At its meeting in March 2019, the Committee received a briefing on the proposed development of an integrated care system across Kent and Medway. In particular, the meeting was informed about the proposed establishment of:
This briefing provides a high level summary of the work to date in establishing these arrangements, and in particular the development of a single CCG.
A presentation was given to the Committee on the proposals, the key points of which were as follows:
· A strategic commissioning function was needed to enable more effective planning and commissioning of services, based upon local needs. This would be realised through the establishment of a single Kent and Medway Clinical Commissioning Group (CCG).
· It was anticipated that, nationally, single CCGs would be created to match Sustainability and Transformation Plan (STP) footprints. A single CCG would be able to achieve scale efficiencies that could not be achieved by the existing 8 Kent and Medway CCGs. There was a need to reduce CCG running costs by 20%.
· Services were not currently as joined-up as they could be, with there being too many individual agencies and it was acknowledged that there was currently too much inequality and not as much prevention work as there could be. Differences in life expectancy between areas needed to be addressed.
· Government policy had acknowledged the internal health market was not working to improve quality or reduce costs. The internal NHS market was being replaced by a culture of collaboration and mutual responsibility.
· The health system also faced a number of workforce related challenges.
· It was anticipated that the establishment of a single CCG would help facilitate the commissioning of the services required to meet need rather than blanket commissioning by area.
· Integrated Care Partnerships (ICPs) would include acute hospitals, primary care, community services the voluntary sector, council services, the ambulance service and mental health providers. Four Integrated Care Partnerships would cover Kent and Medway, including one for the Medway and Swale area. The Integrated Care Partnerships would work collaboratively to provide services commissioned by the single CCG. The Sustainability and Transformation Plan and Medway CCG was working closely with Medway Council to develop this collaborative working.
· Primary Care Networks would help facilitate groups of GPs to work collaboratively to deliver services to populations of 30 to 50 thousand. This would enable pooling of resources and a greater focus on the holistic needs of the local population, including preventative work. The Networks would be able to draw on local intelligence to identify and address local need, with analysis having already been undertaken by the Council’s Public Health function. Seven Primary Care Networks had been established in Medway and three in Swale.
· The single CCG would use findings of population needs assessments to identify and prioritise service provision in conjunction with partners. The Kent and Medway Joint Health and Wellbeing Board would have an important role.
· Development of this work was being overseen by the Sustainability and Transformation Plan Programme Board, which was attended by the Leader of the Council.
Members asked a number of questions as follows:
Business case, funding, staffing and the role of Medway – A Member raised concern that they had not seen a business case, that there may not be sufficient staff and funding available and that the Medway and Swale Integrated Care Partnership area was too small. The Committee was advised that the proposals aimed to make commissioning more efficient through collaborative working. Multi-disciplinary working was likely to make GP practice more attractive as a career and the aim was to persuade more people entering the profession to train, live and work locally. The total population of Medway and Swale was about 400,000, which equated to around a quarter of the population of Kent and Medway as a whole.
Role of CCGs and need for change – A Committee Member was extremely concerned as he considered that the presentation undermined assurances that the Committee had previously been given that effective partnership working was taking place, that health inequalities were being effectively addressed and that workforce and value for money challenges were being tackled effectively. The Member was also concerned that there had been many changes to health service commissioning already and asked whether there would be further changes in the future. The Clinical Chair of the Kent and Medway System Commissioner Steering Group said the strategic commissioning capacity needed to improve while ensuring local needs were addressed. It was acknowledged that CCGs had not always had access to staff numbers or budgets required. The majority of factors that influenced life expectancy were social rather than being directly health factors. It was considered that a more collaborative approach, that was not dependent on an internal market, would help to address inequalities more effectively.
The Clinical Chair of Medway CCG said that under the current system, acute and community providers often did not work together effectively to resolve issues, instead looking to commissioners to do so. The development of a more collaborative working environment would help to reconfigure relationships. Much successful prevention work was already taking place covering a wide range of health challenges, such as smoking, diabetes and cardiovascular conditions.
It was recognised nationally that existing CCGs were not delivering as much as they could, hence the wish to reframe the way they operated. There could not be guarantees that there would not be further restructures in the future but this would be determined by Government.
