Agenda item

4.1  Members gave consideration to a briefing paper from the CCG “The future of health and care for the people of north east London” and the Chair welcomed for this item

Dr Mark Rickets (MR), Chair, City and Hackney CCG

David Maher (DM), Managing Director, City and Hackney CCG

Tracey Fletcher (TF), Chief Executive, Homerton University Hospital NHS Foundation Trust (HUHFT)

Laura Sharpe (LS), Chief Executive, City and Hackney GP Confederation

4.2  The Chair explained the background and context for the creation of a single CCG over the NEL footprint.  It was noted that the GP Practices who are members of City and Hackney CCG will be voting in Oct on the merger to create a single CGG covering the 8 north east London local authority areas.

4.3  DM and MR took Members through the briefing paper in detail.  He described the long history of partnership working and the long plans for devolution. Working in a collaborative way had created integrated workstreams across health and care which had been very successful. Stakeholder engagement was currently on going and they would seek members endorsement in October.  This would then allow the current Integrated Commissioning Board in City and Hackney to transform into an Integrated Care Partnership (ICP) which would also have on the key local providers on it.  Staff would be TUPE’d to the single CCG but would be posted back to continue their work in City and Hackney. Covid had delayed the process but NHSE London still requires a vote by October.  The discussions with the Primary Care Network leaders locally were very constructive they will be co-producing with them the governance documents over quarters 3 and 4.  The Neighbourhoods Programme (the PCNs) were progressing well and fit well with the required new system.  There will follow a series of Transformation Programmes which come out of the Strategic Operational Command (SOC) led by Tracey Fletcher and set up to respond to the Covid crisis and the Enabled Groups in Integrated Commissioning are making these happen.  A Neighbourhood Health and Care Board (NHCB) will be established under the ICP.  The current CCG staff will align themselves with what is needed to deliver the Neighbourhoods system and will stay within C&H.

The new local ICP and NHCB have been established under an Accountability Framework and will include both execs and non-execs from all the commissioning and provider partners locally.  Commissioning decisions, where necessary, will yield to the legislation currently in place and where there has to be conflict of interest boundaries e.g. primary care commissioning these will continue to be respected.

He added that the two Health and Wellbeing Boards (Hackney Council and City of London) will be critical in shaping the wider population healthcare management approach as they will focus on wider determinants of ill health and attitudinal issues.  The Health and Wellbeing Board will therefore be supported by new Population Health Hub which is being developed between the CCG and the Director of Public Health.  This will provide a focus for co-ordination wider population health strategies and will lend its expert support to the NHCB.

Clinicians will be involved at each level and decision making will be at ‘Place’ level, unless it is clearer that more can be achieved on a particular issue at the NEL level.  A principle of subsidiarity will therefore apply. 

In terms of finance flows, 98% of existing CCG allocation will be devolved back down to City and Hackney to be deployed via the local ICP and NHCB.  The ICS for NEL will retain a 1% budget for corporate costs and all ex CCG staff will be employed by NEL.  There will also be a 0.5% contingency and 0.5% risk reserve as was the case previously.  He added that these allocations were subject to national policy and post pandemic resources may of course differ.  He noted that the Chancellor was deferring the budget to support Covid during the winter period so CCGs are working on the basis of current allocations in these models.

He concluded that co-production and clinical leadership would be key, that the providers in C&H were all high functioning and driven by quality.  On Primary Care leadership they were proposing that the clinical leadership executive of it will be reshaped.  Jane Milligan would remain the Accountable Officer at NEL level of course at the ICP level there will be Elected Member input from the Council.

4.4  Members asked detailed questions the following responses were noted:

(a) Chair expressed concern that CCG members were being asked to consider a merger without seeing the new Constitution or what formal powers they were giving up. Assurance was also needed on the 80:20 split agreement.

DM replied that a draft of the Constitution went to Members that afternoon.  The focus was less about the NEL Constitution per se but more about the working relationships locally and that is what members were seeking clarity on.  MR explained about the scheme of delegation and how a principle of subsidiarity would guide it going forward. It was noted that much of the practical detail would be in the Operating Handbook. This would describe in more detail the financial framework, the allocations and how the money would flow down the system. There would also be new money under the Long Term Plan and detail on how that would be manged at NEL level.  98% of the funding would come down to City and Hackney level and all of the previous Primary Care budget.  He added that he was working with his equivalent in Tower Hamlets on a Declaration of Principles which all CCGs have signed up to which articulates the principles against which they would be judged in the future.

