To provide an update and overview of the developing Integrated Care System and One Herefordshire.

The Director of Strategy and Transformation for NHS Herefordshire Clinical Commissioning Group (CCG) and One Herefordshire, and Joint Programme Director for the Herefordshire and Worcestershire Sustainability and Transformation Partnership (STP) [hereafter referred to as ‘director of strategy and transformation’] was invited to update the board on the Integrated Care System and One Herefordshire.  In response to a question from the chairperson, the director of strategy and transformation clarified that the purpose of the item was to bring the proposals to the board for discussion and approval, rather than as a formal public consultation.

The director of strategy and transformation delivered the ‘Integrated Primary and Community Services’ presentation, starting with the slide ‘The NHS Long Term Plan’.  Questions and comments from attendees included:

1.           The chairperson drew attention to paragraph 4 (agenda page 138) of the covering report, ‘The plan commits funding to the networks for additional resources …’, and questioned how much funding was being committed for Herefordshire and how this compared to Worcestershire.  The director of strategy and transformation said that there was a national funding formula which would support a range of activities and provision of staff in the Primary Care Networks over the next five years.

2.           Referring to paragraph 9 (agenda page 139), ‘As part of the development of STPs into ICSs the local ‘place’ will need to be developed…’ the chairperson questioned the stage that the local system was at and the role of the health and wellbeing board.  The director of strategy and transformation commented on the work of the One Herefordshire integration programme and considered that partnership working was relatively mature compared to some other areas, although there was more work to be done.  Local ‘place’ was seen as being coterminous with the health and wellbeing board boundaries and there was a strong role for the board as convenor of the system, particularly given its links with prevention, wellbeing, and local accountability.

3.           The director of public health commented on the need to reflect on the roles of the system partners as ‘anchor’ organisations, including opportunities in terms of healthy workforces and the climate change agenda.  The director of strategy and transformation suggested that this could be a future topic for the board and noted that addressing inequalities and prevention were key threads in the work being undertaken.

4.           The Managing Director of Taurus Healthcare commented on the distinction between Primary Care Networks and general practice, and the vision to engage with communities and the prevention agenda.  The vice-chairperson noted the importance of education and addressing the broader determinants of health and wellbeing.  The cabinet member - children and families added that eating healthily was also a key factor.

5.           The chief executive said that, as explored at a recent meeting of NHS and local authority leads across the Midlands, there was a clear need for the NHS to work with local authorities in the co-shaping of the plan.  Therefore, the starting point needed the joint development of a long term plan for Herefordshire.  The council had an aim for people to live at home healthily and independently for a longer period of time, with services constructed to allow this to happen and with support from voluntary and community sectors, which would have the outcome of fewer people requiring urgent and emergency care.  The Non-Executive Director of Gloucestershire Health and Care NHS Foundation Trust said that the integrated approach was key to translating national strategy into a local context.

6.           The Chair of Healthwatch Herefordshire said that the Long Term Plan was supported and that the STP had committed to take the 2019 Healthwatch Engagement Report into account.  The need for the local ‘voice’ in the detailed plans, including the development of the Primary Care Networks, was emphasised.  The vice-chairperson said it was important that the public, including representation through Healthwatch and local authority councillors, should not have to react to changes in the NHS but should be driving them, with more positive ownership and partnership.  The chief executive commented on: the importance of community connection and direct support to enhance capacity; the need for mental health needs to play a more central role; and the opportunity to address the big questions jointly through a local long term plan.

The director of strategy and transformation continued the presentation with slides on: ‘NHS Action on Prevention’; ‘Integrated Care Systems (ICSs)’; ‘H&W STP Vision’; and ‘The Tiers in an ICS (work in progress)’.  Questions and comments from attendees included:

7.           In response to a question from the Chair of Healthwatch Herefordshire, it was reported that smoking cessation services were provided to high risk groups and would be extended to inpatients in hospitals.

8.           The Leader of the Council, noting reference in the STP vision to ‘Put prevention, self care and personal resilience at the heart of our plans’ questioned whether the population was receptive to this or if a degree of education was needed.  The director of strategy and transformation, noting the value of the recent engagement work, said that the position was mixed.  The Chair of Healthwatch Herefordshire commented on the challenges in some parts of the population which required further exploration.  

The Leader of the Council noted that community participation was essential but it could be difficult to motivate some individuals.  The director of strategy and transformation said that it was multi-faceted question, involving healthy environments and opportunities, which could be explored at a future workshop.  The director of public health added that it was a complex topic, especially in view of inequalities, and reiterated the role of system partners as anchor organisations in helping their workforces to make healthy choices.  

