In a four-hour Adults Health and Social Care Scrutiny meeting on 16th September, Calderdale Councillors tried to get a grip on how the Health and Care Bill is going to change the NHS, public health and social care in the borough and across West Yorkshire.
In response to bureaucratic smoke and mirrors from West Yorkshire Integrated Care System and Calderdale Clinical Commissioning Group officials, Councillors managed to clarify that:
- The Clinical Commissioning Groups will be abolished by 1.4.2022 and their commissioning functions and staff transferred to the new statutory Integrated Care Board.
- The West Yorkshire Integrated Care Board will take over commissioning of dentistry, optometry and a couple more specialised services from NHSE. The West Yorkshire and Calderdale commissioning and integrated care bureaucrats claimed that commissioning these services “at scale” – ie at the West Yorkshire level – will be advantageous. This was disputed by Councillors as likely to lead to a further run-down of District General Hospitals and problems for patients in accessing remote services.
- Commissioning at the Integrated Care Board level will not be clinically led.
- NHS decision-making and commissioning functions are likely to be split between Calderdale and West Yorkshire, while remaining under the control of the statutory Integrated Care Board.
- Specifically, it is likely that the West Yorkshire Integrated Care Board will delegate some of its commissioning functions to the Calderdale Cares Board, which will be a subcommittee of the Integrated Care Board. These commissioning functions are likely to include finance, performance and QIPP (efficiency cuts), in relation to primary and community care and routine planned/elective care.
- The split of commissioning functions between the West Yorkshire and ‘place’ (Calderdale) levels seems likely to solidify the centralisation of specialist services in Leeds while leaving a relatively stripped-out set of primary, community, planned care and A&E services in Calderdale.
- Membership of the statutory Integrated Care Board and its committees (which are likely to include the Calderdale Cares Board) is to be decided on the basis of the Integrated Care Board constitution, which has been delayed because NHS England has been tardy in producing guidance on key matters.
- There is a lack of clarity about finance/ resource allocation.
- There is a lack of clarity about workforce.
There was no scrutiny of whether this significant redisorganisation of the NHS is in the interests of the public and the NHS in Calderdale.
And because of NHS England’s delays in producing guidance on key matters, the answer to many of the Councillors’ questions was “wait and see”.
Ian Holmes, Director of West Yorkshire Integrated Care System, admitted that,
“The timeframe is tight and the context is difficult. ”
“What corrective processes do we have if the Integrated Care System gets things wrong in this rushed process?”
In response to Cllr Mike Barnes’ question, Ian Holmes said they were not starting from scratch and claimed they already have arrangements that are almost shadowing the Health and Care Bill arrangements anyway.
But Stephen Gregg, the Integrated Care System governance lead, conceded that the tight time scale meant,
“We are focussing on ‘must does’ so we can operate effectively from April 1st.”
Integrated Care Board’s delayed Constitution will define how NHS decision-making and commissioning power is to be split between Calderdale and West Yorkshire
Cllr Colin Hutchinson pointed out there is very little in the Health and Care Bill about how NHS decision-making and commissioning functions are to be split between the statutory Integrated Care Board and ‘place’-based Integrated Care Partnerships, and it is to be left to the constitution of the West Yorkshire statutory Integrated Care Board and its committees to sort it out. He asked when people would be consulted on the constitution.
Stephen Gregg (WY ICS Governance Lead) admitted that the Constitution should have been published in September. But because of NHS England’s delays in providing guidance, the Integrated Care System was now planning to publish the draft constitution at the end of October, to be followed by “significant engagement” with “stakeholders” up until Christmas.
