Agenda item

Attached to this report is a paper from the Integrated Care Board (ICB) which gives an update on the procurement of community services. Also attached is an updated substantial variation assessment questionnaire for the Committee’s consideration.

Discussion:

The Chairperson asked the Chief Executive and Director of Corporate Governance from NHS Kent and Medway, as well as the Deputy Leader of the Council and a representative (Opposition Spokesperson) from the Children and Young People (CYP) Overview and Scrutiny Committee to introduce themselves. The Chairperson explained that both the Chairperson and Opposition Spokesperson (Independent Group) of CYP were unable to attend the meeting whilst the Vice-Chairperson of CYP was also a member of this Committee.

The Chief Executive of NHS Kent and Medway (CE, ICB) introduced the item and apologised unreservedly to the Committee that a report on children’s community (physical health) services had not been brought before the Committee before the decision had been made to include it within the re-procurement exercise, alongside adult services.

Members were informed that there was a history of a successful joint commissioning arrangements with NHS Kent and Medway and Medway Council and due to previous evidence, at the time that the decision was made to procure adults services, procurement of children’s services was not a consideration. He advised the Committee that subsequently a joint decision had been made earlier this year to include children’s services as part of the procurement process and create a grouping of services for Medway and Swale. This was because contracts for children’s community health services had grown significantly over the last few years. Services were currently being provided by various organisations and a procurement process had not taken place for nearly 10 years. The decision was made in order to test the market to establish what could be delivered for children and procure the best quality services for children and young people.

Consultation had taken place to obtain views, this included engagement events, surveys and interviews as well as adult and children’s surveys.

He advised that discussions had taken place with Medway Council senior officers and the decision to procure had been made jointly. Assurance was provided to Members that the Integrated Care Board (ICB) did not plan to change any of the current services or diminish access for the people of Medway as part of the procurement process.

The Deputy Chief Executive and Director of Children and Adults Services stated that the joint commissioning arrangements between the ICB and Medway Council worked very well and the recent Special Educational Needs and Disability (SEND) inspection where the joint partnership arrangements were praised by inspectors was a testament to that partnership arrangement. The apology by the ICB on not bringing this matter to the attention of the Committee was acknowledged but had highlighted a need for more work to be undertaken to reinforce the statutory responsibilities of the Health and Adult Social Care Overview and Scrutiny Committee that must be taken into account by officers of the ICB and the Council in their decision making and ensuring that matters were brought to the attention of the Committee in a timely manner.  A training offer was proposed in relation to the functions of health scrutiny to ensure that instances like this did not occur in the future. She also stated that the joint commissioning arrangements between the Council and the ICB were in need of a review as well as the need to ensure that the effective arrangements were in place to ensure that NHS matters were reported to this Committee.

The Deputy Leader of the Council raised concern that this inclusion of children community services as part of the procurement process for adults’ community services was not brought to the attention of officers and elected Members at the earliest opportunity. She expressed that whilst there was no expectation for politicians to be involved in strategic board meetings there was an expectation to be kept up to date with matters. The chronology on page 31 of the report highlighted how the narrative changed as the inclusion of children’s services in the procurement services was not mentioned in the report that was previously brought to the attention of the Committee. There had been a tacit agreement about the need to transform the services and this was accepted as the service for adult and children were different. Members were, however, conscious of the differences between the services and the way children’s services had been developed with specific co-designed services that were not replicated in Kent. When intelligence was received on the intention of a procurement exercise, Medway commissioners became concerned. Medway had been joined with Swale in this process and Swale was an area which experienced challenges due to their high number of children who required services. Medway being grouped with Swale would increase pressure on services and could result in significant impact on services for children of Medway and as a result a report should have been brought forward to scrutiny.

The ICB had liaised extensively with the Children and Young People Overview and Scrutiny Committee on the recommissioning of Children’s Mental Health Services but that important commissioning process had now been paused to allow for this commissioning process and it was vital to understand how that decision was made.

The importance of partnership working would continue to be emphasised as well as the co-design that could have taken place prior to this process.  The consultation that took place would have occurred during an inappropriate time for families which resulted in a small number of respondents, and it was assumed that they would have struggled to fully grasp what was being asked of them. Officers were reminded that the Health and Adult Social Care Overview and Scrutiny Committee was there to act as a representative for the community of Medway and this included ensuring that residents received the best possible service, and this would always take precedent over any joint arrangements.

Members, including the Children and Young People Overview and Scrutiny Committee representative, then raised a number of questions and comments, which included:

Wait times – it was commented that SEND inspection found waiting times for children’s therapies, and neurodevelopmental pathways to be unacceptable. As a major partner in the upcoming monitoring visits what assurance could the ICB give that these waiting times would be addressed if the procurement was on an “as is” basis, given the contracts were last let in 2018 in Medway?  Waiting times had increased steadily across all providers year on year and there had been no increase in investment since 2018 despite referrals increasing more than threefold since 2021. The CE, ICB said that there were distinct cross overs between mental and physical health and acknowledged that wait times for assessment as well as services was too long. There had recently been a positive review of SEND provision and it was anticipated that there would be developments as part of the proposed transformations process that would be vital to addressing wait times.

