Agenda item

4.1  The Chair stated that the purpose of this item was to look now at the first Integrated Delivery Plan for the City and Hackney Place Based Partnership which replaced the CCG as the local end of NHS North East London.  He welcomed:

Nina Griffith (NG), Director of Delivery, City & Hackney Place Based System

Helen Woodland (HW), Group Director, Adults, Health and Integration

4.3  Members gave consideration to a background report: The Integrated Delivery Plan

4.3  NG took members through the report. The Place Based Partnership works under the guise of the City and Hackney Health and Care Board and has a range of sub committees and groups beneath it. It’s an evolution of existing integrated commissioning arrangements which of course have been in place for some time. In March the C&H HCB set strategic priorities to improve services and outcomes. That Board also works closely with the Health and Wellbeing Board and so they agreed not to set a whole new strategy but to formally adopt the same strategic focus areas.  They also formally adopt the strategic priorities of NEL ICS.  This shows how they aim to deliver on local priorities but also part of the wider ICS in NEL. The HCB agreed on 9 strategic focus areas - 3 on population health groups (children, mental health, long term health and care needs) and 6 cross cutting priorities on approaches relevant to all of them. These includeL social connection, healthy places, greater financial wellbeing, joining up health and care needs, tackling racism and supporting the health and care workforce.

4.4  NG explained that from these strategic focused areas they looked at how they would address the priorities and this set out in the Integrated Delivery Plan.  It’s a Partnership developed plan which describes what they will be doing over the next 2 years.  It doesn’t describe all the work of the constituent organisations but is about where they are specifically going to focus on in order to drive improvement.  There are 3 Big Ticket Areas and 9 Big Ticket items and the Plan summarises what is being done and the outcomes they want to see. Underneath this document is a much more detailed delivery plan. The structure also includes 3 Enabler Groups on: Workforce, Digital and VCS and developing the Enabler Groups is the next key task.  They will also share the plan with residents and the next step will be to pull together an Outcomes Framework which quantifies how they want to see delivery against outcomes.

4.5  Members asked detailed questions and the following was noted:

a) The Chair commented that the ability to achieve all this is built on the premise that Hackney has levers available to it in the formal Scheme of Delegation from NEL ICS.  He asked would the Health and Care Board have the same volume and quantity of decision making as the local ICB which preceded it.  He was also interested in a comment of Louise Ashley’s at the  previous meeting concerned about devolving more commissioning to Place but with no additional money to help deliver it. If most commissioning is at a higher level, he asked won’t we lose the connection that we’ve built up between commissioning and our knowledge of local populations.

b) NG replied that this is still a live debate.  C&H HCB is structured as a formal sub cttee of the NEL ICB so there is an expectation that financial and decision making delegation will be given to that cttee. There are 2 documents at each Place Based Partnership one is a Financial Strategy for that Place and the other is the Place Accountability Framework. The former envisages the money flows and the second describes what they see Place as being accountable for within the wider system. 

NHS Trusts will receive monies in block contacts from the NEL ICS directly.  The remainder will come down to Place based HCB budgets on the expectation that Place Committees will have local oversight of Primary Care, Community Based Care and VCS activity.  In City and Hackney the Homerton will also come to the table with consideration of their resources and decision making as well.

c) NG explained that 1% of ICB budget (so £40m of £4bn for NHS NEL) will be held back for Transformation and Places and Provider Collaboratives will be able to bid on that Transformation Money. Exactly what that process looks like and the criteria to be used has not yet been determined. She added that the really important context here is that we’re in a really difficult financial situation and seeing a deficit at NEL level which is quite sizeable so there may be a  question about the feasibility of even being able to hold that £40m solely for a Transformation Fund as there is a live debate on whether that money could be used for anything other than future cost saving initiatives. It may only be drawn on if the bidders can evidence that their spend will contribute to savings in the future.

d) On the Place Accountability Framework, NG explained that the document describes the kinds of things the ICB suggests people be accountable for.  It’s a positive document and puts accountability on Place for improving local population health.  Louise Ashley was concerned that whilst the system is still in a position of not knowing exactly the final shape of the  ICB and the human resources required, that a lot of ‘asks’ might be put on the 7 ‘Places’ without having adequate financial, commissioning or quality support to deliver on those. The Place wants accountability but the resources must follow, NG added.

e) The Chair commented that except for the block contract funding of Acutes, the money delegated to Place needs to be formally commissioned and signed off at ICS level and won’t this create problems if we don’t have a commissioning tier of management locally and unless that funding is allocated to Place won’t there be tensions.  NG replied that the NEL ICS is still establishing itself and about to launch a full consultation with staff about the more detailed organisational structure. We need to make sure that resources are properly aligned to accountabilities and finances follow that.

f) The Chair stated that a senior commissioner at NEL ICS could commission at a thematic level across the 8 boroughs but lose connection to the Places or you could divide your commissioning teams by Place which is what we had. While there is a danger of duplication, are we advocating strongly enough to retain a local commissioning link? NG replied that it depends on the topic.  The local link is incredibly important for all the agenda but we must recognise that it makes more sense for specialist commissioning to be commissioned across the NEL footprint and some pathways such as cancer are already designed that way.