“We are keen to hear from our partners, and anyone interested in our work, their thoughts on the content of our draft constitution. You can do this in different ways:
“Let us know your thoughts about the draft constitution in the comment box below
“Contact us via the comment box at the bottom of this page to invite us to discuss the draft constitution with a group or at a meeting
“Use the information on this webpage to discuss this with colleagues in your organisation and send comments to Stephen Gregg, the Partnership’s Governance Lead by email to email@example.com “https://www.wypartnership.co.uk/engagement-and-consultation/integrated-care-systems-legislation/integrated-care-board-constitution
End of Constitution update
Involvement about the contents of the draft Integrated Care Board constitution will finish on 14 January 2022
Neil Smurthwaite, Calderdale Clinical Commissioning Group Chief Operating Officer, said that the Clinical Commissioning Groups will be abolished and their functions – and most of their staff – will transfer to the new statutory Integrated Care Board from 1.4.2022. There is due diligence to do for this transfer.
Dr Stephen Cleasby, Chair of Calderdale Clinical Commissioning Group Governing Body, said that the function of clinical commissioning will hopefully not be lost. But it won’t be clinically led at West Yorkshire Integrated Care Board level. The challenge is how to strengthen clinical representation and “not lose gains we’ve made over the last decade”.
Neil Smurthwaite said that they would be setting up local clinical forums for GPs etc. And that the Constitution will delegate back to Calderdale “a significant amount of Integrated Care System functions.” These could include the Clinical Commissioning Group’s finance, performance and QIPP (efficiency spending cuts) functions
He hoped the Health and Care Bill will delegate funds to “place” via the local place-based governance structure – whether joint committees of the statutory Integrated Care Board, or other structure.
He said the West Yorkshire Integrated Care System and Place (ie Calderdale) “will work as one.”
Rachel Bevan, Programme Manager for Integrated Care Partnership Development in Calderdale, said the local “place” Integrated Care System will be based on Calderdale Cares, which started in 2018.
Ian Holmes made it clear that all NHS commissioning staff will be employees of the statutory West Yorkshire Integrated Care Board, whether they are commissioning NHS services for Calderdale or West Yorkshire.
If Parliament passes the Health and Care Bill, the existing Calderdale Cares Partnership Board would become a committee of the West Yorkshire Integrated Care Board and would carry out its delegated commissioning functions, as shown in this slide:
This Calderdale Cares – Next Step on Place Based Integration paper for Calderdale Council includes a list of the membership of the Calderdale Cares Partnership Board and its governance structure.
No one mentioned that NHS England’s August 2021 Interim Guidance on Integrated Care Board Governance explicitly states that it would only be lawful for statutory Integrated Care Boards to delegate their functions, on the basis of Department of Health and Social Care statutory guidance and statutory instruments, once Parliament had passed the Health and Care Bill. The Bill itself does not contain any provision for delegation of IC Board functions.
Cllr Mike Barnes asked
- Who will determine the membership of Calderdale Cares Board?
- How will clinical leadership at local level be enhanced by scrapping the Clinical Commissioning Group?
Delegation of dentistry commissioning, optometry and a couple more specialised services from NHS England to West Yorkshire Integrated Care System
Neil Smurthwaite said this was
“A big step and huge responsibility, shifting from NHSE to local accountability”.
It raised the question, when the Integrated Care System is the statutory NHS body for West Yorkshire: What is done once at the Integrated Care System? And what is done once at ‘place’?
Neil Smurthwaite suggested elective recovery work from C19 will be better done across West Yorkshire rather than just using CHFT. And he said access to more capacity in some specialities will benefit Calderdale.
Ian Holmes said they have quite a clear idea from the past 5 years about what works best at the West Yorkshire System level – eg acute cancer services, hyper acute stroke services, vascular services. Things like primary and community care, more routine planned stuff, should happen at place.
Cllr Colin Hutchinson challenged the advantages of “at scale” work for Calderdale. He said:
- We know dentistry is only funded to 52% of its projected demand. What difference will delegated commissioning make?
- What will happen to District General Hospitals? The 2012 Health and Social Care Act separated commissioning of specialised services, resulting in increased centralisation. How will delegation of specialised services commissioning reverse the centralisation that is running down District General Hospitals? And is damaging, as it makes them less attractive to consultants?