Consultation – A number of questions were asked in relation to consultation. Consultation and co-design was a crucial part of the SEND inspection. Due to the significant interdependency of children’s health services with education,  how many Medway schools had been consulted for this procurement? How many children and young people had been consulted as part of the commissioning process? Considering this was currently the largest commissioning exercise in the NHS nationally – did this process feel sufficient? Of the 175 people, that had signed up to attend the 8 engagement events, how many had attended? Additionally, had someone from every service given their view on the proposals? The CE, ICB undertook to provide a briefing note to Members which would answer the questions raised regarding the consultation process.

Funding – concern was highlighted at the lack of details in the report on investment and funding and lack of awareness of where this would come from. Swale required more additional resourcing than Medway and it was asked how it would be ensured that the needs of Medway’s children would not be adversely impacted by the needs of Swale. The CE, ICB said that they served the whole of Kent and Medway, and the proposals were not based on taking investment from one area to serve the other. The proposals were focused on targeting investment in areas that had the most needs. The NHS was operating on a budget of £4.2 billion this year, which would go up with inflation, decisions would have to be made on what areas of the service to invest in.

It was further asked how it would be ensured that funding was not taken out of one area to serve another in the face of pressures. The CE, ICB said that the current high spend in some areas of the health system could be better utilised elsewhere.  A greater focus on prevention for example would free up resource in other areas of the NHS such as acute services, which could then be used for community care.

Members challenged that without the publication of financial statements, there was a risk of creating a level of expectation that could not be met by providers and it was asked how this would be mitigated. The CE, ICB said that this would be tested as part of the procurement process to ensure the appointed provider was able to deliver and had the ability to respond to changes in circumstances. The provider would be monitored and held to account to ensure delivery as required and the contract would be awarded on the basis of the expectation of a degree of flexibility. The decision of awarding the contract would be made by the ICB.

It was commented that a year ago, the Committee was presented with the same issues of not being provided with the financial details and it was difficult to scrutinise the risks and mitigations without this information. It was asked if the ICB had this information as the Committee needed to see those details for assurance. The CE, ICB said that this process would culminate in entering into a contractual arrangement with provider/s and each submission would be assessed and the decision based on quality of proposal or service, transformative ability and not based solely on a financial envelope. A commitment was made to share financial information once commercial discussions were concluded. The contract awarded would be for longer than three years and built into the contract would be a no exit without fault on either side.

Assurance – assurance was sought that in light of the difference in challenges experienced by Medway and Swale, the procurement of ‘as is’ services would not result in the use of amount of money across a larger area which could be  detrimental to Medway children. The CE, ICB said that the ‘as is’ procurement would apply to Medway as well as Swale and once funded, would be invested in both Medway and Swale.

Rationale – in response to a question on the rationale of grouping Medway with Swale in this commissioning process, the officer said that that this was done on the basis of reflection of conversations that had taken place as well as geographical and logical grouping.  Members were informed that through working with a population of a certain size, there were increased opportunities to attract a skilled workforce and the ability to recruit and retain staff may have been impacted without the grouping of the local authorities.

It was further asked how it would be ensured that there would be no detriment to Medway as a result of grouping with Swale and if the current process was working well; why the need for change for Medway?  The CE, ICB said that there were parts of the current model that worked well but not all. The current model reflected how physical health services that were created over eight years ago, things had since evolved with more modern and effective ways of delivering services and this needed to be addressed through modernisation of provision. The proposal was for a contract to be awarded on an “as is” basis with the expectation of transformation in later years.

Needs assessments – given the paper stated the ICB sought to “Provide consistency to the contracts and procure based on local needs rather than historical services,” it was asked what needs assessment the ICB had carried out for this procurement. The CE, ICB said that a comprehensive needs assessment had been  carried out using information from colleagues in public health, feedback from organisations that provide services and information from the voluntary community sector.

Timeframe – given the procurement lots for children were only decided in May – was 3 months sufficient time to fully scope services, understand and plan to mitigate for risk, consult widely (given SV decision)? The normal commissioning cycle was 1 year – for such a large contract 3 months felt very tight. How did the ICB intend to manage the gaps that may become known post award and ensure a smooth transition to new services for both adults and children whilst also ensuring future ambitions were met within year 1? The CE, ICB said the process would not be taking three months. It had already begun and would not be concluded until the extensive process finished in 2025.

Impact – it was asked how the impact to the lives of Medway residents would be realised and to understand what this process would look like for Medway? What would need to be done and put in place to enable delivery of ambitions? It was vital to have services that were specific to needs of the area and this could not be achieved by offering a blanket service. The CE, ICB said that at the end of the calendar year, Kent County Council, NHS Kent and Medway, and Medway Council approved the integrated care strategy which was designed to address inequality. The delivery of healthcare had changed significantly as a result of the Pandemic and it was now normal for some services to be delivered through digital means rather than face to face, the outcome of which, if delivered appropriately, could be just as effective. For example, it was recognised that there was an increase of pupils through the Pandemic that were dropping out of the school system and the role of the school nurse had to be adapted to pick up on the number of children not attending school due to mental health issues and the role had to include the ability to respond to the needs of those children.