(b) Chair stated that currently under primary legislation our local CCG as a body got c. £450m for commissioning and this provided some solidity. Without formal agreements what would happen in say 5 years if NEL didn’t want the same provision at HUHFT. More attention needed to be paid therefore to the medium and long term implications of this for Hackney.

DM replied that he didn’t think that level of detail would be articulated in any Constitution.  A CCGs responsibility was to purchase services for its population and a Constitution wouldn’t go into detail about where the provision would come from.  He added that City and Hackney was playing to its strengths here with the framework it had now been presented with.  City and Hackney had been recognised as a sub-system within the ICS.  Tracey Fletcher as CE of HUHFT as member of the system would now be part of it and they were was an additional tethering of accountability back to the local health system and back to the new ICP.  The counterbalance to the Constitution was the Acountability Framework which they had established so that City and Hackney would get the best outcomes.  The mandate that City and Hackney ICP will receive from NEL will include this detail and will state the outcomes expected of City and Hackney and will also outline what resources will be available to them to deliver these. 

(c) Members asked how accountability could be clarified without seeing the full Constitution.  They commented that the Constitution alone wouldn’t address all of the issues of concern re the dissolution of C&HCCG and that there needed to be clarity and what would happen down the line. They asked whether the 80% referred to money or levels of operation.  They asked if there was evidence that the 1% admin costs represented value for money and asked whether a decision could be deferred until these issues were clarified. They gave the example of the ISS issue at HUHFT as an example of the need to future proof constitutional arrangements stating that certain provisions in the Constitution could affect the wider community interest.

DM reiterated that they would share the draft.  He stated re the HUHFT example that the Constitution would not be able to illustrate how parameters for that kind would work.  He stated that the Constitution was a nationally mandated NHSE framework document.  MR replied that CCG Members were looking at the draft Constitution at the moment and that most of the nuance councillors were seeking would be expressed instead in the Operating Handbook.  He stated that they had wanted to defer the vote because of the pandemic but NHSE had refused stating that NEL already had been given an additional year, unlike other STP areas, and it was a requirement to get on with the process. This allowed for very little wriggle room.  They would like to have been further ahead with it but this had not been possible because of the Covid situation. 

(d) Members asked if the Constitution was not set in stone was there scope to change it.

MR replied no and that any changes to the framework document would have to be agreed nationally by NHSE and it was instead in the Operating Handbook where there would be more leeway to make changes.

(e) Members asked for clarity of the 80:20 ratio and on admin costs.

MR replied that this was not a prescriptive rule but rather an overarching principle.  DN stated that this principle had been put forward very early in the whole process in order to illustrate the potential local levels of devolution.  In C&H it was actually 98% in terms of financials.  He added that CCG staff would be employed by the ICS NEL but the majority will continue to work locally.  The money, the staffing, the activity, the scheme of delegation will all try to follow the 80:20 principle.  On the 1% admin costs, this was a requirement on every CCG from NHSE.  C&HCCG had always underspent by about 20% which was then reinvested in front line.  At the same time NHSE also required CCGs to deliver 20% efficiency savings on running cost.  The 3 subsystems were working through all of this.  He viewed the performance of the C&HCCG team as being excellent value for money.

(f) Members questioned whether now was the right time to make these changes (in the context of the pandemic upheaval) they stated that in their view the case did not seem to be made.  They expressed concern about the loss of local involvement and asked how much the actual change process would cost and whether it was taking away valuable resources from the front line at a difficult time.

DM replied that the draft Constitution provided the material detail CCG members will need to vote on.  A draft went out that day and he would be meeting other CCG Chairs later that day. The draft Operating Handbook would flesh out, in as much detail as possible at this stage, a lot of the issues of concern here but the plan was to finesse this and improve it over Q3 and Q4 in order to get it right.  He was leading a group on developing that process and Tracey Fletcher was doing the same with a group developing the City and Hackney Neighbourhood Health and Care Board sorting out its membership and operational procedures. As the Operating Handbook developed they would keep the Commission updated on the progress. 

(g) Members asked to be reminded what the original premise was behind the centralisation of CCGs both in NEL and nationwide.