g) Cllr Kennedy (Cabinet Member) commented that ultimately the opportunities  offered by the ICS is that you manage to get better economies of scale than you had previously but that threat is that this comes with losing hyper local knowledge. When the CE of the ICS gets the teams and the structure right it will be in a way that retains the local knowledge but affords her the ability to run a system where we can benefit from important economies of scale and in his view is the Chair and CE of the NEL ICS fully get this point.

h) Members expressed concern about using the same number of staff to deliver the same number of responsibilities in the new structure.  NG replied that there is no plan to cut clinical or care workforce but each individual service will need to think about what they need to do.  On Workforce Planning, this sits within each of those services.  At the Place Based Partnership they don’t get into the detail of what level of workforce is needed in each of the services but they do think about opportunities for new approaches to workforce to reduce the pressure on difficult to recruit parts of the system.  She gave the example of how the Neighbourhoods Team and the PCNs think about how they can bring in different types of roles to support pressures. She described how it is hard to recruit GPs but GPs are also supporting people with non medical issues and so they have introduced roles such as Social Prescribing or Care Coordinators to take the pressure off GPs. 

i) Members asked about impact assessments on the implications for the workforce.  NG replied that this issue sits within each service provider.  Each of the services will have resilience plans and continuity plans and will understand the pressures on them and will know what future workforce needs to look like to meet future plans.

j) Members asked about the mental health crisis and supporting people at home as a safe alternative to A&E.  Was this already in place as recent reports suggested not. NG replied that this current spike was the tip of an iceberg but there are a huge range of crisis response services including 24 hr mental health crisis lines, crisis response teams, the Crisis Cafe and other community based support in place to respond.  The focus was on getting help to people earlier so they do not end up in A&E needing a crisis mental health bed.

k) Members about what were the barriers to recruiting GPs and how these would be overcome. The Chair added that in the January meeting the Commission would be looking at GP Access, Registration and Recruitment.  NG replied that City and Hackney does well on this compared to other parts of London but it remains a national challenge. They were working with the GP Confed to support local practices to make the roles more attractive to new recruits and to help take the pressure off them. 

l) A Member commented on the excellent track record locally of using non medical staff to support GPs but was concerned about VCS funding as much support is via that route. She commented that while the Delivery Plan looks good, much of it depends on using VCS skills and knowledge and asked what are the plans to keep the VCS on board, how will they be used and how will they be funded. NG replied that this was a challenge all partners were grappling with. The VCS was key to driving tricky challenges around population health and they hold many of the solutions to tackling entrenched health inequalities, improving economic wellbeing and improving social connectedness.  She explained the VCS Enabler strand of the HCB which funds infrastructure within the borough for the VCS. She added they are committed to make sure they continue to engage with the VCS to find joint solutions. They also have access to health inequalities funding from NHSE and some Prevention funding which is held locally and they are thinking how that funding can support the VCS.  They frequently consider which services should best be provided by the VCS either delivering whole or by partnering with others. The Chair commented that an added dimension here was that the Lottery funded Connect Hackney was now coming to an end.

m) Members asked about how the priorities in the Delivery Plan align with the priorities of the Neighbourhoods Programme. They also asked about how will anti race discrimination measures in health and care be effectively measured, and about Virtual Wards, their quality and how their offer will differ from current services.

n) On Virtual Wards NG replied that the aim there was to take the rigorous daily monitoring a patient receives in an in-patient setting and apply that to a community setting and that it involves looking at two clearly defined specific cohorts: those presenting with frailty and those with acute respiratory conditions who may need a hospital stay.  If such patients are included in the pilot they will first need to be deemed safe to be sent home and then will have twice daily or more monitoring at home either via telephone or digital technologies such as a pulse oximeter that they can manage. Patients are then checked in on a number of times a day. It represents a new model of care which is an extension of existing community based care for frail patients and doesn’t depend on personal access to kit.

o) On monitoring anti racism actions NG replied that anti racist practice will continue to be instilled in their commissioning approaches and work is being done on how they will best measure outcomes to get this right.  She offered to come back to a future meeting with an update on this once this work is further evolved.

p) On alignment with Neighbourhoods Programme priorities NG stated that the 8 City and Hackney Neighbourhoods are key to the City and Hackney Place Based System and the advantage of them is that they can have a different focus within different Neighbourhoods.  In the North the focus is more on children so more resources are supporting children elements of the Delivery Plan such as on immunisation and vaccination.  In Shoreditch and City there is a larger older population so the focus there is on their long term health and care needs. Aligning with the Neighbourhoods allows the Place Based Partnership to take a more localised approach depending on what the local health needs are and what the local demographic is.

4.6  The Chair thanked NG for her detailed report and attendance.  He stated that when the Outcomes Framework has been more developed e.g. in March or April it might be useful to consider it at the Commission and that may dovetail with the issue of measuring the impact of anti racism actions and look at them both.

ACTION:

Updates on (i) Outcomes Framework for City and Hackney Place Based System and (ii) Measuring the impact of anti racism actions in commissioning and service delivery to come to a future meeting.

RESOLVED:

That the report and discussion be noted.