financial limits. But they will try and improve ways of working.
Each Clinical Commissioning Group gets its allocation and has to live within its resources.
Care Closer to Home – making do with ‘community assets’ and voluntary organisations, because of shortage of GPs
Cllr Rhodes was scathing about the lack of capacity in GPs and in the community, where for example funding has been cut to community centres, just to keep the doors open.
She wanted specific information for the Joint Health and Overview Scrutiny Committee, in good time for the next meeting, about the preventive strategy and care closer to home.
Cllr Flynn said he was struggling to see why the Integrated Care System was taking the lead in moving services as close to communities as possible, when most action will take place locally. He asked what the relationship is between the Integrated Care System and local Sustainability and Transformation Plans.
He said that at the West Yorkshire level they had had a discussion of data and possible interventions, to agree consensus about what to tackle. But implementation is through Clinical Commissioning Groups and local GPs.
He said cryptically that there was no leadership team outside of place. (Accountable Care gobbledygook for Local Authority/Clinical Commissioning Group area.)
Rachel Loftus, the Integrated Care System Head of Regional Partnerships (meaning what?), wittered:
“So much work is done in place and there is a lot of place learning from each other, rather than from programmes that are done at West Yorkshire and Harrogate level.”
(Place in this context is jargon for the area of a Local Authority/Clinical Commissioning Group.)
Cllr Rhodes chided,
“For over 20 years I have heard about closer working with the community, care closer to home. Show this committee how that’s going to be delivered when GP practices are saying they’re going on a preventative role and there aren’t enough GPs coming out of school.
“Paragraphs in reports are meaningless without the information to give to people we represent in our areas.”
Dr Andy Withens, said Primary Care Homes each serving 30-50K patients is a local thing but the “architecture” is for 40 Primary Care Homes across the 7 Local Authorities.
Community assets, community groups and the voluntary sector is way of delivering preventive care so that the few GPs we’ve got can do what GPs are best at.
‘Community assets’ are basically local social networks. This is basically David Cameron’s Big Society nonsense applied to an underfunded NHS and social care service. As even its advocates have warned,
“There is a need to be cautious in the application of asset based working in light of the current economic downturn as this can be perceived as a means and/or justification for removing services to save money, rather than delivering more and better outcomes.”
Defensive update by Integrated Care System Director
Ian Holmes defensively announced that the Integrated Care System has a facilitative role, not a dictatorial role. It works on the subsidiarity principle. But some things are better at the West Yorkshire and Harrogate level. It is not about privatisation – but a partnership with NHS & Local government.
He said the announcement of the shadow Integrated Care System at the end of May means that the Sustainability and Transformation Partnership has been given backing to progress more quickly. Transformation funding is essential to progress. It is not a big bang, but an evolution.
It will have a more streamlined relationship with regulators and access to support and expertise.
He added the next step is to set up a West Yorkshire and Harrogate partnership board – like the Greater Manchester partnership board. It will include executive leaders, chairs and members of public to talk about strategic partnership. Democratic accountability is important.
The single financial arrangement will support primary care networks and population health management.
Partnership Board was drawn up on back of fag packet
Ian Holmes couldn’t say if there will be Councillors on the Board, or if they will have a vote, or what the Board’s about. He waffled:
“We anticipate there will be a voting arrangement on the Board if needed. We anticipate more Transformation funding and more leeway about how and where to use it. So the Board will make those decisions in future.”
He didn’t know how they were going to make a balance between elected members and non elected members. He said they would probably get to that level of detail by the autumn.
Cllr Rhodes observed that
“The Board seems to have been drawn up on the back of a fag packet.”
“How will Health and Wellbeing Boards feed into this Board?
Local Authorities used to have 3 Councillors on the old health board. There seems to be lot of duplication between the Integrated Care System board and Health and Wellbeing Boards. And where is the accountability for things the Integrated Care System is doing? Because we don’t see it.”
Ian Holmes wittered that the need for greater democratic accountability and transparency would be met through Health and Wellbeing Boards and Scrutiny. The Partnership Board doesn’t want to duplicate them. He would welcome further conversation on that.
Cllr Smaje was concerned that West Yorkshire and Harrogate Integrated Care System was responsible for delivering local plans and asked for clarification because she’d thought it was place up, not top down.
Ian Holmes said he’d misspoken if he’d said West Yorkshire and Harrogate was responsible for delivering local plans.
Rachel Loftus, the Integrated Care System Head of Regional Partnerships, wittered,
“How do we get to systematic use of democratic accountability in the Health and Wellbeing Boards and aggregate that up to larger footprint? Really complicated relationships.”
Cllr Smaje asked how they are bringing in social care Local Authority organisations.
Rachel Loftus waffled that they were working to make a close fit between social care services and the NHS. They were also working on wider determinants of health where the Local Authority has a role that can contribute to healthy lives
Cllr Smaje asked how long the Integrated Care System would be in shadow form. She pointed out they’d been talking about governance arrangements for some time. There were no timescales for different workstreams in the Integrated Care System update paper. Surely they need the governance system to bring finance into the area, so how is that shadow form?
All the local Sustainability and Transformation Plans are about working differently to cut spending
Jo Webster, Wakefield Clinical Commissioning Group Chief Officer , said each place (ie local authority/Clinical Commissioning Group area) has a Joint Strategic Needs Assessment, led by the public health department, that is the basis of local plans (local Sustainability and Transformation Plans). In Wakefield the Clinical Commissioning Group is part of that relationship.
“All those plans require working differently to reduce spending.”
Those plans are basis of the Integrated Care System Partnership. The Integrated Care System Partnership does stuff to spread good practice eg generalising the Bradford Healthy Heart scheme across the Integrated Care System.
Shadow form means leading the way – there is no blueprint for the Integrated Care System governance system. More than 30 organisations are involved. It is challenging to get them to work together. There are sets of arrangements they are trying to work with to co-design these things.
At some point it will become a mature Integrated Care System and take on more responsibilities at its own pace.
Cllr Greenwood asked how the Partnership would help Bradford if they have a higher incidence of a specific illness than others.
Rachel Loftus said they would investigate and then would put as much effort as possible into prevention and high quality care for those who need it.
Dr Andy Withens said it’s about learning and sharing what’s worked well in other areas. They can industrialise and standardise the offer.
Cllr Greenwood pointedly asked,
“But don’t we do that already?”
Andy Withins said they’d come up with a shared target and approach to atrial fibrillation that is expected to deliver better outcome than continuing to work as set of local programmes.