DM replied that NHSE’s Long Term Plan had set out expectations that ICS would be set up by April 2021 to work across larger population footprints of 1m people plus and the expectations that Primary Care should begin to organise itself into Primary Care Networks bult on populations of 30-50k. They would work at a more granular population level and the intention was that by leveraging providers and commissioners together at a wider scale this would allow the grassroots to drive change and improvement through the Primary Care Networks.  In the LTP Simon Stevens had expressed that the legislative change had to happen to remove competition from the market.  The requirement for commissioners of services to use market forces to define best value did not seeing to be playing out under the current legislation yet it was there in the NHSE Commissioning Board principles.  The changes under the LTP would break down the purchaser-provider boundaries and allow greater robustness to manage those market forces until new legislation could be put in place.  MR added that allowing us to move away from the traditional contractor provider relationship was positive.  The focus was on co-working until the legislation can be changed.  The contractual formal arrangements will allow all partners to come together to share planning, the Accountability Framework and financial control and there will still be a need for a CCG. The checks will be there but it allowed us to move into a shared way of working to manage population health in a much more holistic way. The new approach would also allow us to marshal resources better to manage the wider determinants of ill-health and to work more with the VCS for example and to work in a model where the focus will be at neighbourhood level.  Commissioning already done at NEL level will continue at that level and new money for specialist commissioning will also flow through the system.  This was why C&H needed to be at that STP table.  These changes came with real opportunities for C&H and the best of them represented an important step change for the local health economy.

(h) Members questioned how local accountability can be maintained across 8 boroughs.

DM outlined how the current accountability structures work locally including the CCGs Members’ Forums, the role of the Single Accountable Officer and how she holds the 7 CCG MDs to account.  He was also held to account by the CCG Governing Body and the local Members Forum.  The future model would not be that different he explained. There would be 7 Members Forums elected by the local Practice Members, they will then elect a chair to be part of the NEL ICS Governing Body and as part of the local ICP structure they will sit on key decision making bodies in City and Hackney.  Jane Milligan was also held to account in each of the 7 CCG areas. Executives from the Providers are also now on the ICP and there will be Executive Lead sitting on the ICP Board so accountability is locked in locally.  In addition, there were excellent Healthwatches continuing in each of the 8 boroughs.  He added that local representation and accountability to this Commission would continue and of course the local provider partners would be locked into this structure and made accountable also via Scrutiny.

(i) The Chair expressed a concern that the NEL ICS governance structure might be too unwieldy as it would have over 20 chairs of trust boards and council leaders holding another board with over 20 chief execs on it to account.

DM replied that they were confident that with 98% of resources flowing down into each local system they stood a very good chance of getting on with the work and making the changes needed locally.  The response to Covid-19 demanded something akin to an ICS Board to already be created and it had worked well.  Tracey Fletcher had been working very closely too with the key Provider partners across the Provider Alliances in the NEL patch. The work was already happening.  It was important that we worked with partners across a wider geography, he added, because that is the nature of trying to coordinate scarce health services in a more equitable way.

Tracey Fletcher commented on the changes from the Acute Provider perspective, stating that a lot of what they provide locally was determined by Regulation and not commissioning structures.  Any changes at that level had never sat with CCGs but much more in Regulatory Frameworks and there was a vital need to work on that at an NEL level.  During Covid relationships improved greatly between the acute providers.  She added that acute providers don’t of course provide all that is necessary and they hope that these arrangements will better solidify how they need to improve for example the local care pathways on cancer.  This change should lead Acutes to have more leverage to improve these.  She described how at HUHFT they already provided particular specialist services to NEL in neo natal care and in bariatric surgery.  She added that while it is easy to talk about what may be lost from there changes there are also opportunities to really gain. They expend a lot of hours and a lot of energy in commissioner-provider battles or in provider to provider battles and one of key shifts needed in this whole process was to engender a better sharing of this responsibility.  She added that a new and different financial regime is almost certainly going to come in and with that will come different challenges and different opportunities to operate as a system.  Arguably it will bring different incentives and different pressures too for all the acute trusts but it’s going to happen and in her view the removal of commissioner-provider battle locally will help this and provide an emphasis on making the system work collectively. This was an opportunity and we should emphasise this rather than focusing on potential losses.

4.5  The Chair thanked TF, MR and DM for their comments and contributions.