The vice-chairperson said that it should be recognised that some people’s lives started in more complicated places than others and mental health issues may limit access to, or interest in, certain lifestyle choices.  He added that the recent launch of the Children and Young People’s Plan had been a positive event and hoped that all the organisations represented on the board were fully engaged with this work.

The chief executive emphasised the importance of getting people to change behaviours and attitudes, to take responsibility for their own health and their family’s health, and do more to support others in the community.  The example of Wigan Council’s ‘Deal for Health and Wellness’ was outlined.  The chief executive considered it critical to find ways for communities to take on and feel ownership of such matters.

Slides were presented on ‘One Herefordshire’ and ‘Integrated Care in Herefordshire’.

9.           In response to a question from the Leader of the Council about the statement that functional integration was ‘not about Shifting Risk’, the director of strategy and transformation noted that this was a high level principle which could be applied to many constructs, including finances, governance, clinical risk, and organisational risk.  In terms of clinical or professional accountability, each service or intervention would need to be considered and agreed.

Slides were presented on ‘2019/20 Delivery and Assurance’ and ‘Talk Community Key Programmes’.

10.        In response to a question from the Leader of the Council about motivating people to become involved, the head of partnerships and integration said that harnessing the interest in, and the experiences from, the initial Talk Community hubs would help to promote the initiative in other parts of the County.  The assistant director all ages commissioning added that people were coming forward with their own ideas for their communities.  The director of public health said that it was important to focus where there was energy but also to identify the more vulnerable groups within those communities and how to work with them.

11.        With reference made to the way in which broad family intervention in Leeds had successfully reduced childhood obesity, the vice-chairperson questioned how a positive vision for population health and wellbeing would be picked up locally.  In response, the director of public health commented on the potential for Herefordshire to become a sustainable food county.

A slide was presented on ‘Integrated Care Alliance Board Work Plan’.

12.        The chief executive commented that social care was on the frontline of prevention for NHS clinical needs and felt that there should be greater emphasis on prevention under the work plan.  In response, the director for strategy and transformation outlined the work programmes for the identified projects and the linkages to prevention.  The Managing Director of Wye Valley NHS Trust emphasised the need to address heightened emergency demand and to provide better and more efficient care for frail older people as a priority but recognised the potential of Talk Community and the prevention agenda, particularly in childhood.  In response to a question from the vice-chairperson, the head of partnerships and integration said that the Home First team was primarily focused on discharge currently but there was an intention to invest further in admission avoidance and wrapping care around individuals at home.  The director for public health reiterated the need to look at the broader determinants of health and wellbeing in order to have a real impact.  The director for strategy and transformation acknowledged the need to articulate not only the operational specifics but also the context of the ongoing conversations about prevention.

A slide was presented on ‘To Deliver the Vision of Our STP Long Term Plan Submission’ and ‘Delivering Our Commitment to Transform Out of Hospital Care and Fully Integrated Community Based Care, Reducing Pressure on Emergency Care’.

13.        Referring to the system commitment to ‘deliver digitally enabled care and self care…’, the Chair of Healthwatch Herefordshire commented on the need to think differently in terms of localities that did not have access to reliable digital communications.

The director for strategy and transformation drew attention to slides showing the draft delivery plans for ‘General Practice and PCN Development’ and ‘Integrated Primary and Community Services’.  It was reiterated that addressing inequalities and prevention were key threads throughout the submission. 

A slide was presented on ‘The Four Strategic Priorities for Integrated Primary and Community Services’. 

In conclusion, the director for strategy and transformation said that the presentation attempted to summarise a detailed piece of work to meet national policy requirements and in such a way which best meets local needs, makes health and care services more resilient and supportive, embeds prevention and reablement, and supports people in their communities.

The Chair of Healthwatch Herefordshire commented on the need for the board to ensure that all the right linkages were made. 

The director for public health said that the board had a role in terms of: providing leadership and oversight; putting challenge into the system to identify where progress was not being made with this agenda and to address any associated issues; and to hold all partner organisations to account, on issues such as working with communities and changing employment practices, to achieve the objectives set out in the plan.

In response to a comment from the Leader of the Council, the head of partnerships and integration noted the need for the partner organisations to identify potential issues for inclusion in the work programme.  The director for strategy and transformation said that it would be helpful if the board could identify where the system needed to focus on, including any specific matters to prioritise. 

The assistant director all ages commissioning commented on the need to shift resources progressively to prevention and suggested that the board could come to a collective agreement on how it would evidence as a system this shift in resources and investment.

The chief executive commented that other initiatives would support the prevention agenda, such as extending cycle routes and installation of fitness furniture in public spaces.

The vice-chairperson proposed the following recommendation which was seconded, and supported by the board.

Resolved:  That the board has an active interest in this work and recognises the need for oversight of the difference this will make to the people of Herefordshire, with a focus on prevention and on communication with, and active involvement of, our population(s).