Neil Smurthwaite said “there are discussions to have with NHSE” about dentistry
He claimed that centralisation of specialised services works well in commissioning for West Yorkshire, and commissioning of specialised services won’t come down to ‘place’ level. West Yorkshire Association of Acute Trusts brings together acute hospitals (ie District General Hospitals) to share resources and benefits from this.
Cllr Mike Barnes asked,
“Why not use a hub and spoke model for specialist services? So people who live locally can access them.”
Neil Smurthwaite said cardiology in Leeds works like that already. They are also using digital solutions. But scale in commissioning needn’t involve any change to services, for example commissioning Yorkshire Ambulance Service once instead of 6 times by Clinical Commissioning Groups.
Ian Holmes confirmed that services won’t be centralised away from Calderdale. The Integrated Care System will be “able to provide mutual aid across hospital trusts and have a stronger voice on the national stage.”
What about commercial organisations as voting members of the West Yorkshire Integrated Care Board, its committees and the Integrated Care Partnership?
Cllr Colin Hutchinson asked this question, with reference to the Nolan Principles for standards in public life. The first principle is that holders of public office should act solely in terms of the public interest. Which is directly at odds with the legal duties of public companies’ directors to promote benefits to their shareholders at all times.
Ian Holmes said he couldn’t talk about all 5 ‘places’, but that at the West Yorkshire level there are no plans to have commercial providers on the Integrated Care Board. It’s likely to have Voluntary and Community Social Enterprise partners involved but there are “absolutely no plans for commercial providers” on the West Yorkshire statutory Integrated Care Board.
Cllr Colin Hutchinson said that Foundation trusts don’t actually fit into the Integrated Care System but retain a considerable degree of autonomy. So how will the statutory Integrated Care Board and Foundation Trusts work together? And how will the Integrated Care Board work if Foundation Trusts sit outside it?
Ian Holmes admitted he was not really aware of what the Health and Care Bill says about Foundation Trusts. He can’t really tell the difference between Trusts and Foundation Trusts in terms of their participation in West Yorkshire Integrated Care System. But there’s a duty to collaborate/cooperate on all providers including Foundation Trusts, regarding finance and performance.
Stephen Gregg said Foundation Trusts are required to be part of Integrated Care Systems but NHS England will have former Monitor powers over Foundation Trusts.
How finance/ resource allocation is to be split between Calderdale and West Yorkshire
Neil Smurthwaite noted that the Health and Care Bill’s move away from 2012 Health and Social Care Act competition requirements is a “big change that creates alignment of commissioners’ and providers’ finances across the System”.
Cllr Mike Barnes pointed out that the allocation of resources had not been covered at all.
Cllr Colin Hutchinson wanted to know about the West Yorkshire Integrated Care System Forward Plan 2022/23 and the Calderdale Place Plan. He said that the Calderdale place plan 2021/2 wasn’t available to Scrutiny to look at.
Neil Smurthwaite replied that the place-based plans are on the Calderdale Calderdale Clinical Commissioning Group website as part of the West Yorks and Harrogate Integrated Care System 2021/22 operational plan. They are for the first half year only, mainly due to Covid complications. They are waiting for NHS England guidance for the 2nd half of the plan.
He said nothing about the West Yorkshire Integrated Care System Forward Plan 2022/23 – but there’s more info about the Calderdale Place Plan, in Calderdale Clinical Commissioning Group’s Freedom of Information response:
And in an Attachment to FOI 2122095:
Substantial ‘efficiency savings’ – ie cuts
Cllr Colin Hutchinson asked, What about substantial ‘efficiency savings’ that have been mentioned for 2nd half of this year?
Neil Smurthwaite said there will be efficiency savings, we haven’t had those finalised yet. We expect some reduction in the level of Covid funding. Guidance should have come today.