Financial Savings, stroke services, commissioning challenges and GP numbers – A Committee Member considered that the proposed changes were motivated by the need to make financial savings of £44million, which had subsequently increased to £46 million. The Member had not seen figures to indicate how much the changes would cost or how the restructuring would impact on the ability to realise savings. The decision taken not to establish a hyper acute stroke unit in Medway was a particular concern in view of the acuity and number of patients in Medway. Patient transport and dermatology were examples of where there had been significant commissioning related challenges. It was asked how capacity had been strengthened to avoid similar occurrences in the future and how services outside the scope of a single CCG would be commissioned. The Member also asked whether the system would have capacity to adequately address health needs and inequalities and whether the local shortfall of GPs would be addressed.
The Clinical Chair of Medway CCG acknowledged that budgeting for prevention could be challenging as it required current spending to realise future benefit. It was hoped that the proposals would help to facilitate an increase in preventative and collaborative work. There was unlikely to be an increase in the number of GPs per person but the extension of multi-disciplinary working, involving other medical professionals, would help to address patient needs. Some complex services commissioned by NHS England would continue to be commissioned by that organisation but the majority would be commissioned by the single CCG. It was anticipated that future commissioning would be undertaken more collaboratively and would be better placed to meet local needs.
The Clinical Chair of the Strategic Commissioner Steering Group said that the framework for Integrated Care Partnerships did not make them more likely to lead to privatisation and that it was envisaged that the proposals would enhance joint working. Although there was an ongoing need to do commissioning efficiently and make savings where possible, the driver of the proposals was not the need to save money, rather they were about making better use of existing resources. This could be better achieved through the creation of a single Kent and Medway CCG. A single Accountable Officer for the Kent and Medway CCGs had been appointed in April 2018 and savings had already being made.
Probity – A Member asked whether there were appropriate safeguards in place to prevent inappropriate contracting of services from persons or organisations that those involved in the commissioning process had a personal connection to.
NHS representatives in attendance felt that the way in which the question about probity had been asked was inappropriate. The Committee was advised that declarations of interest had to be made at CCG meetings, in a similar way to which they were made at the Council and that there were thorough processes in place to deal with potential conflicts. It was considered that establishment of a single CCG would be likely to lead to greater transparency as decisions would no longer be taken by eight separate CCGs. The Committee accepted assurances that the questions raised were not directed at those present.
Public Meetings – A Member expressed concern that the Joint Meeting of Clinical Commissioning Groups, that had made the decision in relation to the Kent and Medway Stroke review, had concluded in private due to disruption caused by some audience members. This had also resulted in Medway Councillors having to leave the meeting. Following a question about Medway Council processes, the Democratic Services Officer advised that there was provision for the press and public to be required to leave a Medway Council meeting if there was repeated disruption and following warnings from the Chairman.
Population increases – In response to a Member question that asked whether population increases were taken into account when funding was allocated to an area, the Clinical Chair of Medway CCG said that funding was determined by a national formula that was based on the population at a point in time. Ensuring that resources available matched growth was therefore a challenge. The centralisation of some services was necessary in order to ensure that specialised 24/7 care could be provided. This required there to be sufficient staff and patient numbers within the catchment area.
Voluntary Sector Support – In response to a question about engagement with the voluntary sector, the Committee was advised that some CCGs had engaged closely with the voluntary sector in relation to social prescribing. It would be important for Integrated Care Partnerships to have a close relationship with voluntary organisations. The skill for the single CCG would be to set outcomes based contracts that would require Integrated Care Partnerships to involve all partners. The Deputy Managing Director of Medway CCG added that the voluntary sector was a key workstream for Medway CCG and that it had performed better than the national average in terms of voluntary sector engagement.
Stroke Review and Integrated Care Partnership Geography – A Committee Member questioned whether the conclusion that a single CCG could be more effective than eight separate Kent and Medway CCGs cast doubt on the Kent and Medway Stroke Review decision as this had been made within a structure that was considered to no longer be suitable. It was also asked which specific areas would fall within the Medway and Swale Integrated Care Partnership area.
The Sustainability and Transformation Partnership Director of System Transformation said that the existing CCGs had come together to develop the Stroke Review process and that the review was considered to have followed an appropriate process. The Clinical Chair of Medway CCG said that the population covered by the Medway and Swale Integrated Care Partnership included all patients registered with practices in the Medway and Swale area. This included those living outside Medway and Swale who were registered with one of these practices.
i) Noted and commented on the update provided.
ii) Requested that:
a) Details of CCG and Sustainability and Transformation Partnership meetings be provided to the Committee, to enable Members to attend those meetings open to the public.
b) Details of current Council representation at Sustainability and Transformation Partnership meetings be provided to the Committee.