It was expressed by Committee Members that assurance and certainty was required that the procurement process would ensure that services would be tailored to specific needs. The CE, ICB said that the proposals on what the services would look like would be brought back to Committee and that they were looking for a long-term provider that would be clear on the requirement that services would be expected to evolve over time.

It was further asked how particular groups would be targeted and to ensure the targeting of the right people and not providing a blanket offer. The CE, ICB said that an equality impact assessment (EIA) and quality impact assessment (QIA) would take place and that documents would be shared with the Committee. Technology was now at a place where services were better equipped to target outcomes. For example, there was now technology in place to be able to provide genome profiling for every child born in Medway and this would provide the ability to determine how best to proactively track and address the needs of the child as they grow to adulthood.

Interdependencies and Pathways – it was commented that there were interdependencies in all services and this commissioning process could have a resource impact. How did the ICB propose a collaborative approach that would benefit the children and young people in Medway in particular though a transition stage? The CE, ICB said that there was more work to be done at the transition stage. There was focus on defining a strategy for NHS Kent and Medway to enable all organisations to work together effectively and if they continued to build on what had been achieved to date through the Integrated Care Strategy would lead to a better opportunity to more effectively work better, together.

It was further commented that it was important to make the transition process seamless for children and families and that technology should be used in a way to compliment that transition process after the technology had been stress tested away from families. The CE, ICB agreed and said that some technology was already in place, and they would ensure that bidders were aware that they had to have the capacity to test solutions.

It was further asked what mitigation was in place when there were different providers in the management of transitions. The CE, ICB acknowledged that there were risks that still needed to be tested. Members stressed the importance of ensuring that the complexities were highlighted in the risk register as there were nuances in children’s mental health that providers needed to be aware of.

It was commented that there were significant interdependencies across Medway and Swale, for example, Medway had an integrated 0-19 contract for Public Health Nursing and Children’s Community Health. This model was held up as best practice by SEND inspectors. What consideration had been given for these interdependencies, should a different provider be successful? It was also asked what mitigation was in place if/when different providers won adults contracts and not children’s contracts and/or vice versa, particularly in terms of transitions/preparation for adulthood whilst keeping in mind interdependencies such as Public Health Nursing, especially when Medway currently had one provider for both? The CE, ICB said that on award of the contract, it would be stipulated that the first year of the contact would be to keep services “as is”, as they knew what worked well, but the expectation was for transformation in later years through an extensive review of identification and development of areas of best practice. Any proposals to change services in the future would be brought back to the Committee at the appropriate time.

Demand – it was asked how the system would meet current demand, in particular, complexity and demand of waiting lists, and current backlogs if procuring on an “as is” basis. The CE, ICB said that the new or existing provider would be expected to address this issue as part of their bid.

Both the CYP representative and the Deputy Leader of the Council were provided with an opportunity to make some concluding comments. This included discussion on at what stage the Committee should decide whether proposals could be decided to be a substantial variation and why service transformation was being looked at with new providers in the first year of the new contract which could lead to instability and instead that it would be far more effective to undertake the transformation work before the re-procurement exercise was undertaken.

The Head of Democratic Services provided Committee members with advice around the steps they needed to take to decide whether or not the proposals constituted a substantial variation, with reference to the discussion at the meeting and the substantial variation questionnaire as set out in appendix 2 to the report. The CE, ICB recognised that it was a matter for the Committee to decide whether or not the proposals constituted a substantial variation, however, he questioned the benefit, in terms of the delivery of service provision of the substantial variation given that the information being requested would be provided in any event.

A proposal was put forward that this procurement process be considered as a substantial variation (SV) of service, which was agreed by the Committee. The CE, ICB shared his view that the change did not meet the criteria for an SV, as no variation was taking place in the first year of the new contract, as stated in the paper which had been submitted to the Committee.

The Chairperson thanked those in attendance. It was hoped that lessons had been learnt following the historical situation with the adult services procurement process as officers and Members worked extensively to rebuild relationships.

The situation with this process unfortunately appeared similar and at this stage the transformation journey appeared unclear to the Committee. This proposed process would be a significant change to services for children and young people of Medway and further assurance was needed on this process to ensure that it would be carried out correctly.

Decision:

a)    The Committee noted the update from the Integrated Care Board (ICB), as set out in Appendix 1 to the report.

b)    The Committee agreed that the updated proposals from the ICB constituted a substantial variation or development in the provision of health services in Medway.

c)    The Committee requested the ICB to publish the timescale, specifically the date by which it requires the Committee to provide its comments in response to the outcome of consultation and the date by which it intends to make a decision, as set out in paragraph 4.9 of the report.

d)    The Committee requested that the ICB provide a briefing paper on the questions in relation to the consultation process.