[Here is the finance and contracting guidance for the second half of the operational plan 2021/2, issued by NHS England on 30.9.21]
Calderdale Clinical Commissioning Group don’t understand the new statutory Integrated Care System’s financial allocation process
Cllr Colin Hutchinson said that a big thrust of Bill is the financial control mechanism and the Integrated Care Board’s system control duties over place partnerships. He asked how that would be achieved.
Ian Holmes said one thing, Neil Smurthwaite said another.
According to Ian Holmes, it would be quite similar to the last few years:
- Allocation to 5 Clinical Commissioning Groups – the allocation to 5 place partnerships will probably be similar (with a few differences because of the delegation of dentistry commissioning, etc)
- Will have an arrangement across West Yorkshire Integrated Care System to manage risk across the System.
- They’ve been doing this for 2 years and since 2 years ago have delivered balanced budget across WY for the first time
- Aligned Incentives Contracts and move away from Payment By Results
- Continuation of single control total system
But Neil Smurthwaite said a lot of work is going on to understand the allocation process and they don’t understand it yet. But they expect to use the Clinical Commissioning Group allocation methodology for the first year until understand allocation system.
Instead of doing 3-5 years financial plans, they are expecting to work from 6-12 months on financial plans – called H1 and H2 (2 halves of financial years)
The fixed aligned incentives contract has been used for 2 years in West Yorkshire. But they are still waiting for NHSE guidance on the allocation process – it may be on basis of a national consultation.
[Here is some NHS England info. on developing the 2022/23 payment system and discussion of other aspects of the potential financial environment in place from April 2022.]
[Here is Margaret Greenwood MP’s letter to Health Minister Edward Argar about concerns about the implications the proposed Integrated Care System payment scheme could have for those who work in the NHS: ]
Workforce planning – suppressed pay, huge vacancies, high local unemployment
Cllr Colin Hutchinson said,
“It’s no secret that there’s a severe workforce crisis across NHS and social care – so what are the opportunities of the Health and Care bill for workforce planning in the West Yorkshire Integrated Care System and Calderdale? The Bill is limp on workforce and most references are to moving staff around and TUPE arrangements. So what can we do about a proper West Yorkshire workforce plan?”
[A question first asked in 2016.]
Neil Smurthwaite referred again to “scale advantage”, this time from passporting staff to work across W Yorks instead of Trusts competing for staff. He said that identifying the true need to lobby government across the whole System rather than by place, gives lot more clout at W Yorks level.
He added that place-based plans are not siloed but are now talking about workforce plans to address staffing needs in all disciplines eg doctors, nurses, social care etc.
[My comment: only 6 years late. Calderdale Sustainability and Transformation Plan was meant to produce a workforce plan in 2016. We asked for it to be published. It hasn’t been.]
Ian Holmes said,
“Suppressed pay rates for NHS and social care staff have led to huge vacancies.”
And that there are around 150K nursing vacancies nationally – which it’s impossible to fill. There’s quite high unemployment in parts of W Yorks so Trusts are starting to look at their responsibilities as anchor institutions to get local young people involved in working for them.
Dr Stephen Cleasby said that over the last 20 years siloed working between GPs, District Nurses etc has got worse. But he believes the 5 Primary Care Networks in Calderdale will lead to improvements for patients, because team working around patients mean they will have to work together more closely.
He asked how they are to address workforce challenge in Calderdale – it has to come from the people of Calderdale – they have to bring together education, training, apprenticeships, hospitals etc.
“And how do we work together to manage demand and expectations? Now we have an avalanche of demand and we can’t cope.”
Iain Baines (Calderdale Adult Social Care Director) said,
“It’s a crying shame there’s no national Adults Social Care workforce plan.”
And that they need pay parity between NHS and social care staff. But people are benefitting from work in a more integrated way in Calderdale. (He didn’t say how.)